This epistle is dedicated to a dear friend. She is a great ER nurse who recently "caught" a baby.
Docs, nurses, cops, and EMT's don't deliver babies. Women deliver babies. Everyone else involved just helps. The hospital where I "live" has a busy OB service. More than 3,000 babies a year enter this troubled world from within our doors. Highly trained labor and delivery nurses and special care nursery staff along with obstetricians, anesthesiologists and pediatricians all work hard to ensure a safe and healthy outcome for mother and child.
Occasionally the delivery occurs in the ER. ER docs and nurses are trained, have the appropriate equipment and are ably backed up by the L&D and nursery pros. Deliveries in the community are the responsibility of police, firemen, and EMS personnel. The mother and child arrive in the ER and stop only if not stable enough for transport upstairs.
A recent episode highlights an unusual OB and neonatal case. The call was for a precipitous delivery in an apartment. The mother was OK but the baby was reported to be blue. The night ER staff was ready with a warming stand, and all the equipment for entubation and resuscitation of the newborn. The baby arrived crying lustily. His face was blue but the rest of his body was pink. He had good muscle tone and good respiratory efforts. His oxygen saturation was 100%. The blue face was caused by bruising from his too rapid descend through the birth canal. His mother's use of cocaine was probably a factor in his hasty entrance.
The twilight zone of deliveries resides in the cars that drive up to the ER entrance with a usually male driver yelling that his wife/girlfriend is having the baby in the car. In my 30+ years of ER experience, I have done 2 "auto" deliveries.
The first was in a small car. It was February and the ambient temperature of 20 degrees (F). The delivery was easy. The cold was the problem. Being a much younger "world's oldest ER doc", I placed the baby on the mother's stomach, wrapped both in a blanket and lifted them up in my arms and rushed into the ER. All went well for mother and baby.
My second drive-up delivery was very different. My "old" friend (the nurse to whom this blog is dedicated) ran out to the minivan in response to the husband's cries for help. A rather large woman of about 110 Kg was lying on the passenger's seat that was in the reclined position. The mother's feet were up on the dash and between her legs the nurse saw two tiny feet dangling from the vagina. The nurse's calls for help were clearly heard in the ER core as she yelled my name. I grabbed some gloves and went through the ER waiting room to the minivan. An obstetrician (who no longer works at our hospital) arrived almost at the same time.
A breech delivery is when any part of the lower half of the baby leads the way down the birth canal. This unfortunate mother was scheduled to have an elective Cesarean section at 8:00 AM that day for an ultrasound proven breech presentation. I was faced with a double footling breech delivery. Most emergency medicine residencies give little training in the management of abnormal deliveries. Ultrasound has decreased the unexpected brow, breech, or shoulder presentations. The OB doc who met me at the minivan offered only the advice that I should get the mother upstairs and then turned and reentered the hospital.
There was no way to safely lift and transport this woman from the van to the ER. My mind and hands recalled a single leg and full breech delivery that I had done while on my obstetrical rotation, during my EM residency back in the seventies. I probed and brought out the upper arm and then the lower arm and finally the baby's head. I clamped and cut the umbilical cord and rushed the baby into the ER. The mother followed soon there after. The baby had a broken clavicle but was otherwise perfectly healthy.
My nurse-friend and I were shaken by this close call. My partners all commented that they had never seen any type of breech delivery and were relieved that I (not they) had been working that night. The nurse shared with me that she had nightmares about this case. The what ifs were hard to digest. I slept well that morning, after my shift ended and I arrived home. Being OCD, I brushed up on all less than normal deliveries with a very old textbook from my medical school collection.
There is nothing more satisfying to anyone who works in health care than being part of a delivery. The birth of another human being is awe inspiring. It was a privilege to have had the opportunity to assist these 2 women. My dear friend currently works in the ER of a tertiary care hospital that handles most complicated OB cases in our region. Her occasional per diem shift in my ER and our friendship keep us connected. The case of the double footling breech is our special bond.
Saturday, November 20, 2010
Saturday, November 13, 2010
GGB redux
One of my earliest blogs was about falls in the elderly and the subsequent ER visits from the injuries suffered. I bloviated about the neurological, cardiac and pharmacological issues that led to these all too frequent events.
A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.
Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".
After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.
The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.
I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.
One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.
There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.
The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.
A recent ER patient and my elderly mother reinforced for me, the extent of this increasingly common health care problem. My patient was 101 years old and lived in an assisted living facility. She had some mild dementia but was amazingly intact mentally, considering her age. She arrived on a back board in a cervical collar and was crying out in pain. She complained of right hip pain and had an obvious deformity with her right leg being shorter than the left and externally rotated. A review of her medical record showed a fall had fractured her left hip a few years ago and she had a repair and successful rehab of this injury.
Two days later I awoke from my AM nap, after working my usual three night stretch, to find a text from my sister. My 91 year old mother had fallen at her assisted living facility and broken her right hip. Two years ago my mother had fallen and fractured her left hip. The repair and rehab required only one month before she was able to return to her "home".
After a lengthy stay in the ER, my mother was finally transferred to an in-patient bed and put in traction. The next day I drove 75 minutes to spend the day with my mother. I met the surgeon and anesthesiologist and signed the consent forms for her surgery. My mother also has some mild dementia. All her memories are present and accounted for, but the filing system is not very accurate. I had an interesting conversation with her anesthesiologist. I stressed that my mother did not wish any resuscitative efforts if she had cardiac or respiratory failure. He told me that in the OR they might need to do CPR temporarily if her heart rate dropped. My mother has severe kyphoscoliosis of her back. She is shaped like a question mark. One CPR compression would shatter her rib cage. I persuaded him that no CPR should be given under any circumstances. I kissed Ma and told her I would see her after the surgery and went to wait for her return to her room.
The surgery was successful. My mother's right hip was repaired. She has been oxygen dependent since the surgery because of persistently low O2 saturation. She is depressed and says she cannot understand why God won't answer her prayers and let her die in her sleep. She is frightened and dreading the rehab process. My siblings, our spouses, her grandchildren and their spouses and partners have all been to see grandma. Her nieces and nephews have been in touch. She is the last of her generation in her family that included more than 40 first cousins.
I spent some time with Ma yesterday at the nursing home/rehab center. The place is clean, well staffed and cheerful. She is no longer actively suicidal but still says she would welcome death. The challenge is whether she can be ambulatory enough to return to her "home". She and I talked about her marriage of 50 plus years to my father. She told me she had a wonderful life. She had a loving husband, and friends from her childhood that have survived and maintained contact. She has 4 grandchildren and three great grandchildren. She is loved and cherished by all her nieces and nephews.
One week post-op, she was lucid and on the mend. She still required supplemental oxygen and the pace of her rehab is much slower than it was 2 years ago. Thanksgiving is in less than 2 weeks. My wife and I play host to our extended families on this, our favorite holiday. I set turkey day as a goal for Ma. If she can walk even 10 steps with her walker by Thanksgiving, she can celebrate with those who love her. I'll keep you posted as her recovery continues.
There are two ER relevant issues from my patient's and my mother's cases. The first is the diagnosis of dementia. Not all confusion and memory problems in the elderly are Alzheimer's disease. The loss of neurons from aging and "ministrokes" cause much of the late onset dementia in the elderly. The diagnosis of Alzheimer's disease is anatomically based. Only a brain biopsy or a post-mortum examination of brain tissue can definitively make the diagnosis. Early onset dementia is presumed to be Alzheimer's unless some other cause is found. The level of confusion and even agitation in patients with dementia fluctuate from day to day and even during the day. Sundowning, increasing confusion beginning in the late afternoon or evening, is a well established phenomenon in patients with dementia.
The other problem, highlighted by my 101 year old patient, is the back board. These are used in some form to stabilize patients who might have an injury to the spine. Their design hasn't changed for decades. They are flat. The human spine is not straight. The normal spine arches forward in the neck, posteriorly in the thoracic area and forward again in the lumbar region. New designs have incorporated this natural curvature. They would be much more comfortable for the patient and give greater stability to the spine during transport. The newer models are also more expensive and the cost of replacing all the boards used by EMS services would be prohibitive. I understand the reality of cost containment but both my patient and my mother said that the board was more painful than their fractured hip. Food for thought.
Wednesday, November 3, 2010
Resquiescat in pace
RIP. As a new member of the medical staff of my hospital in the early 80's, I needed advise and guidance. A smiling pediatrician welcomed me to Local General Hospital. Dr M worked in a large multispecialty group practice. He later started his own office with his wife who managed the practice. Children from his practice would arrive in the ER after a phone call from M. The information would often include insights into the dynamics of the family. Having M's friendship and confidence was greatly appreciated by a naive ER doc.
I was privileged to be Dr M's personal ER doc. He and his beloved wife honored me by their confidence in my abilities. When my nephews needed a new pediatrician, Dr M welcomed them into his "family" of patients. Eight days ago M made his last visit to the ER. He had suffered a cardiac arrest at home. Despite CPR by his wife and the best efforts of EMS, ER and intensivists at our hospital, Dr M died on Halloween morning.
A memorial service was held this morning. I had worked the past three nights and grabbed two hours of sleep. A shower and my best dark suit made me presentable to say goodbye to my friend. The church was packed with colleagues, family, friends and patients. The receiving line at the wake last night began forming an hour before the viewing began. A reading from "Winnie the Pooh" was given by one of M's son. His other son who joined his office 5 years ago, read a pertinent passage from the New Testament. The CEO of our hospital gave a deeply felt and moving eulogy. A life long friend added a eulogy that gave insight into M's personal life.
What is the measure of a man? Dr M was a loving husband and father. Friend, mentor, care giver, teacher. He served as president of the medical staff, member of the board of trustees, and tirelessly raised the profile and brought in donations for the hospital. The loss of this extraordinary man will be felt by everyone who was embraced by his warmth and humanity.
The epitaph for Dr M is what he told my sister-in-law and the parents of all his kids, "take him home and love him".
I was privileged to be Dr M's personal ER doc. He and his beloved wife honored me by their confidence in my abilities. When my nephews needed a new pediatrician, Dr M welcomed them into his "family" of patients. Eight days ago M made his last visit to the ER. He had suffered a cardiac arrest at home. Despite CPR by his wife and the best efforts of EMS, ER and intensivists at our hospital, Dr M died on Halloween morning.
A memorial service was held this morning. I had worked the past three nights and grabbed two hours of sleep. A shower and my best dark suit made me presentable to say goodbye to my friend. The church was packed with colleagues, family, friends and patients. The receiving line at the wake last night began forming an hour before the viewing began. A reading from "Winnie the Pooh" was given by one of M's son. His other son who joined his office 5 years ago, read a pertinent passage from the New Testament. The CEO of our hospital gave a deeply felt and moving eulogy. A life long friend added a eulogy that gave insight into M's personal life.
What is the measure of a man? Dr M was a loving husband and father. Friend, mentor, care giver, teacher. He served as president of the medical staff, member of the board of trustees, and tirelessly raised the profile and brought in donations for the hospital. The loss of this extraordinary man will be felt by everyone who was embraced by his warmth and humanity.
The epitaph for Dr M is what he told my sister-in-law and the parents of all his kids, "take him home and love him".
Saturday, October 30, 2010
All Hallow's Eve
Tomorrow is Halloween. I will be working my usual night shift. I fear that my fellow B.O.N.E.R. doc, Zorba, will have the scarier time tonight. Young adults and older teens use the occasion for excessive drinking, drugging and hormonally fueled shenanigans. Costumes, alcohol, parties, and hell raising are guaranteed to bump up the ER census.
My wife loves to hand out the packaged candy to the local kids. Our neighborhood contains many families with young children. Frightening tales of tampered goodies with poisons, needles and medications require that treats must be commercially produced and dispensed in their original wrappings. Earlier in my career, the ER offered to x-rays treat-bags to ensure that no metallic foreign bodies had been secreted into the candy.
The tricks of Halloween usually are benign and stale; egging, "TP ing", and flaming dog poop bags are common pranks. More innovative tricks such as hallucinogens in the cider, can swamp the ER with spaced out patients dressed as witches, devils, and assorted celebrities.
The application and adornment of the physiognomy of the Halloween party goer may lead to visits to the ER. Superglue is often used to attach horns and other embellishments. The problem arises when the glue gets into the eyes or near the nether regions. Removing the glued-on bits may cause avulsion of the underlying skin. OUCH!
In the Northeast, where I reside, hypothermia is also a risk during Halloween revelries. Costumes are often skimpy in their coverage and wearing a coat would ruin the ensemble. The effects of alcohol contribute to the hypothermia potential. Alcohol irritates the esophagous and stomach giving the imbiber a sense of inner heat. The vasodilating effects of alcohol cause increased heat loss from the skin and more rapid lowering of the core body temperature.
The truly tragic aspect of Halloween is the four fold increase, in auto-pedestrian accidents involving children, compared to the other 364 days of the year. Parents be advised, make your child visible and keep their own vision unencumbered. Glow sticks and necklaces, flashing LED lights, and reflective material are all excellent measures to make your child visible to drivers. Avoid masks and hoods that can limit the child's visual field. Drivers need to be extra cautious. The aftermath of injuring or killing a child are devastating for the victim's family and for the driver.
I do not wish to spoil the joy of Halloween. The world's oldest ER doc has fond memories of "trick or treat" ing with my friends back in the 1950's and 1960's. As a avid mimic, I would couple my costume with an appropriate accent. My mother's jodhpurs, and riding boots (she was a volunteer in the Women's Army Aircorp during WW 2) were paired with a puffy white shirt, monocle and my best British accent. A dhoti (Indian garment), begging bowl and an accent I learned from the movie, "Gunga Din" transformed me into Gandhi.
Today, October 30, is my twin sister's birthday. Yes, our birthdates are 28 days and almost 2 years apart. Think Danny Devito and the Arnold in the movie "Twins". No one embraces the joy and exuberance of the holiday more than my friend and spiritual twin, Joanne. Happy Birthday sis!
My wife loves to hand out the packaged candy to the local kids. Our neighborhood contains many families with young children. Frightening tales of tampered goodies with poisons, needles and medications require that treats must be commercially produced and dispensed in their original wrappings. Earlier in my career, the ER offered to x-rays treat-bags to ensure that no metallic foreign bodies had been secreted into the candy.
The tricks of Halloween usually are benign and stale; egging, "TP ing", and flaming dog poop bags are common pranks. More innovative tricks such as hallucinogens in the cider, can swamp the ER with spaced out patients dressed as witches, devils, and assorted celebrities.
The application and adornment of the physiognomy of the Halloween party goer may lead to visits to the ER. Superglue is often used to attach horns and other embellishments. The problem arises when the glue gets into the eyes or near the nether regions. Removing the glued-on bits may cause avulsion of the underlying skin. OUCH!
In the Northeast, where I reside, hypothermia is also a risk during Halloween revelries. Costumes are often skimpy in their coverage and wearing a coat would ruin the ensemble. The effects of alcohol contribute to the hypothermia potential. Alcohol irritates the esophagous and stomach giving the imbiber a sense of inner heat. The vasodilating effects of alcohol cause increased heat loss from the skin and more rapid lowering of the core body temperature.
The truly tragic aspect of Halloween is the four fold increase, in auto-pedestrian accidents involving children, compared to the other 364 days of the year. Parents be advised, make your child visible and keep their own vision unencumbered. Glow sticks and necklaces, flashing LED lights, and reflective material are all excellent measures to make your child visible to drivers. Avoid masks and hoods that can limit the child's visual field. Drivers need to be extra cautious. The aftermath of injuring or killing a child are devastating for the victim's family and for the driver.
I do not wish to spoil the joy of Halloween. The world's oldest ER doc has fond memories of "trick or treat" ing with my friends back in the 1950's and 1960's. As a avid mimic, I would couple my costume with an appropriate accent. My mother's jodhpurs, and riding boots (she was a volunteer in the Women's Army Aircorp during WW 2) were paired with a puffy white shirt, monocle and my best British accent. A dhoti (Indian garment), begging bowl and an accent I learned from the movie, "Gunga Din" transformed me into Gandhi.
Today, October 30, is my twin sister's birthday. Yes, our birthdates are 28 days and almost 2 years apart. Think Danny Devito and the Arnold in the movie "Twins". No one embraces the joy and exuberance of the holiday more than my friend and spiritual twin, Joanne. Happy Birthday sis!
Saturday, October 23, 2010
Algia
Almost every ER patient complains of some type of pain. Cephalgia, neuralgia, arthralgia refer to head, nerve and joint pain respectively. The root algia is from Latin. Angina from the Latin for choking also is used for several painful conditions. Angina pectoris is the term for pain in the chest from narrowing or blockages of the coronary arteries. Intestinal angina is used to describe pain from narrowing or blockages in the arteries that supply the GI tract. Ludwig's angina is severe throat pain from an infection in the mouth or throat that spreads towards the chest through the fascial plains of the neck. Colic is another medical term for pain that were thought to occur from intestinal sources. It's three types are infant (general crankiness without another source), renal (from the passage of a kidney stone) and biliary (from gall stones or bile sludge).
Pain is a protective mechanism. If one touches something hot, a reflex arc in the central nervous system causes withdrawal from the source of the heat even before we become fully aware of the pain. Noniceptors in the peripheral nervous system respond to heat, cold, pressure and sharp stimuli. These pain signals are carried to the brain by tracts in the spinal cord. The brain processes the information that one consciously perceives as pain.
Pain from an injury is from an obvious source and will resolve as the injury heals. A broken ankle will cause severe pain. Elevating and immobilizing the injured part with give some relief. As the fracture heals the pain will lessen and eventually resolve with complete healing. Similarly pain from an intrabdominal infection or from colic will resolve after appropriate treatment.
Treating acute pain is an important part of ER care. Unfortunately many physicians under treat acute pain. I have become much more "generous" in treating acute pain after my experiences as a patient with four major abdominal surgeries. PCA or patient controlled analgesia gives the pain sufferer, usually post-operative, the means to obtain IV pain meds by pushing a button. The amount and time interval between doses are set and locked. My only use of PCA was a failure. When I told the anesthesiologist (PCA may also be ordered by the surgeon) that the dose was too low and that I was getting little if any relief, he assured me that the dose was adequate.
Conscious sedation is used in the ER for patient comfort during painful procedures such as reducing fractures or dislocations, incising and draining an abscess or for a lumbar puncture. The drugs used for this sedation may include short acting pain medications such as fentanyl. A short acting benzodiazepine sedative such as midazolam is often combined with fentanyl to provide sedation with pain control. I prefer propofol. This drug causes a dissociation between the painful procedure and the perception of the pain. It's short duration and lack of long term side effects make it a valuable asset for the ER doc.
There are three main types of pain medications. NSAID's include ibuprofen, naprosyn, ketorolac and others. Acetaminophen is also a mild analgesic that may be taken solely or combined with an opiate. NSAID's are very effective for most mild to moderate short term painful conditions. Toothaches, menstrual cramps, minor orthopedic injuries and most headaches respond well to NSAID's. Moderate to severe pain usually require the third class of pain meds, opiates.
Opiates work by binding to the mu receptors in the nervous system. These receptors are widespread and are the target for our intrinsically made pain suppressors, endorphins. Anyone who has hit the "runner's high" during a prolonged workout has felt the effects of endorphins. The placebo effect is relief from the pain and other symptoms of disease or injury by an inert "sugar" pill. The belief that one is receiving treatment may cause the release of endorphins and explain the placebo effect.
Heroin, opium, morphine, codeine, hydromorphone, methadone, hydrocodone and oxycodone are all derived from the alkaloids obtained from the opium poppy. Other medications in the opiate group include meperidine, propoxyphene and fentanyl. Pills, liquids, patches, suppositories and injections are all ways of introducing these medications into the body. When given in adequate amounts for a limited time, opiates are both effective and safe.
The problems arise with pain that is never ending and psychological issues that effect pain perception. Neuralgia or nerve pain can last a lifetime and be debilitating. Damage to nerves from injury, infections (shingles), or metabolic diseases (diabetic neuropathy) may lead to constant pain. Pain from arthritis or disc disease may not resolve with treatment of the underlying condition. Phantom pain from amputated limbs is common and may be permanent. Pain from cancer is another example of the need for chronic pain management.
Patients with depression have an altered perception of pain. The flip side to this is that chronic pain may lead to depression. Antidepressants are often used with other medications to treat some forms of chronic pain. Anticonvulsants such as gabapentin have been used to treat neuropathic pain. Psychological counseling, physical therapy and exercise are also tools in the holistic approach to chronic pain management. It is important that patients with chronic pain be given long acting pain medications such as methadone, prolonged released morphine or fentanyl patches. A short acting medication such as hydrocodone or oxycodone should be available for acute exacerbations of the underlying chronic pain. The physician must take tolerance into account, and be willing to gradually increase the dose of the long acting medication as needed.
Physicians must accept some of the blame for the abuse of opiate pain medications by patients. Giving too little medication, for less time than is required for healing, will force the patient to try and find relief somewhere else. Some physicians give too strong an analgesic and this may lead to tolerance. Tolerance and addiction are the downside of opiate medications. There is evidence that the number of mu receptors increases in patients taking opiate medication for a prolonged period of time. The need for greater doses of pain meds to achieve the same level of relief (tolerance) may be the result of the increased number of mu receptors. The symptoms of withdrawal from opiates are all too real. The "screaming" of the mu receptors "feed me" is what makes withdrawal a living hell.
Drug seekers are the bane of an ER doc's existence. The causes of the pain may be genuine but their drug addiction makes them a drain on the time and patience of the ER staff. It is sometimes difficult to separate the patients with pain and the addicts looking to score. I have received letters, from various regulatory agencies, telling me that a patient who I prescribed opiate pain meds had received multiple prescriptions from multiple doctors. Multiple ER visits for minor problems, "allergies" to every drug except the one they want, and reported pain out of proportion to the injury, all may be indicative of the drug seeker. Threats to "call my lawyer" and verbal and physical assaults also are the signs of drug seeking behavior.
When I graduated from medical school in 1977, I didn't take the Hippocratic oath. My classmates and I took the Oath of Maimonides instead. "In the sufferer, let me see the human being."
Pain is a protective mechanism. If one touches something hot, a reflex arc in the central nervous system causes withdrawal from the source of the heat even before we become fully aware of the pain. Noniceptors in the peripheral nervous system respond to heat, cold, pressure and sharp stimuli. These pain signals are carried to the brain by tracts in the spinal cord. The brain processes the information that one consciously perceives as pain.
Pain from an injury is from an obvious source and will resolve as the injury heals. A broken ankle will cause severe pain. Elevating and immobilizing the injured part with give some relief. As the fracture heals the pain will lessen and eventually resolve with complete healing. Similarly pain from an intrabdominal infection or from colic will resolve after appropriate treatment.
Treating acute pain is an important part of ER care. Unfortunately many physicians under treat acute pain. I have become much more "generous" in treating acute pain after my experiences as a patient with four major abdominal surgeries. PCA or patient controlled analgesia gives the pain sufferer, usually post-operative, the means to obtain IV pain meds by pushing a button. The amount and time interval between doses are set and locked. My only use of PCA was a failure. When I told the anesthesiologist (PCA may also be ordered by the surgeon) that the dose was too low and that I was getting little if any relief, he assured me that the dose was adequate.
Conscious sedation is used in the ER for patient comfort during painful procedures such as reducing fractures or dislocations, incising and draining an abscess or for a lumbar puncture. The drugs used for this sedation may include short acting pain medications such as fentanyl. A short acting benzodiazepine sedative such as midazolam is often combined with fentanyl to provide sedation with pain control. I prefer propofol. This drug causes a dissociation between the painful procedure and the perception of the pain. It's short duration and lack of long term side effects make it a valuable asset for the ER doc.
There are three main types of pain medications. NSAID's include ibuprofen, naprosyn, ketorolac and others. Acetaminophen is also a mild analgesic that may be taken solely or combined with an opiate. NSAID's are very effective for most mild to moderate short term painful conditions. Toothaches, menstrual cramps, minor orthopedic injuries and most headaches respond well to NSAID's. Moderate to severe pain usually require the third class of pain meds, opiates.
Opiates work by binding to the mu receptors in the nervous system. These receptors are widespread and are the target for our intrinsically made pain suppressors, endorphins. Anyone who has hit the "runner's high" during a prolonged workout has felt the effects of endorphins. The placebo effect is relief from the pain and other symptoms of disease or injury by an inert "sugar" pill. The belief that one is receiving treatment may cause the release of endorphins and explain the placebo effect.
Heroin, opium, morphine, codeine, hydromorphone, methadone, hydrocodone and oxycodone are all derived from the alkaloids obtained from the opium poppy. Other medications in the opiate group include meperidine, propoxyphene and fentanyl. Pills, liquids, patches, suppositories and injections are all ways of introducing these medications into the body. When given in adequate amounts for a limited time, opiates are both effective and safe.
The problems arise with pain that is never ending and psychological issues that effect pain perception. Neuralgia or nerve pain can last a lifetime and be debilitating. Damage to nerves from injury, infections (shingles), or metabolic diseases (diabetic neuropathy) may lead to constant pain. Pain from arthritis or disc disease may not resolve with treatment of the underlying condition. Phantom pain from amputated limbs is common and may be permanent. Pain from cancer is another example of the need for chronic pain management.
Patients with depression have an altered perception of pain. The flip side to this is that chronic pain may lead to depression. Antidepressants are often used with other medications to treat some forms of chronic pain. Anticonvulsants such as gabapentin have been used to treat neuropathic pain. Psychological counseling, physical therapy and exercise are also tools in the holistic approach to chronic pain management. It is important that patients with chronic pain be given long acting pain medications such as methadone, prolonged released morphine or fentanyl patches. A short acting medication such as hydrocodone or oxycodone should be available for acute exacerbations of the underlying chronic pain. The physician must take tolerance into account, and be willing to gradually increase the dose of the long acting medication as needed.
Physicians must accept some of the blame for the abuse of opiate pain medications by patients. Giving too little medication, for less time than is required for healing, will force the patient to try and find relief somewhere else. Some physicians give too strong an analgesic and this may lead to tolerance. Tolerance and addiction are the downside of opiate medications. There is evidence that the number of mu receptors increases in patients taking opiate medication for a prolonged period of time. The need for greater doses of pain meds to achieve the same level of relief (tolerance) may be the result of the increased number of mu receptors. The symptoms of withdrawal from opiates are all too real. The "screaming" of the mu receptors "feed me" is what makes withdrawal a living hell.
Drug seekers are the bane of an ER doc's existence. The causes of the pain may be genuine but their drug addiction makes them a drain on the time and patience of the ER staff. It is sometimes difficult to separate the patients with pain and the addicts looking to score. I have received letters, from various regulatory agencies, telling me that a patient who I prescribed opiate pain meds had received multiple prescriptions from multiple doctors. Multiple ER visits for minor problems, "allergies" to every drug except the one they want, and reported pain out of proportion to the injury, all may be indicative of the drug seeker. Threats to "call my lawyer" and verbal and physical assaults also are the signs of drug seeking behavior.
When I graduated from medical school in 1977, I didn't take the Hippocratic oath. My classmates and I took the Oath of Maimonides instead. "In the sufferer, let me see the human being."
Friday, October 15, 2010
Plus ca change
The more things change, the more they stay the same. It sounds classier in the original French. I was somewhat blocked as to a subject for today's blog. While waiting in line at Starbucks, I ran into an old friend. This gentleman is 11 years older than me. He went into medicine in his 40's after a career of writing. He and I worked together in the ER where I still practice. He was forced out and went to work in a small town in Vermont with an ER that sees 1/5 the volume of my hospital. He is approaching seventy and still going strong. I am only hoping to get to 67 before retiring.
There are quirks of ER practice that occur repeatedly. New generations of patients still have the same odd behaviors. The numbers keep going up and the mix of patients varies but somethings stay the same.
"I have this pain in my back for a month." After sliently groaning, I try not to roll my eyes and ready my questions. Bladder function, bowel habits, fever, chills, numbness, weakness... "I have an appointment with my primary care at 11:00 but I couldn't wait any longer." This is said to me at 2:00 AM. Why? The patient waited weeks to get an appointment but was unable to wait an additional 8 hours.
I approach a lovely woman in her eighties. The chief complaint is abdominal pain. "What is the problem tonight?" I ask with some trepidation. She begins her story in 1936. She regales me with issues from the Great Depression, WW2, her marriage and children. An older gentleman responds to the same question by taking out a notebook that details everything he has eaten in the past 6 month and how his body reacted to each and every meal.
A mother and infant on the stretcher resembling a renaissance painting of the Madonna and child. The chief complaint is fever and a runny nose. I ask what she gave for the baby's fever and she says "nothing, I brought him to the ER". In loco parentis. ER's have become substitute parents. This is especially true of first-time teen mothers. My dear friend Elizabeth, was an ER nurse who trained at Children's Hospital. She cared for the baby and gently educated the mother.
Vomiting and eating is a recurrent issue in the ER. The toddler who is in the ER for vomiting is being fed cheese puffs by his mother while seated on the stretcher. The first thing a patient who is retching in the barf bag asks is, "can I have something to drink?".
0600 on a Tuesday morning, after a three day weekend. The bus has arrived. Five patients in triage for mild complaints. The hidden agenda is the doctor issued work note. Mr Jones skipped work on Friday and now needs a note to justify his absence. Citizens who have scheduled court appearances also seem to develop vague symptoms early in the morning of their court date.
The patient generated diagnosis is usually from a visit to WebMD prior to arriving in the ER. When a young man tells me that he has Lupus, when I see a contact dermatitis on his face from his new cologne, I know that the internet is to blame. The appropriate cliche is "a little knowledge is dangerous". The herd of zebras that thunder through the ER is driven by various web pages devoted to empowering the patient. I am told what tests and scans that the patient feels he or she needs. I gaze over my reading glasses and try and explain a more rational approach to finding a cause of their listed symptoms.
My colleagues in primary care and other fields of medicine contribute to the cavalcade of self diagnosing and self ordering by my patients. "My pediatrician says Susie needs a CAT scan because her stomach ache could be appendicitis." "Jimmy has a headache and my doctor said it could be meningitis, so I want him to have a spinal tap." Susie is playing her video game while scarfing down an ice cream sandwich, and Jimmy was seen running around the waiting room and yelling at the other patients.
As my good friend Clyde pointed out to me over a cup of good coffee, plus ca change, plus c'est la meme chose.
There are quirks of ER practice that occur repeatedly. New generations of patients still have the same odd behaviors. The numbers keep going up and the mix of patients varies but somethings stay the same.
"I have this pain in my back for a month." After sliently groaning, I try not to roll my eyes and ready my questions. Bladder function, bowel habits, fever, chills, numbness, weakness... "I have an appointment with my primary care at 11:00 but I couldn't wait any longer." This is said to me at 2:00 AM. Why? The patient waited weeks to get an appointment but was unable to wait an additional 8 hours.
I approach a lovely woman in her eighties. The chief complaint is abdominal pain. "What is the problem tonight?" I ask with some trepidation. She begins her story in 1936. She regales me with issues from the Great Depression, WW2, her marriage and children. An older gentleman responds to the same question by taking out a notebook that details everything he has eaten in the past 6 month and how his body reacted to each and every meal.
A mother and infant on the stretcher resembling a renaissance painting of the Madonna and child. The chief complaint is fever and a runny nose. I ask what she gave for the baby's fever and she says "nothing, I brought him to the ER". In loco parentis. ER's have become substitute parents. This is especially true of first-time teen mothers. My dear friend Elizabeth, was an ER nurse who trained at Children's Hospital. She cared for the baby and gently educated the mother.
Vomiting and eating is a recurrent issue in the ER. The toddler who is in the ER for vomiting is being fed cheese puffs by his mother while seated on the stretcher. The first thing a patient who is retching in the barf bag asks is, "can I have something to drink?".
0600 on a Tuesday morning, after a three day weekend. The bus has arrived. Five patients in triage for mild complaints. The hidden agenda is the doctor issued work note. Mr Jones skipped work on Friday and now needs a note to justify his absence. Citizens who have scheduled court appearances also seem to develop vague symptoms early in the morning of their court date.
The patient generated diagnosis is usually from a visit to WebMD prior to arriving in the ER. When a young man tells me that he has Lupus, when I see a contact dermatitis on his face from his new cologne, I know that the internet is to blame. The appropriate cliche is "a little knowledge is dangerous". The herd of zebras that thunder through the ER is driven by various web pages devoted to empowering the patient. I am told what tests and scans that the patient feels he or she needs. I gaze over my reading glasses and try and explain a more rational approach to finding a cause of their listed symptoms.
My colleagues in primary care and other fields of medicine contribute to the cavalcade of self diagnosing and self ordering by my patients. "My pediatrician says Susie needs a CAT scan because her stomach ache could be appendicitis." "Jimmy has a headache and my doctor said it could be meningitis, so I want him to have a spinal tap." Susie is playing her video game while scarfing down an ice cream sandwich, and Jimmy was seen running around the waiting room and yelling at the other patients.
As my good friend Clyde pointed out to me over a cup of good coffee, plus ca change, plus c'est la meme chose.
Saturday, October 9, 2010
ITIS
A beautiful fall day and I have an aching left shoulder. Tendinitis or bursitis. Popping aspirin helps. I know exactly how this injury occurred. A poorly done weight training session, one day after turning 58, caused this "itis".
Arthralgias, joint pains, are divided medically into inflammatory and non-inflammatory subsets. Rheumatoid arthritis is the poster child for inflammatory joint disease. The body's immune system attacks the components of the joints with pain, swelling and ultimately destruction of the joint. Anti-inflammatory medications such as aspirin and NSAID's have always been part of the treatment. Immune modulators are the newest and most beneficial treatment modalities. The side effects of this immunotherapy are an increased risk of infections and cancer.
Osteoarthritis is the most common form of joint disease. There is a familial risk of the more severe form of the condition. Wear and tear of the joints from work and recreational stresses make all of us susceptible to OA. Our bones may get thicker as we gain weight but our joints don't get larger or more robust from added body weight. Arthritis, leading to joint replacement, is increasing because of the epidemic of obesity in our nation.
Joint pains may also be caused by injury and inflammation of tendons, ligaments and bursas near joints. My shoulder pain is most likely tendinitis of the biceps tendon. Bursitis is a possibility. Bursas are sacs that help lubricate the tendons and bones around the large joints. A plain x-ray of an aching shoulder may reveal calcification in the bursa from chronic inflammation. Those calcium crystals are like microscopic knifes, stabbing at the tender lining of the bursa.
NSAID's are the first line of treatment for all the "itises" in or around the joints. Rest, ice, creams such as Icy Hot may give additional relief from pain. A well placed shot of a corticosteroid by a physician is the best long term treatment. I am contemplating a visit to my favorite orthopedic surgeon, "the Czar", even as I write this blog.
Another condition that causes joint pains is nerve impingement. Carpal tunnel syndrome is pain in the wrist with numbness, and pain in the fingers from injury to the median nerve, as it courses through the wrist bones (carpal tunnel). Repetitive motions such as typing, assembly work and carpentry may lead to swelling in the carpal tunnel and pressure on the median nerve. Nerve impingement can also occur at the elbow, knee and ankle. Temporary relief with splints, anti-inflammatory medications and avoidance of the mechanical cause is possible. Surgery is often necessary and curative.
As we age, our joints simply wear out. Our bones thin, our muscles become weaker, and our connective tissue becomes less flexible. Arthritis is part of the natural aging process. There is no cure, despite the many "snake oil" sellers in newspapers, magazines and especially on the internet. There is no scientific evidence that glucosamine and/or condroitin alleviate or arrest the progression of arthritis. Ditto for shark cartilage, "super fruits", and assorted creams and lotions. Maintaining an "ideal" body weight, regular low impact exercise, and a good night's sleep are your best weapons in the fight against degenerative joint disease.
I feel obliged to mention a disease that makes ER docs cringe when listed on a patient's medical history, Fibromyalgia. Back in the mid 70's, as a medical student I had an instructor named John J Calabro, MD. Dr Calabro was a rheumatologist. He was a dedicated teacher and a compassionate physician. He also wrote one of the earliest treatises on a condition known as fibromyalgia. I remember him telling me that the woman he married had been one of his patients, who he diagnosed with fibromyalgia.
Muscle fiber pain is a loose English translation for fibromyalgia. As with Chronic Fatigue Syndrome and Chronic Lyme disease, two other conditions associated with severe and long term muscle and joint pains, there exists no specific lab test to confirm the diagnosis. Tests for lupus, rheumatoid arthritis and general inflammatory markers are all negative/normal in fibromyalgias. The disease is diagnosed by objective criteria. Harrison's textbook of medicine describes fibromyalgia as a "common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesias, disturbed sleep and easy fatigability along with multiple tender points". The tender points are usually symmetric and number more than three. The upper back, shoulders and neck are common sites. This heightened (exaggerated?) and painful response to applied pressure is the hallmark of fibromyalgia. The ratio or women to men with fibromyalgia is 9:1. Certain anti-convulsants and anti-depressants, anti-inflammatories, "trigger point" steroid injections and long term opiate pain medications are used to treat fibromyalgia.
Improved sleep, exercise, weight loss and stress reduction have all proven helpful in treating fibromyalgia. In patients under fifty, fibromyalgia is the most common diagnosis for musculoskeletal pain. Despite my respect for Dr Calabro, I remain an agnostic concerning fibromyalgia. research into the levels of neurotransmitters in the pain-sensing portions of the brain may ultimately confirm the cause of this condition. Stay tuned!
Arthralgias, joint pains, are divided medically into inflammatory and non-inflammatory subsets. Rheumatoid arthritis is the poster child for inflammatory joint disease. The body's immune system attacks the components of the joints with pain, swelling and ultimately destruction of the joint. Anti-inflammatory medications such as aspirin and NSAID's have always been part of the treatment. Immune modulators are the newest and most beneficial treatment modalities. The side effects of this immunotherapy are an increased risk of infections and cancer.
Osteoarthritis is the most common form of joint disease. There is a familial risk of the more severe form of the condition. Wear and tear of the joints from work and recreational stresses make all of us susceptible to OA. Our bones may get thicker as we gain weight but our joints don't get larger or more robust from added body weight. Arthritis, leading to joint replacement, is increasing because of the epidemic of obesity in our nation.
Joint pains may also be caused by injury and inflammation of tendons, ligaments and bursas near joints. My shoulder pain is most likely tendinitis of the biceps tendon. Bursitis is a possibility. Bursas are sacs that help lubricate the tendons and bones around the large joints. A plain x-ray of an aching shoulder may reveal calcification in the bursa from chronic inflammation. Those calcium crystals are like microscopic knifes, stabbing at the tender lining of the bursa.
NSAID's are the first line of treatment for all the "itises" in or around the joints. Rest, ice, creams such as Icy Hot may give additional relief from pain. A well placed shot of a corticosteroid by a physician is the best long term treatment. I am contemplating a visit to my favorite orthopedic surgeon, "the Czar", even as I write this blog.
Another condition that causes joint pains is nerve impingement. Carpal tunnel syndrome is pain in the wrist with numbness, and pain in the fingers from injury to the median nerve, as it courses through the wrist bones (carpal tunnel). Repetitive motions such as typing, assembly work and carpentry may lead to swelling in the carpal tunnel and pressure on the median nerve. Nerve impingement can also occur at the elbow, knee and ankle. Temporary relief with splints, anti-inflammatory medications and avoidance of the mechanical cause is possible. Surgery is often necessary and curative.
As we age, our joints simply wear out. Our bones thin, our muscles become weaker, and our connective tissue becomes less flexible. Arthritis is part of the natural aging process. There is no cure, despite the many "snake oil" sellers in newspapers, magazines and especially on the internet. There is no scientific evidence that glucosamine and/or condroitin alleviate or arrest the progression of arthritis. Ditto for shark cartilage, "super fruits", and assorted creams and lotions. Maintaining an "ideal" body weight, regular low impact exercise, and a good night's sleep are your best weapons in the fight against degenerative joint disease.
I feel obliged to mention a disease that makes ER docs cringe when listed on a patient's medical history, Fibromyalgia. Back in the mid 70's, as a medical student I had an instructor named John J Calabro, MD. Dr Calabro was a rheumatologist. He was a dedicated teacher and a compassionate physician. He also wrote one of the earliest treatises on a condition known as fibromyalgia. I remember him telling me that the woman he married had been one of his patients, who he diagnosed with fibromyalgia.
Muscle fiber pain is a loose English translation for fibromyalgia. As with Chronic Fatigue Syndrome and Chronic Lyme disease, two other conditions associated with severe and long term muscle and joint pains, there exists no specific lab test to confirm the diagnosis. Tests for lupus, rheumatoid arthritis and general inflammatory markers are all negative/normal in fibromyalgias. The disease is diagnosed by objective criteria. Harrison's textbook of medicine describes fibromyalgia as a "common disorder characterized by chronic widespread musculoskeletal pain, aching, stiffness, paresthesias, disturbed sleep and easy fatigability along with multiple tender points". The tender points are usually symmetric and number more than three. The upper back, shoulders and neck are common sites. This heightened (exaggerated?) and painful response to applied pressure is the hallmark of fibromyalgia. The ratio or women to men with fibromyalgia is 9:1. Certain anti-convulsants and anti-depressants, anti-inflammatories, "trigger point" steroid injections and long term opiate pain medications are used to treat fibromyalgia.
Improved sleep, exercise, weight loss and stress reduction have all proven helpful in treating fibromyalgia. In patients under fifty, fibromyalgia is the most common diagnosis for musculoskeletal pain. Despite my respect for Dr Calabro, I remain an agnostic concerning fibromyalgia. research into the levels of neurotransmitters in the pain-sensing portions of the brain may ultimately confirm the cause of this condition. Stay tuned!
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