HOW I FOUND MY RHYTHM WHEN THE MUSIC STOPPED

At a time in everyone’s life, we come to find ourselves in a situation where the music stops, and we must go on.  The unfortunate truth about life is that the unexpected will happen. Some of us learn from it, some of us change because of it and some of us find our life’s calling because of it. The latter was the case for me.  After our dad picked us up from middle school, we spent that afternoon like we had every afternoon that month. We went to the oncology unit at the hospital, where my brother was admitted.

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THE MAN IN A BLUE SARONG

I remember him. I remember the man in the dark blue sarong the same way I remember the lines on back of my own hand. He was hunched over next to a column on a dirty platform at a railway station in Calcutta, India in the middle of the harsh summer sun. His hands were withered, his fingers and toes looked like tiny nubs, and he was completely malnourished and alone. He had opaque blue eyes, as if fog had taken place of his irises and pupils.

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PATIENT “OWNERSHIP”

I studied insects in college; my favorite insects were the bees (I found them diligent and so helpful to humankind).  One of my favorite classes was about medical diseases caused by insects. My professors noticed my interest in the medical side of things and connected me with a professor who did clinical research. Our work focused on a clinical trial for children with intractable epilepsy and exposed me early on to patient care and patients.

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hospital is in Louisville at Our Lady of Peace. While they are generally very helpful to ED physicians, it is a 90-minute ambulance ride to Our Lady of Peace. For OUD and SUD patients, this poses some risk by traveling that far for that long on an interstate highway. While Our Lady of Peace staff is very cooperative in their attempts to help, they still cannot cover the needs of the ED physician fully.


Comorbid physical medical problems of SUD patients are also a substantial issue for the ED physician.  For instance, intravenous drug users commonly develop upper extremity abscesses. It is difficult to get other physicians to see them for the surgical needs they have. They are very difficult patients to engage, and they have high rates of signing out of the ED against medical advice.


Dr. Stack reasons that to manage the OUD patient in emergency departments, it is necessary to have a well-functioning, competent, aggregate team in the ED.  That is difficult to accomplish in most hospitals. Moreover, he agrees that there is a significant current need for flow maps for critical treatment teams to follow with SUD patients and provide appropriate care.


The stress of dealing with SUD and OUD patients in the emergency department is tremendous upon the staff. These patients tend to “suck the air out of the room.” Steve believes that in an emergency department seeing 100 patients a day, at least one to two of those in Lexington will be SUD patients. Every day, the entire panoply of SUD patients runs about 7 percent to 10 percent of the patients seen. This requires approximately 15 percent to 20 percent of clinical time used in the emergency department.


Overdose OUD patients are a major issue for most emergency departments. They must be watched carefully, which takes significant staff resources. If they have received Narcan, they often are belligerent, confused, and fighting for a while. There are no resources in most community-based hospitals to provide non-medical staff to convince these patients to be referred for appropriate SUD treatments.  Moreover, the homeless population is a serious stress to ED physicians. Again, Steve provided me a direct clinical example of a recent patient who left against medical advice from the University of Kentucky. He had been seen at Central Baptist Hospital before coming to St. Joseph Hospital East and refused the other hospitals.  At all facilities the patient had used, he refused any offers for help with substance use.


Lastly, Dr. Stack stressed that physicians want to be patient advocates for these individuals, but you must be a pragmatist as well. He notes that a physician will burnout trying to solve serious social-medical problems of the SUD patient unless he/she has non-medical resources to help deal with the complex social issues of these persons and provide treatment for substance use.


Overall, it is the author’s opinion that the opioid crisis will defy significant management unless resources can be developed to provide ED physicians and treaters of SUD significant consultation support, and a developed referral system that is willing to take these difficult patients in transfer for inpatient/outpatient treatment.     

I had the opportunity to interview Steven Stack, M.D. regarding opioid issues confronting emergency department physicians.  Steve is well known to many of us, as he is a very recent president of the American Medical Association and currently is employed as an ED physician at St. Joseph Hospital East.


Steve’s opinion of the opioid crisis currently is that it is sad, tragic, and an enormous problem.  From the patient perspective, the patients that Steve sees are very hopeless and have limited resources. The nature of their disease leads to poor compliance with treatment recommendations and a continuation of their substance use disorder (SUD) or relapse.


From the clinician perspective in the ED, opioid use disorder (OUD) is a destructive condition to patients. For instance, Steve noted that after receiving Narcan for over dosage and then being seen in the ED, patients are often confused, belligerent, and must be kept in observation for quite some time before a reasonable history can be obtained. Dr. Stack does note that by talking with OUD patients and being respectful, you can get more information than you would expect. It is not unusual for OUD patients to answer questions about how they started on the substance, their use of it, frequency of use, etcetera. The greater percentage of these individuals respond well to this approach. Most OUD patients are used to being rejected when presenting for health care, and thus tend to respond negatively to rejection. Dr. Stack has learned that with a positive approach from the physician, they are much more willing to provide needed information.   

BY ROBERT P. GRANACHER JR., MD, MBA

Steve does report that the stress to an ED physician is so great that after one completes their shift, it is not unusual to feel as if you have PTSD. The issue of substance use disorder (SUD) was graphically told to me by Steve. He very recently saw an alcoholic man who was placed on a stretcher in a hallway because of continuing intoxication. For the next 45 minutes, he used personal derogatory ad hominem language toward all staff near him.  Such SUD patients tie up beds in the emergency department for 8 to 14 hours. Medical staff cannot communicate with them until they become lucid. It is also very difficult for ED physicians to obtain consultation with a behavioral health person by the time the SUD patient becomes capable of discussion.


Steve’s wide experience as president of the American Medical Associations, and the travels and consultations he engaged in while president, have enabled him to see the opioid problem from perspectives other than his own current treatment of patients. For instance, working in an emergency department is a very high stakes issue for physicians. The SUD and OUD patients are very angry people generally. There is usually no support system for them, and the ED physician has no place to easily refer patients. The link of the ED physician to hospitals that treat substance abuse is meager at best. For instance, in the St. Joseph Hospital system, the nearest major psychiatric and substance use

ROBERT P. GRANACHER, JR., MD, MBA

Robert P. Granacher, Jr., MD, MBA practices clinical and forensic neuropsychiaty in Lexington and Mt. Vernon, KY. He is a noted scientific author and past president of the Kentucky Psychiatric Medical Association. He is currently president-elect of the Lexington Medical Society and Clinical Professor of Psychiatry at the University of Kentucky College of Medicine.