A Cigarette

 The mental health team meets us outside. “We should wait for the police,” the clinician says. “She’s a big woman. When we went back up there she had a knife near her that wasn’t there the first time we were up with her. She’s very anxious today. When she’s off her meds, she can be volatile. I’ve seen her tear a door off its hinges.”

“Okay,” I say. “We’ll wait for the PD.”

When the first officer arrives, she repeats the story to him. He calls for backup.

Once backup arrives, we walk up the three flights of outdoors stairs and then force the door open because she will not come to it. Inside we find a completely bare apartment. I am always surprised when I walk into what is actually a fairly common occurrence — a psychiatric patient living in an empty apartment. In the kitchen there is a bare table with no chair and in the living room, there is no furniture, except the single folding chair in which the woman sits facing the window sill, smoking a cigarette. She wears a dirty flowered robe and slippers. She is about two hundred and ninety pounds and built solid like a rhinoceros. When the officer starts talking to her, she turns her head around slowly and says, “Don’t you be talking to me in my house. I don’t give a good god damned about any of you, so for all I care, you can all go ahead and kiss my ass. I ain’t getting up, and I ain’t going anywhere.” She goes back to looking out the window and slowly smoking her cigarette

One at a time we try to talk to her, but she just gets more agitated. When it is my turn, I say in a soft monotone, “We’re just to give you a nice easy ride down to the hospital where you can get something to eat and talk with a doctor and nice nurse about all that’s going on.” She turns full on me, and even though I am several feet away, I can feel hot breath coming out of her flaring nostrils. I just let her rant, and whenever she stops to catch her breath, I start talking again in a real quiet, slow voice. It doesn’t get me far, but at least it wears her down some.

Our efforts to talk her into going having failed, the lead cop and I discuss various game plans. He wants us to get restraints. I offer chemical as an alternative, but suggest we just try to get her to walk first. They stand her up and she starts yelling, but once they cuff her she calms down. We walk down the stairs with her, and she yells again at the top of her voice about what motherfuckers we are and how the world is corrupt. “You think you can just go in and take a woman out of her house, you all a bunch of god damned honkey ass motherfuckers! I have my mind set to take you all out, and I will leave nothing, nothing in my wake. Do you hear me? I said do you hear me! Make no mistake. You all can kiss my black ass cause I’m going to take you all down, treating a poor black woman like this. You should be ashamed of your punk asses, motherfuckers!”

When we get her down on the stretcher, she says, “My wrists hurt.” I start talking soft to her again, “I’m sorry they hurt. I’ll ask the officers to take them off if you agree to not fight us." I nod to my preceptee who is probably about six-four and close to three hundred pounds himself. “The two of us will ride in the back with you. We’ll just take a nice easy ride to the hospital, where you can talk to a doctor. You don’t even have to say anything to us.” She seems to be listening. “And we’ll let you have a cigarette outside the hospital before we go in if don’t fight us.”

“Okay,” she says.

The cops seem a little dubious. “You’re going to have to ride with her.” I nod at my partner. “We can handle her.” They look at the two of us, and they have to admit, she’s big, but the two of us are not likely to be easily handled even by an enraged rhino, and I do have the Haldol and Ativan at the ready. “It’s your choice.”

“She’ll be good,” I say. “We’ll let her have a smoke.”

“You best not be tricking me,” the woman says.

“We’ll get you a smoke.”

They uncuff her and she is quiet on the way in. She even lets us take her pulse and blood pressure. While we are still in the ambulance, I have a vision of us pulling her out on the stretcher and letting her smoke while still on the stretcher, and a newspaper reporter taking a picture of us “ambulance attendants” standing around letting our patient have a cigarette, and what a storm of controversy it might cause. When we get to the hospital, I ask her is she wants to walk in or go in on the stretcher. “I’ll walk,” she says. We’re supposed to keep everyone on the stretcher and while there is no policy about not letting them smoke, I think that is only because no probably imagined crews would let their patients smoke.

We have her step out of the back of the ambulance, and so she is standing when he give her the cigarette. If a photographer were there, it wouldn’t be apparent that she is our patient. She looks like your typical weary two hundred and ninety pound late fifty year old lady in a dirty flowered robe and slippers, smoking a cigarette on a cold grey day. And that’s good, because if she were on the stretcher people seeing a photo in a newspaper might not understand the power of a cigarette. It often works better than brute force, better than pepper spray, handcuffs, Haldol and Ativan. It’s a simple acknowledgement that a person is having a tough day and needs a break, a chance to have a smoke and collect yourself before heading on into another tough day.

In the ER, she says she has to use the bathroom. The nurse tells her she has to pee into a cup.

“I’m going to need a bigger cup,” she says. “And why can’t I just go in the bathroom?”

The nurse says all females have to pee into a cup to see if they are pregnant.

“I ain’t pregnant,” she says.

“We require this of all females,” the nurse said.

“You’re wasting a cup on me.”

Still she takes the cup and shaking her head, waddles over toward the bathroom.

(I first posted this ten years ago.)

Suffering in the World

 We are sent to a detox center for a diabetic. We find a sixty-year old Puerto Rican with a blood sugar over 600, although he has no complaint. He has come to the center to kick his heroin habit. But first now he will have to go to the ER to get his sugar under control. I did three bags of heroin this morning, he admits, then I flushed the rest of the bundle down the toilet, and came here.  He is a man with deep eyes. He speaks quietly. I spent eighteen years in prison, he says. When I came out, I saw there was so much suffering in the world. People on the outside are used to it, and they don't see it, but I saw it. That's how I got started. I've been on and off of it for most of my life.  He tells us how he lost two brothers to heroin and a sister and two cousins to crack cocaine. My father died at ninety last week. He was all I had left. I was lost without him. It was a setback for me, but I looked at myself this morning and knew I wouldn't see seventy if I didn't get a hold of myself. I knew it was time for me to come in.

At the scene of a motor vehicle accident, a wife yells at her husband who has driven his new Toyota into a parked car. He called her and gave her the address so she could bring his insurance card. The address isn't in the best part of town. After she leaves, he waits with the cop for the tow truck to come. The cop thinks something isn't quite right with him, and asks if he is a diabetic. He is, he says, so the officer calls us to check him. He looks to be in late thirties. He wears blue jeans and a college athletic sweat shirt. His sugar is 43 a little on the low side. His answers to questions are slow. He can't remember if he ate or how the accident happened. When I go to roll up his sleeve to look for a vein, he at first refuses. I have issues, he says. We don't care about that, I say. He has track marks on his arms. I put in an IV and give him some sugar that clears his mind up. He looks at the front bumper of his car which is all mashed in. Driving along and he veers off the road. I wonder what he's thinking now. Maybe I should have stayed home. Maybe I should have had a sandwich before I shot up. I wonder up the road what lays ahead for him. I don't think he has thought about that yet.

A wife comes home from work and finds her fifty-year old husband on the kitchen floor, semi-responsive with vomit on his face, chest and the linoleum. His skin is cool. She calls 911. He recently had shoulder surgery and is on blood thinners for clots in his legs. She has no idea what has happened or how long he has been there. When we arrive, we find he can answer questions. He is not hurt, his grips are equal, there is no facial droop, but his speech is slow. He looks at his wife and says Sorry. I ask what meds he is on. I'm thinking maybe he has taken too many and maybe drank, although I can smell no liquor on his breath. He seems familiar to me; not his face, but his whole manner as we pick him up. We are in this new freshly built home, a large sparse home with hardly any furniture, but he seems just like a homeless man in his demeanor. Here is this guy with a well dressed wife, and he seems in his faded jeans and grey tee-shirt and flushed face to be just a street man. He looks up at her and again says, sorry. We get him up on the stretcher and as we start out the door suddenly I hear the wife say, Hold on a minute. She has found something in the bathroom. Heroin.

She is beside herself, she is so angry. The officer asks her if this is something he regularly does.
"No, He's been clean for almost sixteen years since before I met him. He's been very upfront about his past with me, but I've never seen it. He doesn't even drink. I can't believe he did this. I could kill him.

It's the most addictive drug in the world, the officer says. No one ever completely beats it.

I just can't believe this. I'm in shock.

She comes to the hospital with us, riding in the front. Is he okay? she asks.

He's stable, I say. He'll be all right.

She cries. He's been so depressed, she says. He lost his grown son two weeks ago. He's been out of work with his injury. He's had no money. We have a new home and with him not working, we can't afford to put anything in it.
He's beaten this before, I say, He can do it again. Don't be too hard on him. It sounds like he's had a rough go.

I could just kill him, she says, but not as harsh this time.

After we leave them in an ER room, I come back later and glance in. She sits next to his bed, leaning against him, her head against his shoulder, his big arm around her. He brushes her hair. Neither of them speak.

***

I first posted the above ten years ago. No easy street solving this problem.

***

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Opioids for Chronic Pain

 Should paramedics give opiates to patients with chronic pain?

I want the answer to this question.

Now, until recently I have not questioned this practice. Today, I still medicate (well, most*) patients with chronic pain of 4 or more, who do not have contraindications, and who say yes when I ask them if they want pain medicine. I am following our regional pain guidelines, which I helped write. Underlying the guidelines in the premise that pain is what the patient says it is, and human suffering should be relieved.

Today at one of the hospital EMS rooms, I saw a flyer for a CME being offered on February 10 at a local ambulance service (Windsor) about pain management that included a mention of when it was appropriate and when it is not appropriate to give a a patient opiate pain meds. My question! It sounded like an absolutely first rate CME, which unfortunately I can't make because I will likely still be at work on the ambulance when the CME kicks off. The flyer mentioned a virtual guest speaker, Dr. Ruben Strayer. I googled the guest speaker and found this fascinating lecture that questions giving opiates for chronic pain. Now while his lecture does not get down to the paramedic level, it does touch upon the ED MD.

Pain, Compassion, Addiction, Malingering: How To Use Opioids (and how to not use opioids)

Having only listened to it once, it boils down to this.

Big pharma funded a huge effort to convince doctors that opiates are harmless, so people were overprescribed opiates, and this created a generation of addicts that has wreaked havoc on our nation as the opiate epidemic is killing more people today than motor vehicle accidents and destroying families and millions of lives. I wrote about this recently in Pain Myth.

And key to my question, Strayer says giving opiates for chronic pain may in fact be harmful for patients, and while providing temporary relief, may cause hyperanalgesia (where opiates actually make patients more sensitive to pain), and it may further their dependence and make them sicker. There may be better alternatives, he suggests. He breaks down the risk strategies that an ED MD should go through before giving opiates. Perhaps such a model could be developed someday to help paramedics decide who to administer opiates and who to defer treatment to the ED.

Here is an except from the web page about the talk:

For patients at high risk to be harmed by opioids, including patients with chronic pain and patients with flags for opioid misuse, avoid using opioids in the ED and outpatient settings, utilize non-opioids to manage symptoms, and, when misuse is suspected, nudge the patient to addiction treatment.

If opiods may be harmful in the ED setting, then maybe they are harmful in the prehospital setting. If they are, I don't want to give them.

I am not ready to change yet, and before I change, if I become convinced of a better way, I will try to change our paramedic treatment guidelines at the same time. I want to hear what other doctors who I respect think of Strayer's ideas and the general issue, and I, of course, want to read more about this topic.

Two points to make clear. Strayer is not talking about acute pain or about cancer pain. Both of those categories are clearly appropriate to treat with opiates.

As a footnote, in his talk, he mentions the possible benefits of ketamine for chronic pain, and he also says marijuana may be better and less harmful for someone with chronic pain than opiates. I have been in EMS many years, but doubt I will be around long enough to light a bong pipe for a patient in the back of my ambulance. Strayer, of course, is not advocating this either. But a prescription for medical marijuana may in the future replace percocets as the take home prescription of choice.

Bottom line, it is a provocative talk, and as an almost militant pain management advocate, it caught my attention.

*If I believe a patient is outright lying to me, I may withhold medication. The same with if the patient has been identified to me as a patient who an ED does not want getting opiods, then I will withhold. In general, I have always erred on the side of the patient and given the opiate.