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.
When you get ready to examine a patient, there are a few clues you can use beforehand to determine how sick they are. There are some quick ones, such as how many visits they've had in the past 30 days for the same back pain, or whether or not they have any vital sign abnormalities. Sometimes you're in luck and labs or xrays have already been performed.
But all of these methods pale in comparison to Dr. Zac's Rule of Twofers. Now, I don't mean to talk myself up, but this formula is genius. Allow me to demonstrate:
Where the total sickness of your patient is equal to a coefficient (δ) times the total possible sickness of any given patient divided by the number of patients in the room. Please note, there is a separate but directly related theorem when multiple people from one family check into different rooms in the ER.
You may ask yourself, "What exactly is δ, Dr. Zac?" Quite simple. It's the Coefficient of Chief Complaint, goes from 1-10, and it is used to scale the importance of certain chief complaints. Usually it equals 1, but if the chief complaint is, say, "horrific car wreck on the interstate," it allows us to overpower the denominator.
A few examples:
- Mom checks in her four children at the same time, all who have "Fever x 1 Day" listed as a chief complaint. Fever has a δ coefficient of 1. Thus, the maximal sickness per patient is divided by four, leaving us with an essentially social visit. Make your pleasantries, crack a joke or two, look in the kids' ears, no antibiotics necessary.
- Dad, drunk, lights the house on fire. He and his 8 illegitimate children are brought in as well as his mistress. "House Was On Fire," naturally, carries a δ of 10. Thus, 10 divided by 10 patients gives us 1, leaving us with a maximal potential sick value equivalent to that of any other patient in the ER.
- A friend sitting in the room with your patient mentions offhandedly that she coughed once earlier today. Unfortunately, all the sick in the room has already been used up by your patient, leaving the friend with a δ = 0. This is a special case, also known as the "convenience coefficient" and occurs when someone is so far from being sick they couldn't even be bothered to check in at triage.
There you have it, folks. Dr. Zac's Rule Of Twofers. It's bulletproof.
I'm really enjoying being a senior resident. This month I'm mentoring our medical students, and it's been loads of fun so far.
Today we had a "simple" laceration that needed closing. Typically this is the medical student's job, since the residents have traumas and coding patients to take care of. I sent Medical Student to sew up the lac, but two minutes later he came out of the room, pale-faced and nervous.
"Dr. Zac... I took off this guy's pressure dressing and he's kind of... bleeding out from his wound. Like, sort of spurting blood. Kind of everywhere. I think I need help."
I'm a pretty laid-back guy, but years of emergency training have instilled a GO switch in me. I immediately popped in the room. Sure enough, this guy was hemorrhaging blood from multiple severed arteries in his leg. I grabbed Med Student's gloved hand and shoved it in the wound.
"You feel where that's pulsing? I want you to keep your fingers right there and hold pressure. I'll be right back."
There are varying degrees of emergency; this is one that can be fatal if left unchecked. I ran out of the room, grabbing the necessary equipment and sutures. Med Student seemed quite relieved when I returned. Quickly I tied off the bleeding arteries while explaining what I was doing (throw your stitch under the artery, loop back around again, and tie it off. This is called a figure-of-eight suture and it will save your ass in a pinch). Within a minute I had the bleeding stopped. Med Student appeared impressed.
Suddenly, it was a simple laceration repair again. I supervised him closing the wound with little teaching points along the way, and to his credit, he did a fantastic job. It will look great when it heals.
The patient's wife pulled me aside later. "Doc, you really seem like a fantastic teacher. We were both so reassured that you were there. Thank you so much for taking such great care of us!"
It was a great day, and it's been a wonderful month so far. If the rest of my life is like this, I'll be a very happy physician.
I'm officially a senior resident. It may seem an arbitrary milestone - leave the hospital a second year resident, return as a senior - but the changes are easy to see.
During my shift today, I placed a central line in a matter of seconds; the first one I ever did took an hour and a half. I casually transfused a trauma victim two pints of blood while on the phone with a consultant. I coached a family through their mother's catastrophic brain bleed, answering their questions and initiating palliative care. A man's heart stopped beating - twice - and I restarted it. Another patient went into flash pulmonary edema and I prevented him from drowning in his own secretions.
It was a good day. It's been a excellent year. I'm excited to see what happens next... I love this job.
I'd like to take a moment to thank the field of Emergency Medicine for something I hold very dear: scrubs.
Wake up, throw on a pair of glorified pajamas, and roll into work as an acceptably dressed physician? That, friends, is awesome.
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.
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."
A few weeks back I had to leave our med school tailgate to put in a shift at the urgent care. While I was truly saddened by my inability to contribute to the shotgunning of copious beers, alas, some of us are productive members of society. Then again, I'm of the mindset that shotgunning beers at tailgate is productive, but that's a debate for another time.
I had a pretty great shift, mostly because drunk college kids were brought in for various and sundry complaints†, and they were stoked to see the school colors under my scrubs. Halfway into the night, though, there was something... different. Cruising around the corner, I immediately noticed two things.
Firstly, my nostrils were assaulted with the pungent odor of vast, unimaginable quantities of shit; a horrific wall of feculent odor that knocked me backwards. This was shit to be reckoned with. This was shit that didn't take "no" for an answer.
Second, there was a very attractive sorority girl in school colors and butt shorts screaming blindly "I'm NOT as DRUNK as you THINK I am" at the nurse who was unsuccessfully trying to start an IV.
The incongruity of these two simultaneous events was difficult for me to comprehend, so I used my carefully honed powers of medical observation. "Ah, there's the problem" I thought to myself, "that lovely young lass has shat herself".
I mean, folks, I didn't realize you could even poop that much††. It was all over the poor guy drawing blood, the bed, the floor. It was splattered on the wall like a Jackson Pollock painting. It was a veritable cornucopia of fecal matter. It was Shitterhouse-Five.
That, my friends, is why I both love the ER and could never make it as a nurse. We love you so very much, you don't even know.
† If by "various and sundry" you mean "solely related to alcohol and the imbibing thereof". Pearl: if a piece of a broken beer bottle pierces through the insole of your Chucks, your antibiotics must cover Pseudomonas Aeruginosa.
†† let alone a girl who couldn't have weighed more than 90 pounds.
A few days ago our office's nurse cornered me "Zac, I don't know what to do about the patient over in room 2. She was diagnosed with an ammonia over at the urgent care yesterday and was sent home... she just told me she's having trouble walking, has difficulty breathing, feels nauseated, and has a horrible headache. Dr. S is in with another patient so I figured I'd ask you if you think we need to get him in there right away."
Now, hyperammonemia is no laughing matter. Especially when it presents with gait problems, vomiting, and a headache you start to worry about all sorts of stuff, including alcohol withdrawal, drug overdoses, and liver diseases. Warning bells were going off in my head; I asked the nurse if the patient was a drinker; lo and behold, she was.
Rather than seeing my other patient, I waited outside the room for Dr. S so as not to miss him. I gave him the brief synopsis, and he dropped what he was doing immediately to walk over to room 2.
As we entered the room, he started smiling. The patient was sniffling a bit but looked just fine otherwise. She was 62 with a walker.
Dr. S: So they diagnosed you with a pneumonia at urgent care, huh?
Patient: Yep, that's what I told your nice nurse.