Saturday, September 27, 2014
Wednesday, September 24, 2014
A higher standard.
So a common phrase muttered in the ER is "this is not burger king".
They are right; this is not burger king. As a patient you cannot walk up to the counter and order rocephin-burger with a side of prednisone for your (very likely viral) laryngitis. There are a lot of good reasons for this. 1. You don't need antibiotics, especially strong antibiotics for a viral infection. 2. Overuse of antibiotics has lead to superbugs that are bad for the community as a whole. 3. If your only symptom is that you can't talk, you will be just fine until Monday when you can follow up with your primary care provider.
But let's talk about us healthcare providers. We mutter in disgust when someone asks for something unreasonable, because it's annoying that people don't trust us with their health even after they have signed in and gotten the blood work. So here's the other side of the coin. This is NOT BURGER KING. We don't serve slabs of greasy beef between sesame seed buns. We have a standard to uphold. We have to give these people a reason to trust their health to us. If we mess up, someone could get really sick, their life could be seriously altered or they could die. For example, Walgreens has screwed around getting my prescription refilled for 6 days. They can't manage to figure out how to get my beta blocker, my SSRI or my whelcol refilled. (Beta blocker is a heart medicine that should not be suddenly changed or stopped, abruptly stopping an SSRI can cause suicide ideation and stopping my whelcol prevents me from eating anything for the last 6 days). I am very diligent with my medications to keep my body working to the best of it's ability. Being out of medications for almost a week is doing serious damage to me.
So, here's the deal. Next time you mutter that this is not burger king, take a look around and make sure you are running a 5 star restaurant.
They are right; this is not burger king. As a patient you cannot walk up to the counter and order rocephin-burger with a side of prednisone for your (very likely viral) laryngitis. There are a lot of good reasons for this. 1. You don't need antibiotics, especially strong antibiotics for a viral infection. 2. Overuse of antibiotics has lead to superbugs that are bad for the community as a whole. 3. If your only symptom is that you can't talk, you will be just fine until Monday when you can follow up with your primary care provider.
But let's talk about us healthcare providers. We mutter in disgust when someone asks for something unreasonable, because it's annoying that people don't trust us with their health even after they have signed in and gotten the blood work. So here's the other side of the coin. This is NOT BURGER KING. We don't serve slabs of greasy beef between sesame seed buns. We have a standard to uphold. We have to give these people a reason to trust their health to us. If we mess up, someone could get really sick, their life could be seriously altered or they could die. For example, Walgreens has screwed around getting my prescription refilled for 6 days. They can't manage to figure out how to get my beta blocker, my SSRI or my whelcol refilled. (Beta blocker is a heart medicine that should not be suddenly changed or stopped, abruptly stopping an SSRI can cause suicide ideation and stopping my whelcol prevents me from eating anything for the last 6 days). I am very diligent with my medications to keep my body working to the best of it's ability. Being out of medications for almost a week is doing serious damage to me.
So, here's the deal. Next time you mutter that this is not burger king, take a look around and make sure you are running a 5 star restaurant.
Wednesday, September 17, 2014
Changing perceptions from the inside out
I want to address something that really irks me as both a medical professional and a patient with a rare disease.
So if you've read this, you know that I work at an ER. I've worked in the hospital, as a medical assistant and done some EMS work. We are trained to follow algorithms that indicate what is most likely to be wrong with our patient. The key words here are most likely. Yes, the old adage is usually correct. When you hear hoof-beats, think horses, not zebras. Most patients are horses, but that doesn't mean zebras don't exist. It takes a critical eye to catch the elusive zebra, but we are often so stuck on the flow chart that we miss these patients. They deserve to have someone think critically about their case.
In emergency medicine, the first glimpse of a patient we get is usually another persons notes. In EMS, we get our dispatchers notes, information they got from the caller. In the ER, we get triage notes, again another person's interpretation of the situation. It usually includes the persons age, sex and chief complaint. This initial assessment greatly influences the way we view the situation. A 19 year old female with chest pain is less of an emergency than a 67 year old male with chest pain. They may put the 19y/o down as a level 3 and the 67y/o as a level 1. 98% of the time, their assessment is dead on. The 67 year old is almost always more acute than a 19 year old.
Here is what I'm asking. Look closer. As much as I respect triage nurses and dispatchers, they can be wrong (so can I). Don't allow your mind to dismiss the 19 year old until you have looked at the vitals, the whole nurses note or laid eyes on the patient. Don't dismiss that patient and go to lunch because they will be fine until you get back (and I know about how hard it is to get a minute to eat, but you can ask the nurse how they are or poke your head in the room first).
Sometimes, the 67 year old, has a burning pain that began 10 days ago and is relieved by TUMS and the 19 year old has a connective tissue disorder and ripping pain with an acute onset an hour ago. We have all coded a young person and had no idea why they were in our ER. We need to learn to go into a patient encounter without presuppositions as to what is wrong with the patient, so we can catch the zebras. In the end, we are more than just a person following a flow chart.
So if you've read this, you know that I work at an ER. I've worked in the hospital, as a medical assistant and done some EMS work. We are trained to follow algorithms that indicate what is most likely to be wrong with our patient. The key words here are most likely. Yes, the old adage is usually correct. When you hear hoof-beats, think horses, not zebras. Most patients are horses, but that doesn't mean zebras don't exist. It takes a critical eye to catch the elusive zebra, but we are often so stuck on the flow chart that we miss these patients. They deserve to have someone think critically about their case.
In emergency medicine, the first glimpse of a patient we get is usually another persons notes. In EMS, we get our dispatchers notes, information they got from the caller. In the ER, we get triage notes, again another person's interpretation of the situation. It usually includes the persons age, sex and chief complaint. This initial assessment greatly influences the way we view the situation. A 19 year old female with chest pain is less of an emergency than a 67 year old male with chest pain. They may put the 19y/o down as a level 3 and the 67y/o as a level 1. 98% of the time, their assessment is dead on. The 67 year old is almost always more acute than a 19 year old.
Here is what I'm asking. Look closer. As much as I respect triage nurses and dispatchers, they can be wrong (so can I). Don't allow your mind to dismiss the 19 year old until you have looked at the vitals, the whole nurses note or laid eyes on the patient. Don't dismiss that patient and go to lunch because they will be fine until you get back (and I know about how hard it is to get a minute to eat, but you can ask the nurse how they are or poke your head in the room first).
Sometimes, the 67 year old, has a burning pain that began 10 days ago and is relieved by TUMS and the 19 year old has a connective tissue disorder and ripping pain with an acute onset an hour ago. We have all coded a young person and had no idea why they were in our ER. We need to learn to go into a patient encounter without presuppositions as to what is wrong with the patient, so we can catch the zebras. In the end, we are more than just a person following a flow chart.
Monday, September 1, 2014
Tips for talking with the ER doctor about pain (for chronic illness patients)
Do not say "everything hurts"
Try to localize your pain, even if it is a very long list. If you really have pain everywhere, call it body aches instead. It helps to differentiate sharp pains from aches. If you have pain it your joints, say joint pain. These docs think we are being literal when we say pain all over and there isn't any disease documented that makes absolutely everything hurt (and before you jump on me about fibromyalgia, think about it. Does your inner ear, your head, your genitals ect. hurt? fibromyalgia does make almost everything hurt, but it mainly affects muscles, so we have to be specific and say "my muscles hurt".) A good example of getting the right pain control is sciatica, if you can say, I have this pain that starts in my low back and shoots down my buttock to my leg, you are more likely to get the appropriate pain control. Sciatica hurts like a beeyatch and the ER docs know it. If you simply say my leg hurts, and they don't find a break in it, you are probably going to go home with pain medication for a 3/10 instead of the 7/10 you would get if you were diagnosed with sciatica.
Be honest about your pain
ER doctors are living bullshit detectors. These guys will ignore you in a second if you say you have 10/10 pain and you have your cell phone in your hand. Your body has gives off physiologic signs of pain. For example if you have 10/10 pain, you will likely be crying, sweaty, have an increased heart rate and respiration rate. Your doctor will look for these, but he will discount them if you don't appear uncomfortable. It sucks for those of us who have trained ourselves to not look like we hurt when we do. You are more likely to get the pain medication you need if you are real about it. 7/10 with some tachycardia or laying quietly is more likely to get you the meds than saying 10/10 and not showing any indicators of pain. If you repeatedly give the 10/10 line, you will be labeled a drug seeker and you will not get the pain relief you need. Remember 10/10 is supposed to be the worst pain imaginable or the worst pain you have ever felt (depending on who you ask) statistically you will only get that pain once or twice in your life. It is OK to tell the doc that your pain was a 10/10 but is better now that you aren't moving or since some medication. On the flip side, if you don't tell them you are in pain, they can't fix it. It's not good for your body to be in a lot of pain for a long period of time, let them help.
Don't rely on the pain scale to communicate your pain level (I hate the pain scale!)
The pain scale is subjective, which means it is not something that other people see or feel. It's only what you tell them. Because of this, it is not a reliable measure of pain. One persons 5/10 may be the same as another persons 10/10. It's almost impossible for the ER doc to understand exactly what you are feeling. Add other descriptors. Is the pain sharp, is it dull? Does it come and go or is it always there? Does it feel like someone is stabbing you?
Anxiety medication is not just for anxiety
Let them give you the Valium/Xanax/other anxiety medication. It isn't always used just for anxiety, it can help with pain, especially the muscular kind. When we are tense, or body knots up and hurt us even more, the anxiety medications help us relax so that some the pain can naturally dissipate. Accepting these medications also helps rule out a psychosomatic (when the body responds to mental stress) condition causing your pain, and help lead to the correct diagnosis and treatment.
Don't discount non-narcotic medications
Ultram and tramadol help sometimes, and can be very good in conjunction with other medications. Motrin is a better medication for pain than narcotics in a lot of situations because it reduces inflammation, instead of just masking pain. Medications like neurontin are often a better medication for nerve pain than a narcotic. Narcotics have their place, but we shouldn't be looking at them for long term use. Think of them as band-aids, they can cover a wound, but it wont actually heal the wound. The goal is to heal the wound.
Some medications take time
If you go to the ER and are given a non-narcotic med, give it a chance before you decide it doesn't work and go back. Some medications take time to really start working. Don't discount a medication after taking just one or two doses. If you have inflammation, it takes a while for the medication to get to the site of inflammation and bring that inflammation down, reducing your pain. When you have muscle pain, keep on top of taking those medications on a schedule for the first few days, then move to taking them only when you have pain, weaning down.
Don't expect pain to disappear
Sorry. Pain sucks and it's not going to just disappear. Pain medications are designed to help bring the pain level down to something manageable. I once had a patient who took far too much pain medication and fell asleep on a light bulb. She sustained 3rd degree burns and eventually died from and infection of the burn site. The goal is to take the least amount of pain medicine necessary for you to preform normal daily functions.
The ER is not the place for chronic pain management
Most chronic pain patients freaking hate the ER. I don't blame you. If you have to go, go. Please know that the ER doctor is NOT a specialist in pain management. They don't know all of the options. As of a month or so from now, most ERs aren't going to even be able to give prescriptions for norco/vicodin. If you find yourself going to the ER frequently for pain, please find a pain management specialist (your ER doctor will be glad to give you a referral). They are best at managing chronic pain.
Ideally, we should be able to be honest about our pain level, and get appropriate pain management. Unfortunately it just isn't that simple. ER doctors have to think about before prescribing pain meds. Is the patient being real about their pain? Is this going to be good for the patient in the long run? Will it interact with other medication? Are we over-medicating this patient? Is this pain consistent with the diagnosis? What level of medication does this diagnosis usually require? We need to help them out. We need to find a way to be part of the team instead of bucking against it. ER doctors are most definitely affected by drug seekers. Some of them are so jaded that they don't seem to understand pain and its affect on life anymore. I hate that. I'm not saying that they way these guys work is the right way, just trying to give a different view point that might help next time you have to utilize the ER (so no comments about how wrong they are, I know it's not perfect, but they are doing their best). I know how frustrating it can be to try to get the right pain management from the ER doc that has been burned multiple times. But hopefully these tips can help.
Try to localize your pain, even if it is a very long list. If you really have pain everywhere, call it body aches instead. It helps to differentiate sharp pains from aches. If you have pain it your joints, say joint pain. These docs think we are being literal when we say pain all over and there isn't any disease documented that makes absolutely everything hurt (and before you jump on me about fibromyalgia, think about it. Does your inner ear, your head, your genitals ect. hurt? fibromyalgia does make almost everything hurt, but it mainly affects muscles, so we have to be specific and say "my muscles hurt".) A good example of getting the right pain control is sciatica, if you can say, I have this pain that starts in my low back and shoots down my buttock to my leg, you are more likely to get the appropriate pain control. Sciatica hurts like a beeyatch and the ER docs know it. If you simply say my leg hurts, and they don't find a break in it, you are probably going to go home with pain medication for a 3/10 instead of the 7/10 you would get if you were diagnosed with sciatica.
Be honest about your pain
ER doctors are living bullshit detectors. These guys will ignore you in a second if you say you have 10/10 pain and you have your cell phone in your hand. Your body has gives off physiologic signs of pain. For example if you have 10/10 pain, you will likely be crying, sweaty, have an increased heart rate and respiration rate. Your doctor will look for these, but he will discount them if you don't appear uncomfortable. It sucks for those of us who have trained ourselves to not look like we hurt when we do. You are more likely to get the pain medication you need if you are real about it. 7/10 with some tachycardia or laying quietly is more likely to get you the meds than saying 10/10 and not showing any indicators of pain. If you repeatedly give the 10/10 line, you will be labeled a drug seeker and you will not get the pain relief you need. Remember 10/10 is supposed to be the worst pain imaginable or the worst pain you have ever felt (depending on who you ask) statistically you will only get that pain once or twice in your life. It is OK to tell the doc that your pain was a 10/10 but is better now that you aren't moving or since some medication. On the flip side, if you don't tell them you are in pain, they can't fix it. It's not good for your body to be in a lot of pain for a long period of time, let them help.
Don't rely on the pain scale to communicate your pain level (I hate the pain scale!)
The pain scale is subjective, which means it is not something that other people see or feel. It's only what you tell them. Because of this, it is not a reliable measure of pain. One persons 5/10 may be the same as another persons 10/10. It's almost impossible for the ER doc to understand exactly what you are feeling. Add other descriptors. Is the pain sharp, is it dull? Does it come and go or is it always there? Does it feel like someone is stabbing you?
Anxiety medication is not just for anxiety
Let them give you the Valium/Xanax/other anxiety medication. It isn't always used just for anxiety, it can help with pain, especially the muscular kind. When we are tense, or body knots up and hurt us even more, the anxiety medications help us relax so that some the pain can naturally dissipate. Accepting these medications also helps rule out a psychosomatic (when the body responds to mental stress) condition causing your pain, and help lead to the correct diagnosis and treatment.
Don't discount non-narcotic medications
Ultram and tramadol help sometimes, and can be very good in conjunction with other medications. Motrin is a better medication for pain than narcotics in a lot of situations because it reduces inflammation, instead of just masking pain. Medications like neurontin are often a better medication for nerve pain than a narcotic. Narcotics have their place, but we shouldn't be looking at them for long term use. Think of them as band-aids, they can cover a wound, but it wont actually heal the wound. The goal is to heal the wound.
Some medications take time
If you go to the ER and are given a non-narcotic med, give it a chance before you decide it doesn't work and go back. Some medications take time to really start working. Don't discount a medication after taking just one or two doses. If you have inflammation, it takes a while for the medication to get to the site of inflammation and bring that inflammation down, reducing your pain. When you have muscle pain, keep on top of taking those medications on a schedule for the first few days, then move to taking them only when you have pain, weaning down.
Don't expect pain to disappear
Sorry. Pain sucks and it's not going to just disappear. Pain medications are designed to help bring the pain level down to something manageable. I once had a patient who took far too much pain medication and fell asleep on a light bulb. She sustained 3rd degree burns and eventually died from and infection of the burn site. The goal is to take the least amount of pain medicine necessary for you to preform normal daily functions.
The ER is not the place for chronic pain management
Most chronic pain patients freaking hate the ER. I don't blame you. If you have to go, go. Please know that the ER doctor is NOT a specialist in pain management. They don't know all of the options. As of a month or so from now, most ERs aren't going to even be able to give prescriptions for norco/vicodin. If you find yourself going to the ER frequently for pain, please find a pain management specialist (your ER doctor will be glad to give you a referral). They are best at managing chronic pain.
Ideally, we should be able to be honest about our pain level, and get appropriate pain management. Unfortunately it just isn't that simple. ER doctors have to think about before prescribing pain meds. Is the patient being real about their pain? Is this going to be good for the patient in the long run? Will it interact with other medication? Are we over-medicating this patient? Is this pain consistent with the diagnosis? What level of medication does this diagnosis usually require? We need to help them out. We need to find a way to be part of the team instead of bucking against it. ER doctors are most definitely affected by drug seekers. Some of them are so jaded that they don't seem to understand pain and its affect on life anymore. I hate that. I'm not saying that they way these guys work is the right way, just trying to give a different view point that might help next time you have to utilize the ER (so no comments about how wrong they are, I know it's not perfect, but they are doing their best). I know how frustrating it can be to try to get the right pain management from the ER doc that has been burned multiple times. But hopefully these tips can help.
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