Agraphia Medical Tragicomedy

7Jan/1410

Righteous outrage

I came across this blog post recently by a retired surgical chair who is pretty upset with a court case about an emergency physician.

Here's the short and outraged version: a man is found during a routine traffic stop to have marijuana in the car. He's taken to jail, doesn't comply with the officer's questions, then barricades himself in the interview room. They proceed to violate all of his 4th amendment rights by strip searching him, but don't find anything. Then they cart him off to the Emergency Department for a forcible cavity search. They have an ER doctor who has done a few rectal exams for them before, so he decides to aid the police, and follows their orders. He's unsuccessful, so he sedates the guy against his will, intubates, and puts him on the ventilator all for a rectal exam ... then the doc pulls a 5.7 gram rock of crack cocaine out of his rectum, and turns it over as evidence.

People are demonizing the physician for forcing this poor man to undergo a "warrantless search" and being a "tool of law enforcement." What I find so frustrating is how quickly people decry the actions of this emergency doc - and assume that law enforcement was just out to make an unconstitutional bust. In my mind, this is a medical case, not a legal one.

Why? Because here's how I can retell the story. Bear with me for just a moment, and assume that the doctor and the police are good people trying to do the right thing. Also, read the actual court case.

A man is pulled over with expired tags. He consents to a search of his car, but his passenger, Felix Booker, is really bugging out and making the officer nervous. The officer actually recognizes Booker; he's taken drug-deal quantities of marijuana from him before. The officer finds marijuana and a "powdery substance" in the car and brings Booker in. At this point, this guy really starts losing it. He barricades himself in the interview room - not a normal thing to do - and starts acting crazier and crazier. There are several physical altercations with police. He keeps clenching his buttocks and trying to use his hands to stuff something further up his rectum. What he's doing is so obvious that the officers actually re-cuff him with his hands in front so he can't reach in back. They strip search him and see a string hanging out. In conjunction with the white powder in the car, they figure this might be a medical emergency.

So, imagine you're Dr. LaPaglia. Police bring you a guy that is acting so crazy he's naked and strapped to a chair, and the officers tell you they brought him in on a drug bust with $1,700 in cash in his pocket. They found a white powder in the car, and now he keeps trying to reach around to shove something further up his rectum. Remember - it is not normal for someone to be so agitated that you have to strap them down. Most normal people calmly and politely ask you to take the restraints off and apologize for all the confusion.

Booker is acting crazy enough you suspect it's either cocaine or PCP in his rectum. Who knows, maybe he's been dipping wet or doing bath salts. The concern is, if he's a known drug dealer, has a bunch of cocaine stuffed in his rectum and he's already this agitated, his baggie may have ripped and now is leaking high-grade cocaine directly into his GI tract. Just like a lot of Emergency Medicine, you cannot know what it is until you take it out; it's Schrödinger's baggie. Then the cops tell you there is a string hanging from his rectum. It's pretty clear you need to get it out.

Your patient actually agrees to let you do a rectal exam, but even after giving him 10mcg of Versed you can't retrieve the baggie - which you now know is there because you can feel it - and the only real way to get it past his anal sphincter is to paralyze him. Is this a medical emergency? Absolutely. If it leaks and he dies, it is your fault. This is a classic toxicology scenario, and that baggie might be a ticking time bomb. So, you sedate and paralyze him, pull the baggie out and... sure enough, you pull out a 5.7 gram rock of crack cocaine. Congratulations, you're a hero! You just saved this man's life. Then you get hit with a lawsuit.

Now, I don't know which version of the story is correct. I'm sure there is truth to both. From what I can tell, the court ruling is still in appeals. I don't have the benefit of seeing the medical record. That said, I have been in situations similar to this more times than I can count. People do drugs, and some people do so many drugs that we need to intubate them for the staff's safety and for their own. We don't like to do it, but I have seen people tear through bed restraints, spit HIV+ and HepC+ bloody saliva at nurses and police, and bash their heads against the wall until they bleed. I've been kicked and punched. We routinely find knives and guns in our metal detectors. If you don't think it's scary to deal with someone who is high on cocaine/PCP/wet/bath salts in the ED, you have never been in the situation. It is one of the few things that still makes me nervous.

It is really easy to armchair quarterback this story and to get all upset about how this man's rights were violated. A lot of the court brief centers around Booker's "consent" to the rectal exam but not to the intubation. This is a very difficult, murky area, especially in the heat of the moment. To the best of my knowledge, if the patient is altered, they no longer are capable of refusing consent. You as their physician must act in their best interest. It seems to me that there was no other way of getting the cocaine out of this guy, and that the doctor had enough reasonable suspicion that it was medically indicated.

Not having been there in the moment, I really can't say. On the flip side, if that cocaine was left in Booker and Dr. LaPaglia refused to do the rectal exam - and Booker died in police custody from a cocaine overdose - well, then there would be an entirely different court case.

And there would be a whole lot of fingers pointing at Dr. LaPaglia then.

11Aug/138

(I Can’t Get No) Satisfaction

My resident told me today that he was planning on giving antibiotics to a kid with a fever. I asked him where the fever was coming from - he said he didn't see anything on the exam, but the parents were pretty insistent that the kid needed antibiotics, and he was tired of arguing. "Plus," he added, "it's good for patient satisfaction scores."

Bringing up patient satisfaction scores as justification for unwarranted treatment is a great way to earn my disapproval as an attending.

I popped into the room and saw a happy, healthy, smiling 5 year old pulling all the paper towels from the dispenser. He ran over to the door, gave me a high-five/low-five/fist bump combo, and then asked me when he was able to go home and watch cartoons. I did an exam which revealed absolutely nothing abnormal. The mom looked at me askance as I began to explain that her kid did not, in fact, need antibiotics.

"But he's got a fever," she said, "every time he has a fever my pediatrician puts him on antibiotics. My child needs antibiotics!"

Over the years, I've gotten very good at having this conversation with parents. Usually they leave the ER happy and reassured that their child looks healthy and well, with the understanding that antibiotics will make no difference - and in fact, may cause harm, predisposing their child to vomiting, diarrhea, allergic reactions, and resistant bacterial infections. In this case, mom was having none of it. There was no way she was leaving happy without antibiotics.

And so, in the end, she left - but unhappy, and without antibiotics.

I had a sit-down discussion with the resident afterward. Patient satisfaction scores have become increasingly important in recent years. Physician compensation is often directly tied to percentile ranking on these scoring systems. At one hospital I worked in, the patient satisfaction score was a 20% "bonus" to the yearly salary. Put in other terms - I could be personally at risk at losing $20,000 for every $100,000 I'm supposed to make.

If you think this doesn't change physician behavior, you're wrong. Emergency Physicians have something of a gallows humor about the whole idea - we have addicts that come in, needing their fix... and when we don't give it to them, our "satisfaction scores" go down. The same, however, is broadly generalizable to a vast swath of ER patients who want something. Sure, the easiest example is the drug seeker, but people come to the ER seeking just about anything; from antibiotics, to sandwiches, to MRI's. One famous patient last year used to come to the ER on a weekly basis asking for a male physician to perform a pelvic exam.

In the end, I feel very strongly that it is my duty as a physician to take care of my patients, and to me it supersedes my salary. It has become somewhat of a mantra for me and the residents lately, "Give your patients what they need, not what they want." I've spent tens of thousands of hours studying medicine and seeing patients. I've seen countless kids with fevers, including ones that are truly sick. Just because mom's doddering old pediatrician hands out pre-printed, pre-signed Amoxicillin prescriptions at the slightest hint of a fever... well, it doesn't mean I will.

This is an Emergency Department, not a Convenience Department. As an aside, my patient satisfaction scores are excellent. I'm chalking this mom up as an outlier.

8Jun/1326

How To Fix The Prescription Drug Problem

As I am wont to do lately, I've been thinking an awful lot about prescription drug abuse.  My last shift, I saw a guy who got in two car wrecks in the space of a few hours while taking his 2mg prescription Xanax "bars" six times a day as prescribed.  I saw a woman with over 300 prescriptions (each of which contained 30-120 individual pills) for opiates and benzos in the past 3 years from around 40 different doctors.  Another woman lamented that she ran out of pain meds just in time for the weekend, and her primary doctor wasn't going to give her "Roxi 30's like I asked for" - street slang for oxycodone 30mg, the highest-value street drug currently on the market.

I've said it before, and I'll say it again.  Prescription drug abuse in this country is a massive issue.  There were over 16,000 fatal overdoses in 2010 and the number continues to rise.  More people are dying from overdose than from car wrecks in some states.  While I care about alcohol abuse and illicit substances to a lesser degree, I'm fixated on prescription abuse because it is preventable.  One source states that the USA uses 80% of the world's opiate supply and 99% of the world's hydrocodone.

There are several issues at play.  One is that no physician wants to be confrontational if they don't have to.  I think ER docs do it by necessity, but primary care doctors can't afford to antagonize their patients - and thus, jeopardize their revenue stream.  When someone comes in and has been on Xanax three times a day for the last 10 years, you throw up your hands and write the script plus refills.

This particular behavior needs to stop.  We ER docs see the overflow from the primary care physicians, the psychiatrists, and the dentists who turn into unwilling pill mills.  As long as there is no oversight, this will continue.   Aside from the nebulous concept of "doing the right thing", there is no reason for any individual provider to wean patients off these meds.  In fact, the opposite is true - patients would simply leave your practice and go to another provider who will give them their fix.

I believe the solution lies with the state medical licensing board.  Here's my plan.

  1. The state board sends all physicians an alert "Your license may be in jeopardy!  Statewide, physicians must come up with a plan to wean all of their patients off prescription opiate medications and benzodiazepines, unless there is a documented and valid reason to keep doing so.  You have 1 year to comply."
  2. At the six month mark, remind physicians that they are coming up on the deadline. Give them a progress report.
  3. At the year, patients on chronic Xanax, Klonopin, Ativan, Valium, Percocet, Oxycodone, Vicodin etc have all had this discussion with their primary doctor "The government is cracking down on physician controlled substance licenses.  Neither myself nor other physicians can prescribe controlled substances on a recurrent basis any more."
  4. Any physicians not playing ball get 3 notices, then lose their controlled substance license.
  5. The end goal is to have meds prescribed as intended, with short courses written for acutely painful or stressful episodes.  Long-term opiate management would be tightly restricted to the setting of cancer, fractures, and a few other conditions.  Long-term benzo use should be flat outlawed.

I'd love to hear your thoughts.  Soon here I'm thinking of marching on Capitol Hill.

24May/1323

An Argument Against The Poppy Seed

I know I talk a lot lately about drug seeking.  A large part of this is that I work as the community ER doctor in a small town rife with opiate and benzodiazepine addiction. It's a massive issue.

During one particularly miserable shift, I decided to catalog the degree of drug seeking behavior. I saw 25 patients.  Of those, 15 had presented to the ER for overuse of opiates. These split into three categories:

  1. Chronically on massive doses, now with new pain - one woman in particular had been prescribed around 3,000 pills in the last 12 months and "needed something stronger than her OxyContin."
  2. Came in by EMS not breathing due to an opiate overdose.
  3. Doctor shopping for narcotics, with over 2 ER visits a month for pain meds.  One patient had been seen 175 times in an ER over 5 years without ever having been to her primary care doctor, divvying up visits between local ER's so none would be the wiser.

Let us pause for a moment.  15 patients out of 25 is 60%.  That is a staggeringly high percentage of patients whose primary reason for an ER visit is related to overuse of opiates.

That night has influenced my medical practice quite a bit.  I've started to think about appropriate patient care in terms of what I would need in the same situation.  Bruise to the shoulder?  Maybe some tylenol or motrin, and a careful exam to make sure I didn't break anything.  Sprained ankle?  Ice packs and naproxen.

The truth is, my little community is plagued by addiction, which wouldn't exist without physicians to fuel it.  Patients refer to their thrice-daily Xanax dose as "footballs" or "bars". They say that they need their "hydro 10's" or "perc 10's" to get through the day - slang for hydrocodone 10/325 and oxycodone 10/325.  Inevitably they've used more than prescribed.  I look most of my patients up on our controlled substance database and I'm never surprised to find ten, twenty, thirty prescriptions for controlled substances from various physicians over the past few months.

This brings me to a case that stands out in my mind.

I had a young woman a few weeks ago who came in with excruciating leg pain.  She looked absolutely miserable, rolling around in the bed, screaming obscenities.  I finally managed to convince her to keep the "FUCKS" and "SHITS" to a minimum since she was sharing a room with a 6 year old child who looked absolutely terrified.

She was incredibly upset when I didn't provide her with pain relief - specifically in the form of intravenous Dilaudid.  Even for an ER doctor who deals with this on a daily basis, it was worse than usual.  At one point she said "it really sucks that there are drug seekers in this world. You aren't giving me pain relief because of them, and I'm a normal person.  I can't believe how jaded you've become.  You're a bad doctor."

Her controlled substance search didn't turn up much, but I still got the sense that there was something not quite right here.  I chose to give her non-narcotic pain medications.  She threw a string of curses at me when she found out.

It is hard to explain the hurt I experience in a situation like this.  I'm a nice person. I went to medical school to help people.  Given a normal patient, I will bend over backwards and do everything in my power to diagnose and treat illness and pain. At the same time, "help" does not mean "give you your drug fix".  Implying that I'm witholding pain relief just because I'm a jaded, bad ER doctor cuts down to my core.

I ended up apologizing for my inability to prescribe the Dilaudid and Percocet 10/325's that she so desperately wanted.  She left cursing my name, stating that if she had to, she would "get relief on the streets". It left a sick feeling in the pit of my stomach.

A week afterwards, I reviewed her chart.  She had been seen by one of my partners for a nearly fatal overdose.  Apparently she was living in a commune with a bunch of drug addicts and overdosed on narcotics.  The reason she didn't show up on my controlled substance database on that first visit is that heroin isn't something we prescribe.

I've wrestled with her case since then.  I know that in the end I did the right thing because I trusted my instincts.  Still, the accusation and the hatred in her eyes haunts me.

"I can't believe how jaded you've become."

"You're a bad doctor."

But I did the right thing.

Filed under: Best Of, Medicine 23 Comments
29Mar/130

Ripping It Up

One of my favorite things is when patients rip up a prescription - it's just such an unnecessary, childish action. Usually it goes something like this:

Patient: "I need purpleset tens for my back pain. My doctor is out of town."
Me: "That's Percocet, and the fact that you abbreviate the dose 10/325 as 'tens' makes me concerned that you're far too familiar with this medication. We're going to give you some Tylenol today."
Patient: "I can't take Tylenol."
Me: "You know there is Tylenol in Percocet, right? That's the 325. It stands for 325 milligrams of Tylenol."
Patient: "Its a different kind of Tylenol. You don't understand."
Me (sighing): "I know.  These medical degrees, they hand them out like flyers these days, don't they? Doctors just don't understand medications like they used to."

I routinely write prescriptions for Motrin and Tylenol for patients. I'm not trying to be snarky or insulting - I truly want them to take those medications on a scheduled basis for their pain. They may not be prescription-only, but countless studies have shown that they are effective and are an integral part of therapy.  I also write Sudafed prescriptions for sinusitis and otitis, and Prilosec prescriptions for heartburn.  Both of those medications are over the counter, but patients may not know when and how to use them appropriately.

For this patient, though, there is one thing he wants from his ER visit  - opiates. His body has gotten completely hooked on that sweet candy, and when he runs out and start jonesing badly enough... he comes to me.

What drug seekers want is multifactorial.  I've sat down and talked to these guys occasionally and asked them what their gain is.  They hate coming to the ER for the small 12 pill score they might get from us if lucky.  What they really want is to find someone who is going to fund the habit; hopefully a doddering old primary care doc who is loose with his script pads.  From him they can score 120 oxycontins with another 120 morphine sulfate tabs - doses that DWARF what we give from the ER.  We're merely the safety net when their score doesn't come through.

And so, my little Tylenol script tends to make them upset. I've seen more of these ripped up, thrown on the ground, and stomped on in a pique of rage than I care to.  One guy even accidentally ripped up a prescription for Vicodin along with the Motrin prescription I gave him. This will come as a shock, dear readers... but I did not reprint the script for Vicodin.

27Mar/134

The Patient Satisfaction Dilemma

I saw an exceptionally malignant patient with back pain a few days ago.  Readers who work in an ER know exactly what I mean just from that statement; for my lay readers, let me try to paint a picture.  He was a 50-something, shabbily dressed guy in somewhat of a constant state of disrepair.  There was a musty odor of tobacco about him, and when the nurse entered the room he sneered "Oh, there you are.  So there IS someone actually attending patient needs today.  Get me a damn soda, I'm thirsty."  He had been triaged, registered, and taken to a room within 25 minutes of arrival.  His wife piped in, "Make it a Coke for him and a Mountain Dew for me.  We don't do Diet."

I walked in the room to a hostile environment.   His wife was tapping her foot on the floor impatiently, lips pursed, and apparently we were fresh out of Mountain Dew.  He had his arms crossed and began to lay into me before I could say a word.

"I want an MRI.  I hurt my back lifting something a couple hours ago, I've had a bulging disk before, and I've been waiting now for the better part of 30 minutes to see ANYBODY who is competent around here."

I took a mental breath, calmed the raging inner demons, and introduced myself.  I apologized for not seeing him earlier as I had been performing CPR in another room and broke away just as soon as I was free.

I'll cut the story short here and get to the chase.  He left the ER with a diagnosis of back sprain sans MRI, shouting at staff, extremely angry... but it was clear from our first interaction that this was inevitable.  Interestingly, he didn't come to the ER for pain control - he came because he wanted an MRI, and was livid that I wouldn't give him what he wanted.

This gets to the crux of the matter at hand.  There has been a rising emphasis on patient autonomy in medicine, a deliberate shift from the paternalistic attitudes of physicians of old.  It is one of the four central "pillars" of medical ethics; Autonomy, Beneficence, Non-Maleficence, and Justice.  Most of the time, it is a good thing.  I involve patients and family members on their medical decision making as often as possible.  If I'm waffling about admitting a patient to the hospital, I'll ask them, "do you feel comfortable going home tonight?  We can try home therapy first and you can always come back if you aren't doing well."  I am often surprised by how adept patients are about making these decisions for themselves.

There is, however, a group of patients we'll call Generation WebMD, who think that 5 minutes of Googling has given them a provisional electronic doctorate.  This guy got it into his head that he wanted - no, needed - an MRI to diagnose his back sprain and wouldn't take no for an answer.

A scenario like this plays out every minute of every day in every ER across the country.  I have had furious mothers physically escorted from the premises by security guards over whether or not their child should get antibiotics for a cold.  Drug seekers have thumbed their switchblades at me when I inform them I will not be providing them with their fix.  One of our regular COPD patients has a strict "only three breathing treatments per day" policy to prevent him from overstaying his welcome, happily puffing on albuterol while lighting cigarettes and tampering with the smoke detector.

It's a huge issue.  Physician reimbursement nowadays is often linked to patient satisfaction scores.  Physicians at a neighboring ER, for example, have 25% of their entire salary directly tied to phone surveys.  That's a huge incentive to make sure people are happy - and people are happy when they get what they want.  Unfortunately, what people want when they come into a medical setting is often not what they need.

Here's the thing.  If all you do is constantly acquiesce to patient demands to make them happy... well, you aren't really a doctor, are you?  You're just a puppet medical license with a DEA number for hire.

I got into a huge argument with a woman a few weeks ago about antibiotics for two days of sinus pain.  She started screaming so loudly at me that a police officer walking down the hall peeked his head in.  She finally asked me a simple question, "JESUS, doc, why are you being so damn obstructionist about this?  All I want is some fucking AMOXICILLIN for my sinusitis!  It has worked EVERY OTHER TIME. It's not like I'm asking for a prescription for medical marijuana!  WHAT IS THE HARM?"

I've thought a lot about her in the past few weeks.   Every single patient I have seen dying of multidrug resistant bacteria, every news article I see about superbug TB, every case of clostridia difficile colitis - I have mentally told her, "This.  This is the harm.  The harm comes in physicians prescribing things that aren't needed, doing tests that aren't indicated, giving therapy just to say we did.  One day we will look back from the brink and realize we should have been more careful."

I could go on, but I've made my point.  It is so easy to roll over and give people what they want.  I fight this temptation every single shift.  Mom wants amoxicillin for her kid's "ear infection".  Guy wants Vicodin for back pain.  Family wants me to "do everything" for the 95 year old demented nursing patient.

With a click of a button I can easily do all these things, even when I know I shouldn't.  And I'll get paid more.  And I'll avoid lawsuits.  And my patient interactions will be far more pleasant.  I suppose in the end, I try to do the right thing instead of the easy thing because I firmly believe that my duty is to take care of my patients.

And sometimes, despite violent opposition, that means simply saying no.

24Mar/133

Diversion

In our little community hospital, opiate addiction is rampant.

It is a well-known problem among the ER crew.  The majority of our county is cared for by around 20 primary care doctors, and most of them are pretty sharp.  There are a few, though, who are pill pushers.  These guys contribute massively to our opiate problem, and on nights and weekends, the ER gets stuck with the flack.

A middle aged woman came in last night for a chief complaint of "back pain".  Just as a protip to you nascent drug-seekers out there - if you want opiates from from an ER doc, don't use back pain as your excuse.  Every single ER physician in the country has an immediate, gut reaction when they see "back pain" as a chief complaint on the tracking board.  Burned too many times, perhaps.

Walking into her room, I couldn't help but raise an eyebrow.  4'2", 280 lb, stretched out on the bed with her arms and legs askew, she looked frankly comical.  She was playing a part, perhaps one she had seen on TV of the patient in distress.  It didn't help that she was completely calm before I walked through the door, but started moaning and shouting when she realized someone had come to see her.

Her: "Aaaoohhhhh, my back!  It's my back, doc!   I need Percocet!  Awwwwoooohhh!"

Me: "And it's nice to meet you also, ma'am.  My name is Dr. Zac.  What brought you in today?"

Her: "AAAaaaahhh!  I fell... a week... two weeks (here she becomes short of breath)... maybe a month... ago... at Wal-Mart.  I can't WALK!  I haven't been able... to WALK! For MONTHS!"

Me: "Sounds miserable.  What have you taken for pain at home?"

Her: "I don't got... I don't got nothing but Tylenol and that ain't TOUCHING the pain!"

In my state we are extremely fortunate to have a scheduled drug database search.  Not all physicians in all states are so lucky.   To be honest, it has been a complete eye-opener for me in some cases - I had no idea how serious the opiate prescription/diversion/overuse problem was until I started really looking some of our patients up.  In this particular case, she had 120 Vicodin prescribed to her 7 days earlier, but neglected to mention this to me.  I went back in her room after looking it up.

Me: "Ma'am, what exactly happened to the Vicodins you filled from Rite-Aid last Wednesday?"

Her (sheepish): "What?"

Me: "The Vicodins.  Where are they?  You're in the ER, asking for pain medications, after getting 120 pills 7 days ago.  By my count, that is 40 grams of Tylenol - along with the opiates - that you've ingested in a week.  If you've taken all those pills, you may have serious liver damage.  What happened to all those pills?"

For lack of a better phrase, she immediately sobers up.  The antics, the capering, it all stops.  Suddenly the truth comes out.

Her: "Well... I'm behind on rent."

Me: "And?"

Her: "I sell my pills every month to my grandkids.  It nets me a few hundred so I can pay my bills, but I had a bad water leak this month and had to pay out of pocket for a plumber.  I'm sorry, doc.  I'm on fixed income and this is the only way I know to support myself."

I'm not used to this kind of honesty from patients.  Some of it is that recently, I've been more comfortable asking patients about their medical misadventures.  As a medical student and resident I was somewhat more reticent.  Nowadays, someone with 20+ ER visits in the last year, each with an end-goal of obtaining Vicodin or Percocet?   You need to see a doctor who can manage your pain - or your addiction.  I'm happy to refer you to detox if needed, but I won't add fuel to the flame.

Frankly, I felt guilty reporting her to her primary care physician, although I knew it had to be done.  Opiate overdoses have tripled since 1990. This cannot happen without the help of prescribing physicians.  I shudder to think of what her grandchildren were doing with 120 Vicodin per month.  Who knows, maybe her family doc would have stayed blissfuly ignorant for years, blindly supplying the kids of our county with Vicodin for their parties... and my patient would have kept her apartment.

These decisions, they give me grey hairs.  Not because I made the wrong choice, but because I never knew this sort of thing existed in the world until I started this job.

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18Mar/1316

Burnout On Its Way Down

I had a moment today where I caught a piece of my own personal burnout on its way down.

The longer I do this job, the more I really appreciate the nice, normal person that comes to the ER for an honest complaint.  They are unfortunately, shockingly rare, but they command a premium of my attention because I believe that there is potentially real disease.

In this case it was a 22 year old, well dressed, well groomed female who came in with a chief complaint of "toothache."  Normally this is enough to make every ER doctor groan - all these patients want are pain medications because we can't pull the tooth for them.  It's miserable.  We get used for vicodin scripts and mysteriously the "dentist appointment" they have in "4 days" doesn't materialize.  They come back the next friday and repeat the cycle.

This patient, however, was one of the rare cases of someone who has never been seen in the ER before.  No drugs show up on her list.  Well dressed, in college, very polite during the exam.  She had a massive, new dental cavity that was just killing her.  The rest of her teeth were impeccably taken care of.   It was Saturday night, she had called her dentist Friday afternoon, and had an appointment set for Monday.

This same story gets told verbatim thousands of times in ER's across the country; the weekend visit, the soon-but-not-soon-enough dentist, the tylenol-isn't-touching-the-pain... but the context sets the stage. Does the patient look jittery, like they're withdrawing from their habituated opiate dose?  Am I their last bastion for some Vicodins before they can get in touch with their drug dealer in the morning?  Is it a kindly grandmother with threadbare clothes and no physical signs of disease, looking to supplement her medicare by selling Percocets to her grandkids' friends?  All of these happen, more frequently than you want to believe.

In this situation, there is a degree of mistrust towards patients, because all of the above scenarios are not uncommon.  We physicians want to help people.  We start out in this field with trust and honor and caring, but then it takes one patient, with one believable story, one time, to sucker you in. In this case, my patient. My wholesome college toothache came back the next day as a mixed vicodin/xanax/cocaine/alcohol overdose and I realize I got played.  And not just that I got played, but that I gave her that last drug to her overdose cocktail because I was too trusting and its now my fault she is sick.  The worst part is, the nurses who were more jaded than me raised an eyebrow when I said I thought she was "legitimate."  I fought for her against the rest of the ER staff.  I convinced them she needed pain relief.

So I see something like this, and I resolve that the next time, I won't get played.  Even if they look honest, people with a toothache can grit it out until they see their dentist.   They may not have dental insurance, they may not have the money to scrape together for anything more than dinner at Jack 'n The Box, but until they pay the $500 to get their root canal, they can tough it out with Tylenol.

It's a catch-22, really.  In this field you have to learn to spot the liars, call them out, and then act on your intuition.  My hope is to avoid being jaded but to entertain a healthy skepticism.  On the liberal pain relief side you contribute to the opiate overdoses that are plaguing our nation.  On the other you miss actually caring for those that need it.  There is no good answer.

This is how you wear down a person who cares too much, one plausible story at a time.

6Mar/133

My mom

A totally healthy 18 year old kid just came in with his 32-year old mother. She was worried that he "wasn't feeling all that well" this morning and didn't want to wake up.
 
Me: "Any chest pain?"
Him: "Nope."
Me: "Shortness of breath?"
Him: "Nope."
Me: "Nausea?  Coughing?  Weakness?  Headache?  Fevers?  Pain?"
Him: "... nope." 
Me:  "So what brought you in to the Emergency Department, exactly?"
Him: "My mom."
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13Feb/1311

Sea Change

So, I'm leaving the private practice world.

It feels good to say.  No, it feels GREAT to say.  I'm going back to academic medicine... massive pay cut, terrified medical students, new residents, the whole 9.  I can't wait.

This year has been transformative for me. Working out in a private ER is so different from academic medicine they might as well be two ends of the same beast. I'll really miss this place.  The nursing staff is fantastic.  The money, equally so.  My colleagues, uniformly, have been incredible to work with - supportive, intelligent, no-nonsense.

The problem is, I've never been able to internalize the feeling that I've "arrived."  Private practice in many ways is the culmination of everything.  K-12, college, medical school, residency... it has been school for 24 years if you count it all up.  Then suddenly you graduate from residency and they tell you you've made it.  You're ready to do things on your own.  No supervision!  You're an adult!  You know everything!

But I know that's not true.  I've always been inquisitive.  I still listen to ER podcasts to and from work, two hours a day.  I learn new things every single shift.  I suppose that's why they call it practicing medicine.  And I want to be on the forefront of medicine; learning, teaching, researching.

I've taken a lot of things away from this year.  I have immense respect for anyone who practices community emergency medicine.  It's honestly one of the hardest jobs I can imagine.  No matter how fast you are, you can always be faster.  No matter how thorough you are, you can always be more thorough.   There are twin pressures at play in the ER - see patients quickly enough to not let someone die in the waiting room, but spend enough time with each patient so you don't miss something life threatening.  It's exhausting, unbelievably stressful, and difficult.

I've also had more free time this year than I've ever had before.  I work 12 shifts per month.  Initially I was bored.  Then I found a passion for cooking and the gym, dropped 35 pounds, and now I'm in better shape than I was in high school.  I'll take this forward with me through my career - being healthy is important to me, and I was too busy in medical school and residency to learn how to do it right.

Perhaps most germaine to the rest of my carer, I've learned about my own personal practice style.  I'm a big believer in patient-centric care.  I ask people if they think something is broken before I x-ray it.  If they say no, that they just want to know what to do for the sprain, I'll forgo the x-ray.   A lot of physicians are over-testers, in large part thanks to malpractice liability.  It's a shame, really.  Many of the best physicians I've known are impeccable clinicians not because they overtest, but because they carefully listen to patients and take the time to properly examine them.

And so, friends, it is with great excitement that I announce... I'll be leaving the south for the midwest in July.  Goodbye, pork BBQ.  Hello, beef BBQ!

Dr. Zac, Academic ER MD

Filed under: Medicine 11 Comments