“A Dios mio! Pain! Pain!” I heard the woman’s cries all the way down the hall as she was led by the ED tech to my last empty bed. I sighed and took the chart from the tech. 60 year old woman with a three day history of left flank pain. “OK” I thought, this should be easy.

I went in to see her, and introduced myself. She was tiny, barely 5 feet tall, her graying hair held back in a bun. She told me her name was Sonya and that her doctor had diagnosed her with kidney stones at one of the other local hospitals. She’d decided to come here because “they don’t give me any help.” I had her put on a gown, started an IV and drew labs, and instructed her to give me a urine sample. “Thank you thank you,” she said in breathless, broken English. “The pain is very much worse.” I smiled and pointed her to her bathroom. She patted my hand before heading that way. I am always a sucker for the older patients.

In the meantime I checked on my other patient in the same room. David was a 30 year old “frequent flyer” who came in via EMS writhing in lower abdominal pain; he was going to be worked up for possible appendicitis, even though he’d presented five times this month already with similar symptoms. His tests had come back negative each time, and the doctors were starting to suspect he might be a drug seeker. David was resting comfortably, having received a morphine and phenergan IV cocktail.

I could tell when Sonya was back to the room by the progressive moans and groaning she made as she ambled back from the bathroom. I helped her into her bed and assured her we would make her as comfortable as possible. I told the ED resident that Sonya was in a lot of pain, and that she was ready to be seen.

Next I saw David’s call light go on and when I went in to check, he told me that the pain was back again, and he asked for more morphine. The pain was rated a 10/10 and he curled up on the bed holding his abdomen. I remembered his last visits, which were the exact same presentation but nothing was ever found on CT. I looked at the clock; it had only been 45 minutes since he’d received the morphine. I tried repositioning David to find a more comfortable position but it was useless. He was in pain no matter what position he was in. I asked the resident for another order of morphine and she wrote it with a sigh, mentioning that it seems David had increased his visits lately and maybe it was time for a psych consult.

The resident saw Sonya while I prepped David’s morphine.

When I took the medication back in for David, Sonya saw me and started moaning again. “Is that medication for me?” she asked. I told her I was sorry, it wasn’t, but that I’d have some as soon as the doctor ordered it. She looked so small and alone in the bed. I brought her an extra blanket. I quickly obtained the order and administered Sonya some morphine. She lay back happily.

Shortly, both patients were transported to CT. I went about my shift caring for my other patients.

A half hour later, after both of the patients had returned, “Look at this” the Dr said, indicating her computer screen. Sonya’s CT was perfectly normal, no evidence of kidney stones.

“And this too,” the resident said, changing computer screens. Sonya’s history came up on the screen; she’d had 15 visits in the last 2 months, all with pain. Futhermore, her history indicated a continuous use of street drugs.

The resident sighed and was about to get up and go see Sonya when her pager went off. She returned the call and turned to me. “David’s got a hot appendix. He’ll be going to the OR within the next half hour.”

As I sat filling out the pre-op paperwork for David and listened to the resident as she attempted to explain to Sonya that there was no evidence of kidney stone and that she would not receive any more morphine, I sighed. In this business, it’s so easy to gain preconceived notions and ideas. This was a good night to remember that nothing is ever necessarily just what it seems.