EM Physician Revived After Suicide

[GatorCHOMPions]

This could probably happen to any one of us. I already know within myself I keep filing away those bad cases and it seems incidental at the time. Just takes one really bad one for it to come to a head. A good support system is key.

http://www.idealmedicalcare.org/blog/doctor-revived-suicide-heres-says/

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[EMIM2011]

Wow..,


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[Why Aitch]

This could probably happen to any one of us. I already know within myself I keep filing away those bad cases and it seems incidental at the time. Just takes one really bad one for it to come to a head. A good support system is key.

http://www.idealmedicalcare.org/blog/doctor-revived-suicide-heres-says/

Hi.
The link above does not work...nor do numerous other links relating to this story. In the link below the audio works but the "read blog & comment" link doesn't:
http://www.pamelawible.com/doctor-revived-near-suicide-heres-says

I get "Error establishing a database connection" when I try.
The next one below I can get to work, but others on my Facebook page have not had success:
http://www.kevinmd.com/blog/2017/02/doctors-revived-suicide-tells.html

This is strange. I am extremely interested in this very sad story as my husband, who is now near retirement age, has endured all the pressures this unfortunate ED doctor has during his career as a neurosurgeon in another first world country (not the USA). It's a story that needs to be told. As a wife who is now retired but worked in radiology for nearly 30 years I have seen first hand the toll it takes.

Take care all of you who are about to embark upon this career. It is not the glorious Cinderella Story society believes it to be.

 

[docdragon]

Make a happy file too. Really. Make a happy file and at least try to get SOME of the saves, the people who were just plain nice, that one quote that kept you going. Mine would have the crochet heart that a patient's wife made me, except it's currently in my clinical prep area where I see it every day.

 

[Why Aitch]

Make a happy file too. Really. Make a happy file and at least try to get SOME of the saves, the people who were just plain nice, that one quote that kept you going. Mine would have the crochet heart that a patient's wife made me, except it's currently in my clinical prep area where I see it every day.

Oh yes, I can do that too. But I was responding to a post that is inherently and unfortunately sad. As that was my first post I have not had the opportunity to balance it with the positive. Herewith my somewhat feeble attempt to do so.
Please view the attached image. It is a picture painted by a grateful patient and titled "Sciatica". It was given to my husband (a neurosurgeon) about 10 years ago, so thrilled was the patient to be relieved of his sciatica. We treasure this painting...and I'm sure the patient would be delighted that we still have it .
Hope this helps.

 

[Birdstrike]

I haven't worked an EM shift in 5 years now, and I'm a pretty content, happy person at this point in time. But I wasn't always that way, as many of you who read my posts circa 2010-2013, know. One day recently, my wife texted the above article to me after reading it after another ER doc, who's a mutual acquaintance, shared it on Facebook. She said, "It made me think of you." It wasn't that I had every done what the guy in the article did, or ever got close, but having lived the life and still knowing people who live "the life" we both understand the article 100% and it seemed to hit home.

With the chronic drum beat of senseless tragedy you see in EM, combined with the inevitable shift-work sleep-disorder, pressure to always work harder, faster, across more hours than humanly possible in a chronically-understaffed environment where administrators have callous, unreasonable expectations generated purely out of greed, such internalized pressure can creep up unknowingly on the toughest of EM physicians who tend to internalize what they're going through, baking inside of a hero's hard outer shell.

Although I much enjoyed my decade in the ED trenches, it seems much like a 40-year career of doing anything else, condensed into 10. I'm incredibly thankful I had the chance to do general EM for the time I did, but I am equally thankful I was able to transition into something easier on my sense of well being, over the long haul. For those working in the trenches, thank you for what you do. What you're doing, may be much harder than you can appreciate from the inside looking out. Take care of yourselves.

 

[WilcoWorld]

Let death and exile, and all other things which appear terrible, be daily before your eyes, but death chiefly; and you will never entertain any abject thought, nor too eagerly covet anything.

-Epictetus

 

[GTP]

I haven't worked an EM shift in 5 years now, and I'm a pretty content, happy person at this point in time. But I wasn't always that way, as many of you who read my posts circa 2010-2013. One day recently, my wife texted the above article to me after reading it after another ER doc, who's a mutual acquaintance, shared it on Facebook. She said, "It made me think of you." It wasn't that I had every done what the guy in the article did, or ever got close, but having lived the life and still knowing people who live "the life" we both understand the article 100% and it seemed to hit home.

With the chronic drum beat of senseless tragedy you see in EM, combined with the inevitable shift-work sleep-disorder, pressure to always work harder, faster, across more hours than humanly possible in a chronically-understaffed environment where administrators have callous, unreasonable expectations generated purely out of greed, such internalized pressure can creep up unknowingly on the toughest of EM physicians who tend to internalize what they're going through, baking inside of a hero's hard outer shell.

Although I much enjoyed my decade in the ED trenches, it seems much like a 40-year career of doing anything else, condensed into 10. I'm incredibly thankful I had the chance to do general EM for the time I did, but I am equally thankful I was able to transition into something easier on my sense of well being, over the long haul. For those working in the trenches, thank you for what you do. What you're doing, may be much harder than you can appreciate from the inside looking out. Take care of yourselves.

What are you doing now ?

 

[Birdstrike]

What are you doing now ?

EM Residency
EM Attending
Interventional Pain Fellowship
Pain Attending

 

[da8s0859q]

EM Residency
EM Attending
Interventional Pain Fellowship
Pain Attending

Bird, I love the idea of what you've done and why, but the thought of pain patients all day -- at least the ones that give the rest a bad name -- makes me cringe. Did you think about anything else while planning your escape?

 

[gutonc]

Bird, I love the idea of what you've done and why, but the thought of pain patients all day -- at least the ones that give the rest a bad name -- makes me cringe. Did you think about anything else while planning your escape?

If Bird's pain practice is anything like the group I send my patients to, the ones you're referring to will see them once, if at all, and then when it's clear they're not getting 1# mofine and will actually have to be responsible for helping to improve their pain, they never go back.

 

[Apollyon]

If Bird's pain practice is anything like the group I send my patients to, the ones you're referring to will see them once, if at all, and then when it's clear they're not getting 1# mofine and will actually have to be responsible for helping to improve their pain, they never go back.

The apocryphal, ubiquitous "1 pound mo-feen". Now THAT is classic!

 

[Birdstrike]

If Bird's pain practice is anything like the group I send my patients to, the ones you're referring to will see them once, if at all, and then when it's clear they're not getting 1# mofine and will actually have to be responsible for helping to improve their pain, they never go back.

Yes. Simply put, I try to focus on non-opiate pain treatment options, as much as possible, because in my opinion that's usually best for patients, long term. It's also why I bent over backwards to find a good, ACGME-accredited fellowship with an interventional focus (and get AMBS Pain Board certification), so I could learn other skills to treat pain, other than using opiates, first line. I'd much rather put a spinal cord stimulator in a patient, than commit them to a life of opiates, assuming they're not already on them. Likewise, I'd rather offer a patient an epidural steroid injection and a course of PT and some NSAIDS for their radiculopathy, as opposed to taking an opiate-focused approach. In both cases, the non-opiate approach is often better for a patient's health, mind and body. Of course, there are always exceptions, one example would be, let's say a 85-year-old with severe hip OA who's too sick for a hip replacement, can't do any more intra-articular hip injections, has never had an addiction to anything, and simply needs two percocet per day to be able to walk and avoid being wheelchair bound and having to move to a nursing home. But coming from an EM background, one can't help but have a large dose of skepticism about opiates, having dealt with the downsides first hand. And yes, there are many patients that don't like a non-opiate approach, or even an minimalist-opiate approach, and they seem to have very little problem, nor waste very much time, finding a doctor that shares their opiocentric approach. And you are correct, that since EMTALA doesn't apply to non-ED settings, you can prescreen patient referrals, decide which consults you'll see and won't see. Similarly, once you've seen a patient, you aren't obligated to accept them to your practice. Many consults are "one and done." Bottom line: If you want to be a good and happy Pain doctor, you have to be comfortable and willing to say, "No" when appropriate. In that sense, it's no different than being in the ED.

 

[Birdstrike]

Bird, I love the idea of what you've done and why, but the thought of pain patients all day -- at least the ones that give the rest a bad name -- makes me cringe. Did you think about anything else while planning your escape?

Argh. Just wrote a 6 paragraph post which got deleted

Summary: I thought about just about everything you can imagine. Anything that would have allowed me to have a normal life, be well rested all the time, was very much in the running. I like the medicine of EM, but shift-work sleep-disorder was making me unhappy and had me on a path towards burnout. Whatever it was, I wanted to be board certified in it, not end up with a pay cut and not have to do more than one year of fellowship.

 

[BAM!]

Yes. Simply put, I try to focus on non-opiate pain treatment options, as much as possible, because in my opinion that's usually best for patients, long term. It's also why I bent over backwards to find a good, ACGME-accredited fellowship with an interventional focus (and get AMBS Pain Board certification), so I could learn other skills to treat pain, other than using opiates, first line. I'd much rather put a spinal cord stimulator in a patient, than commit them to a life of opiates, assuming they're not already on them. Likewise, I'd rather offer a patient an epidural steroid injection and a course of PT and some NSAIDS for their radiculopathy, as opposed to taking an opiate-focused approach. In both cases, the non-opiate approach is often better for a patient's health, mind and body. Of course, there are always exceptions, one example would be, let's say a 85-year-old with severe hip OA who's too sick for a hip replacement, can't do any more intra-articular hip injections, has never had an addiction to anything, and simply needs two percocet per day to be able to walk and avoid being wheelchair bound and having to move to a nursing home. But coming from an EM background, one can't help but have a large dose of skepticism about opiates, having dealt with the downsides first hand. And yes, there are many patients that don't like a non-opiate approach, or even an minimalist-opiate approach, and they seem to have very little problem, nor waste very much time, finding a doctor that shares their opiocentric approach. And you are correct, that since EMTALA doesn't apply to non-ED settings, you can prescreen patient referrals, decide which consults you'll see and won't see. Similarly, once you've seen a patient, you aren't obligated to accept them to your practice. Many consults are "one and done." Bottom line: If you want to be a good and happy Pain doctor, you have to be comfortable and willing to say, "No" when appropriate. In that sense, it's no different than being in the ED.

what percentage of your patients are in acute pain -- similar to someone in the ED?

or is this all ~ chronic pain, not in an acute exacerbation?

 

[Birdstrike]

what percentage of your patients are in acute pain -- similar to someone in the ED?

or is this all ~ chronic pain, not in an acute exacerbation?

I see some acute pain, but most of it's chronic, or acute exacerbation of chronic. I'll see some acute radiculopathies. They get epidural steroid injections. I see a few acute compression fractures (though not everyday, or even every week). I'll kyphoplasty them. Then, a lot of my chronic patients will have acute exacerbations. That, I see a lot of. "Hey doc, my left hip's bothering me. Can we do another shot?" And they'll get a fluoro-guided, intra-articular hip injection, for example. Or knee, shoulder, lumbar, cervical esi, etc.

Or, "Doc, I slipped and fell today on my back and twisted my knee" and the ER doctor in you kicks in.

The key to enjoying it, is to minimize opiates in your practice as much as possible, focus on where procedures are indicated, and focus on the patients you can help, and avoid banging your head against the wall with patients you can't help.

Rules for opiates (with exceptions where appropriate):

-If they're not on 'em, don't start 'em
-If they're on 'em, don't increase 'em
-If they're on 'em, have a dose limit (in daily morphine mg equivalents)
-If they're on 'em, actively look for reasons to decrease dose or stop them
-Screen and monitor aggressively (drug screen on first visit, no opiate prescription on first visit, must have old records sent directly from previous prescriber before opiate rx, check Rx report every time an Rx is written and check publicly available criminal background to rule out drug/alcohol/diversion convictions [reports served up on a silver platter by medical assistant])
-Be firm on what indication you won't consider opiates for due to non-responsiveness or non-verifiability (fibro, headaches, chronic abdominal/pelvic pain of unknown cause, others)
-Don't rx benzos, stimulants or soma, ever (exception, 2 xanax before MRI or procedure in super anxious patient's only)

The key is to switch away from the outdated, damaging mindset, drug-company based Purdue-pharma Oxycontin lie pushed in the 1980's that went like this,

"Opiates are first line. They're almost always safe. There's no reason not to start them. When in doubt start opiates. When in doubt, increase them. There is no dose limit. Addiction and abuse is rare."

And switch to an honest, safer, newer, healthier, more realistic, common sense approach such as,

"Opiates aren't first line, they should be a last resort, if used at all. They have significant dangers. There's lots of reasons not to start them, and try other options first. When in doubt, don't start opiates. There must be a dose limit, and not having one is dangerous, unrealistic and irresponsible. Abuse, addiction and diversion are common and must be actively prevented, looked for, detected and dealt with aggressively with a high index of suspicion for these, which are harmful drug side effects."

This is a big reason I feel that we need more EM physicians to go into pain. That last paragraph is intuitive to us in EM, where as its a "new way" of thinking to many other specialties. Nobody knows the downsides of opiates better than us in EM. Such a mindset is an asset in the Pain world and actually a benefit to one's patients and to the specialty.

 

[WilcoWorld]

The key to enjoying it, is to minimize opiates in your practice as much as possible, focus on where procedures are indicated, and focus on the patients you can help, and avoid banging your head against the wall with patients you can't help.

I see that you've discovered the key to Emergency Medicine along the way.

 

[BAM!]

...This is a big reason I feel that we need more EM physicians to go into pain. That last paragraph is intuitive to us in EM, where as its a "new way" of thinking to many other specialties. Nobody knows the downsides of opiates better than us in EM. Such a mindset is an asset in the Pain world and actually a benefit to one's patients and to the specialty.

I completely agree with everything you've said.

A well known challenge for us ED Physicians is patient satisfaction scores. Given CMS ties reimbursement to hospital satisfaction scores - which we are somehow linked to, guilty by association, because we greet them at the door - there is the ever present push to make patients happy. There will always be the docs who will give the opiate Rx because, let's face it, it's easier. We've all done it at some point. Easier patient interaction. Easier admin interaction. Easier dispo. I imagine your pain clinic isn't tied to such metrics? if so, how do get around this?

 

[Birdstrike]

I completely agree with everything you've said.

A well known challenge for us ED Physicians is patient satisfaction scores. Given CMS ties reimbursement to hospital satisfaction scores - which we are somehow linked to, guilty by association, because we greet them at the door - there is the ever present push to make patients happy. There will always be the docs who will give the opiate Rx because, let's face it, it's easier. We've all done it at some point. Easier patient interaction. Easier admin interaction. Easier dispo. I imagine your pain clinic isn't tied to such metrics? if so, how do get around this?

I'm subject to the same CMS measures as everyone else, as far as I know, which is bad enough. What I don't have to deal with, is a second layer of harassment from non-physician administrators telling me how to practice, in my current set-up. That's mainly because, 1-I'm office-based not hospital-based and, 2-The group I'm with is a doctor-owned, doctor-run group (multi-specialty). In place of that, is insurance company interference (denying procedures, denying MRIs, refusing to cover abuse resistant meds) that I used to be largely isolated from in the ED.


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