Monday, 16 January 2017

Sabotage

Hey look, another post where Doc is unabashedly stealing a title from a popular song. How very original. 

Wow, you didn't even let me get a word in before you started attacking me for my thinly veiled unoriginality.  Besides, this has nothing to do with the Beastie Boys or their song, so thanks very much for your feedback.  I'll be sure to remember that when it comes time for Christmas presents next year. 

Aaaaaaanyway . . .

sab·o·tage
ˈsabəˌtäZH/
verb
  1. 1
    deliberately destroy, damage, or obstruct (something), especially for political or military advantage.

Trauma is a hard job, not that I'm necessarily trying to pat myself on the back or garner any sympathy.  But it is.  In addition to fixing holes, I also sometimes need to fix people or situations, and that is always a much more difficult prospect.  A hole can be sutured or stapled, but people . . . Well, people are different.  Unlike a stab wound to the heart, people have brains and free will, and too often they use that free will for intentional self-destruction.  Sometimes they act harmfully to themselves, but all too often it is others that they harm, intentionally or otherwise.

And no matter how hard I try to fix someone or something, even my best plans can get destroyed in a second, sometimes by the most unexpected source.

Robbie (not his real name™) was transferred to my facility because the facility he first visited didn't have doctors, I can only assume.  Maybe that isn't entirely fair - they presumably had doctors, but none that knew how to evaluate a goddamned patient.  Ok, again probably unfair.  Perhaps they knew how to evaluate a patient, but clearly they had no idea what to do with the information once they collected it.  So in Robbie rolled a bit after 8 AM, just a few minutes after I walked in the door, and even fewer minutes after my morning coffee, but well before my post-coffee coffee.  It's a damned good thing too, because there is no way I would've been able to deal with him had I not yet had my coffee.  Why is that, you may be wondering?  Because I heard him well before I saw him. 

"GOD DAMN IT I'M IN FUCKING PAIN!  I NEED SOMETHING FOR PAIN!"

Sigh.  So it's going to be that kind of day, is it Call Gods?  Well good fucking morning to you, too.  Assholes. 

As he transferred from their stretcher to ours, I couldn't help but wonder why someone would have taken a bat to Robbie's face.  After all, what a polite, kind, and genuinely appreciative person Robbie clearly was.

"OW, MOTHERFUCKERS!  WHAT THE FUCK IS WRONG WITH YOU?  CAN'T YOU SEE I HAVE BROKEN BONES IN MY FACE?  GOD DAMN, BE MORE CAREFUL!"

We could all see that his face was broken, and none of us wondered why someone would want to do such a thing.

"Hey Doc, this is Robbie," the medic started, clearly trying to prevent himself from punching Robbie on the other side of his face.  "He was hit in the face with a bat or a club or something a few hours ago.  Positive loss of consciousness.  He admitted to using heroin . . ."

"I DIDN'T FUCKING ADMIT TO USING HEROIN!  I'M ON FUCKING METHADONE, ASSHOLE!  I FUCKING TOLD YOU THAT!"

". . .for a few years," the medic continued with a deep breath, "but he claims he's clean now ("I AM CLEAN, ASSHOLE!") and takes methadone.  CT showed a bunch of fractures - here's the disc with the images.  He's all yours."

I have rarely seen an ambulance crew scatter as quickly as they did.  Roaches scurry slower than these guys.  And just like that, Robbie belonged to me.

"CAN I GET SOME PAIN MEDICINE?  NOW?!  HELLO??"

I tried, and probably failed, to make my sigh inaudible.

After a quick glance at Robbie's broken face, I took the disc over to the computer and waited approximately 3.2 years (I counted) for the images to load onto the screen.  Sure enough there were several fractured facial bones on the left side of his face (I assume his attacker was right-handed).  However, the fragments were not displaced and there was no evidence that the muscles that control movement of his eye were entrapped.  I seriously doubted he would need any reconstructive surgery, so with the blessing of the facial reconstructive surgeon on call, I could most likely send Robbie home.

Aaaaaaah, yes.

"PAIN MEDICINE!"

Ah.  No.

There was still the issue of treating Robbie's pain and convincing him he didn't need A) a hospital, B) surgery, and C) more narcotics.  Obviously Robbie's most recent methadone dose had worn off, and he had every reason to have pain.  I'm not saying he deserved it, but . . .

Ahem.  The problem with pain control in narcotics abusers is multi-faceted.  First, their tolerance tends to be very high, with effective doses being high enough to kill a whole team of very large mules.  Second (and more dangerously), it feeds into their addiction.  I therefore asked the nurse to give him some ketorolac, which is a rather potent non-narcotic IV anti-inflammatory analgesic.  Robbie had obviously been through this before and knew exactly what to say.

"I'M ALLERGIC TO KETOLAC OR WHATEVER!"

Of course he is.  I asked him what his allergic reaction was, expecting him to say 1) it doesn't work, 2) it makes me die, or 3) I don't know I just am.  Instead, he went off-script and said it makes him feel nauseated.  Ha, nice try but GOTCHA.  I explained very calmly that nausea is not an allergy, but rather an intolerance, so I would just give him some anti-nausea medicine with it.  Right on cue he went back on-script and screamed that the anti-nausea medicine doesn't work for him.  Because of course it doesn't.  I de-escalated a bit and asked if he could take ibuprofen.

"I'M ALLERGIC TO IBUPROFEN!"

And of course his "allergy" was nausea again.  By this time the patience of everyone in the room was wearing thin.  Actually that's not exactly true - our patience had completely run out the second he started cursing at the ambulance crew, and we were now all completely tired of his bullshit.  A few minutes later as I was putting in an order for acetaminophen (I CAN'T TAKE ACEMATINOFEN OR WHATEVER!!"), his parents showed up.  His father hobbled in with a cane, and his mother smelled like an ashtray that hadn't been cleaned in 30 years.  They sized up the situation rather quickly, and they obviously were well aware of Robbie's drug history.  Mum started trying to sooth him with quiet, calm words mixed with tears, and dad stood back towards the door, obviously seething.  It seemed he was rather angry with Robbie, and rightfully so.  

Or so I thought.

After some back-and-forth arguing between Robbie and his mother, dad had seemingly had enough.  He set his jaw and marched forward (as quickly as he could considering his cane), and I expected to hear a thorough tongue lashing.  I did, but the object of dad's wrath was completely unexpected.

"THAT'S ENOUGH, Robbie.  Enough.  God damn it.  Let's just get the hell out of here.  These people don't know what the HELL they're doing.  I'll take you home, and I'll take care of you the way I always do."

There was nothing but stunned silence as Robbie's mother nodded solemnly.

The implication was clear, and dad was not trying to hide his intentions one iota: Since these people won't do it, I'll give you some of my narcotics.

I usually have it in me to confront situations like this, but this had me so taken aback I had no alternative but to let them leave.  This was obviously not the first time they had been in this situation, and it most assuredly will not be the last, since they both fed right into it.  My intentions were nothing but pure: 1) don't feed Robbie's addiction, and 2) treat his pain.  Dad's were the exact opposite.  He was satisfied not only sabotaging my well-intentioned plans, but his son's health too.

I'm not a babysitter.  I can't go home with my patients and make sure they do the right thing, so I damn well can't ensure everyone else does the right thing too.  All too often I have to rely on family members and friends to help their loved ones along and keep them on the right path.  But sometimes those reliable family members just don't exist.

I strongly suspect I'll see Robbie again in the near future.  And I will treat him exactly the same way as I did this day.

26 comments:

  1. Hi Doc'

    This must be a difficult call - it's obviously inhumane to leave a person in genuine pain but equally irresponsible to feed an addiction.

    Is there a scope for using a partial agonist like buprenorhine (actually, that's the only one I know of) to treat the pain without providing the "high" that addicts are craving? I suppose it can be abused or they wouldn't formulate it with naloxone but I assume it's less rewarding to an abuser than a full-on morphine shot.

    Just interested in the strategy in the event that an addict is geinuinely in pain but insists on being allergic to all non-opioids.

    Ugi

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  2. I can see an error in assessment in your story.

    Robbie's assailant COULD have been a lefty with a good backhand.

    but yeah - he'd been hit several hours before, and only just now needed painkillers?

    yeah, used up all his methadone and couldn't get more. I bet his pain was at an 11 out of 10, too, wasn't it?

    I would have expected to see him back in about an hour, this time outraged because of the narcan the paramedics shot him up with because he had stopped breathing.

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  3. You've touched on this issue before Doc & I didn't dive in, but this time, I must. Since you're the only doctor I get to quiz without a copay, I hope you'll indulge me.

    When people come into your care suffering from injuries severe enough to cause intense pain, why won't you give them narcotics, as long as they aren't medically contraindicated? Even if the patient is a raging junkie, that's not what they're in your ER for. They got hit by a car or smashed in the face or burned themselves trying to freebase or got high & jumped off a roof aiming for the swimming pool & missed -- whatever. I don't mean the con artists who only go to the ER looking to score narcs. I mean the folks who have serious injuries & very real pain, regardless of what their recreational drug habits might be. Why not just give them the opiates that have been proven for decades to be the most effective drugs for easing pain?

    I read once that "Primum non nocere" wasn't actually part of the original Hippocratic oath back in the 5th century. That "First do no harm" didn't crop up until the 17th century. But does that edict really require you to play the morals police when your patient has a drug habit? You're not a social worker or therapist -- your job is to save their life & treat their injuries now, today. Otherwise, wouldn't you be obligated to send every addict to rehab after you patch them up? But no trauma doctor does that, esp. not in the American healthcare system.

    So when you're treating someone, why does that patient's addiction trump the fact that they're in pain? Why do you have to concern yourself with not feeding their habit to the point where they may be left with inadequate pain relief because their trauma surgeon made a moral judgement not to give them narcs?

    And I'm not asking just to be as wiseass. I ask for 2 very personal reasons. (cont'd)

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    1. Doc answered your question with his first consideration, but you seem to have missed it in your fixation on his second.

      To reiterate, "...their tolerance tends to be very high, with effective doses being high enough to kill a whole team of very large mules."

      Now, I'm not doctor, but it seems to me that putting a guy in the morgue because his tolerance level is such that you can't accurately gauge an effective dose versus a lethal one is not in the patient's best interest.

      Narcotics are not the only pain management solution. Why would you go for the riskiest approach when there are safer options available?

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  4. (cont'd)

    1) Thankfully, I have not experienced this myself, but I've heard about it from friends/relatives who ended up in the ER over the past few years. They ran the gamut from a 20-odd-yr-old dread-locked college kid to a 40-something-yr-old federal gov't employee to a 60-odd-yr old schoolteacher to an 50-ish engineer at Grumman. All complexions, all sensibilities, nothing remotely shady about any of them. Two had broken bones: 1 femur (which has to be painful AF since that's the strongest bone in the body, yes?), 1 tib/fib). One had a torn rotator cuff. One had a skull fracture. One had a crushed spinal vertebrae. But they all ended up in the ER after mishaps & they all said they spent long hours there, in serious pain. Even after seeing the doctor, even after all the necessary diagnostic scans, they got nothing for the pain stronger than APAP or 800mg of Motrin.

    And they all ended up thinking it was a racial thing, that their doctors must have felt they were engaging in what your profession calls "drug seeking behavior". (Funny how nobody says that when a patient wants to refill their insulin or they ask to be put on anti-depressants.) Or thinking that their pain wasn't severe enough to warrant giving them narcs.

    And I would always say they were trippin' because until last year, I really believed that the vast majority of ER/trauma docs really are colorblind -- it's a job requirement for them. When multiple ambulances roll up to the ER after a gunfight, the trauma docs treat the cops & the gangbangers & the civilians with no thought of who shot who. Which is not to say I think doctors can't be racists. But I always thought trauma docs had some sort of Personal Feelings Chip that they removed before they went into work every day. Otherwise, they couldn't do their job properly. (And if they didn't check their prejudices at the door, a whole lotta Blackfolks would never make it out of the ER in some cities.)

    Then when I read this last year, I realized what an idiot I'd been. Maybe as a trauma doc you already knew this was true. But it shocked me to my core to think that thousands of Black people who end up in the ER in America are denied pain meds for no reason other than their race. Clearly, there really are trained physicians out there who believe that Black people's blood clots faster or that we don't feel pain as much as other races do. But how the fuck is that possible in the 21st century with all the science & technology your profession has available? Do you know doctors who think such things?

    (cont'd)

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    1. whenever I roll on a person with a severe injury, I have noticed that the medics' first order of business is to try to get the patient into a condition that allows them to get some pain management on board. if noting else, this makes the process of getting them packaged for delivery much quieter.

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  5. (cont'd)

    2) America has an ever-expanding group of narcotic addicts that doctors happily supply with refill after refill & nobody says shit about it. They're old & sickly & going to die soon (esp. since the APAP in Lortab & Percocet trashes your liver over time). But apparently, they're not as interesting to journalists as all the middle-&-working-class White suburbanites & rural residents who are dropping like flies from heroin now that Oxy has become impossible to get. (Unless you're on Social Security.) Oddly enough, I don't remember seeing panels of doctors & politicians testifying before Congress about the Black & Latino inner city kids overdosing on heroin back in the oughts.

    I realize you don't provide routine care to geriatric patients, Doc. But why do your peers express such concern now about excessive narcotics use in people under 50 but seem to have no qualms about the same habits in oldsters?

    From my general observations of (some) older relatives, it seems that folks can be addicted to narcotics & function just fine, for DECADES, as long as they keep getting their refills. Nobody's grandma breaks into a pharmacy to support her habit. And they rarely overdose because Rx narcotic doses are incredibly consistent so their effects are highly predictable for the user. Old folks aren't popping Percocets to get high -- they need them to control intractable pain from bad backs, bad knees, etc. And the drugs don't kill the retirees, at least not for a long time. Their doctors are perfectly content to keep refilling their Rxs & let them live their out their comfortably addicted lives. And the media & the politicians don't seem to notice. And nobody, esp. not doctors, moralizes about feeding the habit of aged addicts.

    I know this is not your wheelhouse, since trauma surgeons don't have a practice with patients they see routinely over long periods. But isn't it hypocritical of a doctor to deny pain meds to injured addicts in the ER while their colleagues casually prescribe them to pensioners? Everyone laments when a young addict overdoses on smack because they can't get safe Rx pain meds, yet nobody sheds a tear for the addicted old folks who get to live long lives because Big Pharma makes sure their drug of choice is safely manufactured.

    S'just not right. People in pain deserve effective pain meds -- period. No matter what their race or age or personal history.

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    1. I commented below, but would also like to point out that adequate pain relief isn't always narcotics. I watched my husband cry, lying on the hardwood floors for 3 days because his back and left leg were hurting him so bad. I finally took him to the ER. We told them all the medicine he was on including narcotics for chronic back pain, sciatica, foot drop from a herniated disk and previous back surgery. He stayed in a fetal position on the stretcher because bringing his knee up as close to his face was the only relief he could get. The doc first tried Ketoralac and something else that didn't work. About 20 minutes after that, he was given a steroid in the hip and I watched the clock and 6 minutes later he said he could feel it working and was able to let down his leg for the first time in 3 days. He had almost immediate relief 10 minutes later and we were being discharged. Once the inflammation was taken care of in his back, his narcotics finally took effect and he rested well that night and was able to get up and go to work 1 day later. I have a painful skin disease called Hiadrenitis and pain relief for me is lidocaine patches and warm wet soaks and meditation along with opiates as needed. So my point is.....effective pain relief isn't always a narcotic.

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    2. I wholeheartedly agree with EB' s final statement. Sometimes an anti inflammatory or muscle relaxant can improve pain by working on the cause, rather than just telling your brain it doesn't hurt.
      Now, my points...
      1) It is hard to comment on why one doctor does things differently than another without all the facts, so I wouldn't expect Doc to be able to sort that out for you.
      2) It is kinda comparing apples to oranges to ask about prescribing practices related to long term stable opiate users vs. the opiate abusers. Both are addicted, but need to be approached differently.
      Most of the stable long-term users got started on their medication for pain. They were either not tried on enough nonnarcotic therapies to find one that worked, or really couldn't get relief without narcotics. These are the people who go to pain management clinics, show up with their medications to be counted, have no unexpected results on their tox screen, and don't "run out" or lose their prescriptions. They are addicted, but not abusing narcotics.
      The narcotic abusers are the opposite. They may have started on opiates for pain as well, but they continue with them for different reasons. They frequently need increasing doses because the one they are on "doesn't work." Their Rx doesn't last as long as it should, they use additional substances, they look for other sources for narcotic prescriptions.
      3) In an effort to limit narcotic overuse, it is common to start with a nonnarcotic medication and move towards narcotics if that doesn't work. There are exceptions, obviously, but those are the current recommendations. Example, I had a guy with chronic spinal pain. Had injection by the pain specialist, got better, then worse again. His oxycodone wasn't cutting it. I gave him an oral, minimally sedating muscle relaxant and poof! Lots better and "I'm ready to go, doc!"
      4) It can be very difficult to control severe pain in someone who's used to taking opiates regularly. Every doctor has an amount of opiates that they do not feel comfortable exceeding, and these folks can push past this quickly. Sometimes, it's just not safe to give more opiates. The opiate abuser will scream and yell and insist on more opiates. The addicted, but not abusing guy? He will take the other medications you offer and understand that you are doing your best to treat his pain and keep him safe.

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    3. my wife switched from oxy to a non narcotic pain medication and found the new medication worked better.

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    4. RC - That comment is way too long for me to answer in its entirety, but there are a few points I will address.

      First, I have absolutely no qualms about giving narcotics to patients with serious injuries. None. I do it routinely with barely a second thought. These patients may be old, young, narcotics naive, or addicts, and it doesn't matter. A femur fracture, for example, gets morphine to start, and I escalate from there if necessary.

      On the other hand, patients without serious injuries do not get narcotics. Full stop. A facial fractures (as this patient had) does not count as a serious injury, so he would not have gotten narcotics from me regardless of his history. As a few other folks have already said, I did try to treat his pain. He refused my attempts because I refused to give him what he wanted.

      Then you said "But does that edict really require you to play the morals police when your patient has a drug habit? You're not a social worker or therapist"

      That is a very naive view of what I do. Yes I fix holes, but at times I DO need to act as the "morals police" and do the right thing. I've told many people "My job is not to make you happy, my job is to make you better." And giving people narcotics who DO NOT NEED THEM is NOT making them better.

      As for racial bias, I cannot speak for my colleagues around the world. I think I have made it abundantly clear that I treat everyone exactly the same.

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    5. @ B's Mom--

      "In an effort to limit narcotic overuse, it is common to start with a nonnarcotic medication and move towards narcotics if that doesn't work."

      That must be new. I was prescribed OxyContin when my wisdom teeth were removed in HS.

      Never again. High is very overrated.

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    6. The qualifying portion is "In an effort to limit narcotic overuse." If a provider doesn't care, or is too busy, or is too focused on their patient satisfaction scores or whatever, then they will ignore this notion all together.
      Don't get me wrong, I agree with Doc, if what you have is big and bad, I will go straight to the big guns. An open fracture or an abdominal catastrophe are not going to feel much better with Tylenol.
      The key is that the provider engage in a second of thought, not just the blanket application of narcotics.

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    7. Oxycontin is standard for wisdom teeth removal, as i and many people i know can attest to having been given it. Strangely enough neither that or right after the surgery did I feel high at all- i felt vey normal and just lacked pain. Same with my sister I have no idea why

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  6. RC,
    Doc B DID attempt to help manage this asshole's pain. He ordered several medications that would have helped this guy, but this Robbie refused it all, saying all the things "drug seekers" say. Doc B wasn't withholding medication due to morals or prejudice or whatever you assumed he was doing. He was simply following protocol for treating pain with an addict.

    As an RN, and chronic pain sufferer, I would welcome any kind of pain relief prescribed to me during an emergency. There wasn't any medical reason to keep this man in the hospital and he refused care. Yes he probably was in quite some pain with this injury, but behaved horribly and was refusing first line treatment. Doc B did what he was supposed to do.

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    1. a doctor is obligated to treat injuries. the doctor is not required to treat sobriety or enable addiction. the fact that some doctors are only too happy to enable addicts is beside the point.

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  7. And ppl wonder why I want to work in a NICU or PICU - situations like this are rare and generally occur TO the child, from no fault of their own.

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  8. I had a cesarean section for my son in 2014. I was given a spinal numbing agent, morphine, and then a slew of narcotics as well as ibuprofen 800. I ended the narcotics without a wean off, and was addicted as a new mother, recovering from surgery, 10 days after. It was a horrible feeling, i was nit high, but i was not in pain. I had post partum, because i was not suppported in my birth choices, and now i was unable to properly care for myself and newborn for some months afterwards.
    I had my wisdom teeth taken out in may last year, and compared to my major surgery, ibuprofen barely crossed my threshold.
    I hate taking medicine, especially ones that can be addictive or cause day to day problems, like plumbing issues.
    I am pregnant with my second child now, and will rock my vbac in the coming months, and one thing i look forward to most is not being compromised by narcotics or pain medicine with 2 children to care for. I try pressure points, stretching, massage, compresses, and then medicine as a last resort for pain, though i am the type to get pain checked to be sure i am ok. It hurts, but as long as i am ok, i will endure.

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  9. best wishes on your second. hope everything goes well.

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    1. Thank you, Ken. I am currently the punching bad for a future MMA baby, if his antics prove anything. He is full of spitfire, and it makes me proud.

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    2. I think I would find that a bit uncomfortable.

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    3. As you are a bloke it would be very uncomfortable as well as ground breaking :D

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    4. Ken,
      I can only really describe it as maybe Gas pains to a man. But not painful ones. It's neat having an alien inside. A bit cumbersome, and unwieldy getting around with my center of balance and gravity shifted, but I love it.
      He has not kicked me hard enough to cause me to get sick or soiled, but I am only 25 weeks. Estimated to be due in May.
      Now to go argue with doctors about bodily autonomy and right of refusal for my birth on Wednesday!
      Tania, have you seen the Facebook commercial about if men lactated?! It was quite a hilarious little clip.
      Thank you, Doc B! Long time follower!

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  10. What a sad story. Would have left me speechless too.
    Beautifully written.

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  11. Late to this thread but hoping I may get an answer... I am have a long history of anemia and GI bleeding, NSAIDs are my nemesis, even in small doses. I am afraid to tell my doctors or if ever needed an ER doctor, because of articles just like this. I can take acetaminophen but it's not as effective and I've usually tried it before seeking help. These are the things that make it harder to be your own advocate, if you know too much it makes you look suspect.

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