Certain things, can only come with experience in this field. You can learn textbooks cover to cover, but that doesn’t teach you the “art” of practicing emergency medicine, only years of hard work, seeing thousands of patients and experiencing thousands of unique situation can allow you to truly learn this skill. Here is one such example of the “art of medicine” from my last shift.
We had a man come in via police custody last night, who in the process of a night club altercation and fallen and torn his patellar tendon (which connects your knee to your leg, and lets you kick your leg out). This is a VERY painful sort of injury, basically any sort of movement will cause you significant discomfort. Normally, I am a bit reluctant to go out of my way to offer narcotics to someone in custody, but there was a catch. The gentleman in custody was A) a police officer himself B) got in the fight after someone assaulted his girlfriend. While two wrongs don’t make a right, the guy was not the typical ass brought in by the cops, he knew he was in a lot of trouble with work, and I generally felt bad for him and his situation. He was trying to play it tough and deny that he was in pain, but he was literally trembling while I talked to him, probably both from the fear and pain combined.
The attending on last night has a general rule that nobody gets narcotics in the ED unless they are being admitted or have a definitive, established diagnosis that warrants it. (Ie, all the vaugue 11/10 abdominal pains get zero narcs). I figured this guy, with a tendon rupture, in obvious pain, and a police officer to boot (granted in handcuffs, which were soon removed) would warrant some. So I was a little miffed when the attending still refused to give him any when I asked if it would be okay. I mean, I was hurting just looking at the guy. I wanted to do something for him other than some Motrin. About an hour later, when things quieted down, I asked the attending his thought process on why he didn’t want to give this gentleman narcotics, and this was the reason. “This guy is going to be in a lot of trouble. I’m sure his captain or internal affairs is going to be getting a statement from him at some point tonight. The last thing we want to do for this guy is anything that is going to make him appear intoxicated or under the influence of anything. He needs to be razor sharp for the next hour or so as his career and future is depending on the next few things that come out of his mouth. Go explain this to him, and if he understand this, and still wants narcotics for his pain, I’ll give it to him”. So the nurse went off and explained our reasoning, and came back a few minutes later “The patient is refusing narcotics for his pain and would like to thank the doctors for having his back”.