Things You Didn't Know About Opiates

image stolen from American Apothocary
The Atlantic has a great infographic about the history of opiates in both medical use and abuse. It is full of historical revelations including:

  • Laudanum was first formulated in the 1500s and is still available today by prescription.
  • Heroin was formulated to be a less addictive alternative to morphine.
  • Free samples of heroin were mailed out to try and help morphine addicts kick the habit. 
  • Oxycodone was created as a less addictive substitute for heroin. 
Dig a little deeper and you'll find that:
  • The whole infographic is actually advertorial created by Purdue Pharma 
  • Purdue Pharma manufactures Dilaudid, MSContin, OXYcontin and other opiates. 
What Purdue doesn't sell is Suboxone - a medication that blocks both the craving of opiate addiction and the side effects of withdrawal. With critics pointing to evidence that 12 Step programs don't work for 90 percent of addicts.  Why aren't more people using Suboxone to help kick the habit? Dying to Be Free is a long-form article on addiction and overdose that asks that question while telling the story of an addict who tried to make it on his own and failed. 

The Washington Post reports that there are limitations on prescribing Suboxone because of it's potential for abuse -- even though it is safer that Methadone on prescription pain killers. Some doctors who prescribe Suboxone think the limits are arbitrary.  

"We don't have a patient limit for anything else we do," one MD told the Washington Post. "I can prescribe oxycodone to a thousand patients." 

 A Brief History of Opiates it really is pretty interesting.
Why is Suboxone so hard to get? The Washington Post
Dying to Be Free from the HuffPo
The Cause of Addiction is Not What You Think (at least in rats) by author Johann Hari for the HuffPo


Do We Need C-Collars?

I was first on scene. An extended cab pickup with trailer was in the ditch on its side. Snow was falling, but the ditch was full of icy water. A woman was standing outside the truck "my husband is trapped inside." I had my partner call for extrication help. I opened the back door of the truck and a Rottweiler dog came flying out, barking, but eager to get out of the overturned rig.

 It was easy to see why. Water was pouring into the cab from a broken passenger window. 

"I can't get out." The driver -- from the passenger side of the front seat called when he saw me. "My arm's stuck."

 Broken plastic from the headliner had his arm trapped. He couldn't have been wearing a seat belt, so he was thrown across the front seat when the truck went over. His head and chest and left arm were out of the water -- which was strewn with debris and chunks of ice. The rest of him was hidden underwater. He might have had a leg entrapped as well.

The water was rising.

I slid into the truck. Standing on the transmission console, and holding on to the steering when, I crouched down, trying to keep myself out of the icy water. I pulled at the hard broken plastic until his arm came free.  The water was coming up, at least six inches in the past few minutes. With the help of another firefighter we pulled him out of the truck. As he emerged from the vehicle he said "my neck feels crunchy." 

"Grab a C-collar," I said from still inside the drowning truck. "And get him on a board." 

He ended up having a cervical spine fracture -- a couple of them in fact -- and yet this awkward, frantic extrication made his injury no worse. 
Portland Attorney George Cottrell's patent drawing for C-collar 1964
Is the use of Cervical Collars in trauma about to go away?

We are in the comment period on scientific evidence for the new American Heart Association guidelines which are set to change in 2015.

On the agenda is a recommendation against c-collar use. Other countries are already eliminating the c-collar from trauma guidelines except in the extrication of some unconscious patients.

Since the AHA drives so much of what we do in prehospital care, if this gets adopted it will mean a big change in practice.

It's a long time coming, but the evidence to support the c-collar just isn't there.

The C-Collar has been around for at least 30 years. In pre-hospital care, anyone involved in a major penetrating or blunt force trauma automatically gets a hard plastic splint around their neck.

The idea is that cervical spinal injuries are often asymptomatic until one little movement severs the spinal cord. Better to put on a c-collar ASAP as a precaution.

Now, however, the routine use of C-collars in trauma is being challenged.

That's because the science supporting the use of the c-collar is pretty weak. In fact there is no evidence it does any good in terms of preventing exacerbation of spinal cord injury. At the same time, it is not as benign as originally believed.

That said, changing away from cervical spine immobilization will likely be a hard thing for some in trauma community to accept. It has become ingrained in our algorithms. Spine boards and c-collars are what we do to trauma patients because, well, because it is what we do. Right?

Roll up on a car wreck and one EMT grabs c-spine while the other fits a collar. The patient doesn't come out of the car until he or she is awkwardly rotated and strapped to a hard board.

There has to be a good reason that we do all that, right?
"Whilst the immobilization of alert and co-operative patients may appear intuitive, and is strongly based on tradition, it is not supported by a reliable body of evidence," wrote Jonathan Benger, a professor of Emergency Care in Bristol, England. "We are unable to find any reports of acute deterioration in an alert and co-operative patient with cervical spine injury as a result of a failure to immobilize shortly after injury. 
As blogger Sanscrit noted in "The Curse of the C-Collar:"
The cervical collar has become a curse. It’s seen as the shining proof of good quality trauma care. No ambulance service dare deliver a patient to a trauma bay without a cervical collar. Not based on trauma mechanism or patient symptoms, but solely based on fear of criticism from the in-hospital ATLS-trained trauma team leader. Don’t get me wrong, ATSL has done a lot of good – but it can also be slow to adapt to new trends, and implement interventions in a dogmatic way instead of patient case based. Knowing ATLS is not an excuse to stop thinking.
Recent journal articles have pointed out that there are a lot of assumptions that have lead to the proliferation of c-collar use. A lot of science, however, is knocking those assumptions down one-by-one.

The first assumption is that trauma patients often have c-spine injuries that are not detectable. The evidence however doesn't bare this out. Studies have found that 0.7 percent of patient's considered high risk for head and neck trauma had significant c-spine injuries.

Everybody gets a collar -- yet less than one percent actually wind up having c-spine injuries.

Like any broken bone - if we think it is broken, we want to splint it. The c-collar is that splint, right? Yet we collar people even without evidence of c-spine injury as a precaution.

So what about those 0.7 percent of patients that end up having c-spine injuries? Does a c-collar applied in the field decrease complications? Does the c-collar do what it is intended to do?

So far the science says no.

Limited studies comparing immobilized vs non-immobilized patients have thus far found that there is no decrease in neurological damage from c-spine immobilization.

How can this be? 

In the awake patient, the patient will self-splint and gentle manipulation and transport won't make things worse. Tissue swelling also helps reduce movement in the patient who is not awake.

Drunks are somewhere between awake and not-awake. It is notoriously hard to get a collar on a drunk. Most of them rip them off once they are off the backboard and we don't invite physical altercations trying to keep them on. In my experience even the drunks that ended up having c-spine injuries didn't make things worse by not having a collar on.

Finally, if you have ever seen a collar on a drunk, you know it doesn't really restrict the movement of the neck all that much.

Yet, the pre-hospital c-collar is all about the precautionary principal. As Sanscrit wrote:
OK, OK, so spinal injuries aren’t that common, cervical collars don’t really immobilize the neck, and collars have never been proven to affect clinical outcome – but how about we just put the collar on anyway, to be on the safe side… It sure couldn’t do any harm?
This is an important point-- the underlying motivation for medical treatment is to first do no harm. Can a c-collar make things WORSE?

Studies have shown that c-collars increase pressure on jugular veins which increase Inter Cranial Pressure (ICP). Increasing ICP in a patient with a head injury is bad. C-collars also make the airway more difficult to manage and increases aspiration risk.

These are all bad things.

So how to we balance those risks with the potential prevention of worsening spine fracture?

Easy! There does not appear to be any benefit. So there is nothing to balance.

Cadaver studies have shown that having a c-collar in place actually makes neck injuries worse. Dead bodies were given a neck injury then placed in a c-collar. Imaging studies showed that the collar increased the fracture crease by more than 7 mm. 

The collar we put on millions of trauma patients every year has no proven benefit, no proven protection against secondary injuries. Still, we put it on with the A in ABC and take focus and time from more important interventions. For the patient with a high suspicion of spine injury, careful handling is needed – but not a cervical collar. For all other trauma patients, they will more than likely be better off without the collar. 
Further Reading

From Sanscrit's excellent blog:

The curse of the c-collar

Progress in Spinal Injury Managment

Comment on the new draft AHA/ILCOR SEERS HERE


Human Factors: Electronic Medical Records and Ebola

One of the muddy reports coming from the first case of the Ebola virus diagnosed on US shores is why the patient was initially sent home -- to potentially expose hundreds of people -- when he first presented to the Emergency Department.

Reportedly the triage nurse screened him for recent travel and he told the nurse that he had just arrived from Liberia. After that something broke down -- either two EMR systems didn't talk to each other, or the doctor and charge nurse didn't read that part of the chart. Initially hospital officials said there was a flaw in the system, then they said there wasn't.

Slate notes that billions of dollars have been spent trying to get the US to adopt electronic medical records in the Emergency rooms and hospitals. That sort of makes it sounds like there is one computer program that everyone is using. There isn't.

Athenahealth CEO Jonathan Bush told HeathcareITnews. "The worst supply chain in our society is the health information supply chain," Bush told CNBC regarding the incident. "It's just a wonderfully poignant example, reminder of how disconnected our healthcare system is."

We currently use two computer charting programs in our ED and there is a third program -- supposedly to replace the other two -- coming in the next year or so. That system is EPIC which is the same system used at the Texas hospital. Epic can be customized by the hospital for different applications, but that customization costs. Given the penny-wise pound-foolish nature of the American hospital system, I am not optimistic

The American College of Emergency Physicians recently weighed in on the issue in a paper detailing the unintended consequences of using Emergency Medical Records systems that may not be optimized for emergency medicine and hospital systems seeking the lowest cost option.

That said, you can't blame the medical records if you don't talk to the patient. However, we are seeing increasing patient loads every hour with decreasing resources to do so. Computer records systems are supposed to make our jobs easier, but they actually add to the time and stress of each patient.


Sharpen Your Ax

There are always times when we do too much, take on too much and allow the weight of the world to be placed upon our shoulders.

We think we are strong and can power through anything and we suffer in silence, warped in the warm steam of our own stress. Our ego is swollen and fed by our labors. We tell ourselves that no one else knows how hard we are working. No one else has their nose to the grindstone like we do. We are martyrs. We look around and everyone is enjoying the sun, laughing while we slave away.

When I was trying to get into nursing school I took a college algebra class with a friend who was trying to get into dental school. It was summer session, so after a long class, we would go to the tutoring center at the college to grind through hours of homework while the world lolled about in the sun. I wanted to be home with my family and my new-born daughter Grace. I hated math, hated that I was in my late 30's and starting from scratch trying to build a new career to support my family.

I would grind away at the homework, never taking a break or allowing myself a moment of daydreaming. "I have to get this done," was the mantra that a mouthed with each new problem.

Each day my friend and I would start our homework at the same time and each day we would finish within a few minutes of each other, closing our books and walking out together.

Yet my friend would punctuate his homework with frequent stretches and walks around the building to enjoy the sun. One day while walking out I asked how he manged to get the same work done while finding time to sit on the grass while I was working.

His response is one of my favorite parables - one which my friends have often heard me repeat.

Two lumberjacks went into the woods one day, he said. One was young and ambitious, the other was old and wise. The young lumberjack was eager to prove how much stronger and faster he was and so he worked furiously throughout the day, never taking a moment of rest. As the day progressed, he often found the old lumberjack sitting on a stump relaxing while he worked. He felt sure that his dogged efforts would outstrip the old man when the tally was made at the end of the work day. 

Yet when the work was totaled, the old lumberjack had equaled the work of the strong young man. 

How could this be, he asked in frustration. It seemed like every time I looked around you were taking a break. How could you possibly chop as much wood as I did? 

The old man smiled and said: 

"Whenever I took a break, I was sharpening my ax



The Zen of Nursing

Life is not fair.

If you haven't noticed that by now, either you haven't been paying attention or you don't have enough birthdays under your belt.

Life was never fair, and never meant to be.

While whole religions have erupted from the minds of men to address this one issue, the fact remains, there is no divine justice wrought here upon the Earth.

I learned this lesson while I was very young, but had it reinforced by a decade as a newspaper reporter.  I saw cold-blooded killers set free, saw liars triumph and the honest punished for their honesty. Mendacity rules at all levels of power. Inhumanity and incompetence are promoted. Debased actions and bullying are rewarded. Being a reporter is to strive for truth in the face of lies. Journalists comfort the afflicted and afflict the comfortable.

In journalism, fairness is a watchword and justice is what every young wide-eyed new reporter seeks. Yet, the pay is barely minimum wage and you are disposable to your employer and community. After seven years at one paper -- winning awards and working 60 hour weeks, I was told to move on because the corporation didn't want to start paying reporters more than $18,000 a year.

"You've had too many raises," the executive told me from the hollow of his tailored suit. "You've reached the pay ceiling."

Everyone hates you when you tell them the truth anyway.

I had few illusions when I went into nursing.

Sure, there are golden moments when all is right. When your patients are healed by your actions and grateful for your kindness. Those moments must carry your for six months to a year before you might encounter them again. In the interim, the kind nurses will be cursed at and shat upon, denigrated and abused. They will work long hours and then be mandatoried over to work more -- punished for showing up to work.

They will cast themselves upon the rocks of the suffering and pestilent, the addicted and debauched, to be broken, yet to stand again.

At least the pay is better.

Moreover, as emergency room nurses we see the inequality of life's whims on full display. Children suffer, criminals get out of jail by malingering. The drunk driver murders children, then staggers away without a scratch. The kind die in pain and suffering while the cruel survive again and again. Sickness is not tied to sin.  The good die and suffer for no good reason. The gift of survival falls heedless of whether the recipient deserves another breath.

It is a hard lesson for a nurse to learn. The zen of nursing is learning to heal without judging, without a care about justice. Your job is to make the sick better, not to make the world fair.

No, there is no fairness in this business nor in life.

Yet in our larger lives, we must still strive for justice -- for justice is a thing wholly created by humanity. It is our humane reaction to the unfairness of life. Justice is the perfection we seek but may never attain. Striving for justice, fairness and equality are the only tools we have to battle back against the empire of fates that seek to pound us into submission.

The world is not fair.

It never will be.

Unless by our hands we make it so.