Crash Cart: Trump on Opioid Emergency; Knowledgeable Patients are Helpful; Full Stop Needed After ED Deaths

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This week: Trump may declare opioid epidemic an official emergency; Survey says more nurses appreciate knowledgeable patients than doctors; The common impulse to “move on” after deaths in the ED. Join in as our editors discuss the week’s headlines. Join in as our editors discuss the week’s headlines.

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With 63% of 2015’s 52,000 American overdose deaths due to opioids, urgent federal intervention has been recommended by President Trump’s commission on the epidemic, and Trump has indicated he plans to make it official soon

Doing so may allow funds and other aid to reach hard hit areas more easily, just like aid for natural disasters. Six states have already declared opioid emergencies. Original Article by The New York Times.

Jaime Hope, MD: The opioid epidemic is clearly a problem. In Michigan where I live, in 2014, more people died from overdoses than motor vehicle collisions. Bringing attention and funding to the problem is helpful, but there needs to be strategic use of the dollars. Throwing money blindly at a problem isn’t the answer. I hope this leads to meaningful dialogue to reach efficacious and evidence-based solutions to the problem. We need to change the conversation about addiction from a judgmental/punitive approach to understanding and treating the underlying problems that lead to addiction in the first place. www.artistsforaddicts.com and www.geniusrecovery.com are sites with a mission to help be a force for good in the fight against addiction.

E. Paul DeKoning, MD, MS: Even up here in New Hampshire, we have a real epidemic. Totally agree with Jaime that just throwing money at the problem, while perhaps helpful in the short term, by itself won’t fix it just like it hasn’t fixed public education. Addiction is more than simply a drug problem. Why is it that some patients break a leg, take opiates, and never develop addiction while others get hooked on the first and even appropriate use? I personally believe it is a reflection of deeper issues, whether they be a history of abuse, mental illness, familial propensity to substance use/abuse, trauma, or deep emotional pain. Not everyone for sure, but quite a few. Simply removing the substance won’t work–it has to be replaced with something else, something edifying. We have a lot of work to do. See also below on Patient Death.

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A survey of a thousand attendees at a MedScape event in San Diego in July shows distinctly different feelings between doctors and nurses regarding “patient empowerment,” with 82% of nurses considering it favorable compared to 54% of doctors

Further, 21% of docs deemed it annoying, while only 5% of nurses said they felt that way. Original Article by Medscape.

Jaime Hope, MD: Empowerment sounds like a great idea. However, “I’ve done my research” can elicit eye rolls from many EC staff. Some patients fall into the “Lay persons rarely use their research to create a differential diagnosis but rather to support their preconceived ideas.” camp and some are genuinely interested in their health. The thing is, the internet isn’t going to go away. And people want to learn and have a sense of control; illness is scary and makes people feel disempowered. Because patients aren’t going to stop researching, we need to adjust OUR expectations. It is a golden opportunity to educate people about credible resources. If you have a good patient-physician relationship and listen respectfully, you can engage in an excellent dialogue and help make a difference in a patient’s health. Empowerment is here, embrace it!

E. Paul DeKoning, MD, MS: Uhhh. Agree with this quote form the article, “Lay persons rarely use their research to create a differential diagnosis but rather to support their preconceived ideas.” At the end of the day, “empowerment” (if that’s even the right word) is a two-edged sword: it’s helpful when I can reassure the patient that they don’t have what they think they have (and they believe me). Not so much when the come seeking my advice but don’t want to hear what I have to say. But, as Jaime pointed out, the internet isn’t going away.

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One doctor reflects on the common impulse to “move on” after deaths in the ED

While embedded in ED culture, he argues it’s time to come together as medical personnel and pause—or better still, full stop—any death. Original Article by STAT.

Jaime Hope, MD: I agree!! Even though it is part of our job, witnessing a terrible death is still sad and affects us. We should have support to stop, debrief, and have ongoing dialogue in particularly upsetting cases. We are human beings and we have feelings. This is ok! We need to talk to each other, support each other, and acknowledge that our job can be hard.

E. Paul DeKoning, MD, MS: We’ve talked about this in a prior Crash Cart and I ended up writing about it here. Just my $0.02 but Jaime’s comments and the above article on the opioid emergency are related: EMPs and other physicians aren’t immune to such addictions–we experience and preside over pain every day. It really is what we do. While it is an honor, if comes with a price. Like my own recent trauma code that made me weep on my way home from work. If we aren’t personally grounded, healthy, and whole, and have a system in place to fill us back up after we have experienced such horror, we run the risk of falling into addictive patterns ourselves. Especially if we’re Type As that hate asking for help or admitting weakness. How often do we hear about physicians getting busted for diverting substances from the OR? I’ll answer for you: far too often.

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  1. Nancy J Ferguson MD on

    About 20 years ago, I was on duty in an inner city ED, when the police brought in 3 children from a nearby fire. I was the only attending on duty in the middle of the night, but my nurses, surgical and medical residents did their best as we ran 3 simultaneous and unsuccessful codes. I assigned them by their skillsets as to who was most likely to survive. We then intubated and shipped the mom to a burn center.

    Everyone was devastated and and suffering. I called the 911 dispatch and placed us on a 2 hour divert. Per protocol, we called the administrator on call to advise of our divert status. I was essentially told to “suck it up”and advise my colleagues to do the same. It’s Emergency Medicine, people die, get over it and move on. I was also ordered to take us off divert.

    It was now about 5 am. I ignored the request and left us on divert, and was threatened with termination. I would do the same today.

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