Friday, October 4, 2013

Good thing that Hypocratic Oath.

There is a Doonsbury cartoon about 30 years ago, based on Henry Kissinger's CABG surgery.  In the cartoon the surgeon is talking with Kissinger a day or so post-op.  He notes that during the surgery he was holding the heart of somebody who had condemned thousands to death.  He said, "Then I thought of my Hypocratic Oath and sewed you up".  Kissinger replies, "Good oath that".

A couple of months ago while working I went out to see a patient for a procedure.  His name seemed familiar so I thought that he might have been a patient I had seen before or even somebody I might have have met socially.  I asked him that and he said he didn't remember meeting me.

It was only after I put him to sleep that I realized the man who had placed his life in my hands was the insurance assessor I wrote about here.

I told the staff in the room about him and what he had put me through but at the end of the case I took him to the recovery room and went on with my business (I even gave him something for nausea) and presumably a day or so later he went on with his business and I hope to god we never meet one another again.

Open Letter to Your Friendly Emergency Room Doctor

I found this on Facebook.

Emergency room doctors certainly write a lot of blogs and rants, and they do have the most interesting stories which is is probably why they have TV shows about the ER and not about anaesthesia.

I have seen variations on this rant before either from ER doctors and nurses. I thought it was pretty fun but then I thought about the patients I see in the pain clinic and how I used to treat chronic pain patients when I worked in the ER and how chronic pain patients get treated now. Therefore.


I worked a lot of emergency shifts before I became an anaesthesiologist, both as a family doctor, and as an "emergency room physician", so I actually have some empathy for what you face and I agree with about 90% of what you say. However as a chronic pain doctor who follow chronic pain patients and writes prescriptions for oral opioids, I have to make the following points.

There are a lot of slime balls out there who like to try to fool unsuspecting doctors but there are also a lot of legitimate patients who suffer from either acute or chronic pain. The problem is the tendency to lump all these patients into a single group.

When my patients ask about going to the emergency room, I tell them that the emergency room is for people with fractures and heart attacks and that their chronic back pain is not an emergency. I try to give them some treatments and get them some skills to avoid visiting the emergency. And for the most part the patients I follow don't visit the emergency. I know this know because all emergency records are posted on our province's EMR and I check this. And many of my patients who have been to the emergency describe it as the worst experience of their lives, something they would do anything to avoid. Having said this, patients with chronic pain who take opioids do break bones, or get appendicitis. This is usually a horrible experience for them because most ER docs don't give enough analgesia to normal patients let alone narcotic tolerant patients.

Many of the problems I see in the pain clinic are the result of bad treatment in the ER. Take the episodic migraine patient who has been transformed into a chronic daily headache patient by all the injections of various narcotics, sedatives and anti-inflammatories that ER docs like to give because we all know every ER doc is an expert on treating headaches. Did it occur to you that maybe some of these patients weren't just drug seeking and were actually looking for some type of long term solution. All yeah, ER docs don't do follow up; that's what you like about ER.

Given all the bad side effects and long term consequences of NSAIDs (which all ER docs know about because they were in the top 25% of their class), is it surprising that patients maybe don't want to take them? Especially when they may have been popping OTC NSAIDs all day before they decided to go into the ER. And what is the fascination among ER docs with ketorolac (Toradol)? While it was marketed aggressively by the company as an analgesic, it is an NSAID just like all the other NSAIDs except that it can be injected. Every time I see somebody with marginal renal function who has received multiple doses of ketorolac in the ER, I shudder. None of the patients I see in the pain clinic are allergic to Tylenol. In fact one of the hardest jobs I have in the pain clinic is convincing patients not to take so much Tylenol and acetaminophen containing compounds. In Canada you can buy acetaminophen 325 mg with 8 mg of codeine and that is pretty popular. (Confession: I even get some for myself if I have a really bad cold/flu). This is posted on the patient's EMR now as well and it is interesting just how much of this some patients buy.

And why wouldn't a patient ask for a drug that he know has worked in the past? When I had a dental abscess, tylenol with codeine didn't work percocet did. Guess what I'm asking for next time?

And patients do lose prescriptions and have them stolen. If you lose your BP pills, you just call the pharmacy and they will give you another batch. Because of regulations, pharmacies can't or won't refill your opioid prescription without calling your doctor. Quite a few of my chronic pain patients lose their prescription or have it stolen. This only ever happens once. Likewise occasionally when patients run our of medication, they find that their family doctor is on holidays, has retired, or the office tells them that the next available appointment is in 2 weeks. Sure patients should plan to get their prescriptions filled when their doctor is available. Think though how often you have thru lack of planning forgot to do something really important?

And I confess to being confused by the term drug seeking. Given that about 95% of all non-surgical visits end in a prescription, aren't all patients drug seeking. I have never heard anybody talking about Ventolin seeking or nitrate seeking or Amoxil seeking patients.

Which reminds me. I used to work in the ER and see the patients like the ones described in the rant. They were a pain in the butt, but they did pay the bills if you are on fee for service. Its a hell of lot easier to order Demerol and Gravol, or whatever your migraine cocktail is, than it is to actually figure out a sick patient. And, unless things have changed since I was an ER doctor, about half the doctors just order that to the regulars without even seeing them. Of course when I covered a ER without on-site coverage it was a pain to come in from home which is why most of us just left standing orders for the 10 or so ER regulars every small town had. I can however see why you are upset about having to treat these patients. You are of course very busy with other duties in the ER (which judging from the wrecks who come up to OR from the ER doesn't include working up or resuscitating surgical patients).

When I worked in the emergency room, it wasn't the "drug seeking" patients who bugged me. I actually enjoyed the mental chess games they played with me. What bugged me were the non-compliant patients with chronic diseases who showed up with their suitcases packed asking to be admitted, the patients who came with URTIs and of course the doctors who sent their patients to the emergency room expecting you to work them up and arrange the admission. Not to mention being yelled at by specialists when I wanted a consult.

And who gives a shzt that apparently all emergency room docs were in the top 25% of their medical school classes and are therefore harder to fool. Actually I think anybody who got into medical school is pretty smart. No that's wrong, anybody who got into medical school got good marks, did the appropriate volunteer work and was able to suppress their antisocial personality traits in their admission interviews. This is not the same as being smart. I graduated 44th in a class of 89 (not at the top of class but at the top of the bell curve) and I did okay. With much of medical school marks being passed on subjective rotation evaluations, the fact that you were in the top 25% just means that you were probably good at brown-nosing and back stabbing your fellow students to make them look less good and you look better. Those of us in the bottom 75% remember just what absolute zib-zabs most of the top 25% were.

And oh yes, 30 years ago when I started practice in Canada emergency rooms were staffed by what we called general practitioners on rotation duty plus a few full-time emergency room physicians who were either young doctors fresh out of their internship or older doctors who had given up their practices. And you know what? The care that patients got was just as good then as it is now. If anything it was little better because these individuals knew their limitations.

Just something I had to get off my chest.