Hookin’ Up at Work (How to Get Fired)

June 20, 2009

office romance

I know I haven’t been updating the site recently, and I’m very sorry for that. I have a growing list of posts in my head, but I have been working too hard to get them down. Usually I don’t like to work this much, but I have had to pull several extra shifts because one of our docs got fired. Docs don’t get fired too much these days due to the whole supply-demand thing, but every now and again, some idiot takes it too far and becomes a statistic. This is his story.

Dr. Dumass, as I would like to call him, had a good thing going. Cush hospital, good position, great co-workers, and even a nice office. But apparently for Dr. Dumass, the nursing staff was a little too nice for him. Dr. Dumass was actually working on marriage #4 (I am not making this up) when he met Nurse S. Not only was this his fourth wife, but he had a litter of kids spread out all over the country from the last three. To quote Brad Pitt from Fight Club, “F$%#@* was setting up franchises“.

Nurse S was cute, pretty and they hit it off as friends from the start. She was having problems in her marriage and enjoyed talking to Dumass about her marital conflicts. He in turn would share with her his own marital problems with wives 1-4. They got closer and closer. 

Finally Dumass made a great suggestion, “Why not get divorced from our current spouses and get married to each other!”  I can only imagine that Nurse S was married to a drug addicted, alcoholic bridge troll with anger management issues, because I am not sure what exactly would be the attraction to a guy who has already blown through 4 wives and 10+ kids? Maybe she thought that she would be “the one“. Silly wabbit.

Things were moving along smoothly for our confused couple and they could hardly stay away from each other while at work. Either our darling little nurse would be in the docs documentation area or Dumass would be out at her nursing station whispering sweet nothings into her stethoscope. Just some advice for any of you readers involved in a similar relationship – you may think that no one notices, but in reality, everybody notices. Even the blind frequent flier behind curtain #2 knows about it because he overhears the gossip.

Before long, Dumass had already filed divorce papers and was waiting for wife #5 to-be to do the same, but that’s when trouble in ER paradise started. Nurse S comes in to work one morning and tells Dumass the hard news – she was having second thoughts. Suddenly, Dumass starts to have chest pain – you know the kind you get when you really want someone to feel sorry for you and give you that big hug you want so much and tell you everything’s going to be alright. But instead of calling in a replacement, Dumass decides to work himself up.

He goes and gets an EKG and Troponin heart enzyme done on himself. “Hmmm, looks like there might be some changes on this here EKG“, he says to himself. So he calls up the trusty cardiologist who tells him that he should get a stat echo. The echo ends up showing some wall abnormalities and is not conclusive (imagine that?). So the cardiologist tells him to high-tail it over to the cath lab. That’s when the proverbial crapola hits the fan.

Dumass tells Nurse S that he needs to get cathed … that indeed this might be their last moments together. The sappy soap opera romance is too much for her and she tells the charge nurse that she needs to clock out and take her dying beloved Dumass to the cath lab. There is no ER doc now and the chief of staff – a pathologist (autopsy doctor) – is called in to cover the ER. Must have been interesting for him to have his patients actually talk back to him.

At the end of it all, Dumass’s heart was perfectly fine – no blockages of any concern whatsoever. But folks over at admin weren’t exactly ready to throw the welcome back party for him. Instead they fired him for his Dumass behavior. He had taken this too far, and he put patient lives at risk. I actually thought he deserved an award for entertaining the hell out of the rest of us in the ER though, but decided I would keep that idea out of the suggestion box for now.

What lesson can we take from this story? I will quote a wonderful colleague of mine who once told me, “A doctor can be totally incompetent, but as long as patients like him, he will remain employed. But the moment he has sex with the wrong person or comes to work drunk or stoned, he’ll be fired in a heart-beat.” I guess Dr. Dumass can testify to this one.

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Contributing Factors to the Current Physician Shortage

May 16, 2009

As early as 2005, predictions were being made of a coming shortage of medical providers for the United States. The reason that was primarily referenced for this coming shortage was a lack of adequate forecasting for an aging baby boomer population as stated here in a 2005 USA Today article:

The country needs to train 3,000 to 10,000 more physicians a year — up from the current 25,000 — to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon.

Certainly, there is truth to this idea. I personally get numerous job offers on a weekly, and sometimes daily, basis. But there is something that these studies and articles are missing. A number of doctors are also getting so fed up with medicine that they are choosing non-clinical careers; careers where they don’t do patient care.  This includes working for drug research companies, writing/editing, educating and even leavingmedicine altogether. I read an interesting article on-line by Dr. Kent Bottles in a Physician’s News Digest from 1999 that discussed some of the discontent doctors are feeling these days:

There’s a 1998 survey by Levin of 6000 physicians in 22 different cities that revealed that 46% of all American clinicians often think about leaving clinical practice. That’s over 300,000 physicians in the United States that seem to be unhappy with the state of affairs. There are other indications about physician discontent that you might not think of readily. The number of disability claims by physicians has increased so much that some insurance companies no longer are writing disability insurance for physicians. Recently the AMA, one of the more conservative organizations of physicians, has voted to form a union. And another example I saw was an article that said that physicians are actually moonlighting by selling cleaning products and herbs out of their homes. So, for a lot of statistical reasons and for a lot of those more soft reasons, it looks like physician discontent is widespread and happens throughout the whole country.

I am also personally one of the aforementioned doctors who has thought of doing something else with my life. Medicine has changed so much that it has become unrecognizable to some of the older docs, and it can sometimes be down-right depressing for younger ones like me. Sure, all jobs have the good and the bad right? But to me it seems somewhat different when you dedicate 10 years of your life to learn a skill and then have someone accuse you of intentionally and knowingly trying to harm them.

I posted an article yesterday about how we, as medical practitioners, had misled people regarding the “threat” of Strep throat. I stated that, statistically speaking, the risk of serious side effects from antibiotic use for this condition outweighed the benefit. And in turn, I received comments that reflect what we all unfortunately hear in medicine from time to time. That we “don’t care”, or that we diabolically “want people to suffer”.

To me, this arrow stings the most. That someone would really think that because I make a certain medical decision, that this means that I intentionally wish to harm them or cause them to suffer needlessly. Maybe I’m too young and haven’t yet developed skin thick enough to deflect these barbs. And then again, maybe I never want to develop such thick skin. If I did, then I wouldn’t be able to muster the compassion for other people who do trust us and don’t want to just give us orders.

Overall, I think it is a global phenomenon of lack of manners that has developed. As a doctor, I am humble enough to say that I will not be right all the time, and I don’t have to be. What I am charged with doing though, is not harming my patient. If you are a patient and reading this, please remember one thing. You can always get a second opinion. You don’t have trash someone just because the one snippet you heard on Oprah or read in Time magazine seems to contradict your doctor’s decision or advice.

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You Don’t Need to Come to the ER at 3am for “Strep Throat”

May 15, 2009

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

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Antibiotics for Strep Do More Harm Than Good
By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)

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Our Laziness and the Rise of Diabetes

May 11, 2009

A few days ago, I was attending an interesting CME that was focused on the rise of Diabetes in the US and the world. It was an interesting educational forum because of the ever decreasing age of Type II Diabetes (non-insulin dependent) that we see in medicine. When I was in medical school only a decade ago, Type II Diabetes was considered a condition that people generally only got when they were middle-aged or beyond. Young people with Diabetes were Type I (insulin dependent) almost by definition.

But in recent years, we have been seeing a steady decline in the age of the onset of Type II Diabetes. One ER colleague recently had a 12 year-old girl in the ER with a blood sugar of 850! She ended up being a new Type II diagnosis and did not have ketoacidosis which just shocked everyone involved in her case. Unfortunately cases like this though are becoming more and more common, with the age of onset being as low as 7 or 8 years of age in some cases.

What is Diabetes though and why are the demographics changing?

Diabetes is a condition where the body is unable to properly use sugar (glucose) due primarily to a problem with the hormone Insulin. Insulin is naturally produced in the pancreas and helps the body’s cells to absorb glucose from the bloodstream so that it can be used as an energy source.

To make a metaphor, it would be like saying that oil is sugar, but it can not be used by your car until it is first processed in a refinery (insulin). Without a proper refinery, all the oil in the world just sits around and cannot be used for fuel.

Type I Diabetes is where the person’s pancreas no longer makes Insulin and it is the least common form of Diabetes. Type II Diabetes though is where in the beginning of the course of disease, the body has trouble using the Insulin in its body. In fact, people with Type II often even have elevated levels of Insulin. Why do these people have trouble using the Insulin they already have? Because, amongst other things, they usually have increased amounts of fat tissue (they are overweight) and fat results in ever increasing degrees of resistance to insulin.

Even more concerning, endocrinologists state that at the time a person is diagnosed with Type II Diabetes, they have already burned 50% of the cells required to make Insulin naturally. That means it is only a matter of time before they will come to require Insulin on a daily basis to survive. This is not as much of a problem if a person is diagnosed at the age of 55, but when they are diagnosed with Type II at the age of 20, it is a definite problem with major medical consequences.

So one of the main factors that is contributing to the alarming rise of Diabetes in our society – particularly in younger people and even children – is increasing obesity. ASD reports that in 1962, statistics showed that the percentage of obesity in America’s population was at 13%. By 1980 it has risen to 15% — by 1994 to 23% — and by the year 2000 the obesity progression in America had reached an unprecedented 31%! Obesity is now the second most preventable cause of death after smoking.

Watching a movie like Super Size Me, the award winning documentary by Morgan Spurlock where he went on a McDonald’s only “diet” for 30 days and almost went into liver failure, we see how a small soft drink and small fries in the US is the biggest you can get in other countries. They don’t have a medium, large or super-size. When it comes even to breakfast cereals, you find that the sugar content is different in the US than say Australia. School cafeterias are being replaced by food plazas with McDonald’s, Pizza Hut and Taco Bell. We are too busy to cook at home anymore and so we now regularly eat out or order in. Kiplinger’s Magazine reported in 2000, that the average American eats out at least 4.2 meals per week.

One patient, who later got Diabetes, used to go everyday to her mailbox – which was about 20 feet away from her front door – by getting into her car, backing out of the garage, reaching into the mailbox and then driving back into the garage. Are we too lazy even to walk 20 feet to the mailbox? For those that have seen the animated movie Wall-E, the picture of the future of mankind is truly frightening.

The Future?

The Future?

For those that are fans of Jim Gaffigan, he once did a routine on Fast Food Delivery which was very funny, and at the same time so sad. He said, “I love delivery because it involves two of my favorite activities: eating and not moving”. Then he wondered aloud when it would come to the point where we would expect the delivery man to actually feed us as well because we would get too lazy to lift the food to our mouths. Let’s not get there.

I hope that something in this post will encourage you to start working on a better life for you and your children because to be honest, the medical resources aren’t there to handle a country where 30% of the population has Diabetes; even in a country as wealthy and blessed as the US. Let’s turn this boat around now before we run aground.

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Drug Seeking Personalities: Don’t Be Like These People

May 10, 2009

I recently did a quick search on the narcotic pain medicine Percocet to see what people are saying on the internet. I was hoping that I might be able to give those inexperienced with ER drug seeking personalities a glimpse into precisely the type of people we despise. While we train for years to prepare ourselves to handle emergencies in the most expedient and proficient way, and while we stay up for long hours tending to the medical problems of many – there is another element in society that saps our trust and faith in humanity; the drug seeker. If I had wanted to be a drug dealer, I wouldn’t have spent so much time studying and so much money in training. I am not here to get you high.

Yet, for those who have not spent time dealing with this element of society, our comments and attitude may seem harsh and even inhumane at times. We reserve humanity for the first ten times we deal with these people, and then it pretty much drops off a cliff afterwords. So what exactly are these people like you may wonder? I will allow them to tell you in their own words as recorded by their own hands in comments all over the glorious world wide web. And please try to remember one thing as your read these comments – while you and your sick child wait patiently in the waiting room, or while you try to take your mind off the horrific pain in your broken wrist, or to control the bleeding from your cut – we sometimes are spending way too much time trying to get one of the losers out of our ER.

Just a few Percocet comments:

“on average i take about 20 to 25 and on a bad day 30… i know its gonna catch up to me i dont give a f@#$ though…….im gonna go overdose.. peace!”

[Comment: Just for perspective, the prescription dose is 1-2 tablets every 6-8 hours or maximum 8 per day]

“Percs are like a hug from Baby Jesus….<3”

“i stole my moms perks i was on them for a month straight. snort snort snort..”

“percs/vics/oxy/ is my drug of choice as well…..i know what ya mean by getting you through the work day….”

“Does it really make a differnce to crush percocet and snort it?”

[Comment only if you want to die faster. Stupid idea that puts a lot of people in the hospital and several others in the morgue.]

“im havin fun with my percs :D”

“I gotta say, percocet does rock. Nothing better to take the edge off a hard day of construction work.”

[Comment: And we wonder why it takes roads so long to get finished. Hmmm, let me get stoned and go drive a bulldozer.]

And lastly, I would like those who may be interested to check out this video for even more perspective. I personally am not one to listen to foul language or use it myself, but I guess on this subject it’s all part of the package. The first 60 seconds is what deals with the drug usage and I didn’t care to listen to the rest and don’t recommend you to either. If someone knows how I can cut out the portion I want, please let me know.

Watch with caution:


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Hydroxycut and Fad Diets

May 6, 2009

little_girls_smallA sad day in dieting occurred late last week with the pulling of Hydroxycut – the famed dieting pill (as seen on TV). The FDA is now warning consumers to immediately stop using Hydroxycut.  Apparently, Hydroxycut has been  associated with a number of serious liver injuries ranging from jaundice and elevated liver enzymes, an indicator of potential liver injury, to liver damage requiring liver transplant. One death due to liver failure has been reported to the FDA. Other health problems reported include seizures, cardiovascular disorders, and rhabdomyolysis, a disorder of muscle cell destruction that can lead to kidney failure.

Of course, news like this thins out the competitive field a little bit. True there are still pills out there on the market that promise that you can eat all the Twinkies, Hardee’s thick burgers and Oreo milk shakes that your heart desires without a nanosecond’s worth of exercise. For example, there’s always Alli – the non-prescription strength version of Xenical – which promotes weight loss by decreasing absorption of fat by the intestines, thereby reducing the number of calories you absorb. It also gives you diarrhea and nasty farts that leave skid marks in your underwear. And that’s on a low fat diet. Try that Hardee’s heart attack burger while on Alli and you my friend will understand the true meaning of pain while you spend the next 2 hours on the crapper.

By the way, did you know that the name of the man who popularized the toilet was Thomas Crapper? The guy who actually invented it was Sir John Harrington, hence the usage of “going to use the John”.  Ah, but I digress.

Losing weight is easy and it is hard.  To lose weight you need to eat less calories than you burn – easy in concept, hard in practice. One can also increase their activity level and decrease the amount of calories they consume and they will lose weight.But that won’t keep people from trying to find the magic lazy bullet which allows them to do nothing, eat anything and still have a beach bod. So let’s take a look at some popular, and not so popular, fad diets.

The Tapeworm Diet – Someone actually thought it would be good to eat one of these disease causing parasites. Hey, they’ll just eat all the excess food right? Wrong. Just like any pregnant woman will tell you, parasites eat what they want first and then you get the left-overs. So tapeworms get first dibs on your vitamins, nutrients and minerals. That’s why people with tapeworms usually develop ascites (big round pot-belly). I think I’ll pass thank you.

The Lemonade Diet – Popularized by Beyonce Knowles before filming Dream Girls, this disaster was originally called The Master Cleanser Diet by its creator, Stanley Burroughs in the early 40’s. Stan was a therapist once charged with second-degree murder after a patient died from one of his treatments. The diet eliminates toxins and “congestion” that have built up in the body, and because it doesn’t provide a complete source of nutrition, it is actually consider fasting more than a diet. Beyonce did lose 22lbs in 14 days on this diet, and the diet generally seems to have had good results with others who dare to try it either in Hollywood or elsewhere. Side-effects include lethargy, depression, dizziness, nausea, trouble concentrating, headaches and the one other one … oh yeah, death.  Use at your own risk.

The Paleolithic/Caveman/Stone Age Diet – The hunter-gatherer diet was introduced to modern times in the mid 70’s by a GI doc named Walter Voegtlin, with many variations since. Basically, if you can hunt it or collect it from a plant or tree, you can eat it. That means no dairy and no grains though. Hence the diet is essentially made up of  lean meat, fresh fish, vegetables, nuts, berries and fruits. No sugary calorie bombs or processed, preserved, cancer-causing excuses for food to fatten you up. Good for rapid weight loss in a healthy way but somewhat difficult in practice since you miss out on dairy and grains.

The ABS Diet – Newer kid on the block, created by David Zinczenko, the editor for Men’s Health. For many years most athletes and bodybuilders have applied the same basic fundamentals of the ABS diet to their dietary programs. These principles include eating often (5-6 times per day), a focus on building muscle, eating lean proteins, and striving to eat whole unrefined carbs.The Abs diet is made up of 12 ‘power foods’. One meal per week is designated as a ‘cheat’ meal – where you eat anything you want. The power foods are Almonds (and other nuts), Beans, Spinach (and green veggies), Dairy (fat-free or low-fat milk, yogurt, cheese), Instant Oatmeal (unsweetened and unflavored), Eggs, Turkey (and lean meats), Peanut Butter, Olive oil, Whole grain breads and cereals, Extra-protein whey powder and Raspberries (and other berries). It is a lifetime dieting plan with excellent results and a practical approach.

If none of these seem up your alley, here is one that I think we can all agree on every now again:

The Stress Diet:

This diet is designed to help you cope with the stress that builds up during the day. Breakfast

  • 1/2 grapefruit
  • 1 slice whole wheat toast – dry
  • 8 oz skim milk

Lunch

  • 4 oz lean broiled chicken breast
  • 1 cup steamed spinach
  • 1 cup herb tea
  • 1 small cookie

Afternoon Snack

  • Rest of the cookies in the package
  • 2 pints of  ice creamof your choice
  • 1 jar hot fudge sauce nuts, cherries, whipped cream

Dinner

  • 2 loaves garlic bread with cheese large sausage, mushroom and cheese pizza
  • 1 Liter of your favorite soda pop or cola
  • 1 bag of nachos with tub of hot cheese and salsa sauce

Late Evening News
Entire frozen cheesecake eaten directly from freezer

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Non-Pharmaceutical Pain Management Options and the Vicodin Virgin

May 5, 2009

Ok, it’s time to take a small break from all the jokes and wild stories, and time for a more serious article. Being outside the US for the past few days, I get a new perspective on certain issues like pain management for example. As a child visiting extended family, I can still remember my grandmother’s pure joy when my father gave her a bottle of Motrin. She had been using Aspirin to treat her osteoarthritis. She called him a few days later and thanked him for the miracle medicine. How much was she using? One 200mg tablet a day to control her moderately severe arthritis.

The country I am presently visiting is one of those places where you don’t need a prescription for most medications. You just go to the counter and ask for whatever … an antibiotic course, an asthma inhaler, a skin cream, an anti-emetic; whatever. So I did a little research on pain medicines recently. I asked the pharmacist at the counter what I could use for “severe” pain; you know, the good old “12” on a scale of 10 that we usually see in the ER.

The pharmacist reaches into one of the glass cabinets and pulls out some Cataflam (diclofenac) – an anti-inflammatory somewhat stronger than Rx-strength Ibuprofen. So I look at the box for a moment, and ask if they have something stronger, because my pain “is really bad”. I ask if maybe they have something like Ultram.

The pharmacist looks at me funny, and says that yes they have Ultram but only with a doctor’s note. She then asks me why I don’t try the Cataflam because it is one of the best pain medicines available. Clearly she was treating me like what I like to call a “Vicodin Virgin”.

What is a “Vicodin Virgin”, you might ask? It’s a person who has managed somehow to treat their assorted aches and pains throughout their life thus far without the use of narcotics. By this I don’t mean to say that the use of narcotics equals abuse, but somehow there is a large group of people out there who have gotten through their broken bones, wisdom teeth, headaches and even post-partum pains with non-narcotic methods. I am one of them and clearly this country had a lot of them too.

So this post is for such people. People who have no interest in Vicodin or Percocet for their pain management, and prefer something more natural or at least something that won’t make them goofy, nauseated and drowsy. This post is for you if you are concerned about using something that can be addictive and something which does little more than turn off the pain signal in the brain as opposed to helping pain at the site.

Again, I am not condemning people that use narcotic medications in the indicated way. So don’t get the wrong idea.

For the rest though, I like to divide non-pill based pain management into three broad categories: topical, behavioral and manipulative. Of course, there are other options available, but these are the ones I prefer when talking to patients.

Topical pain management is in my lowly opinion one of the truly underused modalities in medicine today. This is somewhat of a pharmaceutical option of course, but so unused that I wanted to discuss it. It includes creams and ointments like Tiger Balm, Icy Hot, Aspercream and even generic Walgreen’s brand “muscle cream”. The active ingredients are usually menthol (the smelly one), salicylates and capsaisin in any given combination. For most people with muscle aches, strains and sprains, these topical treatments can really go the distance in a safe way.

The second modality is behavioral and has Biofeedback and Progressive Muscle Relaxation (PMR) at the top of a short list. Biofeedback is a treatment technique in which people are trained to improve their health by using signals from their own bodies. Physical therapists use biofeedback to help stroke victims regain movement in paralyzed muscles. Psychologists use it to help tense and anxious clients learn to relax. It has become recognized through several well designed studies to be an effective part of a pain management program. It has even shown success with such severe pain syndromes as Sickle Cell crisis. Progressive Muscle Relaxation is also effective in pain control, as well as good modality in controlling the anxiety associated with pain; although these effects are lesser in degree and more dependent upon the ability of the patient to focus.

The last category involves manipulative techniques. Most people think of osteopathic medicine or chiropractic manipulation first when seeking relief from pain, and for a significant subset of patients these treatments are subjectively very helpful. The reality with all manipulative treatments though is that they are very dependent upon the person doing them. Massage is another manipulative technique which has been shown to be very useful and very effective in managing pain as was demonstrated in this review article in the Annals of Internal Medicine. In medical school, I had the opportunity to work in massage therapy for some time and personally witnessed the powerful effect it had on chronic pain.

So, these are just some of the more widely accepted and evidence based therapies that exist out there for people coping with pain and trying to avoid narcotics for one reason or another. Speaking globally, they do work and there are millions of people around the world who have succeeded in managing their pain effectively without the use of narcotics and their associated dependence. I hope some of these suggestions may prove useful as a springboard to readers – whether they be dealing with pain themselves or interested in helping their patients to find alternative ways of managing their pain.

And enough already with the Toradol allergy. We know what that really means.

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