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.
- 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."
- At the six month mark, remind physicians that they are coming up on the deadline. Give them a progress report.
- 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."
- Any physicians not playing ball get 3 notices, then lose their controlled substance license.
- 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.
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:
- 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."
- Came in by EMS not breathing due to an opiate overdose.
- 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.
I walk out of the ER after my last shift, finished with residency. It's an incredibly bittersweet feeling.
I've been in school for 23 years. Elementary, middle, high, college, medical, and then residency. I've been in training all of my life. For the first time I'm on my own.
I'll always have someone to ask advice from, of course. My fellow physicians, nurses, patients, families. But someone finally gave me the top degree, the final award. I'm an attending physician.
It is liberating - and terrifying. I no longer need to ask if I should bring someone into the hospital because of their mild chest pain. Then again, I no longer can ask if I should bring someone into the hospital because of their mild chest pain.
I'm ready, I suppose. A patient the other day had a serious blood clot in his lungs, and another physician asked me - colleague to colleague - whether or not she should give the patient clot busters. It's a weighty decision. Given to the wrong patient, they die immediately from massive internal bleeding. Given appropriately, a healthy patient goes from death's door to alive and well. We discussed the benefits and drawbacks, and in the end I recommended the drug. Right now, the patient is back with his family, sharing memories he might not have shared.
One of these days, I'll be wrong. Perhaps it will be my failure to recognize the problem. Maybe I will advise the wrong treatment. One day, it will just be bad luck. But from this point forward, it's me and no one else who will be responsible.
I look back now on 4 years of college, 4 years of medical school, and 3 years of residency, and ask myself if it was worth it. I've sacrificed the best years of my life to this profession and to my patients. The other day, one of our nurses saw my ID badge and remarked how much I had aged in only 3 years. My girlfriend pokes fun of my grey hairs at the young age of 29.
Was it worth it? I'll never forget the hard times. To this day I remember almost crying tears of joy when I thought I was stuck in an elevator. I've had so many good people die. I've had so many mean people live. I've been so tired I want to cry, and I've been so hungry I've stolen food off of meal trays.
It's a wonderful, vicious, honest, angry, happy, unfair, and real life that I've lived. I have seen the very best and the very worst side of people. I have been spit at, cursed at, and punched while trying to help the very people that assault me. I've been blessed by, prayed at, and thanked by more people than I can even count.
Is it worth it?
I got asked this question at a dinner party the other night: "What's the difference between emergency physicians and other doctors?"
It took me a moment. I haven't had to answer that question since interviewing for residency, back when I had only spent two months as a medical student rotating through the field. I think I've got some better answers and perspective now. So, for all you aspiring premeds out there , or for laypeople interested in just what makes an ER doc tick...
1) You have to have passion for what you do.
This is true for every medical specialty, but moreso in emergency. A 10 hour shift will run you ragged and exhausted. It's only because I love it that I leave my shifts in a good mood. I helped a couple people, saw some cool things, and sure I'm tired... but at the end of the day I did good work.
2) You have to be willing to roll with the punches.
Usually figuratively. Sometimes literally. Things will be thrown at you that you would never expect. Multicar pileup on the freeway? You bet all those patients are coming to you at the exact same time. Guy found unresponsive in the snow? Yup, take him to the ER. And somewhere in there, a heart attack will sneak on through. Naturally they all arrive without any medical records.
3) You have to love interacting with people.
The emergency department thrives on teamwork. If you're not a people person, or you can't take criticism, you're dead in the water. You live and die by your nurses, techs, and consultants. Plus, you've got all of 5 minutes to meet a patient you've never seen before, shake their hand, and gain their trust so you can figure out what's wrong with them.
4) You can't be offended easily.
Consultants hate being called by the ER. Yeah, they're "on call", but I assure you nobody likes to be woken up at 3 AM. You'll be questioned on your medical judgement, you'll be ridiculed, and you need to understand that the other person is just tired. They simply don't want to see the patient if they don't have to.
5) You need to be quick on your toes ...
Slow people don't typically enjoy emergency medicine. If you don't like the idea that multiple new patients could show up at any time and need to be seen quickly, you may want to consider a specialty where you have time to be methodical, triple-dot your i's, and extra-cross your t's.
6) ... and good with your hands.
You hear this about any field that performs procedures. You will do so many procedures in emergency medicine that you will stop counting - and you will be grateful that you like to work with your hands. Some people simply don't enjoy this.
7) You need to accept your limitations.
You will never be a cardiologist, nor a neurosurgeon, nor a radiation oncologist, so you will not understand everything that they do. You will, however, know about 70% of what they do, which is just enough to babysit patients until the specialist comes.
8) You have to keep an open mind.
Our patients can be very hard to deal with. Suicide attempt by swallowing one tylenol. Alcoholic presents for acute missing sandwich and stat hot shower. Drug seeker needs dilaaa... dilauudaaa... dilaudid, is that it? The earlier you learn these people truly need help - referral to detox centers, shelters and social work, the easier your life will be. Otherwise you will turn into a cold shell of a person, always suspecting someone is trying to get the best of you.
9) You've gotta enjoy a bit of chaos.
For some, fun is a nice round of golf with the chaps. For us, fun is when the ED goes batshit - every patient wants something, every nurse, tech and doc is overworked, yet somehow you're keeping it together. It's trench medicine. It's the front lines of the American Health Care Debacle System. Exhilarating, isn't it?
10) You should be proud of what you do.
The unwashed masses are cast against the shores of the department and you take all comers. You don't ask insurance status. You don't ask if they can pay. No, you treat meningitis, fatal arrhythmias, broken bones, and bring people back from the brink. Why? Because it's the right thing to do.
3AM, and the all-too-familiar beeping starts. I awake to the dull amber glow of my pager. Call the nurse for bed 29, please.
"Zac... we have a patient who is scaring us and we need you to come see him." I rub the sand out of my eyes and stumble out of bed.
It's quiet in the hospital, but there is an ominous tone hanging over the night. Wind whips past windows and the rain has been coming in bursts. The nursing station is silent except for the gentle beeping of the monitors. The lights are dimmed in the ICU, except for Robert's room, bed 29. He's a psych patient who landed himself here by driving full-bore into a concrete median. He's been in and out of consciousness since day one.
I walk down the darkened hallway and towards his room. Eerie noises emanate as I get closer; a mixture of wails and shrieks. It's Robert.
Nurses stand back against the cabinets, and I see Robert lying in his bed, ripping and tearing at his restraints. A thin line of spittle hangs down his mouth and a small trickle of blood trails from where he has chafed at the wrist cuffs. He's hurting himself. He moans like a caged animal.
"Robert, it's the doctor, just coming to check on you..." I stammer, but his eyes are wild and rolled in the back of his head. The rain starts to pick up outside of the room, first brisk and then torrential. I don't want to be in the room alone with him, but the nurses file out now that I'm here.
He mumbles something, eyes darting around the room.
"I can't hear you, Robert, please speak up." He meets my eyes for one brief moment, lucid, and motions me over. Slowly, I advance. I'm keenly aware of the darkened hallway behind me. This feels like something out of a horror movie and I have the distinct sensation that something is there. I glance over my back. I'm being silly, it's nobody. The hairs on the back of my neck crawl anyway.
Nervous, I lean in. "Robert, I can't understand you. You're speaking nonsense." He grunts some more. I edge closer.
Suddenly, he sits bolt upright, his face inches from mine. I jump back, startled. Panting, sweat beading off his brow, his arms are cords of muscle as he fights the restraints.
Robert's head starts turning, slowly, staring straight forward, breath fetid. A slow, terrifying grin spreads across his face as he fixes his gaze to mine, his cracked yellowing teeth in a rictus of madness. Slowly, his head tilts, his bloodshot eyes boring into me. The patter of rain is the only sound in the room. And then he speaks, his voice deep, hoarse, and gutteral.
"Look... out... the WINDOW!"
Panicked, I spin around as a single bolt of lightning illuminates the room. A shadow flits across the glass - no, it must be my imagination - but my heart is pounding. The rain traces lazy rivulets down the window. I turn back quickly, but Robert, spent, is lying back in bed, breathing softly, eyes closed. The room is silent again except for the rain.
And like that, it's finished. No fanfare, no awards. Walk out of the hospital one day an intern, return the next a resident.
My parents called to ask if it felt any different. To my surprise, I answered, "yes... it kind of does."
Countless books have been written about intern year. Every physician gets a bit misty-eyed when thinking back to the nascent, formative moments of their career. Medical students peer forward, trying to pierce that impenetrable veil of transition from student to doctor.
The difference between an intern and a fourth year medical student is simply the M.D. behind their name. But, of course, that's everything. Someone has accredited an intern to make decisions about patient care. An order for a CT scan will result in the same scan, no matter whether an intern, resident, or attending authorized it, but no medical student can give that order.
Exactly one year ago, on my first night on call as an intern, I got a call from a nurse for the simplest of things. "Doctor," she said, "your patient in bed six has a fever of 102.4, and there is no Tylenol ordered. Can I give him some?"
I panicked. Tylenol is the oldest of drugs. Parents give it to their kids like candy. There are elixer, flavor, chew tab, and extra strength variants. It has countless brand names across the world. I was a doctor now, and I should know the answer. Just a simple Tylenol order. And yet.
In a patient with liver failure, Tylenol can be lethal. The primary team didn't think there were going to be any problems with this patient overnight, and suddenly I was presented with a fever. Fevers in the hospital setting are often the harbinger of massive bacterial infections, lethal blood clots, wound infections, sepsis from urinary tract infections, and so on. A simple order for Tylenol... well, it's not so simple.
I sprung out of bed, hair mussed, wild eyed, heart racing. The patient was sleeping, but I woke him up and grilled him for 10 minutes to make sure he felt alright. Gruffly he responded, "well, I was doing just fine until you woke me up!" I pored over the chart, trying to comprehend his care, his underlying pathology. He was postoperative from an appendectomy. Nervously, I reasoned that his fevers were from atelectasis, a common and benign cause of postop fevers, and ordered the tylenol.
What if I was wrong? What if it was infection? What if lying in the bed had caused clots to form in his legs, rocketing off and wedging themselves in his lungs? I went back to my call room and laid awake for hours, exhausted, the dim blue glow of the computer suffusing the room with bits of the electronic medical record.
In the morning, I called the primary team to let them know I had given tylenol to their patient overnight. "Cool, man, thanks, he probably just had atelectasis," said the resident. In a single moment, a night of agony validated and dismissed.
I soon learned that with experience, confidence builds. With every mistake identified, every correct decision confirmed, I grew as a physician. 4,000 hours spent in the hospital, 80 hours a week, 50 weeks a year. Bathed in the milieu of medicine day in, day out.
And at the end of it, one step up the ladder. One layer of supervision, peeled away. One more level of scrubs asking me the questions. One year of training down.
I saw a new intern walking into the hospital on her first day as a doctor this morning, uncomfortable in her starched new white coat, the hospital logo emblazoned proudly on her sleeve. She kept grabbing at the pockets, adjusting her stethoscope, buttoning and unbuttoning, checking her pens. Nervous, but deathly afraid to show it. I remember that feeling well.
"Morning!" I greeted her, cheerfully, "You excited?"
"Yeah..." she allowed.
"It's going to be a fantastic year, " I assured her. "Come find me if you have any questions."
"Hey, brotha. I need help. Look, I'm not gonna shit you, I'm an alcoholic. I'm homeless. I've got back pain. You can help me, you're a doctor. I need Ativan so I don't go into DT's and some Percocet for my pain. Please, brotha, I lay myself at your feet."
Before me lies an emaciated husk of a man, frost-bitten, his bleach-blonde hair pulled into dirty dreadlocks. The room reeks of alcohol, the tang of shitty beer lying uncomfortably in the air. His bloodshot eyes track me as I walk over to examine him.
This was my first introduction to our resident frequent flier. He's famous; every ER doc in the city has treated him for everything from alcohol withdrawal to blood infections. Among other things, he's an asshole, a florid alcoholic, and an abuser of the system (a news article estimated his ambulance rides, ER visits, and ICU stays costing the taxpayer more than $10 million).
Unsurprisingly, my exam is unremarkable. It's freezing out, and the ER is a refuge for a few hours from the biting cold and the unforgiving streets. I prepare myself for his discharge, and give him his papers.
"Your exam is normal today. I can't find a reason that your back hurts. I'm sending you home."
"Fuck you, man. I can already tell, I can't change your mind. I know your type. Yea, I'll fuckin' go. You know how cold it is outside? Yea, I'll fuckin' go. I'll go, you privileged sumbitch. You have no idea what it's like to be homeless."
He leaves without much fuss. A nurse claps me on the back for handling him well. She thinks my no-nonsense attitude approach will serve me well as an ER doc. All the same, a small voice in the back of my head wonders if I should have been more compassionate.
The rest of the shift goes uneventfully, and as I drive home, I notice it's cold out, cold enough to freeze the windshield on my car. I run inside my heated house and crack a beer. Life is good.
"You have no idea..."
Out of guilt, I throw on a sweater and my overcoat, and shuffle outside. It is bitingly cold; I start shivering instantly. The stars are frigid, beautiful, and unforgiving, the moon austere behind a single veil of cloud. He was only wearing a sweater and some thin pants when I discharged him. He must be freezing right now. I last all of 5 minutes; my teeth chatter so hard I fear I'll break the enamel. I rush inside, the warmth enveloping me like an old friend.