Acute and “Next Steps”

There are many times in the ER when I see a patient and have to pause the conversation to break it into two very distinct parts: the acute problem and the chronic problem. It may not always be a truly chronic condition, so perhaps a better way to frame it is the acute problem and the “next steps” problem.

During a shift, I saw two patients with debilitating chronic pain.

One had chronic low back and hip pain and had already been evaluated by outpatient providers. There was a plan for an upcoming procedure, though no date had been set yet. The patient had tried to obtain a prescription for a new medication that day, but due to common delays in communication (a topic that probably deserves its own post), he was unable to get it. When I saw him on Friday night, he had already been waiting in the ER for almost four hours, and it was nearing 11:00 p.m.

After a thorough discussion of his symptoms, we determined that—despite his severe ongoing pain—he had no new symptoms and did not need hospital admission, as he remained safe to care for himself. He did not need any diagnostic testing. I explained that there was no way I could expedite his outpatient procedure on a Friday night in the ER. He needed a specific injection in his back, typically performed by a spine or pain specialist—neither of whom would be coming to the ER in the middle of the night, particularly on a weekend.

Eventually, we addressed the acute problem: I gave him a dose of the medication his outpatient providers had planned, and I sent a prescription to a pharmacy that he could pick up the next morning. Fortunately, he understood that I had no control over the “next steps” problem.

My other patient with chronic pain had multiple myeloma. He was on high-dose opioids at home, which had been controlling his pain adequately. But now he had new pain that was no longer controlled by his home medications. He required multiple doses of IV opioid pain medicine, which only minimally improved his symptoms. We performed CT scans to ensure he did not have a new issue requiring hospital admission.

Fortunately, the ER was not particularly busy that night, allowing me to have multiple in-depth conversations with him and his wife about the plan. Again, we separated the issues into the acute problem and the “next steps” problem. Unfortunately, there was no obvious solution or clear reason for his sudden severe pain that would be easily fixed with a specific procedure or medication to provide quick relief.

The acute problem is often straightforward. With the resources available to me in the middle of the night, it’s usually clear what needs to be done. However, solving the downstream or “next steps” problems is not something I can control, and it’s often frustrating for patients because things rarely align smoothly in Big Medicine.