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.
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.
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.
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.
My mom
Me: "So what brought you in to the Emergency Department, exactly?"
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
Pulling The Trigger
One of our nurses just started nurse practitioner school and today was her first day seeing patients in her new role. She came back from her first patient's room and was completely paralyzed by fear.
"I think I want to check some bloodwork on him... but what if I'm wrong? What if he doesn't need it? What if the IV blows? Is it a waste of money? Oh my GOD I had no idea how much harder it is to pull the trigger when you're the one responsible! All the nurses are telling me I'm overreacting and he's fine, but what if I miss something? I've been a nurse for 10 years but I don't know what to do!"
She suddenly understood something that all practitioners realize during their first day - there is a huge difference between making a suggestion (should we check a CT?) and making a decision (we need to check a CT.) I even wrote a whole post back when I was an intern about a freakout I had about giving tylenol.
The weight of that responsibility rests with the physician, and it is both extremely stressful and extremely rewarding. After the fact, decisions are praised if correct, and second-guessed if wrong. It is easy to criticize both from the sidelines and through a retrospect-o-scope. The weight of those decisions - and the guilt when we chose incorrectly - are one of the main reasons we physicians earn our grey hairs.
For just this reason, I learned a long time ago to trust nurses when they are worried, but not to listen when they blow patients off. Just tonight I picked up on rib fractures in a drunk. "He's just an alcoholic," they said, "kick him out the door so he stops wasting everyone's time." He had shattered his entire left ribcage from a fall.
As an intern, I let a seasoned nurse sway me one shift and I didn't order a test I thought I needed. One of the best mentors I've ever had, who sadly passed away last year well before his time, caught the omission. We picked up what could have been a catastrophically disasterous illness.
When I beat myself up over the mistake, he stopped me. "Zac," he said, "all you have in this profession is your gut, your heart and your brain. Do what you think is right, every shift, every time, for every patient and you'll do right by them."
I've taken that to heart, and I to this day it's the best advice I've ever gotten. I passed it on to the NP student today.
"If you think he needs bloodwork, just pull the trigger and do what you think is right. Every shift, every patient."
Turns out, the bloodwork clinched the diagnosis. Having evaluated the guy myself I could have told her something was wrong, but I wanted her to learn to make the call. The glow of satisfaction on her face when the labwork came back abnormal was incredible.
RIP, John. Your passing has been an unbelieveable blow to our field. You are missed by your colleagues and all the young physicians who will never know what they have missed without your tutelage.
The Radiologist Dilemma
The other day, I had a kid come in with a pretty obvious forearm fracture. I took a look at the xray, sedated the kid, reduced the fracture, splinted it, called orthopedic surgery for followup, and discharged the kid in about 20 minutes. An hour later, I got a call from our radiologist.
"Hey, man. I was just looking through some films up here in the reading room. You know you've got a forearm fracture in room 18?" Politely, I thanked him and said I'd look into it.
In the past, radiologists were a prerequisite to the interpretation of films, in part because of how the images were processed. Before the electronic era, xrays were put through a complicated chemical exposure and then a lengthy drying process in the radiology department. If needed, a "wet read" could be obtained by having a radiologist look at the film prior to the full drying process - literally looking at a wet film.
The term "wet read" still persists, although now it implies a preliminary or stat read. Since images are instantly available on the computer after being taken, often this is an unofficial read by an ER doc or another specialty. Sometimes it is the opinion of the on-call radiologist who is looking at an xray or CT scan outside of their subspecialty, which then gets looked at by a second radiologist the next day.
This means that often xrays don't get a definitive reading until well after the patient has left the ER. This leaves us ER docs to read most of our own xrays and sometimes even interpret CT scans if things are moving slowly. There is an entire fellowship in emergency ultrasound, cutting out the radiologists entirely.
For the most part, if it's not something complicated, I'm pretty comfortable reading my own films. I also have the benefit of directly correlating the images with the history and physical exam. Here's a paper from 12 years ago showing only a 0.1% discordance rate between ER docs and radiologists when the ER doc is confident of their interpretation.
Now, this gets into some significant medicolegal liability issues (and more than a few turf wars on both sides) that I don't have time to discuss here, but suffice it to say - medicare/medicaid and insurance companies are not super excited about paying two doctors to look at one xray. One way or the other, I suspect change is coming.
I suspect that eventually radiology will turn into a centralized, 24/7 field. It's a growing concept called tele-medicine, comprising radiologists, pathologists, and other specialties whose intellects but not physical presence are needed in many locations at once. With the exception of interventional radiologists who need to be on-site, all radiologic images will be reviewed by large groups not bound by hospital or timezone. I'm honestly surprised it hasn't happened already. Think of it as the Netflix vs. Blockbuster of medicine.
I envision a huge group of radiologists, comprised of every radiologic subspecialty. Need an xray of the knee read at 3:15 AM? You'd better believe there's a trained musculoskeletal radiologist reading it within 5 minutes of it being performed. Do things on a massive scale and the vicissitudes of any given hospital's patient volume gets washed out in the flood. To some extent this already exists, but for the most part it's purely night coverage until the local radiologists put the official stamp on the report in the morning.
Radiologists aren't going anywhere - they are invaluable at picking apart small subtleties I will never see without their training and their high-end, high-contrast monitors in dark rooms. The field as it exists now, though? I suspect that will change a lot in the years to come.
Playing With Fire
He looked pretty comfortable on the stretcher - unconcerned, even.
32 years old, already with bilateral toe amputations from massively uncontrolled diabetes. He had already had bone infections, a condition known as osteomyelitis, and he had been through a few months worth of IV antibiotics through a PICC line. Somehow he still managed to be completely noncompliant with every and all medical therapy suggested for him.
"Evening, sir, my name is Dr. Zac. What brought you in tonight?"
"I think I got the bone infection again, and I want my Dilaudid," he said, casually, "I'm allergic to morphine and Vicodin, all I take is Percocet and Dilaudid now. Also, I would like Phenergan and Benadryl with it."
I paused. There are few things that bother me more than a patient requesting Dilaudid, Benadryl, and Phenergan in the very first sentence. That particular cocktail of drugs is well known among ER physicians for being an incredibly potent high, and the immediate request for that triumvirate somehow belies a concern of illness from the patient. Most patients come in worried about what is causing the pain, and want an answer - the pain control comes second.
In this particular case, though, he was really quite sick. He had a fever, his heart was racing at about 120 beats per minute, and his foot looked infected - and the infection was spreading up his leg.
Turns out he hadn't been bothering to check his blood sugars - routine for him, upon reviewing his chart - and his blood sugar was also around 350, which is great for hungry, thriving bacteria.
I started an IV on him, drew cultures of his blood, started potent IV antibiotics, and immediately called the admitting physician. I begrudgingly gave him a small dose of Dilaudid - he had put our other pain medications on his "allergy" list, a common gambit among patients who want their physicians locked in to giving them the stronger medications only.
The nurse came to get me 30 minutes later. "Room 5 says he's leaving. He's got stuff to do at home."
I was floored, so I went and had a long talk with him. I'm a firm believer that fear-based talks don't do anything for people and that positive reinforcement is more useful.
Still, I tried both.
"I can't force you to stay, and I know you don't like checking your sugars. Listen, I'm not the diabetic, I never have been. I have no idea how difficult it is to check sugars and dose insulin all day, every day. What I do know is that from what I'm seeing here, you're probably about to lose your leg, just like you lost both toes. I don't know, maybe the infection will even spread throughout your body this time and kill you."
"I can help you if you stay. I can get your sugars down, I can get antibiotics in you, we can try to figure out a way to make your diabetes control work for you before you become crippled."
"Tonight is one of those turning points in your life. Stay, and we have a fighting shot at stopping this. Go, and you'll always regret not staying, right here, right now, when you lose your leg."
Nothing I said stopped him from going. He said he'd come back in the morning, but he never showed. It's not often I feel like I've failed someone, but I feel like I failed him. Then again, if I couldn't convince him to stay despite my best efforts? Well.
I guess some people just like to play with fire.
Delivery
A beat-up Corolla with a faded Papa John's tag rolled up to the ambulance bay of the ER. A pockmarked teenager got out and knocked hesitantly on the ambulance bay doors. With a raised eyebrow, the charge nurse let him in.
"Delivery for Jenny?" he said.
We looked around, a bit confused. Jenny, our nurse wasn't working that day.
"Says here she's a patient in room 5," he added, helpfully.
Ah, Jenny. Too bad for you, Hawaiian is my favorite. You just became NPO.
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