A friend of mine is serving with this team. Keep them in your prayers, and consider donating or volunteering.
My column in the Winter 2017 Gray Matters, Newsletter of the Osher Lifelong Learning Institute at Furman University.
THE NEWSLETTER OF THE OSHER LIFELONG LEARNING INSTITUTE @ FURMAN
PAIN MANAGEMENT AND THE TIE TO ADDICTION – PART 2
Sometimes medicine offers us wonderful, almost unimaginable gifts. Heart attacks that were devastating, life-altering events a few short decades ago are now treated with an expediency and skill that our grandparents couldn’t imagine. A couple days pass, and the victim is home with stents in occluded arteries and directions to modify activity and diet. Pneumonia, once the ‘old person’s
friend’ (so called because it took the aged to eternity), is far less terrifying, thanks to both antibiotics and the pneumonia vaccine.
However, some of the things we do give benefits that are less clear. Although it could be an entire column in itself, the ‘stroke center’ movement, with the promise of miracles from ‘clot-busting drugs’, is a thing full of as many questions as answers. And what about depression and anti-depressants? When I looked up the side-effect profile of an anti-depressant a friend was taking, I was reminded that all of them have the potential side effect of increasing suicidal behavior.
But what about pain management? Thanks to improved understanding of the physiology of pain, the persistence of medical providers, and the investment and research of pharmaceutical companies, we have a wide array of pharmaceuticals available for the treatment of pain. Some are over-the-counter, like acetaminophen and ibuprofen. And others, those we refer to as narcotics or opioids (because in previous times they were derived from opium), are useful, potent, and (as is increasingly evident) fraught with danger unless used very cautiously.
Of course, for a very long time, physicians were taught to be judicious in prescribing narcotics. Our venerable teachers warned young doctors in training to be frightened of the side effects. We were especially aware of the very immediate danger that patients would stop breathing and die due to excess sedation. We were also aware that over time, patients on narcotics might develop problems with addiction.
About 20 to 25 years ago, that whole paradigm shifted and physicians were suddenly accused of callous disregard of suffering for prescribing too few narcotics. I remember this because I was in my emergency medicine residency at that time. We were constantly reminded to give more narcotics and be sensitive to pain. We were taught to use the ‘pain scale,’ in which a patient-reported score of zero meant no pain and a score of ten meant ‘the worst pain of your life.’ Never mind that it was entirely subjective and that there was no objective standard, no ‘painometer’ against which to measure it. We were instructed to see pain as the ‘fifth vital sign’ after blood pressure, pulse, respiratory rate and temperature. Of concern to many, these initiatives coincided with the development and aggressive marketing of ever more powerful, addictive medications like Oxycontin tablets and Fentanyl patches and lozenges.
Patient satisfaction surveys included the question ‘was your pain adequately treated?’ Physicians were castigated when those satisfaction survey scores fell. Physicians were instructed, by non-clinician
administrators, to give more pain medication to make patients more satisfied. (A satisfied customer/ patient is one that may come back!) Physicians who resisted, in the name of science or safety, were too often met with threats of reduced income or job loss if patient satisfaction scores fell. In some instances, physicians were (and still are) reported to state medical boards for alleged inadequate treatment of pain.
I sincerely believe that most of those encouraging us to write more narcotics prescriptions did so out of genuine concern and compassion. People are in pain, so why not treat the pain? In medicine, where science meets suffering humanity, it’s so easy for us to say, ‘Well, it just makes sense, doesn’t it?’ We assume that our compassion will be supported by our science. It happens with infections; sure it’s probably a head cold, but what’s the harm in an antibiotic to keep the patient happy? The child bumped her head pretty hard, so what’s the problem with a CT scan, even though she looks good? The parents are customers, after all, and want a scan!
With tragic consequences, our compassion sometimes causes harm as the Law of Unintended Consequences rears its ugly head. For instance, those antibiotics for colds? They can cause dangerous allergic reactions and life-changing intestinal infections requiring hospitalization or surgery, and resulting in death. Those CT scans everyone wants? Physicians are trying to reduce the number of scans, as many of us are concerned that they may induce malignant tumors later. And those pain medications? The evidence looks pretty damning.
Addiction to prescription narcotics is growing at a terrifying rate in the U.S. Likewise, death rates from narcotic overdoses have soared. The U.S. has seen 165,000 deaths from opioid overdose between 1999 and 2014. http://www.cdc.gov/drugoverdose/data/overdose.html. In fact, opioid-related deaths have now surpassed deaths from firearms in the United States. http://www.cbsnews.com/news/drug- overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/ Admittedly, some of those deaths are not due to prescription opioids but rather to injected heroin. However, many heroin addicts began their addiction issues when taking legitimately prescribed pain medication.
Sadly, seniors are not immune. Physicians don’t want to see seniors suffer, so they often give narcotics even for pain that in decades past would not have been treated with those drugs. We give them for back pain, headache, arthritis, or other less serious conditions. And we use them extensively in treatment of chronic, intractable pain. In fact, in 2015, one-third of Medicare recipients received a prescription for an opioid analgesic; some 40 million prescriptions. https://www.statnews.com/ 2016/06/22/many-opioid-prescriptions-seniors/
Furthermore, seniors not only develop addiction, not only die from accidental overdoses, their narcotic analgesics have a host of side-effects, including (but not limited to) the following: excessive sleep, impaired thinking, increased pain sensitivity, nausea, constipation, and cardiac arrhythmia. In addition, opioid drugs contribute to weakness and loss of balance and thus to falls, resulting in head and spine injury, various fractures, and other trauma. Their already impaired reflexes are dampened by their medication so that for those who still drive, it becomes an even more dangerous activity than before.
No one is immune from this devastating epidemic, not rich nor poor, not young nor old. The medical profession, the mental health community, law-enforcement, social services, churches, families, and friends all have to come together and find ways to roll back the rising tide of death and addiction, which came as an unforeseen outcome of attempting to ease suffering with compassion and science.
This problem will be highlighted this spring at an OLLI bonus event, March 31, 2017: Seniors and Opioids: Unexpected Origins of a Greenville Epidemic. I will be speaking in conjunction with James Campell of the Phoenix Center addiction and rehabilitation facility. We really hope you join us to learn more about this pressing public health crisis.
My column in the December issue of Emergency Medicine News. Merry Christmas to all and to all a good shift!
I remember the early trials of thrombolytics; not for stroke but for MI. During my residency we were still comparing tPA with Streptokinase. It was pretty incredible stuff. Now we’ve moved beyond that positively ‘medieval’ method of treating heart attacks and have advanced to incredible interventions in coronary and cerebrovascular disease. Furthermore, we are able to rescue more and more people from the brink of death with advanced medications and with techniques, like ECMO, that our medical forebears couldn’t even imagine. These days, people can say things like: ‘I had severe sepsis last year, but I recovered,’ or ‘A few years ago I nearly died of Stage 4 cancer, but here I am!’ Fifty years ago, twenty years ago, their families would have told their stories with sadness.
What we do is amazing. The science behind our saves, coupled with our training and passion, make medicine all but miraculous. I am proud of what I know, proud of what I do. I am so impressed with my colleagues. And I am often awestruck by the scientists and engineers, without whom we would be apes poking bodies with sticks (good-looking apes in scrubs, mind you).
If we could, at the end of our lives, look back at the gifts we gave to the sick and injured, we would see that they far outweigh our errors and mistakes, our losses and failures. And yet, for all our modern innovations, we have limits. We can ask and answer a constellation of questions, and we can fix untold numbers of problems. But there are questions that defy us, and problems that leave us shaking our heads.
In spite of our pride in science, and our common dismissal of all that is ‘unscientific,’ suffering remains, and we can’t answer why. Who knows this better than those of us who have dedicated ourselves to emergency care?
For all of our miraculous saves, men and women, boys and girls, still suffer horrible injuries and have cardiac arrests, fatal pulmonary emboli. They still die at the scene of car crashes. They still develop mental illness and kill themselves. Addiction still separates families and leaves parents weeping for children, lost from life or lost in the jungle of drugs and desperate lives.
Despite the extension of life we offer so many, even the healthiest men and women will, at some point, leave one another and pass away from this life. And, knowing this fact does nothing to ease the pain of the loss. The most ancient husband or wife still shudders and weeps with the loss of a spouse the way a newlywed would; perhaps more bitterly, knowing love more deeply at 85 than ever they did at 25. And yet, for all our scientific wonders, we can’t say what lies beyond this life.
What I’m saying is that for all our medical wonders, there are just questions we can’t answer, and things we can’t fix. And it is likely that our science, however wondrous, never will have that capacity.
We know it. It’s why we cry after failed resuscitations, and why we call our children when they travel, frantic to know they have arrived. It’s why every EMS tone terrifies the parents of teens and every scan of a loved one is terrifying to those of us in medicine. We can’t control the troubles of this life nearly as much as we think.
Mankind has always known this. Ancient physicians, as limited as they were, did their best and wanted more. They saw the dangers of this life, and their own incapacity, with what was likely more immediacy than we. And sick, injured humans have always known the fear of loss, the questions of suffering, the pain of death.
Into this ‘vail of tears’ we proceed every shift. This is why I often tell young physicians that they should read and understand more than medicine. I favor religious faith, natural to mankind as it is. But if they decline religion, they must have a philosophy. Or they should read great novels, stories, poetry; or reach into the depth of music for some kind of solace in this mess of the unknown.
But let me say this, now that December is here: Christmas comes to offer hope to the hopeless and answers to the hardest of questions. There are those of us who believe its message with all our broken hearts. But even those who find it a charming myth can surely see beauty in the story of God (however you perceive God to be) become man. God suffering with men and women and rescuing them. God come to give a hope of forever to humans trapped in mortality. This is especially poignant to those whose lives have been a succession of one devastating loss after another. It is comfort beyond medicine for them to believe in a God, come to forgive their wandering ways, answering them in the midst of their cutting, suicidal, self medicating cries for rescue. No pill is as good as God come to make every loss whole, and heal every pain in eternity. No resuscitation comparable to God come to die and defeat death.
The pain of this life is enormous. We try so hard, but we can do only so much. The manger in Bethlehem is, if nothing else, a beautiful story to remind us that just maybe, there is healing for the wounds that lie beyond our science. Perhaps the very dream that there is meaning, that there is hope, is a suggestion that there is more there, more here, than meets the eye.
And maybe, the manger is even more than a distant dream, more than a quaint bedtime story, glowing as it does in the chaotic night of human suffering that darkens our ER’s and trauma centers.
Dear physicians, PAs, NPs, nurses, medics, assorted therapists, techs and all the rest:
The great thing about our work is that we intervene and help people in their difficult, dire situations. We ease pain, we save lives. Our work is full of meaning and joy. However, we sometimes make mistakes. But remember, in the course of a career you’ll do far more good than any harm you may have caused.
I know this issue lingers in many hearts. I know it because it lies in mine. And I’ve seen it in other lives. I said this once to a group of young residents and one young woman burst into tears. I never knew the whole story, but I imagine there was some burden of pain she was carrying for an error she had made.
But just in case you too have lingering anxiety or guilt about some error you made in patient care, I feel it necessary to say this: neither honest errors nor even malpractice are sins. They are mistakes, born of confusing situations, fatigue, inadequate experience or knowledge, overwhelming situations, the complexity of disease and the human body, social situations, systems problems, general chaos. Born of your own humanity and frailty. Your ‘shocking’ inability to be perfect at all times, and in all situations. They do not make you evil, bad, stupid or even unqualified. (PS If you’re not actually a physician but pretending to be one, you’re actually unqualified so stop it.)
As a Christian physician I have contemplated this over and over and have come to the conclusion that God knows my inadequacies and loves, and accepts me, regardless. He has forgiven my sins. I embrace that reality every day. He forgives my pride, anger, sloth, greed, lust, all of them. But he doesn’t have to forgive my honest errors. Because they are not sins. Go back and read that again. Your honest errors are not sins.
Mind you, all of the brokenness of this world is, in my theology, the result of ‘Sin’ with a capital S. (Not in the sense of minute, exacting moral rules, but in the sense of the cosmic separation of the creation from the Creator.)
So, my mistakes, my failures are born of Sin, but are not ‘sins.’ If my mistakes, if the harm I may cause, come from rage, vindictiveness, cruelty, gross negligence, murder, drunkenness or other impairment on the job, then they could reasonably be due to ‘sin.’ But even so, those sins can be forgiven, and washed away with confession and true repentance. (Not platitudes or superficial admissions of guilt, mind you, but genuine heart felt ‘metanoia,’ the Greek for repentance, which means ‘to change direction, or change one’s mind.’)
If you are not a believer, join us! But if you aren’t interested, I love you too and want you to move forward, not burdened by unnecessary guilt. If you are a believer, and a practitioner, remember that Jesus (The Great Physician) set the bar pretty high and doesn’t expect your perfection, only your honest, loving best.
Mistakes, even mistakes that rise to malpractice, are not sins. But even if they rise to sin for reasons listed above, they are no worse than any other. Which means Jesus atoned for them as well.
Move forward in joy. You were forgiven before you even started worrying about it.
Now go see a patient. The waiting room is full of people who need you!
What do you mean it’s a cold?
A poem for viral illness season.
Fever, cough and runny nose,
Muscle aches from head to toes,
Scratchy throat and stuffy ears,
Doctor, please allay my fears!
Can’t I get some Zithromax?
Lortab for my aching back?
Maybe just Amoxicillin,
For my stuffy, whiny children?
You say virus I, but I’m dying;
Surely there ain’t no denying,
What I have is devastating,
And I spent an hour waiting!
Hook me up and make me better,
Else I’ll write your boss a letter;
Don’t you tell me ‘it’s a cold,’
That tired line is getting old.
I know it must be bronchitis,
Strep throat, Zika, meningitis!
I require a strong prescription
For my horrible condition!
Cipro, Doxy, Levaquin
That’s what someone gave my friend,
After two weeks they felt well
So why should I endure this hell?
Please throw in a week off work,
Percocet’s an added perk,
My tolerance for pain is high,
But I am just about to cry!
What, I don’t get any meds?
Drink some fluid, go to bed?
Are you crazy, are you cruel?
I think you’re a quack, a fool!
I’ll go home but I may sue
Everyone, especially you.
I don’t need this here abuse…
Fine, now what about that work excuse?
Some dear friends of mine, at Busy Community Hospital, are having a momentous day. Today is the ‘Go-Live’ for their brand new, shiny EPIC EMR.
For those of you outside the hallowed, creaky halls of medicine, EPIC is one of the most widely used electronic medical records systems in America. It’s big, it’s expensive, it captures lots of data, integrates ER’s, hospitals, clinics, labs and everything else. (Probably your cat’s shot records too.)
EPIC is also a company highly connected to the current administration; big donors to the President. FYI.
The problem isn’t what you get out of it, it’s the cumbersome way you have to put it in. In my opinion, for what that’s worth, EPIC is not intuitive. It takes a long time to learn to use it well. I have never used it in a situation where it could be fully customized, but I’m told that makes it easier. And admittedly, some docs and nurses truly love EPIC and are at peace with it. I suspect they have implanted brain chips or have undergone some brain-washing.
Typically EPIC instruction occurs over weeks, as it has for my friends. The first time I used it was in a busy urgent care, which was part of a large medical system. And I learned it over one hour. On the Go-Live day. So I’m sympathetic.
Thus, I have a prayer for those in the belly of the beast right now:
A Go-Live Prayer for those with new EMR systems.
Lord, maker of electrons and human brains, help us as we use this computer system, which You, Sovereign over the Universe, clearly saw coming and didn’t stop.
Thank you that suffering draws us to you.
Thank you for jobs, even on bad days.
Forgive us for the unnecessarily profane things we have said, or will say, about this process.
As we go forward, we implore you:
Let our tech support fly to us on wings of eagles and know what to do.
May our passwords and logons be up to date.
Protect us from the dreaded ‘Ticket’ submitted to help us.
May our data be saved, not lost.
Let the things we order be the things we have.
Shield us from power loss, power surge, virus and idiots tinkering with the system.
Give our patients patience to understand why everything takes three hours longer.
And may our prescriptions actually go to the pharmacy.
Keep us from rage and tirades.
Protect the screens from our angry fists.
May everyone go home no more than two or three hours late.
And keep our patients, and sanity, intact.
Great physician, great programmer, heal our computers.
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.
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.
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.
Ah, EMTALA! The revered ‘Emergency Medical Treatment and Active Labor Act!’ It’s one of those things which is like a nursery rhyme to emergency medicine folks like me. We’ve heard about it from the infancy of our training. ‘And then the bad doctor sent the poor lady to another hospital because she couldn’t pay! And the King came and crucified him for doing it!’ The end.
EMTALA, for the uninitiated, is a federal law which ensures that we don’t turn people away from the ER because of finances, and also keeps us from transferring people to other hospitals without that hospital’s agreement. It also exists to guarantee that we stabilize them as much as possible before they go.
I’ve said before, and always will, it was a good idea. But like many laws, it was subject to the law of unintended consequences. For instance, being forced to see lots and lots of people (who may not really be that sick), and do it for free, has huffed, and puffed and blown the hospital and trauma center down on too many occasions. But that’s not my point here.
My point is that when EMTALA forms meet electronic medical records, chaos can ensue.
Allow me to illustrate: This is a standard EMTALA form. Check, check, check, sign. It takes a busy physician less than a minute, and the nurses a few more since they have to call the other hospital and record times, etc. This has worked well for a very, very long time.
Enter EMR. This is the procedure for doing an EMTALA form at Tiny Memorial Hospital, which has been enchanted by the dark Lord Cerner. Mind you, I’m sure the ‘powers that be’ feel that this is a perfectly wonderful way to do the form. Indeed, it captures lots of information and stores it in the system. But two facts remain: first, the people who designed the system generally work at Large Urban Hospital, which owns Tiny Memorial. They don’t transfer things out very often. They receive things. Second, most of the patients being transferred are going within the system. All the data is on the EMR, and it isn’t as if they’re going to some strange facility far, far away.
This, children, is the EMR based procedure (on a cheat sheet developed by a frustrated and confused provider):
Not long ago my team worked a cardiac arrest at Tiny Memorial, with a successful return of cardiac activity. Given our size and staffing, it took pretty much all of the staff available and nothing moved for a while. A helicopter whisked our patient away.
Of all the things we did; drag her out of the car, do CPR, start IV’s, intubate, talk with family, chart, arrange transfer, nothing was as complicated or frustrating as this process to complete the EMTALA form. In the end, I still got it wrong somehow.
Mind you, I never violated the spirit of the law in any way. She was treated, stabilized (to the extent of our ability) and sent away to a receiving hospital with the capacity to care for her.
I don’t want to impugn the motives of those who developed this. I’m sure they were trying their best. But if you don’t use it, you can’t see how hard it is. And you also can’t see how much time it takes in a place with limited resources and staff.
So please, folks, let’s use technology to simplify, not make things more complicated! And let’s remember that charting isn’t the same as doing the right thing. And sometimes, doing the right thing isn’t perfectly reflected in the chart.
But paper or electrons, it’s still the right thing. And that’s what EMTALA is about.
Dear reader and locums travelers, past, present or future. These are the four columns I have recently written for Emergency Medicine News as a series about locums emergency medicine. For now, rather than post the entire text of each, or put them in four separate posts, I am lumping them together for your ease.
I hope you find this helpful!