Alcoholism and the ER

[thegenius]

Anyone think that the ER probably does more to allow people to continue drinking alcohol than to stop drinking?

Took care of a guy today who has been to the ER numerous times, and admitted numerous times, for complications from EtOH. The very first thing he said was "I having pancreatitis from my drinking." He was honest, and I said I appreciated his honesty.

Now, what would happen 100 years ago was these people would sit around at home in pain for several days, vomiting, and go through hell and eventually get better. Maybe a very small subset of them would die due to EtOH withdraw or complications from pancreatitis. But the vast majority would live.

Today we pump them full of LR, morphine/vitamin d(ilaudid), zofran and they get better much quicker, allowing them to drink much more quickly (at least so I think).

My guess is that we are not necessarily enabling them to drink more, they are going to drink no matter what. It just seems like we are easing their natural, toxic pain from alcoholism more easily these days. It's a terrible disease. Probably foolish to think that "they would learn a lesson from the harsh toxic realities of acute gastritis or acute pancreatitis so lets let them suffer."

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[hundreddaysoff]

Anyone think that the ER probably does more to allow people to continue drinking alcohol than to stop drinking?

Took care of a guy today who has been to the ER numerous times, and admitted numerous times, for complications from EtOH. The very first thing he said was "I having pancreatitis from my drinking." He was honest, and I said I appreciated his honesty.

Now, what would happen 100 years ago was these people would sit around at home in pain for several days, vomiting, and go through hell and eventually get better. Maybe a very small subset of them would die due to EtOH withdraw or complications from pancreatitis. But the vast majority would live.

Today we pump them full of LR, morphine/vitamin d(ilaudid), zofran and they get better much quicker, allowing them to drink much more quickly (at least so I think).

My guess is that we are not necessarily enabling them to drink more, they are going to drink no matter what. It just seems like we are easing their natural, toxic pain from alcoholism more easily these days. It's a terrible disease. Probably foolish to think that "they would learn a lesson from the harsh toxic realities of acute gastritis or acute pancreatitis so lets let them suffer."

No argument. The perspective of my admin on this is the customer is always right. They want us to feed the bears. More treatments, more admissions, more money.

My residency experience was that the academic perspective is basically the same; they just spout more altruistic foma about it. The two exceptions were attendings I had who refused to feed the bears and, not coincidentally, no longer work at my residency (not for lack of good care, just for lack of going with the flow on this and many other things; they happened to be 2 of my 3 favorite attendings there and had the greatest impact in how I actually practice day to day as an attending now).

But I'm not much of an idealist. If I admit 100 garden-variety acute pancreatitides to prevent one from necrotizing and needing surgery, I'm OK with that. (Usually I draw the line at giving 'em Dilaudid though.)

 

[d2305]

I always tried to point them toward AA, but most of them were rudderless.

 

[Birdstrike]

Most of the time what you do in the ED with addiction is futile, but not always. Here's a weird story.

The last ED I worked in, I had this one partner who was the same height, same hair color and looked similar enough that he and I would get confused at times. One day I was at my computer doing what doctors do, going click click click clickclickclickclickclick mousing in some data with eyes tethered by beams of light to a computer screen. He comes around the corner and goes, "Lol. I walked into this room to see this patient and she runs up, gives me a big hug and says, 'Thank you Dr. Birdstrike! You saved my life!'"

I was a little puzzled, "Wait. Your patient thanked you for me saving their life?"

"Yep. I looked her up, and you saw her a couple years ago. She was here for a bad drinking binge. She says you talked to her and after that she got clean. She says you saved her life. She thought I was you. Lol."

Apparently, the talk we had was the spark for her to go to AA and whatever I said, somehow stuck. And in such EM fashion, it touched her deeply enough to thank (someone other than) me for saving her life! Lol I never went in there to actually talk to her that day. But I remember to this day the message she sent, through my doppelganger.

 

[sah]

Most of the time what you do in the ED with addiction is futile, but not always. Here's a weird story.

The last ED I worked in, I had this one partner who was the same height, same hair color and looked similar enough that he and I would get confused at times. One day I was at my computer doing what doctors do, going click click click clickclickclickclickclick mousing in some data with eyes tethered by beams of light to a computer screen. He comes around the corner and goes, "Lol. I walked into this room to see this patient and she runs up, gives me a big hug and says, 'Thank you Dr. Birdstrike! You saved my life!'"

I was a little puzzled, "Wait. Your patient thanked you for me saving their life?"

"Yep. I looked her up, and you saw her a couple years ago. She was here for a bad drinking binge. She says you talked to her and after that she got clean. She says you saved her life. She thought I was you. Lol."

Apparently, the talk we had was the spark for her to go to AA and whatever I said, somehow stuck. And in such EM fashion, it touched her deeply enough to thank (someone other than) me for saving her life! Lol I never went in there to actually talk to her that day. But I remember to this day the message she sent, through my doppelganger.

Very much as Dr. Birdstrike says. We dont have a high percentage of success turning addicted patients around. However, for the few, we may be there at that critical teachable moment to make a difference.

I have very close family and friends that have serious addiction problems. At times, they can suck the life out of you trying to figure out what to do to help them.

 

[gamerEMdoc]

Depends on your view of medicine. If you think the job of a physician is strictly to cure disease, then absolutely you are basically enabling them, because the chance of curing any addiction in a 10 minute encounter is very unlikely.

But our job isn’t really one of solely curing disease. Much of our job is to ease suffering, even though we can’t ever cure someone’s disease. Alcoholism and drug addiction are not glamorous lifestyles, those people are miserable. Sometimes sitting down and just talking to them like you would any other patient with a disease, like cancer, and offering them whatever help you can does make a difference. Just treating them like a person, not an addict. Many times it doesnt, but Ive been thanked by many addicts before, never for giving narcotics, but just sitting and talking to them about their addiction.

 

[bearstanley]

this is a patient population who i still really love to serve. i know i'm an idealistic hippy resident, but still. these people in particular are want for kindness, and it's rewarding (to me, still, currently) to provide that.


... old man down... way down, down; down by the docks of the city...

 

[Birdstrike]

this is a patient population who i still really love to serve. i know i'm an idealistic hippy resident, but still. these people in particular are want for kindness, and it's rewarding (to me, still, currently) to provide that.


... old man down... way down, down; down by the docks of the city...

Was his name August West, by chance?

 

[RustedFox]

Curtis Loew.

 

[Birdstrike]

Curtis Loew.

Aha. Speaking of southern rock (which I love) have you heard of Blackberry Smoke?

Saw them live. They’re awesome. I’d put them right of there with Skynyrd. Lots of great songs.

Listen

 

[RustedFox]

Aha. Speaking of southern rock (which I love) have you heard of Blackberry Smoke?

Saw them live. They’re awesome. I’d put them right of there with Skynyrd. Lots of great songs.

Listen

I know of Blackberry Smoke.
But I only learned about them two years ago or so.
They are pretty awesome.
I'll put "The Steeldrivers" on that short list, too - with country powerhouse Chris Stapleton being the central character, there.
"Hammer Down" is such a fantastic album... from track 1 to track 14.
Saw Chris Stapleton live two summers back. He actually stopped the concert because two idiots were getting into a fracas near the front to be able to see the show. He called 'em out, told them to behave or else he would call their mama's, then started the song again once they'd calmed down.
What a guy.

 

[thegenius]

I have very close family and friends that have serious addiction problems. At times, they can suck the life out of you trying to figure out what to do to help them.

That's how I feel most of the time. I take a pretty narrow view of Emergency Medicine and it's the single one thing that I wish I could easily change. Because I think if I ever get driven out of the ER it will be due to the following. If you don't need to be acutely resuscitated and if you don't have an emergency medical condition, I lose interest and think about the next patient waiting to come in. This is what I think the ER was designed for in it's nascent stages in the 70's and 80's, but now we are expected to do a whole lot more, including things like public health monitoring and reporting, being available so other doctors (surgeons, cardiologists, GI) don't have to live in the hospital, provide weather-appropriate clothing for homeless, screen and begin treatment for chronic diseases like high blood pressure and diabetes, symptom relief, and customer service. And I'm not really trained in most, if not all of these things besides identifying and treating EMCs and resuscitating acutely ill people.

I would probably feel different if I approached addiction as if someone had cancer. Someone smokes for 40 years. Now they have lung cancer and chronic pleurodynia. For whatever reason I really don't have any compunction giving them dilaudid because they have cancer. But if you drink and get pancreatitis over and over and over, I hate doing it. In both cases you are addicted to a substance that is toxic and slowly kills you.

 

[scummie]

Had a patient that drank a bottle of hand sanitizer to prevent withdrawal. ETOH was about 200. Yum.

 

[gutonc]

Had a patient that drank a bottle of hand sanitizer to prevent withdrawal. ETOH was about 200. Yum.

Used to see that all...the...time at the VA when I was a resident.

They had to switch to a CHX based product and post signs saying there was no alcohol in it.

 

[VA Hopeful Dr]

Used to see that all...the...time at the VA when I was a resident.

They had to switch to a CHX based product and post signs saying there was no alcohol in it.

Listerine was prominent where I did residency

 

[gutonc]

Listerine was prominent where I did residency

The funny thing is that the VA had beer available to be prescribed to alcoholics who were not interested in quitting, to help with w/d. So if you admitted to drinking a 5th of vodka a day, you'd get a few beers a day unless otherwise medically contraindicated. But the ones who lied and said they didn't drink, or undersold how much they drank, were the ones who used to pull the stuff off the wall and drink it.

 

[Birdstrike]

Because I think if I ever get driven out of the ER it will be due to the following. If you don't need to be acutely resuscitated and if you don't have an emergency medical condition, I lose interest and think about the next patient waiting to come in. This is what I think the ER was designed for in it's nascent stages in the 70's and 80's, but now we are expected to do a whole lot more...

This is exactly what finally broke me. When the “sub-15 min door to doctor time” for people who weren’t sick became more important than people who needed their lives saved, I knew I couldn’t justify the toll the cancer of circadian rhythm destruction took on my peace of mind and family life.

That’s when it became, “Get out before you stroke out.”

 

[scummie]

This is exactly what finally broke me. When the “sub-15 min door to doctor time” for people who weren’t sick became more important than people who needed their lives saved, I knew I couldn’t justify the toll the cancer of circadian rhythm destruction took on my peace of mind and family life.

That’s when it became, “Get out before you stroke out.”

I totally hear you and agree. Had an absolutely soul sucking shift yesterday and starting daydreaming about just driving away and not coming back. I am basically a new grad, 1 year out, and am worried if I’ll make it to 10 years. Unfortunately I have a lot of loans and didn’t marry someone rich. But I have hope that there’s a dream hospital, one where physicians are supported, where patient care is more valued than customer service and there are resources to do the care. Not, don’t go on diversion because that makes the numbers look bad, or every suicidal patient goes to the front of the rack, skipping everyone else. Even if they were suicidal two other times that day! Triage is in order of arrival, not acuity.

I could go on forever and I’m sure everyone here could add to that list of frustrations. In residency I would show up 15 mins early, take extra shifts, was in it to win it. This change is incredible. Isn’t it crazy that in 2019 it was finally okay to eat and drink at our computers? I ask a nurse to do something while they are on lunch break, forget it it. I’m stuffing my face with a sandwich, dictating with Dragon and signing EKGs at the same time. Do you dare heat something in the microwave? Ain’t pretty. The system is sucking us dry, turning around and asking for more. Then they say they care about wellness but don’t fix any of the systemic issues in the first place.

But so what? Not a great amount of faith in ACEP and AAEM is so small. So then try to find a SDG? Don’t take a job with team health or EMcare? Somebody else will. I don’t see a way forward for our specialty. This is not sustainable.

 

[Birdstrike]

Unfortunately I have a lot of loans and didn’t marry someone rich.

I didn’t either. My wife makes $0 per year and 19 years after graduating medical school, I still have a loan payment. I have 2 kids. They’ll both likely go to college + graduate school. The load I’m carrying made the “I’ll retire by 45” plan not an option.

I like you, was worried about “making it 10 years” and I didn’t. I made it 8 years (11 if you include residency). So I was dead set on making it so it didn’t have to make it 10 years because of exactly what you’re talking about. 2-3 years in, I started thinking about how I was going to make it sustainable for myself. Because the administrators won’t change the system for you and I. They have it set up to benefit them and they’ll never upend that. So, you have to formulate your own plan. Their “wellness meetings” are just a way to brainwash you into thinking it’s your fault that their system burns you out and that you need to do “X” so you can suck it up better.

So people go the administration route. Some open a free standing. Some search and search and find a place to work that’s a diamond in the rough. Some do a fellowship. Others seem to have that magic mindset that allows them to plug along unaffected while chaos swords around them. Some live career of quiet desperation. Some leave Medicine altogether.

For me, I decided to take a stab at doing a fellowship that couldn’t be more 180 degrees opposite from EM: Pain. It could have been anything else. I just happpened to get lucky, get it, and it’s worked out well because I have autonomy and no on tells me or pressure me to do anything I don’t feel is right.

While you guys look at me saying, “That sucks, I could never do what you do. That would be hell,” I plug along doing spine injections, kyphoplasties and nerve ablations. I wrote the occasional low dose script for an elderly person that needs it to walk, all while thinking, “I could never do what you do” and “how did I ever do it.”

Taking a year off to go back to training was hard. Losing a year income was hard. Leaving everything I knew was hard. Changing my mindset was hard. Moving my whole family to a new state, new city and paying for two homes for a year was hard.

But I get to sleep at night, go at my own pace, I’m never on call, don’t have to see or treat any patient I don’t want and administrators mean nothing to me.

You have to find what works for you. And you will find what works for you. But you have to demand it for yourself and realize you owe it to yourself. It’s not you who’s nuts. It’s them.

 

[TooMuchResearch]

This is exactly what finally broke me. When the “sub-15 min door to doctor time” for people who weren’t sick became more important than people who needed their lives saved, I knew I couldn’t justify the toll the cancer of circadian rhythm destruction took on my peace of mind and family life.

That’s when it became, “Get out before you stroke out.”

We're still resisting this stuff from our hospital systems, but I think it's only a matter of time before one of us is forced to sit in triage.

 

[GonnaBeADoc2222]

We're still resisting this stuff from our hospital systems, but I think it's only a matter of time before one of us is forced to sit in triage.

I'd be fine sitting in triage. One less midlevel to screw things up, and the correct orders put in.

 

[scummie]

I’d argue the bigger picture here is that addiction is incredibly hard to treat in the ED and either we are not the right setting or are under equipped to do so. They have a chronic issue that there is no definitive curative intervention. Oh, and they are usually rude if not also violent.

4 addicts last night, none of them sick. Varying levels, different substances. Took at least 60% of shift. 100% percent dramatic. -125% my life span.

 

[Groove]

Triage isn't the end of the world. In one of my old gigs (Schumacher site) we actually had a MSE "screening" shift for the physicians. It wasn't very popular at the time but would cook the numbers for admin. Those of us that volunteered for it quickly figured out that it would significantly increase our RVU/hr as you could treat and street tons of people. We had a few rooms for quick I&Ds or pt's needing a UA/BMP, etc.. Busy shifts, but very productive. On the receiving end, it was great to have these pt's dump into the main ED where a physician had started the work up. I would pick them up with all the appropriate labs ordered, sometimes even accompanied by MRIs and dimers, etc.. 99% of the time it was 100% appropriate.

 

[gamerEMdoc]

I typically do one to two provider in triage shifts a month. Super busy, but some of my favorite shifts. Allows me to work on my own a bit for a change of pace. And having a physician out there quarterbacking dept flow and accurately ordering tests during really busy days makes a big difference.

 

[thegenius]

I'd be fine sitting in triage. One less midlevel to screw things up, and the correct orders put in.

We sit in triage to make our numbers better. It’s manufactured improvements that doesn’t really help all that much. Well some days it makes a difference. But it is an easy way to make a lot of money. Relatively low risk. They people you discharge all tend to not even need the ER and thusly don’t have an emergency medical condition. Both the midlevels and docs take turns sitting in triage. The one thing that is nice about it is to be able to discharge, very quickly, about 15-20% of the baloney that comes in.

 

[gamerEMdoc]

We sit in triage to make our numbers better. It’s manufactured improvements that doesn’t really help all that much. Well some days it makes a difference. But it is an easy way to make a lot of money. Relatively low risk. They people you discharge all tend to not even need the ER and thusly don’t have an emergency medical condition. Both the midlevels and docs take turns sitting in triage. The one thing that is nice about it is to be able to discharge, very quickly, about 15-20% of the baloney that comes in.

Yeah, it no doubt greatly reduces your LWBS, because all the people that don't need to be there are in and out very quickly. It does make a difference beyond metrics as well. When you have a waiting room of 30 deep and no one has seen them, you don't know which of the 8 chest pains have an NSTEMI, which of the 10 febrile patients have early sepsis, etc. But by getting stuff done up front, and having someone screening the results, you can also make sure the sickest people come back quickly once labs are back, as opposed to traditional triage where you are guessing without any data other than vital signs who is the sickest and needs to come back now.

 

[hundreddaysoff]

Triage isn't the end of the world. In one of my old gigs (Schumacher site) we actually had a MSE "screening" shift for the physicians. It wasn't very popular at the time but would cook the numbers for admin. Those of us that volunteered for it quickly figured out that it would significantly increase our RVU/hr as you could treat and street tons of people. We had a few rooms for quick I&Ds or pt's needing a UA/BMP, etc.. Busy shifts, but very productive. On the receiving end, it was great to have these pt's dump into the main ED where a physician had started the work up. I would pick them up with all the appropriate labs ordered, sometimes even accompanied by MRIs and dimers, etc.. 99% of the time it was 100% appropriate.

By MSE do you just mean initial triage before rooming or MSE in the sense of "I have determined you have no emergent medical condition so either you need to pay us upfront to be seen or leave?"

Would love to do the latter for, like, 80% of our patients as it just seems like the right thing to do for them ethically. My understanding is it ultimately saves the patient money if they refuse to pay and choose to leave? So I'd think it'd actually be better for most ER patients (and their credit ratings) who don't need to be there and aren't trolls.

However, I've never tried an MSE. It wasn't in the culture of my residency for some reason and in my current job, our medical director forbid us from doing it at all after a seeker was discharged, immediately checked back in, was MSE'd by a busy doc, and immediately complained to admin that we didn't take her pain seriously.

 

[scummie]

By MSE do you just mean initial triage before rooming or MSE in the sense of "I have determined you have no emergent medical condition so either you need to pay us upfront to be seen or leave?"

Would love to do the latter for, like, 80% of our patients as it just seems like the right thing to do for them ethically. My understanding is it ultimately saves the patient money if they refuse to pay and choose to leave? So I'd think it'd actually be better for most ER patients (and their credit ratings) who don't need to be there and aren't trolls.

However, I've never tried an MSE. It wasn't in the culture of my residency for some reason and in my current job, our medical director forbid us from doing it at all after a seeker was discharged, immediately checked back in, was MSE'd by a busy doc, and immediately complained to admin that we didn't take her pain seriously.

We have a unique set up now where M-F during business hours, PAs siphon off 4s and 5s using the MSE and send them to the primary care clinic next door. My last year of residency, they started added triage shifts because of boarding and crowding issues. It is a pleasant surprise to have a chest pain patient brought back with all the labs, neatly done, and you just have to say “bye Felicia”. It also helps to get rid of bad nursing triage.

 

[deleted836128]

Ugh. Sometimes I agree with this. But this ONE time I had a patient with addiction that I helped. He came into the ER for an abscess and mentioned his years of heroin use and how he wanted to get clean. I offered a behavioral health consult but he refused. So I spent probably a half hour (legit... don’t know how I had time that day) to hear his story and see how and why he got addicted (felt like crap after running out of Percs after an Ortho surgery... Ortho Rxed more... ran out again... felt horrible and realized he was withdrawing... got it off the street, then realized heroin was cheaper and there he was). we talked about his hopes and dreams for his life and how drugs got in the way. He said everyone he ever saw in the ER treated him like a low life druggie and he couldn’t believe I listened. He thanked me. He said he felt ready to kick his habit and asked me for meds to make it easier. I think I prescribed clonidine and ondansetron. A long while later I am walking through a parking lot and I see a guy walking up to me. It was the middle of the night and I was ready to be attacked. I quickly realized it was him. I can’t forget him. He cried and told me he had been clean since that day. Then he hugged me. I cried. We just stood there hugging each other and crying in a dark parking lot at like 1:00 AM. I will never forget that.