Footprints

 Three sets of footprints in the snow. Two with fully defined treads. Mine barely register. I’m twelve years older than the two of my partners combined. This is my fifth pair of boots and the soles have gone smooth. I walk carefully. We do a call and I can’t make it up the icy driveway. I keep slipping down the incline. I have to hike up through the snow to get to the door. I have had this pair of Fort Lewis’s seven years, and they have stood me well. I order a new pair that night and they arrive on Christmas eve. I put them under the tree so I it will look like there are even more presents when my daughter awakes in the early hours and checks to see if Santa has come. In life we give way to youth, all of us do. We fade away. But I hope this new pair of working boots won’t be my last. I have more earth to tread on, more inclines to climb.

Pain Myth

 In my standard talk urging paramedics to be generous with pain management, I have a section called pain myths. One of the myths is entitled Fear of Creating Addicts On the powerpoint I have two pictures, one of an all-American housewife, the other of a skanky drug-addled prostitute.

Here is the text from the slide:

"4 patients out of 11,882 patients treated with opioids at Boston University developed opioid dependence."
-Research from Boston University
http://www.emedmag.com/html/pre/fea/features/121501.asp

***

Imagine my pain and surprise when I read recently that this study, which in various sources has been hailed as a landmark study, etc, was in fact just an obscure letter to the editor in The New England Journal of Medicine consisting of no more than a paragraph, written in longhand. The man who wrote it, Dr. Hersel Jick, kept a database of medication side effects suffered by patients hospitalized at the University Hospital. Curious about the opiate addiction question, he had an assistant run the data, which prompted him to write the letter. Little did he know, but his letter, which was titled Addiction Rare in Patients Treated with Narcotics, initially forgotten, was later found and trumpeted by the pharmaceutical companies who were trying to convince the world their oxycontin and other opiates were not addictive, and should be given liberally to those in pain.

As most in EMS know the country is in the midst of an opiate overdose epidemic never seen before. Here is the narrative of how that epidemic has come to play out, according to an excellent book I just finished called Dreamland, the True Tale of America's Opiate Epidemic by Sam Quinones.

Drug companies pushed oxycontin on well-meaning doctors as the panacea for patients's pain at the same time the medical establishment was coming to recognize pain as the fifth vital sign, and that pain was what the patient said it was. Using landmark studies such as the Jick letter, they encouraged the prescription and represcription at even higher doses of oxycontin. While the meds helped countless patients, others quickly became addicted, and they required more and more of the drug to keep from being drug sick. Pill mills sprouted up across the country where easy money was made charging $250-$500 cash for an exam with a resulting prescription for opiates. Many of the patients at these clinics, faked pain to get the prescriptions to sell the drugs to addicts. In time, the pill mills were shut down and the drugs became much harder to acquire. For those without insurance the pills could cost $200 a day on the street. With the advent of safer tamper resistant oxycontin drugs, it was harder and harder to be an oxy junkie. In the meantime, the cost of heroin dropped drastically at the same time its quality improved. (A dual narrative in the book describes the Mexican retail trade in black tar heroin that is fascinating reading.) With heroin cheaper and easily accessible and working on the same receptors, the switch from oxycontin to heroin was a no brainer.

Hartford, where I work, has several methadone clinics, and it is quite an education to respond there in the morning and see the lines stretching down the block. The addicts are not predominantly young minority men from the inner city as they were years ago. Today, they are of all ages and races, from the city and the suburbs, high school athletes, grandmothers and housewives. The same with the heroin calls we get. Last week, I picked up a man sleeping the bushes, who had come to the city looking for heroin and pills. He wore a jacket with the name of a construction business on it. We asked if that was where he worked. He said he used to own the business.

The book explains that the patients in the Boston University database were cancer patients getting small amount of opiates under strict control, not patients with chronic pain. No real study has been done on how many people get addicted to opiates, but the number of deaths suggest it is much larger than the number quoted in the letter.

There is an ongoing health care battle in the country today between two opposing and well-meaning groups -- those whose primary goal is to provide pain management to those who need opiates to function and those whose primary goal is to stop the deaths. It is hard to find the proper balance between the two.

Where do we as medics fall in it? I don't see but we have any choice but to continue to provide pain relief to those in need, and let the hospital sort out any addiction problem. I do ask now if patients have pain contracts and if they say they do, but are requesting transport to a second hospital, then I am hesitant to dose them. I continue to treat acute pain, even possible faked acute pain (I have pancreatitis!) as I always do. If their pain is greater than a 4, I ask "Would you like some pain medicine?"

I can't say definitively that there is no risk that I am starting them on the road to addiction and ruin. I doubt the number is great, but maybe I am giving them their first taste of an opiate and they really like it (I'm not certain what they gave me for my colonoscopy, but I left the procedure feeling great!), and they are cursed with the addiction gene. Maybe the same business owner today who hurts his shoulder in a fall and gets fentanyl from me, I might find on a future day laying in the bushes in his tattered work coat, an addict who lost his wife and children and home and business, ruled now by the opiate lust.

But then again, promptly medicating the business owner with the damaged shoulder, I am, as others have argued, intervening quickly and sparing him the physical changes that acute pain can cause that often lead to chronic pain. Perhaps, I am sparing him from ever having to go on oxycontin in the first place.

Here is another slide from my presentation that is a bedrock of my pain management philosophy:

Prompt treatment of acute pain may prevent both short- and long-term deleterious consequences and resultant chronic pain syndromes.“ Pain Management and Sedation: Emergency Department Management, Mace Ducharme Murphy, McGraw Hill 2006

I just hope someday I don't read that that is a phony argument too.

Same Old Song and Dance

 When couples get old, they communicate with fewer words or sometimes just a look.

I am feeling that way about my EMS reports at the ED.

Where I used to rattle off every detail I could think of (from brand of cereal they had for breakfast to the number and locations of the moles they had removed a month prior), nowadays I try to keep it short.

Here are some examples:

"Last drink two days ago, got the shakes. 2 of Ativan and some fluid."

Low speed, belted, neck and back.

History of seizures, had a seizure.

 Curtis, same old

Sugar of 20, forgot to eat, gave her D10.

He thinks he's the Devil, gave him 10 of Versed.

"Cold and flu."

They shot him in the leg.

Eight years old. Acting up in school.

ETOH.

Coughing up green phlegm for two weeks.

2 of Narcan IN.

Sometimes, I don't say anything at all. I just point to the patient. Every picture tells a story.

It helps if the nurse or doctor I am giving the report to has been around as long as I have. They just nod like all those times before.

Legends

 On Sports Radio this morning they were talking about the decline of three sports legends – Tiger Woods, Peyton Manning and Kobe Bryant. The radio host, a retired athlete himself, was saying how no one who hadn’t played professional sports could possibly understand what these three were going through. He said they dedicated their lives and heart to a sport. They were the center of everyone’s attention. And now their bodies were betraying them. They could no longer perform at the level they were accustomed to performing. They couldn’t be the hero anymore. It was like they were suddenly staring into a void, left with nothing.

I love sports, but seriously…

I thought today of all the paramedics past I have known, men and women, who stood tall, who were the center of attention, who performed at the height of their abilities when human life and death were on the line, when people were sick or injured and in need of someone special to walk through their doors and make things better, and these men and women did. EMS was their life and their identity, and then the day came when their powers started to fade. They grew old or got hurt and they could no longer do the job they loved. They were no longer the center of attention; they no longer had the power to heal.

I think of all the medics I saw over the years, who instead of riding the ambulance, were consigned to the light-duty chairs, consigned to paper work, washing ambulances, or delivering supplies. I think of the others who went out on injury and never came back.

They might not have been known to the world as Tiger, Peyton or Kobe, but they were known to those who worked with them, and to those they took care of.

You don’t have to be a professional athlete to understand what age does to people or to yourself.

We all one day vanish.