Damned if you do, damned if you don't

[EvoDevo]

Saw this in this morning's ACEP email, and it really bothers me. I can see the day where a physician gets hammered for the patient's poor judgment. While on the other hand we get hammered by administration because we "Didn't do anything to treat the patent's pain."


http://www.latimes.com/news/local/la-me-rxdeaths-20121113,0,510353.story

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[docB]

I assumed this would be about tPA for stroke but this is a huge deal too.

I don't think anyone outside of medicine and EM in particular realizes (or could give a crap about) all the competing issues we are dealing with now. In the last 10 years so many new trends have emerged including patient satisfaction, stewardship of various things, new things like pain as the 5th vital sign and so on. Good medicine is now only a competing goal.

 

[EvoDevo]

You're right. I should clarify that this article talks about automatic medical board review for any pt where Rx od is the cause of death and sanctioning the prescribing physician.

 

[EctopicFetus]

Perhaps I am still too idealistic but I think this isnt bad. It will tighten up some of the EM docs who hand out narcs like tic tacs. My typical is 12 pills. If someone has a real injury they get more. 12 is enough to get someone through the acute problem they have going on and gives them enough time to see their other doc.

 

[GeneralVeers]

Perhaps I am still too idealistic but I think this isnt bad. It will tighten up some of the EM docs who hand out narcs like tic tacs. My typical is 12 pills. If someone has a real injury they get more. 12 is enough to get someone through the acute problem they have going on and gives them enough time to see their other doc.

I agree. Too many doctors have turned patients into addicts because of their lax prescribing policies. 90% of the "chronic pain" patients are really just drug addicts who've become addicted due to overzealous doctors.

 

[EvoDevo]

You guys are right.I guess what upsets me are the numerous visits from "patient advocates" who make me take time out from my other patients when my drug seekers complain....

 

[docB]

I agree. Too many doctors have turned patients into addicts because of their lax prescribing policies. 90% of the "chronic pain" patients are really just drug addicts who've become addicted due to overzealous doctors.

And in many areas "pain management" is a joke. As Veers can attest in Vegas (and some other cities) I never have a pain patient mention their contract. None of them here are even on contracts.

You guys are right.I guess what upsets me are the numerous visits from "patient advocates" who make me take time out from my other patients when my drug seekers complain....

I agree. The stance where every complaint is taken seriously is pressure on us to acquiesce to the seekers. The fact that administrators and medical boards don't understand this is silliness.

 

[EctopicFetus]

I guess its different. We have a "pain Protocol" to prevent us from having to be pseudo chornic pain docs. Simply put its not our realm and pressure from administrators has cause some docs in my community to prescribe narcs we dont really work with. (dilaudid tabs, methadone etc).

Personally outside of percs, vics and an occasional oxycontin, morphine IR i dont prescribe other narcs. I dont know them, I never prescribed them in my training and anyone wantign that, their fentanyl patches etc needs to find another doctor.

I dont think the article or what the people in cali hope to accomplish would affect most normal ED docs.

We had a case in town where a doc prescribed his wife over 500 narc tabs in a month.. I think thats a problem.

 

[Old_Mil]

I only order or prescribe narcotics for objective pathology that is verified by my retina, my radiologist, or my lab. Also, for the "pan allergic" patient I tell them that "i'm sorry - you seem to be allergic to both classes of pain medicines. I really don't want to give you something that could result in you having a fatal reaction" in the most apologetic tone I can muster.

I usually manage to seriously piss off 1-2 seekers a year with this approach, but word gets out and I see far fewer of them overall.

 

[EvoDevo]

I only order or prescribe narcotics for objective pathology that is verified by my retina, my radiologist, or my lab. Also, for the "pan allergic" patient I tell them that "i'm sorry - you seem to be allergic to both classes of pain medicines. I really don't want to give you something that could result in you having a fatal reaction" in the most apologetic tone I can muster.

I usually manage to seriously piss off 1-2 seekers a year with this approach, but word gets out and I see far fewer of them overall.

I get this and I practice like this. However for now I get the feeling that patient "satisfaction" is sometimes more important than the medically right thing.

Oh, and I hate self-proclaimed VIP patients. The WORST in my experience and unreasonably demanding...

 

[Apollyon]

I get this and I practice like this. However for now I get the feeling that patient "satisfaction" is sometimes more important than the medically right thing.

Oh, and I hate self-proclaimed VIP patients. The WORST in my experience and unreasonably demanding...

"Don't you know who I am?"

I'll tell you a story, completely true:

Two car MVC. Car #1 rear ends car #2.

Guy in car #2 gets out, yelling, "Do you know who I am? I'm Lindy Ruff!" (former Buffalo Sabre, now coach)

Guy in car #1 (who hit #2) gets out, and keeps getting out (because he is HUGE), and yells, "Do YOU know who I AM? I'm Craig Wolfley!" (former NFL player for the Steelers)

True story, from around 1994, maybe 2-3 years earlier.

 

[JacobMcCandles]

"Don't you know who I am?"

I'll tell you a story, completely true:

Two car MVC. Car #1 rear ends car #2.

Guy in car #2 gets out, yelling, "Do you know who I am? I'm Lindy Ruff!" (former Buffalo Sabre, now coach)

Guy in car #1 (who hit #2) gets out, and keeps getting out (because he is HUGE), and yells, "Do YOU know who I AM? I'm Craig Wolfley!" (former NFL player for the Steelers)

True story, from around 1994, maybe 2-3 years earlier.

I would have been in car #3 saying, "I don't know who either of these idiots are".

 

[Apollyon]

I would have been in car #3 saying, "I don't know who either of these idiots are".

You kinda miss the point. At the time, these were name people.

 

[RustedFox]

I would have been in car #3 saying, "I don't know who either of these idiots are".

This.

I have a similar story. I went to undergrad at a place with a big-time basketball team. I remember being out at the pub one night with my buddy. He has a menu in hand and an empty seat next to him (on the opposite side of me). He has the bartender's attention, and is trying to order some food. Some hotshot basketball player interrupts him not once, but twice by slapping him on the shoulder and saying - "Is anyone sitting here ?" My buddy ignores him the first time, then after the second time (which was clearly done with more of an attempt to interrupt), I pipe up:

"Hey, can't you see that he's trying to order his dinner?"

"Do you know who I am?" - comes the reply.

"Nope. Do you know who I am ?" - I retort. "Good, so we're strangers in a bar. Its rude to interrupt someone trying to order his dinner. Nobody is sitting there. Take the chair."

B-baller takes the barstool and walks away.

Friend looks at me, says - "That was Javon McBasketBaller. He's the starting point guard. He's in your western civ class."

I look back - "Wow. I'm RustedFox, and I'm hungry. No idea if he even takes classes, or shows up to them. He certainly has no sense of politeness."

The "entitlement mentality" of athletes drives me nuts. You got a free ride to a Division-I school only to piss it away with a few misdemeanors and get zero meaningful education out of it ? Not impressed.

I know I'm going to be regarded as "lunatic fringe" when I say this (WARNING: TANGENTIAL RANT COMING), but Universities should get in the time machine and go back to a time where if you weren't going to do something useful with your education and time spent there.... then you had no business being there. I know legions of "psych" and "communications" majors that did nothing but party away their 4.5 years, and now they're drowning in debt and can't find a job.

You wanna do something professional and useful with your life ? Go to a university, make the most of it. Wanna play basketball and smoke various quasi-legal substances, and maybe appear as an extra on a rap album ? Go.... somewhere else. You can do that without a degree.

 

[Farmer2DO]

At the time, these were name people.

Especially in our home town.

 

[docB]

I know I'm going to be regarded as "lunatic fringe" when I say this (WARNING: TANGENTIAL RANT COMING), but Universities should get in the time machine and go back to a time where if you weren't going to do something useful with your education and time spent there.... then you had no business being there. I know legions of "psych" and "communications" majors that did nothing but party away their 4.5 years, and now they're drowning in debt and can't find a job.

You wanna do something professional and useful with your life ? Go to a university, make the most of it. Wanna play basketball and smoke various quasi-legal substances, and maybe appear as an extra on a rap album ? Go.... somewhere else. You can do that without a degree.

I apologize about continuing the tangent but...

I totally agree. I've work as a minor league team doc in 2 sports (baseball and hockey). Both of these sports have actual minor leagues. The players have the choice of going to college or not. If they go to college for the most part they want the degree because they know sports don't last forever. If they're more the type you alluded to then they can go minor league where their BS doesn't tarnish their school.

Football and basketball don't have minor leagues so the NCAA fulfills that role. And the result is a corrupt system that is at best an educational farce and at worst a frequent embarrassment to the schools. The big sports schools need to rehab off their addiction to sports money and let the NFL and NBA run their own minor leagues.

Since the above will never really happen the next best thing would be to spin off the NCAA and let every school sponsor professional, minor league teams. That would at least cut down the outright hypocrisy the current system creates.

/endhijack back to your regular thread

 

[RustedFox]

*** Continuing Hijack ***

- and I love my minor-league baseball and hockey. Such a great atmosphere, such great seats, such a great experience. When I was a resident, I would go to my minor-league ball/puck games every chance I got.

Want an education ? Go to skule. Wanna play ball ? Go play ball.

 

[RustedFox]

I also recently learned that there exists an "NBA D-league". No idea where it is, or where anyone can go see a game. I later learned that the "D" stood for "developmental". I thought it might have stood for "drugs, delinquents, dropouts, deejays"... whatever.

 

[southerndoc]

While we're on the subject of "do you know who I am?", this gentleman pulls this crap on me while in a restaurant after I accidentally bumped into him. WTF? So this very prominent politician walks in with his security detail on his way to a private function. The "do you know who I am?" guy says "oh wow, it's so and so." The politician walks straight up to me, says hello, shakes my hand, says it's been a while and I should call him so we can have lunch sometime to catch up. He walks off and then my wife looks at the entitled guy and says "uh huh, that's right, do you know who we are?"

 

[RustedFox]

The concept of an NFL minor-league really intrigues me. I might have some insight as to why this doesn't exist. When I was an MS 3/4, I had a buddy/roommate that was, quite frankly, minor-league-football material. He was a hulking monstrosity of a man, and I was (and still am) not a physically impressive individual. He was a graduate-level student in education at the time. We went to the pub together, went to the gym together, and to this day, are still really good buddies. He played "starting center" for a number of minor-league east-coast football teams as they flickered into and out of existence. I went to a lot of his games; watched him brutalize opposing d-linemen. Guy meant business. I remember asking him one day why we couldn't get a "North Jersey Football League" going. I remember what he said:

"Well, Sanchez (the "franchise" running back) only shows up to half of the practices, so he's never clear on the run-plays. Our QB shows up blazed (i.e. - "stoned on marijuana") every day, and the d-backs all have baby-momma troubles. Getting everyone to "practice" together is a real challenge, given the court dates and all."

Imagine being a problematic shortstop or left-winger. Your ass would be replaced, sharpish. Something about the culture of football/basketball "allows" for this sort of nonsense. Thus, trying to organize a minor-league football TEAM (let alone a league) is akin to herding ostriches into a sandbox.

 

[zinjanthropus]

I would have been in car #3 saying, "I don't know who either of these idiots are".

 

[Old_Mil]

What exactly makes pain management physicians - who spend 99% of their time around seekers in a clinic - think they are any better at appropriate narcotic prescribing that ER physicians who see a spectrum of disease from dissection to drug seeking?

 

[med2UCC]

Ah, pain management, the bane of every emergency department in the developed world. To add to our woes, our hospital is currently having a "Chronic Pain awareness" week, so right above the entrance to our emerg, which is sadly also the front door of the building, is a huge banner that proclaims "Pain can't wait!". I should have taken the whole week off. Had I only known what was coming when I sent in my schedule requests. Cheers,
M

 

[WilcoWorld]

Ah, pain management, the bane of every emergency department in the developed world. To add to our woes, our hospital is currently having a "Chronic Pain awareness" week, so right above the entrance to our emerg, which is sadly also the front door of the building, is a huge banner that proclaims "Pain can't wait!". I should have taken the whole week off. Had I only known what was coming when I sent in my schedule requests. Cheers,
M

Our hospital recently had "If I lived in a world without pain, I would..." quotes all over the desktops. I kept wanting to yell, "If I lived in a world without pain, I would not be able to perceive noxious stimuli so I WOULD DIE."

 

[docB]

What exactly makes pain management physicians - who spend 99% of their time around seekers in a clinic - think they are any better at appropriate narcotic prescribing that ER physicians who see a spectrum of disease from dissection to drug seeking?

Good point. I have a TON of respect for the pain docs out there that actually practice pain medicine. I could never do what they do. You can tell the good ones because they inherit these addicted train wrecks and they immediately put the patient on a contract, stabilize the narcs (which have always been increasing), figure out what's actual pain and what's addiction/withdrawal,institute non-narcotic modalities and then start the narc taper. The patients love the good ones even though they are cutting them down.

We, on the other hand, are expected to treat each of these seekers as a legitimate ACUTE issue and treat their pain and make them "satisfied." That's a recipe for disaster.

I was in a meeting the other day and one of our head nurses wouldn't even use the term "seeker" believing it to be impolitic.

 

[EvoDevo]

I was just thinking about this today. There definitely seems to be two broad nursing groups:

1. Have drunk and the kool-aid and are always on you to" do something more" for the bs pain.
2. The hardcore "just suck it up, Sally!" group. Got love 'em!

 

[EvoDevo]

Also took care of a kid who's going to be starting for my local college football team. Wickedly talented, but humble. Hope that he stays that way...

 

[med2UCC]

Our hospital recently had "If I lived in a world without pain, I would..." quotes all over the desktops. I kept wanting to yell, "If I lived in a world without pain, I would not be able to perceive noxious stimuli so I WOULD DIE."

Yes!! Absolutely! God I hate chronic pain. But even more I had the fad that currently has us treat it as "the 5th vital sign" and treat all of the malingerers and the seekers and the addicts the same as the guy with the crushed femur or the kidney stone.
M

 

[8654Marine]

What gets me is the way a lot of chronic pain patients get shuttled around: They call the office cause the meds aren't working. The on-call doc tells 'em to go to the ER. The primary doc, later, calls blasting the ED for giving them pain meds and admonishes NO MORE NARCOTICS! Later, the patient calls the office for increasing pain, the on call doc tells 'em to go to the ED for more pain meds...

The worst are the CHRONIC LYME patients. Already on Doxy and a Cephalosporin for a year.

 

[southerndoc]

What exactly makes pain management physicians - who spend 99% of their time around seekers in a clinic - think they are any better at appropriate narcotic prescribing that ER physicians who see a spectrum of disease from dissection to drug seeking?

There's a difference in a pain management specialist and a doc running a pill mill. A true pain specialist will use other alternatives to narcotics (Lyrica, gabapentin, epidurals, etc.).

 

[Hypomanics]

I was just thinking about this today. There definitely seems to be two broad nursing groups:

1. Have drunk and the kool-aid and are always on you to" do something more" for the bs pain.
2. The hardcore "just suck it up, Sally!" group. Got love 'em!

You forgot the category that includes nurses who couldn't care less either way, but just want you to give the patient the narcotics so they will stop bothering them.

 

[la gringa]

There's a difference in a pain management specialist and a doc running a pill mill. A true pain specialist will use other alternatives to narcotics (Lyrica, gabapentin, epidurals, etc.).

this... the good ones are also much better than ortho or neurosurgeons at diagnosing the cause of spine pain. they know the good PT's and pain psychologists etc... but you have to WANT to get better for them to help you!