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Should We Just Let Them Die?
I just logged onto our computer system at work to see what our patient list is looking like and if there have been any emergency surgeries this weekend. I noticed something peculiar about the bed assignment of one of our young patients. I opened a nurse’s note to discover that just two days after we operated to repair one of the heart valves that had been damaged by this patient’s IV drug use, the patient was discovered using IV drugs while in the bathroom.
Of course, they deny any wrongdoing but the evidence is overwhelming. I have no idea how this young person’s life will turn out after the follow-up visits are done, but I can say the chances are they will end up like so many of our other patients that require open heart surgery because of their drug use — dead.
When I was working as a bedside nurse in the Emergency Department observation area in Portland at a level 1 trauma center, IV drug users made up about one-third of my patients. They were bread and butter for us. Usually, they came in with abscesses at their injection sites or sepsis. This patient group was trying to deal with; initially, they would be cooperative and seem as though they wanted help, but after 24 hours, they would start jonesing for their fix. Sometimes they would ask to be discharged quickly because of a “family emergency,” they would want to go outside for some “fresh air,” or they would just leave when everyone’s back was turned. After a while, you get hip to their tricks.
The most frustrating part of caring for this patient population is their lack of commitment/willingness to get treatment. Their entire lives are ruled by their need to get their next fix, and not even going through open heart surgery is enough of a wake-up call to get them to change. One patient pushed me past my capacity to care when she came into the ED with her second bout of endocarditis. The first time around, she received treatment when she was flown from another state by a religious health care organization to Portland to have one of her valves replaced. When she was discharged from the hospital, she looked around and decided Portland was a pretty awesome place to be homeless and do IV drugs. I could not ask even the most basic of questions without snark, apathy, and contempt dripping from every answer. At one point, she admitted that she was just going to keep using until it killed her, even if Cardiothoracic (CT) surgery decided to do surgery to try and save her. She was admitted to a medicine service for medical treatment of her infection while CT surgery decided what to do; I never found out what happened to her.
When I left the bedside, the Emergency Department, and Portland for the long hours of CT surgery in Ohio, I thought most of my dealings with drug users were over. I was wrong. So, so, so very wrong. Ohio is at the heart of the opioid crisis. Next to West Virginia, it has some of the highest heroin use in the country. That’s most of what I see — heroin, with a little cocaine thrown in every once in a while.
There’s not much in the way of meth here; that’s more of a rural South and Southwestern thing. But regardless of the drug, the method of delivery is the same, as are the effects on the body. People are careless about cleaning their skin and their needles when they inject. Bacteria colonized on the skin enters the body through the venous system and sets up shop on the valves in the heart- mostly the tricuspid and mitral valves, but sometimes the aortic valve too. We can remove the tricuspid valve and leave it out, causing only some mild to moderate symptoms. It is not absolutely essential the way the mitral and aortic valves are.
Endocarditis causes damage to the valves when bacteria form little clusters on the leaflets of the valve — the flaps of tissue that open and close, regulating the flow of blood flow through the heart. The infection can burrow into the wall of the aorta, requiring replacement of the entire aortic root. Left untreated, many of these people will die.
Last year, I assisted on the first 8.5 hours of an 11-hour surgery on a woman not yet 30 years old who was having her third open heart surgery. She almost died on the table and it is truly by the grace of God and the skill of the surgical team that she did not. Every so often, I check the obituaries online to see if she shows up. Sometimes we find out months after their surgery that they died.
Sometimes they use during their post-op stay and arrest in the hospital, which happened to a patient of mine a few months ago. I came in around 6:30 a.m. to discover that she had died in the middle of the night after taking her heart monitor off and overdosing on something someone brought her. The staff did CPR for 20 minutes and called it. She was younger than me.
Often these patients don’t have insurance and their very expensive hospitalizations are courtesy of the dear taxpayer. Fortunately for these patients, we do not yet have a single-payer system that would ration the care they get. Instead, they get chance after chance, surgery after surgery.
I struggle with this. From a pragmatic standpoint, it is ridiculous to ask the taxpayer to foot the bill for multiple open heart surgeries and the subsequent six weeks of skilled nursing care they will need after their surgery for ongoing IV antibiotics. Especially if they just go home, start using again, and die a few months later. But from a Judeo-Christian standpoint, the need to show compassion and try to heal the way the Great Physician heals compels me to want to give these patients a chance … and another … and another.
Do we continue to give people unlimited treatment, or do we cut them off after a time? Are we being compassionate caregivers, or are we just being crazy by repeating the same action but expecting a different outcome?
There is disagreement amongst the surgeons I work with as to our moral obligation to operate. Some feel operating is a bad idea and call in an ethics consult; others feel that you should always operate even if the patient tells you they have no plans to quit. One large hospital in a neighboring city has a one and done policy — they will not perform redo valve replacements/repairs on people that reinfect themselves with ongoing IV drug use. I truly don’t know what the solution is.
Help me out, folks. My empathy is struggling. And I’m tired from all these long surgeries.
Published in General
In a sense, they proved it.
This makes the most sense to me.
After all, most people understand that minors and the mentally handicapped need looking after. If someone can’t handle being an adult, then we should have them be treated as minors. Make the generous benefits conditional on minor status. Use mechanisms like Drug Courts to work them toward adulthood.
Adults should mostly be able to stand on their own two feet.
Right now, people are having major surgeries and no real pain meds to cope with them, depending on what clinic or hospital they normally are seen at.
There will always be people who abuse drugs. But the idea that our nation’s officials must now insist that there can be no opioid pain meds for people who need them is foolish. I see it as ridiculous that I or a family member must set ourselves on fire to keep someone else warm.
As someone who personally watched an elderly lady’s family scramble around to find a doctor who would let the woman have opioids after her leg was amputated by Kaiser Hospital, I really resent going back to the same Neanderthal policies we mostly scrapped some 20 years ago. We scrapped those policies due to our innate and pure and quite wonderful common sense.
We probably all feel bad for the morbidly obese. And if we instituted a policy of each adult in the USA receiving a ration card allowing only 700 calories per adult and 1,000 calories per child, the morbidly obese would probably still find some way around the system. But a lot of really skinny people would die quite soon.
I feel the same way about our current hysteria over the opioid crisis.
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Exactly. Thank you! This is where I am now.
If I could get my pain levels down to a regular 4/5, I could function better. Since I’ve been off the opioids, I function at 7/8 level. Barely. I also have to take OTC meds to make the other medications to work effectively.
I have kidney issues.
Norco is safer for me than taking the additional ibuprofen or Tylenol. I’m also on such a low dose of Tramodol that it barely takes the edge off. I got myself off of the opioids, but my doctor can’t prescribe them now because of the structure of the laws. I can’t get to the recommended dose for Tramodol because of the morphine equivalents set by the CDC.
Rant over. I don’t want pity or anything. I’m stating the facts as they are.
So we do have the ability to give pain medications in the acute pain setting, like surgery. I’m not making my patients go through heart surgery with no pain medication. They get dilaudid IV while they have their chest tubes in (because that’s the worst part of open heart or thoracic surgeries), and they can have Norco, tylenol, and ibuprofen after the chest tubes come out. But narcotics are not indicated for long-term use as opioids actually alter your pain receptors and create hyperaglesia with long-term use. There are other medications and treatment modalities we can use for chronic pain patients. With chronic pain, we refer patients to pain management specialists. But just doling out an endless supply of oxy to everyone who “hurts” is not the way to manage pain.
So we do have the ability to give pain medications in the acute pain setting, like surgery. I’m not making my patients go through heart surgery with no pain medication. They get dilaudid IV while they have their chest tubes in (because that’s the worst part of open heart or thoracic surgeries), and they can have Norco, tylenol, and ibuprofen after the chest tubes come out. But narcotics are not indicated for long-term use as opioids actually alter your pain receptors and create hyperaglesia with long-term use. There are other medications and treatment modalities we can use for chronic pain patients. With chronic pain, we refer patients to pain management specialists. But just doling out an endless supply of oxy to everyone who “hurts” is not the way to manage pain.
I was on a maintenance dose. I haven’t responded to traditional therapies. I have a pain specialist and we were working together. My husband lost his job in December and I’ve been forced off of any kind of medical insurance. We don’t qualify or it’s too expensive. I’m stuck taking pills because it’s the only treatment I can afford. I also periodically stop taking pain meds for a few weeks.
That’s a tough spot to be in. I really hope you and your pain doc can figure out a good regimen for you.
It’s not my story to tell, so I’ll go light on details, but the lovely and talented Mrs. Mongo had a traumatic injury back in January. 8~9 days in the ICU. First six weeks home sleeping in the downstairs easy chair ’cause there was no way we felt we could safely negotiate her up the stairs. It’s been awful.
One of the worst parts of the whole ordeal has been getting her pain meds for a traumatic injury! The day we were checking out of the hospital, we determined that there was no way she was checking out without pain meds in hand. I went to four different pharmacies with no joy. The hospital docs had to call around (because I was adamant that we were going no where without ‘scripts in hand), and found a place about a half our out of our (my) way that could fill the script.
And, it was only like a two-day prescription. After two days, the doc had to certify that she needed more, and then we got a three day prescription. It was insanity.
The pain management doc told my wife, “this recovery will be a long process, and you will be an addict at the end of it. But we’re starting to plan how to handle that now.” (That doc, by the way, is nothin’ but sheer awesome.) So, everybody involved knew my wife would require heavy meds over the long-term, planned for weaning her off those meds as/when appropriate, yet still we had to play reindeer games to procure the meds. Not impressed. At all.
Two quick points:
-My lovely and talented wife got cleared hot this week to go back to work 8 hours/day.
-I held my wife’s hands and looked deeply in her eyes and said, “Honey, you’re doing great! Your job is to keep getting better.
TLATMM: Oh, thank you honey, it’s good to know you love me so much.
Me: Oh. Yeah. Love. Well sure, that and I’m tired of doing all the cooking, all the cleaning, all the shopping, all the laundry…
Good thing she wasn’t up to 100% at the time; If she could’a caught me, I think there would’ve been a stabbing.
My wife had major surgery a week ago and was sent home with oxycodone for ten days. She has already begun weaning herself off of them.
I had a major back problem about 8 years ago that lasted for several months – couldn’t lie flat for more than about 30 seconds. This makes sleeping difficult. I was able to get about 5 hours a night sleeping facedown in a recliner. The cruel irony was that I was most comfortable in a sitting position at a desk, so I didn’t even get any time off work.
Anyway, I was on percocet for about 3 weeks, then they switched me to hydrocodone from basically September until around Christmas. 60 pill prescriptions, with a refill whenever I wanted. I was taking several a day. I didn’t notice any particular buzz from them, although they did take the edge off the back pain.
When time came to stop, I quit cold turkey, no problem. I took one pill about 3 days later, and haven’t had another since.
That has been my experience exactly when I have taken Oxycodone. I keep wondering what on earth people are taking them for if not for acute pain. The medication definitely eased the pain so that I could sleep. But I didn’t have any emotional reaction to them at all.
I’m wondering if it is, for most people, truly the nonaddictive drug the doctors originally told me it was. My doctors described it as a new drug that didn’t have the side effects or the addictive properties of the older painkillers. I’m wondering if it is addictive to only small subset of people who take it. Perhaps it affects their mind or nervous system in uncharacteristic ways.
My daughter had knee surgery to repair a torn ACL. The surgery was not as straightforward as it sometimes is, and she was in a lot of pain for a few weeks. She took Oxycodone when she needed it for the pain, stopped taking it when the pain went away, and never had an addiction issue with it of any kind. The key to joint surgery recovery is movement, which she could not have accomplished without the Oxycodone. I keep wondering what people are doing in place of it. Not having the surgeries?
And what do the “pain management specialists” do for patients to replace the pharmaceutical painkillers?
As time goes on and more and more people have trouble obtaining painkillers when they need them, they will not have surgery that they need. I’m sure that will be one effect over the long term.
I can’t see my pain doctor anymore. I see my primary doctor every three months and it’s $100/appt. It’s usually just to get my prescriptions renewed. Thanks, though.
This explains the “miffed”.
I like it.
And not to spoil your joke, but the 1994 elections led to a lot of thumb-sucking articles in the media about “Angry White Males”. My reaction was always, I’m not *angry*, just kind of …miffed. And it stuck.
PMs are expensive. Even under insurance. Mine run $30 for doctor visit, another $30 for hospital visit, $250 for procedure. And thanks to government regs what was every 6 month visits is now every 2 months. Nice that. 2 visits become 6 just so bad guys can still be bad guys. I hate our governments habit of punishing the lawful majority because of the unlawful minority.
My pain doctor is $80/visit. So, yes, I’m there with you. I can’t afford the latest treatment for my disease. Even with insurance, it was $500/shot. I have two chronic conditions. Neither of which, has a cure.
I was partially inspired by this post to start a new OP on this topic.
Key items: did Government really create, through incentives, the opioid problem? And by changing the incentives (KPIs, questions, etc.) can we change the outcomes?
Just a little off topic but, when I was going to a pain specialist for years after my 14 hour back surgery, his bill for an office visit was $110.00. When my EOB arrived from Medicare, I would see that the Medicare payment was $11.00. That is typical of Medicare and insurance payments.
I don’t qualify for any government help. We “make too much”, even though we don’t qualify for unemployment and my husband hasn’t had a job since December.