Pain Management and Patient CARE.

I was listening to the recent EMS Garage podcast on pain management, and several things came to mind. One was in regards to “drug seeking behavior”. Many EMS professionals, from medics to nurses to doctors, choose not to treat the pain complaints of patients on occasion.

Sometimes people feels as though they have a personal duty to try to fix the problems of our EMS system by denying drug seekers their “fix”.
A friend of mine who is a physician at a local trauma center once told me, “I’m not going to make an addict, and I’m not going to cure an addict.” When you think about it this way, it makes sense. Your actions on a single day are not going to undo the years of damage to someone’s life that have led them to become a drug addict. You can surely give them all the resources at your disposal to be well, but anyone who has ever studied addiction knows that it takes an enourmous and unwavering desire on the part of the patient to treat an addiction. Our job is to treat their pain, but sometimes we may be too skeptical of their complaints. We may not believe an addict, or believe that we can see right through their theatrics or even lazy attempts at such. Would you believe that they do actually hurt?

It’s known that opioid addicts actually have a downregulation of opiate receptors, and thus are actually in pain longer and more severely than the normal person. This is why they will actually scream and squirm under your IV needle. It’s probably not theatrics. They are actually in pain. Their body feels pain different than yours. It is not our job to judge. It is our job to treat. Maybe they are abusing the system to get their fix. So what? You’re not going to fix it by being a jerk to them. Practice being an excellent caregiver ALWAYS.

Help. Be a patient advocate. Know all that you can about pain clinics in the area and help your patients get in touch with them. Follow up on patients (and subsequently educate your local ER staff that have probably never read HIPAA that it allows for patient follow-up). You know that many of these chronic pain patients become “frequent flyers”. Know what the doc did last time so that you can bring it up, know about a patient’s background and needs, and maintain a continuity of care with the hospital. These are all vital aspects of true “patient care”. There is a difference between caring for a patient and treating a complaint. The difference is caring.

EAP

Employee assistance: What are we assisting? Employee Assistance Programs provided by employers are typically programs designed to deal with psychiatric disease, addicton, and social problems. These are hugely important problems, that employees should absolutely use the resources of an EAP to handle, if they realize they have them. How many colleagues do you know, though, who have these kind of conditions and leave them untreated? How many of them do you think just don't notice their condition, or don't want to, or are too embarassed or ashamed to admit that they need help? How many of us actually know what to look for, or what to do to help our colleagues? Behavior patterns can give a huge insight into someone's psychological health and psychiatric condition, if we take the time to notice and to help.

Many might say that people with such disorders should not work in EMS. These same dissenters may not realize that EMS may have caused the condition in the first place. Fatigue, shift work, irregular sleep patterns, and adrenal stimuli are all known triggers for psychiatric conditions including bipolar disorder ^1,2. The running joke in my local EMS community is "Everyone working in EMS is either on psych meds or should be". It's true, to a extent. Many people in EMS do suffer from diseases ranging from stress and anxiety to bipolar disorder. Some people find their own coping mechanisms that help mitigate the work stresses, exercise being the most effective it seems, but some don't know what to do.

So what about other work-related diseases? EAP dosn't cover chiropractic, fitness and exercise, massage, accupuncture, or any of the things we know to prevent workplace injury. Worker's compensation programs only cover workplace injuries. I've heard some great podcasts about the topic like episode 50 of the EMS Educast and episode 28 of the EMS Garage, but I don't see employers spending any extra money on those kind of benefits in the near future, especially not in the corporate EMS world. Many ambulance personnel don't even have good enough health insurance (or any) to provide themselves these service that are really a necessity in an EMS career.

My point is that employers would be better to just take good care of their employees in the first place than to simply react to the injuries that develop. EMS leaders: bear this in mind. All you have to do is care. Care about your employee's health and well-being, and do something with that caring. Perhaps develop a program to pay your employee's copays for a semimonthly chiropractor visit, or reimburse. Perhaps take the time to chat regularly with your employees and make sure that their lives and minds are healthy, and help them notice the need for help. Maybe even make a semiannual psychiatric and/or psychological assessment (the two are related, but very different) another recommended, or even mandatory thing, like CPR cards, physicals, piss tests, etc.. The long-term cost of maintaining a heatlhy employee is far less than that of trying to fix an ill or injured one. Being medical professionals, you think we'd all get this idea. The problem though comes down to money, I think, and making good decisions with it. When an manager or executive only sees line-item spending, but not the forest through the trees, they end up spending far more money in the long-term.

I'm not a manger. I'm not a CEO. I'm not a board member. Some of you might be. Just care.

1. Umlauf, MG, Shattell, M. (2005). The Ecology of Bipolar Disorder: The Importance of Sleep. Issues in Mental Health Nursing, 26, 699-721.

2. Mendlewicz, J. (2009). Disruption of The Circadian Timing Systems. CNS Drugs, 23, 15-27.

Pseudo-seizures and stolen topics

Mark Glencourse (Medic999) wrote a very interesting blog today. It made me and his other readers think and laugh a bit (I think MsParamedic piddled her pants). I realized that the comment I made was a bit lengthy and full of Jake, so here it is:

MedicJake:
Great post, Mark. I've never worked outside of California, but I'm guessing that every medic in an urban/metro system eventually encounters that call. I've seen partners handle the same circumstance very differently, sometimes based on knowledge and experience, and sometimes tragically based on burnout and fatigue.

I always try to over-triage if there is any question. If I'm not sure, I give the pt the benefit of the doubt, and at least don't chastise them during their performance. With the strange atypical seizures that you mentioned, that are at least common enough for us to occasionally encounter, there's only one way to be sure; portable EEG. A patient can be the best actor in the world, but brainwaves don't lie. The technology exists, and is used in other areas of healthcare, just not EMS.

The day will come when our cardiac monitor, EEG, portable ultrasound, blood analyzer, other diagnostic tools and the charting computer will all be integrated into something nearly pocket-size, like a Star Trek tricorder (Geek? Yes.), and we'll all be educated and trained to use them. People scoffed over the idea of a telephone, a TV, a VTR ( a what?), a stereo, and a personal computer all being the same posket-size device, that wouldn't need any wires to hook it up, and could store every song and movie you've ever heard or watched or even wanted to, and guess what - I'm bloggin on one right now. I can't wait to see how the technology changes over the next few decades.

Where I work we have a frequency of "acute mood disorders" that tend to have higher prevalence among certain ethnicities, which of course lends them the same kind of inappropriate and derogaatory acronyms and nicknames that medics tend to assign things. Anyhow, it seems that the most effective treatment for these emotional emergencies also tends to work on many pseudo-seizures; remove the audience, and the performance stops. If not, then like a crying baby they'll stop eventually, or you'll find out that they have tourette's syndrome or a brain tumor and look like a...gosh darn fool...

You hit the nail on the head I think though with your mentioning things like patterns of movement, incontinence, facial muscle activity, and other the little hints that without being able to analyze a brain's electrical activity in the field are our best diagnostic tools. Our minds and bodies are very reliable tools, and I hope that even once we get new technology in the field that medics will maintain their ability to assess patients excellently without technology at their aid.

Medic999:
Thanks for the comment Jake!

I like the idea of a portable EEG!!

I have a consultant at my local hospital who wants us to start using Ultra Sound Fast Scans in the prehospital environment. Im sure it would be here already if they werent so damn expensive!

MedicJake:
I recall seeing an article in JEMS about a small EMS system in the US using portable ultrasound fast scans in the field. I think it was somewhere in the midwest, possibly Ohio. I'll look for the article. The medics all got special training from physicians in how to interpret the images to look for findings in trauma patients that would justify trauma pre-alerts. I think it was supposed to be a trial study to see if it had an effect on over-triage and under-traige of trauma activations. Of course the cost is the biggest issue. It will be a long time before most of us will ever see them.

MedicJake:
Temple Terrace, Florida.
http://northeast2.tbo.com/content/2009/nov/04/ne-local-paramedics-get-new-diagnosis-tool/

READ MARK'S BLOG NOW! CLICK ME!

Wasn't it socialism already?

Many are mad about the healthcare reform bill. I keep hearing it called "socialist". I choose not to agree, or disagree, because like most American policies it is a compromise between socialism and capitalism, and other -isms. Consider the following:

Before the reform bill, noone was required to carry health insurance. When the uninsured got sick though, hospitals and ambulance providers were required to provide them care, whether they could or would pay for it or not. All people were granted the right to free healthcare (socialism).

Healthcare providers (hospitals, ambulance companies, etc.) have to pay for their costs somehow, and many of their patients are uninsured and can't afford to pay (about half where I live). To cover these costs the providers bill those who can pay at higher rates. Government insurances refuse to pay more than a given amount, so healthcare providers increase billing rates even more to get more money out of private insurances, resulting in higher insurance premiums for the working class. The working class has been forced to pay higher premiums to cover the cost of the uninsured and taxed to provide government healthcare those who qualify. Those who can afford it have been forced to pay for the healthcare of those who can't so that we all get the same benefits (communism).

Now after the bill is enacted, everyone will be required to have health insurance. This will mean more business for insurance companies, more competition, and lower premiums eventually, and probably very quickly. This will mean that every person is required to pay for their own services, on a fees-for-service basis, and no longer able to rely on society to pay their bills for them (capitalism).

It is true that if you only view it from the standpoint that we are being told what to do, then yes it seems very...whatever you want to call it. The fact is that the only other "capitalistic" option is to remove laws that require hospitals and ambulance providers to provide care to everyone regardless of ability to pay. We can let paramedics and triage nurses require insurance cards or cash-in-hand before giving assessments and treatments just like they do at the doctor's office. If you think that would be unjust because "all people are entitled to healthcare", well that is a socialist ideal, and you really want socialism so just think about that.

From my point of view as a paramedic I think that the new healthcare reform bill will be good for people's well being in the long run. People will be healthier because not only will they have healthcare, but they will be able to go to the doctor anytime, and the sooner they go, the cheaper it will be. I have seen all too many times a patient wait through being ill because they couldn't afford to go in, until they were so critically ill that they had no choice, in turn changing what could have been a $100 doctor visit into a $20,000+ visit to the ICU.

The fact is that illnesses, like accidents, just happen. We are required to have car insurnace because of this, and so it only makes sense to have health insurance too. My fiancée had an emergency appendectomy last year. Without warning she was ill, in the ER, in surgery, and then admitted for a total cost after just a couple days of over $50,000. Without insurance...well you can imagine.

Think about what really is socialist, communist, capitalist, or whatever -ist label you want to put on our society before you rant too much. If you really want a truly and fully capitalist healthcare system, be willing to be the one to swipe credit cards and turn away the uninsured at the emergency room doors.

I Didn't Do Anything

Citizen calls 911 for a possible man with a gun. No further details.

Police arrive on scene to investigate, and see a man run away, into a business, and up into the attic.

The attic is large.

Many more police arrive.

Police use fire department’s ladders to send K9 officer into attic.

Noise ensues, and K9 returns uninjured but unhappy.

Much thought is put into the safest way to approach the situation.

Long wait.

The roof is checked, thermal imaging is attempted without success.

Ladders are stuck into every attic access, and officers enter the attic with the K9.

“Come out now or we will release the police dog on you! Come out now or the dog will bite you!”

Wait.

K9 suddenly gets very excited, much noise ensues.

Sounds of person screaming can be heard, and officers are yelling commands to dog and subject.

More yelling, yelling, commands…

Bloody parolee descends ladder, in his underwear.

Parolee is assisted to the ground by officers while yelling “I didn’t do anything”.

Smile and Do What You're Told

I’m not sure where I stand regarding ambulance companies, and I mean “companies” in the terms of business entities. There are so many factors to weigh. On one hand, I know for sure that any and every time that money unnecessarily becomes a motivator and decision maker before the best possible care we can offer our patients, it vexes me at least a little. This happens all the time in ambulance companies big and small, and that’s why the whole idea of an ambulance company being publicly traded or owned by a publicly traded company is anything but ethical in my eyes. It does, however give EMS providers a good opportunity to make a good living as a caregiver, and sometimes even makes them better equipped.

In a large, for-profit ambulance company, the loyalty of the company is certainly most often to the company itself, and not to the patients. In any EMS organization, large, small, private, or public, decisions have to be made that affect the provider’s ability to provide excellent care. Budgets have to be balanced with technology, ethics, and desires. Some EMS organizations have the money for things like portable ultrasound and video lanyngoscopes, and this undoubtedly benefits their patients in the long run. Some companies can’t even afford simple tools though like updated cardiac monitors. Sometimes these decisions are truly difficult to make, because there just isn't enough money to do everything, and sometimes these decisions aren’t made on the basis of what can be afforded by the company, but by determining the bare minimum to keep the company in the same amount of business, and sending the rest to the executives, the management, and the stockholders. It’s a shame that as a country we’ve let our EMS system come to this, but it is what it is and it’s too well developed to change overnight.

On the extreme other hand in ambulance companies, what do you do when a small, private ambulance company serving a rural community can’t afford the equipment they need to provide excellent care? If as the local protocols change they can’t afford the equipment upgrades then what? Should they simply bow out and let another company come in? I think if it’s better for the citizens of that community, then yes. Maybe there can be other ways found to obtain these funds, but sometimes especially in this present economy, a small business just can't afford to be what they need to be. It’s a shame because small businesses are the foundation of this country, and have played a huge role in the development of our EMS system, but realistically their role in emergency care may be facing an abrupt change.

Ultimately when it comes down to business ethics, an organization has the potential to do an injustice to their patients unless they are strictly policed by the agencies that govern them. If there is somebody that stands to benefit from cutting a corner, it eventually will happen. This is the nature of private business and of the human condition and simply won't change. It will be a long time until we get to the point in the USA where our EMS system has structure, uniformity, and keeps the public as its number one priority at every level. I don’t have an ultimate solution. I know that EMS is a public safety profession just like law enforcement and fire protection, but we don’t make it a public service or a public responsibility; not universally, anyhow. If we did, and if every ambulance was an ambulance, equally staffed and equipped, funded according to local needs of operation, deployed according to local needs of coverage, and accountable to the public, what would the difference be? If there were no middle-men that the overflow of money went to; if there were no stockholders, no profit-sharing, no bonuses, just paid personnel, and residual funds reinvested into the operation, what would the difference be? Maybe we should look internationally for the answer. For now, the best we can hope for is that our EMS agencies continue to govern providers well enough to ensure acceptable minimum requirements, and that organizations do all they reasonably can to provide excellent service.

Honestly, we’ll be hard-pressed to right the injustices of our EMS system in the USA in our lifetimes. It’s true that you can find systems run elsewhere without these same problems, but mostly in older societies. Our country is very young compared other societies which are older than their written history.

The problems of United States EMS are similar to the problems that our medical system faces as a nation. There are people making money due to the different levels of healthcare that people receive. Managed care means a lack of care. This, I suppose, is the basis of our capitalist society, which saddens me.

So ultimately, as providers, what can we do about the situation? Well, the answer is to do both everything and nothing.

We can realistically do nothing immediately, and probably nothing in our lifetimes, about the state of the US healthcare system, or the conflicts between capitalism and ideal patient care, so dissenting and rallying and getting angry won’t right what we feel is wrong. We’d be better off channeling our energies elsewhere.

We can, though, continue to do everything in our power as providers to provide excellent care on a daily basis. We learn very quickly the ins-and-outs of our systems, and the agencies we work for. We understand the rules that govern us and exactly what is and is not allowed. We know exactly how much we can do for our patients with what we have, and we can take every opportunity to be excellent providers, counselors, social workers, community paramedics, advisors, teachers, and anything else our patients need us to be. We just have to want to.

We need to get over this idea that our role is all about emergency medicine, because after a short while in EMS it’s obvious that it is not. We need to want to educate ourselves constantly, to learn all we can about the non-life-threatening illnesses and even the non-illnesses that we treat so often. We need to be able to provide expert care and advice, based on true expertise and knowledge. Really we would be at a greater benefit if our continuing education concentrated more on common ailments and social services than cardiac arrests.

So what does it come down to? I don’t know. I do know that perhaps what our employers want of us really is the best thing. Employers love submissive extroverts, meaning that we do what we’re told, and love people. That’s really the basis of being a great provider; love people, and be an exemplary employee so that your organization keeps providing you an opportunity to provide excellent care. As a group of type-A personalities the extrovert part comes easily for EMS providers, but the submissive thing not so much sometimes. We want to have fun all of the time, and to control everything. We can't, and I think now that part of the maturation of a provider is coming to that realization. I love the opportunities that being a paramedic provides, and I'm glad to keep learning these things about medicine, life, the business, and myself all the time.

Thanks to GenMed

Firstly, thanks to the GenMed Show for having me on their second episode, “I’ve Got You Under My Skin”, which was recently posted. Secondly, my sincere apologies to the GenMed Show for my contribution to the night’s technical difficulties. A new headset mic and a little tweaking of my Skype settings and all is well now.

On the topic of microphones, if you’re going to buy a lower-end (under $100) mic, go with Plantronics. Plantronics makes communication equipment, as a trade. Other companies like Logitech make other things like keyboards and such, and just don’t make the same quality when it comes to audio equipment. Plantronics has made every mic and headset I’ve used in all five emergency dispatch facilities I’ve worked in, and I’ve had nothing but good luck.

The GenMed Show episode was a talk about body modification, as it relates to a medical workplace, especially an EMS workplace. They brought up concerns including health and safety risks, professionalism and appearance, developing patient relationships, and conflicts with management. Some excellent points were made by the hosts, and by a couple very thoughtful people in the business who left voicemails that were played on the show.

Despite the technical problems I think the show did great. Those guys and gals are obviously working hard at getting the show going, and doing a great job. I can’t wait to hear future episodes on equally interesting and controversial topics.

Check out the episode and those to come at http://www.genmedshow.com/.

Nanna and Clint Eastwood

I was talking to a friend in the business, thinking of an idea for an episode of the new GenMed Show podcast, and racking my brain for what is a crucially important thing to talk about regarding young people in medicine. I was thinking about all the things we talked about, and about some of the younger partners I've had working in EMS, and thought about when I was brand new myself. Speaking to patients inappropriately is definitely one of my pet peeves.

In EMS, or any kind of medicine for that matter, the majority of our patients are senior citizens (unless you’re in peds, OB, or some other overly lovey, estrogen-laden specialty). It’s important to understand with all patients that you’re treating a person and not a disease. With the huge generation gap between patients and young new caregivers, that idea seems to be getting lost somewhere along the way.

With the modern social media culture, people don’t even know how to talk to each other anymore. It keeps getting easier to get by with emails and text messages, and “OMG LOL” your way through life and society. Learning how to speak to people properly is becoming a lost skill, and that’s apparent in our youth.

With the initial impression many seniors will have of a young caregiver, establishing a respectful patient-caregiver relationship is important not only in the short term of treating your current patient, but in pushing forward the acceptance of our very different generation by our elders. If a patient finds a caregiver to be respectful, intelligent, and caring, despite their body modification, unique hairstyle, and other attempts at individuality, they will ultimately feel more comfortable with that caregiver, and other similarly appearing caregivers in the future.

So, the first step in establishing this relationship is in the address. Call a patient what they want to be called, and what is most respectful. DO NOT EVER call a senior woman "hun", "sweetie", or "dear"! They are not your girlfriend, they’re not in kindergarten, they have been alive three to four times as long as you, been through more than you can possibly understand, and they know it. You need to know it too. You would never dare speak to your own grandmother that way unless you were really trying to be off their Christmas list and out of their will. Men equally are deserving of the respect they’ve earned throughout their lives. Many seniors are military veterans and very accustomed to and expecting of formal address. Upsetting that expectation will not do anything good for your relationship with your patient. Remember Clint Eastwood in Gran Torino? Would you ever call him "dude"?

Beginning an address using the proper title of ma’am or sir in your introduction is appropriate, followed by using Mr. or Mrs. (last name). At that point you have begun a very respectful and appropriate dialogue with your patient, and earned a good deal of their respect by showing yourself to be mature, caring, and respectful. For instance:

“Hello ma’am. My name is Jake. I am a paramedic with the ambulance service.”

“Hello Jake, my name is Mary.”

“Mary may I ask your last name?”

“It’s White. Mary White.”

“Mrs. White how may I help you?”

“Oh, Mary is fine. Just call me Mary.”

Now you’ve established your relationship and an appropriate dialogue. Notice that beginning a question with asking their permission “…may I ask…” is very respectful of their wishes and their privacy. It shows that you’re mindful of the way you’re addressing them.

As you perform an assessment of your patient, explain yourself and ask permission. Ask if you may perform an assessment, i.e. “Mary may I check your pulse while we’re talking? I’d like to have my partner check your blood pressure also if that’s alright.” Speak to them sincerely, and show them that you care who they are and that you have their best interests in mind. Speak to your patient like a person, and like an adult. It’s far too common for a caregiver to address a senior like a child, and treat them like they’re stupid.

Bear in mind that your patient has probably had a history and physical done more times than you’ve done one. They’ve probably been on a cardiac monitor and a pulse-oximeter more times than you’ve used one. “We’re gonna’ put these stickers on you” is condescending, and entirely inappropriate for any patient beyond grammar school. “Mary, may I put you on the heart monitor?” is more appropriate. They know what you’re doing, and may even understand it more than you do. Don’t forget; retired nurses and doctors call 911 too, and generally if a senior patient doesn’t understand something, they’ll ask. They want to be involved in their care, and to understand what is being done to them and why, so explain your actions and make yourself available to answer all of their questions honestly.

While assessing your patient, treat their anxiety too. This doesn’t mean chemically sedate everyone over 55. It means that you need to understand that people call 911 because they’re scared and feel helpless. It’s very common also for seniors to suffer from generalized anxiety and often be prescribed anxiolytic medication. Rushing, yelling, and demanding things will only exacerbate their anxiety. Don’t make your patient be afraid to be in your care. Be calm, collected, quiet, and calculated. Control your scene. Look them in the eyes, hold their hand, listen carefully and attentively, be sincere, make humble suggestions and ask them what they want to do. Your calm presence will set the tone for all the caregivers involved. There is no need to rush anything for a patient that isn’t almost dead, in which case they wouldn’t notice what a spaz you’re being anyhow.

Be mindful of your patient’s social situation. Keep in mind that older senior citizens were depression-era children. They are accustomed to being very frugal and wasting nothing, sometimes even to the point of a psychological hoarding disorder. They may also be very limited in their income, living solely off social security or other very finite income, and they simply can’t afford any loss. The bed sheet you use to carry them may be their only bed sheet. The nightgown you cut open with your trauma shears may be their only nightgown. They will probably feel incredibly uncomfortable and insecure leaving valuables at home or not knowing where they are. Their purse or wallet, their glasses, their medication, their house keys, their list of phone numbers, a couple pieces of precious jewelry may all be crucially important to their comfort. Take the time to attend to these concerns. They may also be incredibly concerned about their pets who have become their closest companions. Offer to speak with a neighbor who has a house key for them before leaving their home. Take the time to call one of their relatives for them from the hospital when you arrive, because you never know when the hospital staff may have the time to do it.

Be respectful of your patient’s dignity. Put a blanket over them when wheeling them out on the gurney in their pajamas. Turn off the lights on your apparatus parked out front if you can, especially if you’ll be there for a while. Avoid talking about private or embarrassing things in front of too many people. Most touchy topics can wait until a more discreet moment.

Be sympathetic to your patient’s medical situation. Their aging may make simple tasks very arduous, and not tending to even their minor difficulties and discomforts makes you a poor caregiver. Some things may also be very embarrassing, like incontinence, constipation, gas, hemorrhoids, etc. and they may not allude to symptoms like this in front of other people. They may be afraid of upsetting their family members with complaints or explanations. Medical information is a very private thing, and you need to treat it as such. It’s completely alright to gather a little extra history from family members alone, but don’t talk about a patient in front of them like they aren’t in the room.

Talk to your patient. Ask them questions. Humble yourself to their knowledge and experience. They very likely understand their medical history better than you do, especially related to obscure diseases. If you don’t know what something is, be honest about it and ask them to inform you. They’ll respect your humility, and you’ll learn something new and interesting.

Mostly, be humble in that you don’t understand exactly what they’re going through. There’s no way for you to have true empathy for what you don’t understand, but you can be caring and sincere, and that’s good medicine.

Homework:

Watch Patch Adams and Gran Torino