Even dogs get pain scales.

Unless you’ve been living under a rock, you’re well aware that the United States is in the grip of a really big epidemic of opioid abuse.  The epicenter of much of this has been my beloved Appalachia.  My home-town, Huntington, WV, might as well be re-named ‘Oxycontin,’ or maybe ‘Heroinville.’  It’s ugly.

Enormous amounts of ink have been spilled on this topic, and I don’t intend to explain the genesis of it in detail.  In short, however, about 20 years ago some doctors thought we weren’t being kind enough in our treatment of pain.  Some articles were published to draw attention to this theory.  We started using the pain scale.  0 = no pain, 10 = the worst pain ever.

Around the same time administrators discovered the customer/patient satisfaction score.  Taken together, physicians and nurses were pressured by 1) academic peers and medical directors as well as 2) administrators, to give more pain medication.

So, to recap mathematically:

Pain scale x Satisfaction score = better reimbursement + death

Recently, smart people have discovered that a lot of what we were told to do in clinical practice was probably (to put it delicately) utterly stupid and ultimately deadly.  Having said that, not all of the drug abuse in the country is because doctors gave out too many pills (although pill-mills are obviously a problem).

Some of it, in particular the heroin and fentanyl nightmare, has to do with bad decisions, experimentation and the high marketability of those drugs.  Enormous amounts of those drugs are manufactured in other countries and shipped here (obviously illegally).  Money talks, as it were.

The problem is, research suggests that patients of doctors with very high satisfaction scores often do poorly.  Think of your kids.  How do they turn out if you give them whatever they ask?  Not usually very well.  Often quite badly.  Ditto for patient care.  Nobody should get a CT scan or antibiotic just because they want it.  Nor should they get narcotics just because they scream ‘it’s a ten!’ Or because they ask to talk to the patient advocate or administrator.

The further problem is that administrators (and government) seem to be lagging behind science.  (Not that doctors don’t also; can’t throw too many stones in the glass house.)  But they get all worried when people complain that their pain wasn’t treated. And indeed, in many insurance payment schemes, pain management is really important. Don’t treat pain?  Don’t get reimbused well.

Ultimately, however, this national obsession with pain relief has landed squarely in the emergency departments of the land.  I work in a mid-volume emergency department in a community hospital.  And I’ll recap a few pain complaints that I have seen which illustrate the problem:

‘I had dental surgery and my oral surgeon said if my pain was worse I should go to the ER.’   My pain?  It’s about a 9/10.’  (Texting and laughing.)

‘I had a car wreck a month ago and broke some ribs.  I missed my follow-up appointment but I need more pain medicine.  My pain is a 10/10.

‘I fell down and hurt my knee yesterday.  (Xrays negative, mild swelling.)  Tylenol and Motrin are like taking candy.  I need something stronger.’

‘I go to the Methadone clinic but I didn’t get there today and I need pain control.’]

‘I’ve had sinus pressure for a few days.  No, I didn’t take anything for it. I came here!’

‘I hurt all over, and I’m hot and cold and sweating, and my wife says I have a fever, but I think I’m dying.’ (Did you take anything, he asked, knowing the answer ahead of time?) ‘I didn’t take anything.  I just came here.’

‘This cough is driving me crazy.  Can’t you give me something stronger for my pain?’  Yep, an inhaler so you won’t cough. And here’s a thought.  Stop smoking!

‘My 7-year-old daughter skinned her knee a few days ago and says that Tylenol and Motrin don’t help at all. Her pain is an 8/10.’  A child with a minor injury understands to rate her pain higher…

‘I just started a job as a brick-mason and my back is sore.  Can I get something stronger for the pain?’

‘I have migraines.  My pain is a 15/10 and Imitrex does not help.  The only thing that helps is Dilaudid.  Morphine is like water…’  (????)

‘Well if my wrist isn’t broken from the fall, Doctor, how come it hurst so much!  I mean, it’s a 10/10!’  (Uh, it’s bruised?)

‘My family doctor doesn’t give narcotics.  His office says I should go to the ER.’

‘My pain specialist is out of the country and his office says I should go to the ER.’

The list is exhaustive.  Ask your nurse and doctor friends; especially those who work in emergency medicine.  Ask them about the pain scale and watch them roll their eyes.

We’ve turned pain into a religion; worse, into a kind of physical victimization in which the victim of the pain is always right.  And is always entitled.  In the process, we have allowed people to forget that pain is important and normal. That it is necessary for our safety. That it probably helps healing; a body that doesn’t know there’s a problem doesn’t heal as well.

And we’ve created far too many people whose entire lives are predicated on a drowsly euphoria spent sitting on the couch or in the bed, while other people provide for them and care for them.

In addition, the constant requests for pain meds can distract us from those in genuine pain, and who really, truly need the ‘good stuff.’  The fractures, cancers, sickle-cell, and other patients who need urgent relief.

This is immoral.  It’s bad, bad, bad for our patients. But it’s also terrible for our hospitals; in particulary my beloved emergency department.  Because it means that around the clock, even as we try to make decisions that will hopefully save lives and prevent permanent harm, we are tasked with responding to every whim of the pain-scale.

All day, and in particular all night, our societal pain obsession has been shifted onto the backs of physicians and nurses in the ER.  There is seldom a break from this. And because federal law prohibits financial screening in the ER, many of our more nefarious and manipulative ‘customers’ know that if the pain clinic expects cash, at least the ER doesn’t. If the surgeon wants money to see you in follow-up, you can hoof it to the nearest ER and get pain meds (if you’re annoying enough) and maybe a sandwich or a ride home. And with all due respect, our Medicaid population knows the same thing. So a 3 AM visit for a minor complaint (with pain thrown in as a side) might get some narcotics; and doesn’t cost anything personally.

This leaves staff members exhausted, bitter and burned out. More so when administrators habitually take the side of the ‘customer’ against the already overwhelmed staff.

The bottom line is we’re hurting people.  Patients and professionals alike.

And it turns out, this is so pervasive that even the dogs have pain scales.  My wife and I cracked up when we saw this in the vet’s office.  I mean, pain relief is fine for dogs (it’s mostly NSAIDs). But a visual analog pain scale for dogs?

‘Lassie! Bark once for each pain scale level! What’s that? 20 barks? What are you a pure-bred Lab? It only goes to ten. You’re a drug seeker and you have a problem…Wait, is that my prescription pad?  Go home, you’re stoned…’

America, not all pain needs to be suppressed and most pain doesn’t require an ER visit.  Many people do need pain relief, and this frantic desire to treat every little ache and discomfort makes it harder for us to threat the ones really hurting.

And sometimes, when it comes to your pain scale, you’re just stupid.

On Veteran’s Day ask, ‘what would I die to defend?’

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Veteran’s Day has always meant something to me.  But then, I was born in 1964.  I’m the last of the ‘Baby Boomers.’  I grew up on stories of family members in time of war.  I remember my father, Keith Leap (my name also) leaving for Vietnam when I was four years old, and remember (vaguely) his return.  I recall my uncle’s stories of the Navy, and of a grandfather in the Army in Mississippi and a great-grandfather who served during the Spanish-American War.  There were others, back to the Civil War, the War of 1812 and the Revolution.

I grew up looking for dates of service on tombstones, and for flags, ranks and units of the fallen.  I grew up with toy guns, toy soldiers and war movies, in a time when we threw plastic grenades with caps in them, which sometimes actually went off and frankly surprised us.

A great-uncle I never met was a Col. in the US Army in France during WWI, and I always heard that he said he was determined to bring his men home safely.  Another great uncle gave me a bayonet he took from an ammo-dump in Italy during WWII; there appears to be a ding in the side from a bullet. A neighbor survived the Bataan Death March; not surprisingly, he suffered as an alcoholic as long as we knew him.  I once met a gracious gentleman who was a former Wehrmacht soldier, who (after a CT scan when his arms were held above his head) said ‘the last time I held my arms like that one of Patton’s soldiers had a rifle in my back!’

I was immersed in veterans and their stories.  And the ones I knew were ever humble and kind.

Was I taught to idolize war?  Was I taught that bloodshed was the answer?  Was I taught that violence was some sort of higher good, as if we were Lacedaemonian children of Sparta?

I don’t think so.  I think I was taught to idolize sacrifice, courage, and simply fortitude.  I grew up in Appalachia; fortitude was necessary, if only for my ancestors to survive against nature.

I suspect that much that these men did had less to do with bravery than determination; in practical application they can look the same, I suppose.

Many brave men and women follow that tradition of service.  They fight, are wounded and die on many fields.  They live or die by their conviction, by their camaraderie, by their patriotism and belief in something higher.

This is hardly limited to the armed forces.  Many live their convictions, in all sorts of fields of endeavor.  But what I wonder now is this:  who will die for their convictions?

We live in a time when many people, especially those in universities, are emotionally wrecked by the slightest challenge to their beliefs, the faintest intrusion into the coddled safety of their own fragile minds.  College administrators give them coloring books, Play-dough, therapy dogs.  Safe rooms are established where they can cry when things don’t go the way they perceive that they should, when there is no trophy or certificate for all.   I suppose this is included in the price of tuition?

But on Veteran’s Day, I must ask of all Americans, what beliefs will they, will we, go through life willing to die to defend?  We should all ask this. What matters most?  Faith, country, family, these are things men and women historically died for.  Ideology?  To some extent, but I wonder.

Will generations of young people learn the lesson of Veteran’s Day?  Not that they need to serve in the military to be real Americans; not that the only heroes are those in uniform, those in battle.  That is a heresy that would produce a warrior class, and we don’t need that.

The lesson, as I see it, is different.  What will you have the courage to stand up and live for, instead of lying down and weeping?  And what will you have the fortitude to die for, if it comes to that?

On this beautiful Veteran’s Day, contemplate that, whether you are or were or never were in the armed forces.  And find an answer.

The future may call on you to decide.

Driving Country Roads to the ER

These days, I work most of my shifts about 45 minutes from my ‘house on the hill.’ At one of those jobs, the day shift starts at 06:30. Which means I’m rising from my bed at 04:30 in order to get on the road in time. I’ve started waking up at four, spontaneously, as if it were the most natural thing in the world.

I lay out my clothes the night before, so as not to awake my darling wife in her sleep. Sometimes I am able slip out without her knowledge. Others she wakes to kiss me goodbye. Then I go downstairs and put together some lunch, get the backpack and make my way out the door. I know that my wife and children are safe upstairs, as I lock the door behind me.

The door creeks a little, or did until my son Elijah oiled it. (One always wonders why a teenage boy oils a front door…) Occasionally I lock it as I realize I left my keys inside, and poor, tired Jan opens the door for me patiently. On the front porch, by the soft yellow of porch-light or the shock of flashlight, I step over dogs freshly awakened from sleep, who look at me with gentle annoyance. The sharp-eyed cats sleep in more secret places, so are seldom seen in the morning. Other dogs (we have five), sleep on the gravel drive in the summer and seem confused as to how to react when my Tundra rolls towards them, slowly, and I roll down the window. ‘Get up, you silly dog!’ Heads and tails down they amble away.

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Up the long drive and down the road, I am suddenly all but alone on the two lane roads that lead me to Tiny Memorial Hospital. Despite the early hour, I am ‘awake, alert and oriented.’ The sky is dark, and in winter stars shine down when clouds don’t lay low against the earth. I scan the roadside for deer, their eyes reflecting the truck’s headlamps. Opossums sometimes shuffle across, along with squirrels and rabbits. (One day I saw a big, black bear on a hill by the road. He ran away as I stopped for a photo.)
I drive through forests, past sleeping houses and across a dark, still lake where sometimes, the light from a bass-boat shines across the emptiness where someone has fished all night…or started very early. Or a campfire on the shore still burns as their line rests untroubled in the water.

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It is so early that I drive past gas-stations and convenience stores still dark and locked, the ‘closed’ sign reminding me to keep on moving. The air, even in summer, is cooler and in winter, positively cold. Winter is my favorite, I think, with the heat of the truck turned out, and the chill wind blowing past.

I think as I drive. And I pray. And I listen to the news, a recorded sermon, a pod-cast. Many mornings I turn on an oldies station from the North Carolina mountains; in the loneliness of the drive the music of Sinatra, Johnny Cash and others, make me feel I’ve gone back in time.

I cannot talk on the phone (hands free or otherwise). I pass through places where cell-signals are only a dream, and often even radio reception is poor. Remote areas, mountainous places, lonely and beautiful places defy cell signals and seem to say ‘look around! What else do you need!’ Even at 5 am, I agree.
Eventually I am near, and I find a fast-food joint for the obligatory chicken biscuit and tea, because, well, the South and all. And then I roll into the ER parking lot, lock things up and head to work.
Because this is no urban trauma center, the early morning is sometimes very slow and relaxed. A few patients may be waiting for turnover, but often none. I can sit and think, I can ask about the previous night. I can ease into work. My drive has already prepared me, but it’s nice to have a few minutes peace in the department before the chaos of the day begins. I text Jan. ‘Here safe, love you,’ and she answers. ‘Love you back, have a great day.’
There are those who don’t have to drive long distances. For most of my career it was about 15 minutes to work. And there are those who have long commutes through traffic, and through the waking body of a large city, people and cars just starting to fill its veins and arteries. Sometimes I am jealous. It can be lonely where I am.
But I think I’ll keep it for now. There is a solemnity, a serenity to my mountain and lake commute, with animals heading to bed and people not yet rising, with my own thoughts and prayers to myself.

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And I suppose that if there were a better way to prepare for the madness, badness and sadness of the ER, I don’t know what it is.

Appalachia Deserves Our Respect (And Already Has My Love)

This is my column in yesterday’s Greenville News.  Happy Birthday West Virginia!  June 20,1863.

http://www.greenvilleonline.com/story/opinion/contributors/2016/06/19/ed-leap-appalachia-deserves-our-respect/85974188/

 

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Tomorrow is June 20th, a special day in the hearts of my people; West Virginians. On June 20th, 1863, West Virginia entered the Union in the midst of a bloody struggle for the soul of the young nation. It was, prior to that, the sparsely populated, wilderness-filled backwater of the elegant, beloved Virginia, soul of the South. After June 20th, however, it was…well, a sparsely populated, wilderness-filled backwater all its own. But a free state that rejected slavery!
Those who live in South Carolina are generally well acquainted with my fellow West Virginians. I have a theory that West Virginians share a gene which, at various times of their lives, causes them to have an irresistible urge to drive to South Carolina’s coast. In fact, when the mines close down for two weeks every summer, untold numbers of miners and their families head to Myrtle Beach, which has been affectionately dubbed ‘the coal miner’s Riviera.’ Some of my earliest vacation memories are of the Grand Strand. My wife Jan, a true ‘coal-miner’s daughter’ has similar memories.
If you doubt the connection between SC and WV, I have a vignette: my brother-in-law Dave worked in the WV coal mines as a young man out of high school. His early cell-phone plan included, as local calls, Huntington and Charleston, WV and (you got it!) Myrtle Beach, SC.
I write about this today because West Virginia is in the heart of Appalachia, which stretches from Southern New York all the way to Northern Mississippi (passing through the Upstate of South Carolina). Appalachia is defined as a ‘cultural region,’ and indeed it is.
More to the point, I write this because Appalachia is struggling. Although poverty has improved over the decades, Appalachia as a whole still faces financial woes, much of it made worse by those who are all too anxious to kill coal, but provide no other employment options for those terminated as part of an environmental purge. As if the ‘coal industry’ is only some vast robotic behemoth, and does not represent the hopes and dreams, and often the only financial possibility, for an entire ‘cultural region’ of America.
Appalachia is also struggling with rampant drug addiction and broken by the many funerals, ruined lives and crimes that widespread addiction brings in its wake. From pill-mills dispensing oxycontin to meth labs and imported heroin, the toll in lost lives and lost hope is crushing.
When Jan and I have traveled home over the years, deeper and deeper into Appalachia, up Highway 23 through North Carolina, Tennessee, Virginia and Kentucky and then home, it’s easy to see a place of magnificent beauty, resilient people and serious, inexpressible hopelessness. I never know if the drug abuse is the cause of the loss of hope, or the result of it. Cart, horse. It’s all tragic.
Sadly enough, America frequently just isn’t interested. Appalachian people are still acceptable sources of scorn for much of urban, coastal America. They’re live in ‘flyover country.’ Trailer-trash, hicks, rednecks. People who ‘cling to guns or religion or antipathy toward people who aren’t like them,’ to quote a well-known political figure. When a culture is endlessly mocked and derided, its people get the message loud and clear. Don’t try. It doesn’t matter.
But this June 20th I’d like to speak for my ancestors, and the forebears of so many, who settled in the Mountains of WV and other portions of Appalachia after leaving the press and stagnation of Europe. I’d like to speak for those who still live there, and who find solace and connection in the ghosts of their ancestors, the starkness of the mountains and valleys, in the life, faith, culture and music of the cities and towns. Like me, they stay there because in Appalachia, the past and the present are difficult but inextricable.
And if nostalgia isn’t enough, let us remember Appalachian people keep the lights (and i-Pads, DVR’s and electric cars) on by mining coal. They also provide timber and produce, work in important industries and share their region for the recreation of any and all. All too many have also shed their blood in America’s many wars, and continue to boldly, proudly ‘stand on the wall’ around the world.
America loves to talk about its multiculturalism. And one of its greatest cultures is firmly entrenched, despite its pains and struggles, in the vast region we call Appalachia. It deserves our respect.

Snow, milk and bread. Still a mystery.

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Snow, milk and bread; still a mystery

(I resurrected this post from 2009, as our entire region of Upstate, SC is on lockdown from ice and snow.  Thank God we have tea and sugar!)

Living in the South for over 21 years, I’ve always been amazed by the general response to snow and ice. In particular, I am constantly fascinated by the grocery store dash for milk and bread. I grew up in West Virginia. Sure, we didn’t have winters like Michigan or Maine, but it was still cold and snowy. Nevertheless, I can’t ever remember my family saying, ‘Run to the store and get milk and bread!  The storm’s a comin’!’

This comes to mind today because all around our hill-top home, the forest is an ice covered work of art and the roads are slick highways to death and disability.  Being South Carolina, of course, everything is shut down.

But I digress.  The point is that I have contemplated this for quite a long time, so I have a few ideas. It may be that there is some secret knowledge that born and bred Southerners possess. Milk and bread may constitute the keys to some Gnostic cultural insight that I’m not privy to knowing. Or, it may be a kind of generally accepted joke.  If so, it’s a lucrative one for grocery stores. Whatever it is, I’ve decided that, in honor of winter, I’ll suggest some reasons why we might actually want, or need, milk and bread when ice and snow descend.

1) The most obvious answer is that we can drink the milk or eat whatever cereal we can find in the cabinet.  We can make sandwiches out of the bread.  And yet, this simplistic explanation it leaves me unsatisfied; hungry for some other answer, so to speak.

2) When the wind is stiff and the house (or camper) poorly insulated, we can mix milk and bread into a paste and caulk the walls for warmth.

3) When mixed into paste, milk and bread could also be used to write HELP, NEED CHEESE PUFFS! (or OXYCONTIN or XANAX) onto the sides of our houses. Unless they’re already white, or too snow covered for the letters to be visible (thus, food coloring).

4)) If a new ice age suddenly descends, we can use the milk and bread to lure animals like squirrels, rabbits, black bears and stray cats onto the porch, then drop cartons of frozen milk onto them, or snare them with nets made of plastic bread bags. We can then make breading to use whilst cooking them. Also applies to gerbils, guinea pigs, hermit crabs and large goldfish.  In a pinch, annoying neighbors may suffice.

5) Milk and bread may be combined with sugar to make some sort of winter confection to satisfy our need for something to eat besides milk and bread.

6) Milk and bread can be bartered on the black-market and exchanged for more exciting things like i-Pods and liquor, or more useful things like ammunition and camouflage. Except that everyone else also has milk and bread, so…

7) If one has purchased enough bread, it can be put under the back wheel of a vehicle stuck in the ice and snow to provide traction, so that the driver can venture forth to find… more milk and bread.

8) When the children are bored from being stuck inside for the 4-5 hours that snow actually lasts in the South, we can play games like ‘dunking for bread,’ ‘pin the cap on the carton,’  ‘cover baby sister in milk’ or ‘bread Frisbee.’  And our children can entertain us for hours asking ‘Mama, can we have something else besides milk and bread?’

9) Because we always get milk and bread but always forget dog food, we can mix the milk and bread and give it to the dogs (who will roll their eyes and eat it out of duty, but who will have already torn apart the trash for chicken bones).  But if thus conditioned, this will make #4 above much easier.

10) We can burst upon the art world with ‘milk and bread sculpture,’ which is almost as cool as ice sculpture but does not require power tools. (But may, unfortunately, sour before art critics can descend upon our area to review our work for the New Yorker.)

11) We can make hot chocolate and toast until the sun shines again. Unless, oh, you forgot the chocolate, didn’t you? Well, it’s back to milk and bread for you.

12) Milk and bread can be used in some sort of odd, Southern fertility ceremony. It must be true, considering the number of children born 40 weeks after the happy couples stocked up.

13) Milk and bread can be substituted for pseudoephedrine and ether in the manufacture of methamphetamine. Well, not really, but it’s much less dangerous and way more healthy.

14) It gives Southerners something to laugh about that people from other countries, like New York and Miami, don’t understand.

15) Going to the store for milk and bread reminds us of the things we need that are really important!  Like sugar and tea-bags,  chicken-livers, pop-tarts and Red Box movies to help us through the next 24 hours until everything melts.

If any of these are right, please e-mail me and let me know. I have to get to the bottom of this! And if it turns out to be a carefully planned conspiracy by dairy farmers and bread makers, then bravo, guys, bravo! Capitalism is alive and well.

Edwin

 

South Appalachian Yoga…a craze to follow!

Jan, my very fit and lovely wife invited me to do some Yoga this morning. I elected to focus in relaxation techniques in the bed as she worked out. (Guys, what’s better than watching your wife do Yoga?) Yes, yes, I know I need to exercise. And I do exercise. Sometimes. But Yoga? Well I don’t think my ancestors (or I) were meant for it. It simply hurts too much. I rarely hurt my muscles lying in bed, you see. But as I listened to the smooth, silky voice of the instructor Jan was streaming on her i-Pad, I imagined something. I imagined the wonders of Southern Appalachian Yoga!

Stand with your feet one shoulder width (or muffin-top) apart. Now, reach up to the sky! This is called lighter at the Skynard concert. Slowly wave your lighter back and forth. Watch your balance and try not to capsize. Now, reach slowly down, down and pick up your imaginary burger. Hold it in front of you at arm’s length. It’s a Triple. Feel the weight. Put the burger down. Pull up your pants; nobody behind you needs to see that.

Legs two muffin-tops apart, now sit on your ATV. This is called ‘riding the trail.’ Grasp the handlebar. Work your wrist muscles as you drive down the trail in your mind. You hit a limb. Lie down on your back, arms and legs out. This is called ‘911.’ Relax and check every limb for injury. Breath deeply and contemplate this: did I take the roast out of the oven?

Roll over. Imagine the rifle in your hands; breath quietly as you sight that enormous eight pointer. This position is called ‘opening day.’ Good shot. Stand up. Reach behind you into the cooler, stretching for the beer to celebrate that shot! Reach for two; Bubba wants one as well. Hand it to him. He’s sitting on the ground.

Now, lie down again. Raise your back and hiss. This is called ‘copperhead at dawn.’ Bite your friend for good measure. Roll quickly onto your back and hold hands and legs in the air, with your mouth open and tongue out.

Then tip to one side, holding the position. This is called ‘road kill.’ Lie there a while and think about lunch. Or dinner. Stand up and take an Advil. You’ll be in shape in no time at all! Reward yourself with fried chicken. That’s Yoga!

Be proud of returning to the fire, doctors

This is my column in the October Emergency Medicine News.  ‘No matter how hot it gets, doctors, be proud of returning to the fire.’

(Who knew that blacksmithing and medicine had so much in common?)

http://journals.lww.com/em-news/Fulltext/2013/10000/Second_Opinion__No_Matter_How_Hot_It_Gets,_Be.6.aspx

 

When I want to clear away the chaos and confusion of medicine, I walk down the worn path in our back-yard (followed by children, dogs, cats and deer). At the end of the path is the shop, which the kids and I helped a friend to build for us. We helped set the foundations and nailed the floor; we raised walls and put in roof trusses.

The shop sits in an area that was once a garden, but a soil-poor garden that yielded more blackberries, brambles and hornets’ nests than corn or beans.  The best crop of the garden was a treasure trove of arrow-heads and Native-American pottery; what still lies there I can’t imagine, but it is evident to me that someone, some people, camped or lived in what is now my yard a very, very long time ago.  They would be surprised to see my shop.

Under the extended roof at the back of the shop is our smithy.  Years ago, my son Seth asked if he could learn to blacksmith.  He may have been born in the wrong century.  He plays the bag-pipes and banjo and black-smiths.  (And is addicted to science.)  But to condense the narrative, we have.  Well, I should say we’ve learned a bit thanks to our gracious teacher George, the man who cannot seem to feel the heat of the hottest fire.  We don’t really even rise to the level of his apprentices,  but we can build and tend a coal-fire, we can handle a hammer and anvil, we can forge-weld iron, twist iron and curve iron; we can quench the iron and we can do most of it without being burned (very often) by the lemon-yellow and orange colored metal.

When I want to let my mind rest from medicine, I walk down that path and look at the old tools and the old anvil and vise.  I look first for wasps and rattlesnakes, of course. But then I just take it in.  The old colors, the bits of rust, the ordered disorder of a work-place; gravel on the ground, coal in the corner.  It isn’t professional and it isn’t perfect.  But it’s beautiful.

Rarely has a hobby captured my mind like this one.  And seldom has any activity enabled me to slip the bonds of medicine so readily.  From the moment I start the walk, I drift into a different place and time.  And when I start the fire, when the coal burns, the green sulfur clouds the air and blows around me, as I turn the crank of the blower that feeds air to the fire, well from that moment I am meditating.

It can be a hot day or a cold day, but cold days are best; cold days when standing by the fire is a comfort; cold days when it’s so hot there that a t-shirt is enough.  It can be a sunny day or a rainy day.  Rainy days fill our bucket with water from the sky with which to quench hot metal from the earth.  It is mystical.

And taking that metal, cutting it, heating it until it is over 2000 degrees, then shaping it from a mundane round or square stick into a wall-hook, a decorative leaf or even into a new tool, well that’s pure joy.

It’s unlike the emergency room.  It is single-minded.  The interruptions are virtually non-existent; and if they exist, they are laughter and jokes between my sons and me; or gentle arguments about how best to accomplish the task at hand.  Or the warning shout, ‘Hot Iron!’ which reminds us to watch lest we be burnt.

There are mistakes, but they are of small consequence.  Burnt metal can be cut off and thrown on the ground.  Crooked metal can be hammered straight.  An item made poorly can remain as a reminder of what not to do next time.

It’s so unlike the emergency room, where mistakes can be life-ending.  Where danger lies at every turn and if we shouted every danger we would shout for 8 hours.  And yet. There’s the heat and smoke.  There’s the risk of injury.  And there’s the shaping of something.  The transformation of something.  Hammer and hot iron and anvil and water; tongs and vise.  The change from what was to what is.  The rescue of an old piece of scrap, a lawn-mower blade, a piece of re-bar and the gift of watching those things have new life.  And the ring of that anvil, made around 1850, that says ‘I’m alive!  I’m alive!  I’m still here and needed!’

They seem connected to me, those two divergent places.  Writers see everything in metaphor and simile. Maybe the heat is metaphor for the pressure and stress of our work in emergency medicine.  Or maybe hammer striking heated metal on anvil is a metaphor for the way we want to shape a new reality; from sickness to health, from injury to healing.  We are blacksmiths of the human body; or red-smiths, maybe, for the blood we see spilled.

I know that as I grow older, I see another metaphor here.  I see my patients like those unshaped bits of iron; of uncertain value and utility, dirty and sometimes abandoned. But I know that in them lies potential; beauty and goodness beneath years of rust and disuse and neglect.  Like the way I put the grinder against my 150+ year-old anvil and when I stopped, it’s rough surface shined like a new platinum ring.

Most of our hobbies, our ‘avocations’ give us insight into our medical work.  Perhaps we choose them for that reason.  Or maybe just for the escape; for the Zen moments of ‘no-mind’ that allow healing and rejuvenation as we work at a thing without feeling as if it is work.

All I know is this.  Medicine seems to be getting more difficult all the time.  And the house of medicine is leaning on our specialty more heavily than ever before.  But whatever your hobbies, let me assure you that we have walked through the smoke and fire, all of us. We have all been ourselves shaped by the fire, hammer and anvil of suffering and struggle.  We have also shaped new realities for the people we have treated and saved.  And most of us keep coming back because we feel a comfort in the artistry that medicine has become; a deep, abiding pride in our craft.

So I say this, friends:  be strong. Do not be afraid of the struggles to come.  Embrace them with joy. Find the peace that comes from artistry well-practiced; for remember, medicine is art.  And however hot it gets, however choked you are by smoke and ash, however tired your limbs, be proud of the skill and strength that brings you back to the fire each day.

Only a few could do it.  And you are numbered among them.

If you’re looking for me, I’ll be down the path, hammer in hand.

 

 

 

 

The New Religion of Narcotics

I just finished reading Neil Gaiman’s fascinating novel, Gods of America.  Here’s a link to it on Amazon.  http://www.amazon.com/American-Gods-Authors-Preferred-Text/dp/0062080237/ref=sr_1_1?ie=UTF8&qid=1362266866&sr=8-1&keywords=American+Gods  I first learned about his work by watching the movie Stardust, then reading the novel.

One of the themes of Gods of America is that the deities of the old world came to America in the hearts of their followers, but over time lose their followers and thus their power.  A war is arranged between the ‘old gods,’ and the new ones that Americans have instituted.  In the story, media, technology, entertainment and others are the new deities for a new age.

I thought about it as I considered my work.  It seems that every day of my life is an endless discussion about narcotics in the emergency department.  Or is it a kind of liturgy to another new god?

‘Can’t I get no Lortabs?’

‘I can’t take Percocet, all I can take is Dilau, Dilaud, what is it called? Dilaudid? I don’t know anything about those drugs, you know!’

‘I’m allergic to the 5mg Vicodin, but I can take the 1omg Vicodin just fine!’

‘Somebody stole my Fentanyl patches and my Morphine pills, and all of my Oxycontin and all I have left is my Methodone, and I only have a few but I don’t see the pain doctor for another month. Now what am I supposed to do, doctor, just suffer?’

‘My nerves are torn up.  I’m out of Xanaxes and my brother’s friends came over and stole all of my Klonopin and Valium!  Sure, I still got some Ativan, but look at how I’m shaking!  Oh, and I’m out of Suboxone.’

‘See, doctor, I have the degenerating disc disease.  I guess I’ve had chronic back pain since I was, oh, 14.  That’s ten years I’ve suffered!  Nobody will do anything for me, so I just take pain pills wherever I can get them.  Can I get some Percocet?’

I could go on.  It’s dialog in a bad novel.  It’s a sonnet to somnolence.  It’s an endless homage to anesthesia.  It’s all but worship.

So it must be a religion.  The people I see are worshippers of pain medication and anxiety medication.  Or maybe, they worship pain and anxiety, and the offer up the drugs to their deities.  Or perhaps they are slipping into amazing dream states, sleeping all the time, and having ephiphanies of wonder and delight.  Scratch that.  They’re dreaming of television and snack food. Of reality shows and disability payments.

And the object, or objects of their worship are taking a terrible toll in lives lost, as epidemic prescription drug abuse sweeps across the land.  (http://oxywatchdog.com/category/surveys-statistics/.)  It’s enabled by a culture that in its own way worships disability and victimization, incapacity and the medicalization of all things.

It makes sense, really.  We cannot possibly suggest that anyone isn’t telling the truth, because a) truth is relative and defined by each person and b) to suggest that would be poor customer service, or discrimination or to be ‘judgmental.’   Furthermore, we reject anything that might suggest an individual take responsibility, or make good moral decisions because morality is relative and faith is irrelevant.

Thus, the internal discord and evil and even legititimate suffering of the human heart must be medical, must be made somatic and mechanistic so that it can be treated mechanistically, and so that no one need concern themselves with uncovering the layers of difficulty and untruth in the human heart, no one need ask hard questions or suggest that one may have guilt or fear for good reasons.  All we want to do is call it a ‘pain’ and offer it a ‘pill.’

Well there you are, America.  We worship at the feet of pain and pills.  We offer our young and our old and our middle aged and vital to the sleepy gods who accomplish so little and cost so much and offer only restless dreams and ultimately breathless deaths.

I will not worship them.  I hate them.  But I acknowledge their power.

Edwin

Homo Sapiens Entitlus: a species emerges

I am here for check...and Sprite!

I am here for check...and Sprite!

Homo Sapiens Entitlus:  a species emerges

There is a staggering degree of entitlement mentality that wanders through America’s emergency departments.  In the 19 years since I finished residency, it has grown in ways I could never have foreseen.  It seems that everyone is entitled to pain medicine (which is causing ever increasing deaths in America) and everyone is entitled to disability at younger and younger ages (‘I got the degenerative disc disease, doc,’ they say at 25 years of age).  Our patients are entitled to work-excuses, and to CT scans, to patient care representatives and in short, entitled to whatever it is they desire.

A recent patient was very angry that we would not give her supplies of both antibiotic ointment and bandages to use for her minor injury over the coming week.  She was adamant that she had no money.  No money, that is, after paying for her cigarettes and smart-phone package.  She was most upset, it seemed, that the nurse failed to bring her a Sprite in a timely manner.

Mind-numbing; truly mind-numbing.

I think over the physicians and nurses, medics and techs, and all the rest who come to work everyday, in places where they are understaffed and often underpaid, and where they will see individuals who will abuse them, and will then say, ‘I don’t know why you’re upset…I pay my bills,’ only to find that those patients have Medicaid.  In fact, the care-givers bringing Sprite and dispensing bandages, working overtime to afford their own children and benefits,  are paying those bills.

But I didn’t write this to moan and complain.  I wrote it to put forth an idea.  My idea is this:  perhaps the ones abusing our systems are the fittest of all!

Consider that evolutionary theory is about survival.  Keep in mind that biologists tend to equate fitness with survival.  It seems, then, that the welfare-queens, the addicts, the chronic criminals, the serial fathers, the Meth-heads who use the system and abuse our good graces may be…the most fit!  They have no compunction about copulation, and thus out-breed the responsible public.  They are sometimes violent and aggressive in positively neolithic ways, and let’s face it, to the modern mind nothing was more true to our natures than that age-old struggle to survive as we envision it in the life of the cave-man!

As the money dries up, and the demands for more sound more loudly, it may be that evolution is happening!   As the workers, the responsible parents, the ones staying up at night helping their kids learn, or caring for sick relatives are asked to do more for less, their opposites find ever more creative ways to receive benefits, avoid work, obtain disability, bring litigation and simply have more time, more things, more children and less responsibility!  And as politicians pander to the loudest and worst among us, the quiet, the best, the producers, the  ones too busy doing right to lobby are simply put upon more and more.  As the morality of the worst becomes ascendent and the ethics of the best are held up to mocking ridicule, it may be that we are simply the victims of natural forces.

Yes, friends, the ones taking and using and abusing may be the fittest of all, in a game where obtaining advantage and survival is all.  And since many believe we have evolved altruism for the collective good, even this tendency (if true) may be aiding the success of those who should not, to all rights, succeed at all as those formerly considered fit are plundered by those now more so.

I’m no Darwinist, though I agree that species change in response to pressures.  And I don’t necessarily agree that survival = fitness (of course, I’m a Christian, so I have a different perspective on that sort of thing).  But from everything I see at work, I have to wonder if I’m not on a fading branch of the evolutionary tree.  And if one day, scientists might not look back upon the time when Homo Sapiens Productive gave way to the rise of Homo Sapiens Entitlus, because the latter had the foresight, and absence of morals, to take what it wanted and continually demand more.  You have to respect their boldness, even if you find their actions horrendous.

In other words, I fear my extinction isn’t so far away.

I think I need a Sprite…of course, I’ll have to get it myself!

(Wait a minute, can I get protection under the Endangered Species Act?   Look at me!  I’m evolving!)

Too many Americans are dying from prescription drug overdose!

This is my column in today’s Greenville News. 

drug overdose

The Centers for Disease Control reports that prescription pain medication abuse, and deaths, are at an all-time high in the United States. In the November issue of Vital Signs, a publication of the CDC, prescription pain medication deaths were reported to number 3,000 in 1999, but 15,000 in 2008.

            However, many in the day-to-day practice of medicine have been predicting this sort of cataclysm for years. We’ve all seen too many young people die from accidental overdoses related to abuse of prescription pain medications. But why is it happening?

            It begins with the very real, very miserable problem of chronic pain in those with legitimate illnesses and injuries. The overwhelming majority of physicians want to ease suffering, and often prescribe narcotics.

            Nevertheless, the deaths are partly the result of efforts by large organizations like the Joint Commission for Accreditation of Hospital Organizations (JCAHO), The Institute of Medicine, the AMA and advocacy groups (physician and patient-driven).

            Those well-meaning but influential groups said that physicians were doing a poor job treating pain. Practitioners started using more and more potent medications.  We were mandated to ask everyone about their pain scale.  It was dubbed ‘the fifth vital sign.’  ‘What is your pain today? On a scale of zero to ten?’ Sadly, it’s rather subjective. And the number of patients with a pain-scale score of ‘ten’ is always surprisingly high.

            The epidemic of narcotic abuse was worsened by financial possibilities.  Pharmaceutical companies are always happy to oblige the market with ever more potent drugs.  And the possibilities were immediately recognized and abused by a minority of physicians who opened ‘pill mills,’ where narcotics were obtained with startling, fatal ease. (Appalachia, my home, has suffered enormously from this sort of activity.)  The economic prospects did not go unnoticed by a subset of ‘patients,’ who realized just how much their prescriptions were worth on the street.

            State medical boards muddied the water by punishing doctors for prescribing too many narcotics. Physicians were left confused between a national campaign and their local regulatory bodies.

            Another grave problem, seldom mentioned, is the customer service model of medicine. Physicians often receive negative patient satisfaction scores from patients who feel they didn’t receive the pain medicine they desired or that was their new-found ‘right.’Hospitals, eager to please ‘customers,’ reprimand those physicians; who learn all too quickly that they should give the patient what he or she asks for to keep the administration happy.

            Not to be excused, our country has an enormous population of individuals whose lifestyles are based upon entitlement living, who come from fractured families, grew up with alcoholism and consume many other drugs of abuse. And not all of them are poor. Prescription narcotics may just be the ‘lowest hanging fruit’ of all in the endless attempt by humans to anesthetize their lives.

            As we struggle with the economics of health, I suspect we have no real grasp of the amount of money spent on prescription narcotic abuse. Not only in treatment of overdose, or rehab, but in the enormous costs we incur as physicians sift through confabulated complaints and outright lies, searching for pathology but finding no objective evidence of anything; except a history of drug abuse and likely drug diversion.

            Physicians obviously share in the blame.  Sometimes we’re lazy and give in too easily. Sometimes, we’re afraid to challenge authorities or cause arguments.  And the medical education establishment has educated away the idea that humans are fallible and may not be truthful, so that in our new-found relativism everyone speaks the truth.  Thus, every pain needs a pill…why would anyone lie?

            What can we do?  The CDC recommends monitoring programs, alternative treatments for pain, improved education of practitioners and access to rehab. But the reality on the ground is that pain specialists and rehab are costly, and not widely available.  Furthermore, the best drug seekers know the drill.  They’ll endure Motrin a time or two, but all too quickly their allergies, or ulcers develop. 

            Prescription narcotic abuse is killing Americans, defaming and harming those truly in need of pain medication, and crushing the health-care economy. There are no easy solutions. But there’s plenty of blame to go around. 

            That is, if anyone of influence is willing to listen to regular physicians and nurses, slogging through mountains of pain-scales and prescription requests, day after day, night after night. 

And sometimes, too many times, giving tragic news to the families of the dead, whose pill bottles lie empty at their bedsides.