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.

Thoughts on Lights and Sirens: Stroke

 I hardly ever go lights and sirens to the hospital. I feel so strongly about not going lights and sirens unless absolutely necessary, I wrote what became our statewide policy on lights and sirens. Although it was toned down through the various committees it went though, the gist of it remained the same. You should only go lights and sirens to the hospital if the hospital can do something in the minutes saved by going lights and sirens that you can’t do that will make a difference in the patient’s mortality or morbidity.

Here’s how it was eventually worded:

When transporting the patient utilizing lights and sirens, the need for immediate medical intervention should be beyond the capabilities of the ambulance crew using available supplies and equipment and be documented on the patient care report.

I used to go lights and sirens quite a lot when I first started, but then I began to wonder. Here I am going lights and sirens, making cars veer out of my way, and running the risk of someone slamming into me, or someone else and for what? To get ahead in the triage line? Or to get to a room to turn the call over to a nurse, who I can’t even find to be seen by a doctor who has four other patients to see first?

Sometimes when I worked at night years ago, we went lights and sirens on bullshit calls, just to drop the patient off in the waiting room to clear to take the next holding call. That seemed more reasonable to me than going lights and sirens to wait in the line.

I posted that once on an early internet EMS list serve and got slammed for it -- and with good cause. I don’t do that anymore. I recognize now getting into an accident going lights and sirens for a patient with a smashed toe is not good form. Mea culpas galore.

Here’s what I have been going lights and sirens in 2015:

STEMI
Major trauma with physiological changes. Decreased GCS, penetrating trauma, hypotension or tachycardia, amputations.
Refractory anaphylaxis.
Pale, cool diaphoretic, abdominal pain. Thinking AAA or ischemic bowel or another surgical emergency
Refractory seizure
Refractory CHF not responding to CPAP and NTG
Major stroke*
Others depending on unique circumstances (like someone who I think is going to crash)
Cardiac arrest (only sometimes).
Seriously impending childbirth. (Some people like to deliver babies, but I think the baby deserves an OB team more than just a paramedic, particularly when things go bad.)

I call your attention to itme 7 on the list -- major stroke. Why not minor stroke? Good question. I acknowledge that I should be going lights and sirens on these patients, but I have been having a hard time, actually doing it. I make excuses. “Let’s just get going I will tell my partner, but keep it on a two. I’ll do everything on the way.” My partner on this day is new and drives rough and doesn’t always know where he is going. I justify my decision that it is a safety issue, which trumps all.

I have a dual role when it comes to stroke. I work at a stroke center and collect data. One of the data fields I collect is whether or not the ambulance went to the hospital lights and sirens. I was shocked to discover EMS only transports a little more than half of stroke patients on a priority, even though we have all been taught -- time is brain. They say you lose 32,000 brain cells every second in stroke. I am not talking about unresponsive Cincinnati 3 here. I am talking about the patient with a mild facial droop and arm weakness, who is hemodynamically stable. I ask medics who have called in stroke alerts why they didn’t go on a priority. 32,000 brain cells a second. I remind them. We are on the clock --the patient is still in the tPA window. They shrug. Maybe it’s the fact it takes hospitals so long to give tpa -- the goal benchmark is 60 minutes. The time it takes to give it is not unreasonable -- the patient needs to be scanned, thoroughly evaluated by Neurology and then have a conversation on the risks and benefits of tPA (IT MIGHT KILL YOU!). If they get tpA within 52 minutes instead of 50, does it matter?

If you buy into tPA (not everyone does) and you buy into our stroke system (which is build around tPA) then we all should be going lights and sirens on even minor strokes. It was shocking to me that 60% of our EMS patients who were recognized strokes and got tPA, were transported nonpriority.

Like many time sensitive interventions the data shows the sooner people get it the better it works. The longer time passes, the greater the risk until the point at 3-4.5 hours (depending on patient) when the risk exceeds the benefit.

Based on the data I collected (showing area medics reluctance to go on priority) we added the following to our regional stroke guideline:

Try to limit scene time to 15 minutes or less, and transport rapidly. Transport should be equivalent to trauma or acute myocardial infarction calls.

I haven’t had a stroke for awhile, so I haven’t been tested, but other medics keep resisting. It’s odd.

Looking at the dispatching side, we noticed early on that only 70% of strokes were being dispatched on a priority, but in certain areas, it was even lower. We looked into those towns and found their dispatch centers were dispatching STROKE (Card 28) in Medical Priority Dispatch non lights and sirens. Reading the card was somewhat shocking.

"STROKE must receive an immediate response that is not subject to delay, lights and sirens are not recommended; however there should be a sense of urgency.”

It is important to note that someone having a massive stroke, leading to say, being unconscious, would be coded out under another dispatch card such as UNCONSCIOUS (card 31) and receive automatic lights and sirens response.

The way EMD works is the EMD system makes recommendations but the medical director makes the final decisions. Stroke coded out as a C or Charlie response and our medical director had ambulances going cold on most of the Charlie calls. We had our medical director, who to his credit is very conservative with calls he will have ambulances go lights and sirens on, change the possible stroke response to lights and sirens. We saw an almost immediate change in times. It seems the historic rationale for the non lights and sirens response on hemodynamically stable strokes is that while stroke was time sensitive, the few minutes saved by going lights and sirens was not worth the risk.

I know there are studies that say using lights and sirens only saves a few minutes. True, maybe when all responses are combined, but there are times of the day when without lights and sirens, you wait forever at strings of lights. There are clearly outliers where lights and sirens will save you 10-20 minutes. That is a lot of brain cells when it comes to possible stroke, and can be the difference in whether or not someone gets tPA. Not only that but tPA, if you believe the studies, shows a better effect the sooner it is given. 1 hour is better than 2, 2 hours is better than 3. After that, the considerable risks outweigh the benefits.

Maybe EMS is reluctant to go lights and sirens on milder strokes because EMS doesn’t get the follow-up on stroke patients. With STEMI, you either go up to the cath lab or you learn the door to balloon time. With trauma, you see the response and when you come back from writing your form, they are up in the OR. Maybe if we provide better followup to EMS, we will come in quicker? I have been a medic over twenty years and I cannot point to one of my patients that I know got tPA. I am sure some of them did, but no one told me, and I never followed up. And it is not like every stroke patient gets it. Our best quarter 20% of ischemic strokes got it, which is quite good. Some hospitals only 1-2% of stroke patients get the drug.

And maybe EMS is reluctant to go lights and sirens because the outcomes are so poor. Even if you believe tPA works, all it means is that the patient has a 10-30% chance of being moderately disabled versus severely disabled. The push tPA and there is the sudden hallelujah moment where the patient can walk and see and talk is largely a myth. Sure, some people can suddenly become better, but it is more likely if they are waking at that moment that it is the natural progression of their individual stroke/TIA and their reperfusion is spontaneous. Even the positive tPA studies show no difference at 24 hours between those who get it and those who don’t.

Over the years I’ve had a number of patients who were completely stroked out, who awoke after I had called in my stroke alert. They just had giant TIAs with spontaneous reperfusion. What if they had been given tPA? Would it have been the tPA or the natural reperfusion? And what if, in getting tPA, it caused them to bleed in their brains and die?

Bottom line, despite my reservations about tPA, I am going to try to go lights and sirens on my future stroke patients, because that is how our system is setup, (tPA is considered a Level I AHA intervention) and 32,000 brain cells a second is our responsibility. I say get them to the hospital quick, and let the neurologists do what they think is best. And if they get tPA long after I am on another call, I hope my lights and sirens transport, made a difference, even if small, to a fellow human’s outcome. I also hope I didn’t cause any accidents on the way to the hospital. Some of the newer people I work with are not the most experienced drivers. I have had a number of intercept medics tell me they won’t go lights and sirens strictly because they don’t trust the driver. I admit to being in that situation at times.

***

Update: I responded the other day to an elderly man with dementia who had suddenly lurched to the right, and then while he did not fall, was observed unable to move his right arm. I palpated all along it for trauma and elicited no response. He could squeeze his left hand on command, but not the right. He failed the pronator drift, but had no facial droop or speech problems. He was elderly and was hypertensive -- 180/100. I would have been more confident in my assessment if I could have had a conversation with him, but I was stuck with his limited ability to converse. His watchers said the right arm was completely not normal for him. I was only a couple miles from the hospital, but I did call it in as a stroke alert, and I did go lights and sirens, although I told my partner to make is an “easy 1”. The patient got a quick neurological exam, and then was sent right to CT scan as a possible stroke. I left for another call, and never got any follow-up.

* Now modified to stroke

Changes

 People are always asking me what changes I have seen over the years.  Here are four changes I have been thinking about lately.

More paramedics.  When I started we had anywhere from two to six paramedics on to cover the entire city of Hartford and backup the other three large towns we covered.  On many days I was the only medic for the northern half of the city.  I never did transfers unless they were ALS, I was rarely deliberately dispatched to drunks or psychs, and I intercepted constantly with BLS cars.  Today, we have anywhere from five to twelve medics on, and I believe if we could do it, we would put a medic in every car.  How do I feel about this?  I miss the old days, but if I was a patient and I was sick, I would want a paramedic taking care of me.  Going along with this, I think today it is much easier to be a paramedic.  Today’s medics have capnography, CPAP, combitubes and other backup airways, EZ-IOs, and much wider array of drugs that no longer require an IV.  Intranasal Fentanyl, oral Zofran, IM Versed area examples.  Gone are the days when you had a cardiac arrest that you couldn’t get an airway and IV access on.  Someone having a horrible time breathing and you don’t know why?  Slap the CPAP on.  I don’t mean this as a criticism, I think this is great for all medics and patients.

More calls at Dr.s offices and walk-in clinics.  We have always done these calls, but the numbers have increased to the point that a shift rarely goes by that I don’t do at least one call and often more at these offices.  For years, the complaint had been people were using emergency rooms as their primary care.  Now with the proliferation of these walk in clinics and more people covered by insurance now having doctors, they go there first.  Blood pressure high?  Short of breath?  Or an odd looking ECG?   911 is called.  Some are true emergencies, others not.

Safer equipment for moving patients.  Power stretchers and stair chairs with treads.  The days of the two person dead-lift and the back-breaking carry downs are largely gone thanks to these wonderful improvements.

More Fire-based EMS.  At least around here, we rarely saw fire departments on our calls.  In Hartford, the PD was the first responder -- their 02 tanks were empty, and they did not like touching patients.  Now, the Fire Department goes to all priority one calls.  And since we have fewer cars in the city than we used to, they are almost always there before us.  It is a big help -- everything from seeing the big red truck to help us pinpoint the location of the call to all the help they give us on scene, particularly with carrying.  In one town we respond in -- West Hartford -- we have seen the Fire Department go from only going to car crashes needing extrication, to going to priority ones, to going to all calls, to starting in January, actually providing paramedic care as the first responders in town.

What do these four changes all have in common?  Money.  The ambulance services make more money through the added paramedic assessment charges.  Walk-in clinics are much more profitable to health care organizations than EDs.  Safer equipment means reduced worker’s comp costs and less employee turnover.  The only outlier here is the fire involvement, which could be argued costs more, but when properly spun, comes out as getting more bang out of the fire personnel for the buck than when they were just firefighters.

I am not criticizing this.  Money has always driven change.  It is the way of the world, and not necessarily a bad thing.

The next big change coming down the pike driven by dollars. --  Mobile Integrated Health Care, aka, paramedic community medicine.  For years, nurses have used their political power (nursing organizations, power of the vote, donations, numbers), as all groups do, to keep paramedics off their turf in hospitals and home care settings, but in today’s world, the dollars to be saved by using medics to fill gaps in the health care system, are too great.  Many states have already gone to this new model of care.  Here in Connecticut, a law was passed to study the issue and consider regulatory change to make it happen.

Here’s how it might happen.  After a medic has completed the additional education, he comes to work and is given a list of appointments.  He takes the ambulance or a fly car and visits people recently released from the hospital for say CHF.  He takes vitals signs, does an ECG, weighs the patient, makes certain they have been taking their medicine, and calls the patient’s doctor with his report, and may either give the patient Lasix and make a followup appointment with him or, if necessary, call for an ambulance to transport.  If all goes well, the patient doesn’t have to use the ED, doesn’t need a costly readmission to the hospital, is healthier for the interventions, and saves the system a ton of money.  A win for everyone.

A patient calls 911 because they took two of their beta blockers by mistake.  Under community paramedicine (which if done properly will pay EMS not to transport), the paramedic calls the patient’s MD and is able to tell him to skip his next dose.  An elderly patient is short of breath because she ran out of her combivent.  The community paramedic will give her a breathing treatment, and then go to the pharmacy to get her refills.  Another patient is a little short of breath and due for dialysis in a hour.  The medics calls the MD, and gets permission to transport the patient right to dialysis, instead of the ED, and the ambulance service now gets paid for this transport.  

Now I did not get into EMS just to do home care, but I also didn’t get into EMS to take people to the hospital who didn’t need to go.   Times change, and thanks to better equipment, my back has made it this far.  Maybe community paramedicine, and all it promises, can keep my paycheck coming long after I would have otherwise retired.  When money and what’s best for the patient and the provider can go hand and hand, it’s all good.