I recognized her shoes before I saw her face. White New Balance, the left one split at the toe seam. She'd been in three months ago with the same chief complaint — lower back pain, chronic, radiating down the left leg. Same room, actually. Bed seven. She was forty-six, worked at a manufacturing plant outside West Fargo, and her chart read like a loop: ED visit, imaging, Toradol IV, muscle relaxer prescription, follow up with your primary care provider. Three months later, repeat.
I pulled her vitals. Blood pressure 142 over 88 — elevated, but it's elevated every time she comes in because she's in pain and she's frustrated and she's been sitting in a waiting room for two hours. I asked the standard questions. She gave the standard answers. On the pain scale she said seven, the way people say seven when they've learned that anything below a six doesn't get taken seriously and anything above an eight gets you looked at sideways.
Here is what I was thinking and did not say: this isn't going to fix anything. The Toradol will take the edge off for a few hours. The cyclobenzaprine will make her drowsy. She'll go home, sleep, wake up tomorrow with the same back, and in twelve weeks she'll be in bed seven again. I know this because I've watched this cycle hundreds of times with hundreds of patients, and the ER is not designed to treat chronic pain. We're designed to rule out emergencies and send you home.
What I also didn't say — what no one in that department said — is that North Dakota has had a medical cannabis program since 2016. That chronic pain is a qualifying condition. That a conversation with her primary care provider about whether cannabis might have a role in her pain management is a conversation she is legally entitled to have.
We didn't say it because the ER doesn't prescribe cannabis. We didn't say it because there's no checkbox on the discharge form. We didn't say it because most emergency physicians have received zero hours of training on endocannabinoid pharmacology and aren't going to recommend something they haven't studied. These are legitimate reasons. I'm not faulting any individual provider. I'm describing a gap in the system shaped like a door nobody installed.
The patient in bed seven went home with the same discharge instructions she'd received in January. Follow up with PCP. Avoid heavy lifting. Take ibuprofen as needed. Apply ice twenty minutes on, twenty minutes off. There was no mention of cannabis on that paperwork, not because anyone opposed it, but because it simply doesn't exist in the emergency department's vocabulary.
Here's what I want patients like her to know.
Your ER visit is a snapshot. We assess, stabilize, and refer. If you have chronic pain — the kind that brings you back to the same bed every few months — the real conversation happens with your primary care provider, not with us. We don't have time, and frankly, we don't have the relationship. Your PCP does.
Medical cannabis is legal in North Dakota for chronic pain. You don't need your ER nurse to bring it up. You can bring it up yourself. “I've been reading about medical cannabis for pain management — is that something worth exploring?” That sentence is enough. If your provider dismisses it without discussion, you're allowed to ask why. If they're honest, many will tell you they don't know enough about it to recommend it confidently. That's not a no. That's a gap in their training, and you can ask for a referral to someone who has closed that gap.
What I'd want to know, if I were the patient instead of the nurse: Is this a fit for my specific condition? What does the evidence actually support? The evidence for cannabis and chronic pain isn't a miracle story — it's modest, consistent, and real. That word matters. Modest. Cannabis is not going to replace physical therapy or surgery for a herniated disc. But for some patients, it's a tool that the current system doesn't mention because nobody assigned it a discharge code.
I watched the woman in the white New Balance shoes walk out past the nurses' station that night. She was moving carefully, one hand on the wall. I thought about what I hadn't said. I think about it more often than I should, which is probably why I'm writing this under a name that isn't mine — because the system I work in is better at handing out prescriptions than it is at having honest conversations, and someone should probably say that out loud.
If you've been cycling through the same appointments with the same results, ask the question your ER nurse can't ask for you. The answer might be no. But at least it'll be an answer.