Allow me to preface this article by saying I’m not against the appropriate use of opioid analgesia when indicated in any age group. While there has been legitimate concern regarding the over prescribing of these drugs especially to pediatric and adolescent patients, it also does not create a generalized scenario where we as health care providers can or should stop using these agents altogether. I completely agree that while using opioids for simple sprains and other similar minor injuries is indeed overkill, that does not mean they should be withheld in all cases. The child whimpering due to a supracondylar fracture, a child with terminal painful cancer, and burn injuries are just some of the cases where these agents should be utilized. Not only should they be used in these instances, I would argue if you are not using them, you need to take a long look in the mirror and ask yourself why you are still in medicine. Part of our job is to ease suffering and if you are willing to withhold proper pain management for significant illness or injury over what may happen in the future, I question why your are still practicing medicine.
That obligatory disclaimer aside, we cannot ignore that over-prescribing of opioid pain medications has become an issue if not an outright epidemic. How many of us know or know of a health care provider who have had their license suspended or revoked for improper prescribing of narcotics? At the same time, we have seen well respected physicians change their views on the dangers of marijuana. We have seen marijuana’s listing as a schedule I controlled substance and it’s label as the gateway drug questioned. I would pose that there is a changing of the guard in respect to what is truly the gateway drug.
It’s not even up for debate that opioid analgesia has proliferated and is ubiquitous. The U.S. uses almost 98% of the world’s hydrocodone . Oxycontin prescriptions rose from 76 million to almost 207 million annually from 1991 to 2013 . What prompted this to occur? In 1999 claims were made that chronic pain was under treated. In response to that, the Veterans Administration came up with the “Pain as the 5th Vital Sign” campaign. Two years later, the Joint Commission spread this notion throughout the rest of the health care system by instituting pain management standards based of the VA’s campaign . What soon followed was pharmaceutical companies convincing health care providers, patients, and regulators that opioid were safe for chronic non-cancer related pain. Some of the misinformation was so egregious that the makers of Oxycontin plead guilty to federal criminal charges . And what has been the end result? Prescription opioids are the most commonly abused drugs in many states, such as in Connecticut . Patient’s who are addicted to prescription opioids are 40 times more likely to become addicted to heroin . The end result is that prescription opioids have become the gateway drug to heroin as patients look for a stronger high or when then can’t get their opioid prescription.
In the other corner, we have marijuana. The cause of the laughable “reefer madness” and historically known as the gateway to other drugs. There is much I could get into regarding non-scientic reasons for its banning (hemp industry) and possible medical uses but they go beyond the scope of what I’m writing about. Dr. Sanjay Gupta has probably been the most famous physician to verbally reverse his views of marijuana being dangerous. Dr. Gupta points out that Marijuana was place on the Schedule I list in 1970 due to “a void in our knowledge of the plant” per Dr. Roger O. Egeberg then Assistant Secretary of Health. Yet there were studies as early as 1944 that showed marijuana did not lead to any significant addiction medically and did not lead to using other drugs. While reports vary, marijuana leads to addiction in 9% to 10% of users. Compare that to cocaine (a schedule II drug which is supposed to have less abuse potential than schedule I drugs) leads to addiction in 20% of users. Tobacco, which is legal leads to addiction in 30% of users, many of whom die from health issues related to smoking . Look at the other schedule I drugs along with marijuana; Heroin, LSD, peyote, and Ecstasy. Let’s use some common sense here. Yes, I know, it’s not very scientific and we humans have a brain and common sense that allow us to assess situations. I’m sure many of you reading this know others who smoke marijuana. Certainly, there are some who do nothing but, however that is the exception, not the rule. Nearly all the people I know who smoke marijuana can take it or leave it, forgetting they even have it half the time. No one smokes marijuana alone, gets behind the wheel of a car, and commits vehicular homicide unlike with our legalized friend alcohol. If anything, they get hungry, eat, and go to bed. No one overdoses and dies from marijuana alone or needs a reversal agent. Many of those who smoke marijuana have a good education and live a responsible, productive life. If not legalized, marijuana should be at least moved to a lower schedule and have well designed studies done with it if indeed we have had a “void of knowledge” all this time. It certainly has nothing in common with its companions on the Schedule I list and even Schedule II. As our medical culture prides itself so much in “evidence based medicine” it amazes me they have let this void exist for so long.
Part of the problem is that many health care providers fall into one of two camps. They either never prescribe narcotics across the board or use them when appropriate AND with chronic abusers enabling their addiction. The age old habit of viewing an issue with a narrow, binary mindset. There are no absolutes and the answers do not lie in the extremes. Opioid pain medications still have a vital and important role in the treatment of acute short term pain due to certain injuries, post-operative patients, and palliative care for terminal, painful conditions. These patient’s should not be made to suffer for what may happen in the future. However, it’s role in chronic, long term pain management has justifiably come under scrutiny and it certainly should not be used for minor injuries. The sad irony is that while marijuana has been the pariah all these years, prescription opioids have actually become the gateway to heroin and other illicit drug abuse. As such, there have been and are health care providers which have enabled this to happen.
- Mularski RA, White-Chu F, Overbay D, et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Itern Med. 2006;21(6):607-612.
Point of Care testing for bacterial vs. viral infections…
Working in Emergency Medicine, we have all sorts of days. We have amazing days, good days, bad days, and days that, for whatever reason, are far beyond bad. I recently had one of the latter. I rather knew it was going to be a bad from the beginning. The ER was already busy when I arrived at 8:00am with a backlog of patients waiting to be seen. Given the day of the week, the next provider would not be in for 3 more hours which had us behind the curve for most of the morning. The day in general was an All-Star roster of the crazy, manipulative, and opportunistic. One patient trying to use the ER to get her outpatient ultrasound, one convinced that the conscious sedation he received a month prior gave him brain damage because the vein in his arm is moving, one for a refill of his hypertension medication because it was the clinic’s fault (when in reality he didn’t show up for his last appointment), plus the usual compliment of patient’s wanting narcotic refills were just a small sampling of the day. Alone or in small numbers, these are pretty par for the course and easy to handle. However, when one faces these in larger numbers, on a busy day, combined with an equally large number of critically ill patients, the potential for the perfect storm is there. Those of you who work in Emergency Medicine I’m sure know the feeling. Overwhelmed by the shear volume, frustrated by the time taken away from the critically ill, it’s hard not to feel like Sisyphus and his boulder. And then it got worse…
While examining a patient for a minor illness, I witnessed in my periphery another person stand up, walker over to a child, and strike them in the side of the face and head. If I may digress for a moment, we as health care providers are well aware of child abuse and domestic violence, many of us unfortunately have seen victims after the fact, some of us may have even been working when it happened in the ER but not actually witness the incident. To actually witness an incident when a child is struck by an adult is another thing altogether. It also brings up two distinct issues. How do you handle it professionally and how do you handle it personally.
Fortunately, what to do professionally is straightforward. While the laws may differ state to state, where I practice if a health care provider even suspects child abuse, let alone witness it, it is mandatory that we report it the Division of Youth and Family Services (DYFS). Regardless of whether one agrees or disagrees with hitting a child as a form of punishment, it does not matter. You have to report it. As I went to evaluate the situation further, it turned out the two involved were actually the next two patients I was to see. The person and her grandchild were both there for mild viral symptoms with the grandparent also requesting a refill of her narcotics, something I did my best to not let cloud my judgement. It was quite evident the child was very guarded of even me when attempting to evaluate the situation and injuries, shielding their eye and saying very little. Fortunately there was no serious injury and at the same time I thought, if this happens in public, what could be happening at home. I advised the nurse of what happened and then we both pulled the grandparent aside for evaluation and advise that DYFS had to be called. Obviously irritated with us, we explained that we had no choice in the matter. That legally we were obligated to report any suspected or witnessed abuse. DYFS was contacted and security stood by in the interim. Being the busy day it was, I had to continue seeing other patients, all the while with the grandparent on the phone making assumptions out loud about my sexual preferences (which oddly enough I took more as a compliment).
That is a very cold and calculated description of what was done from a professional stand point. We as clinicians are not stone, we are not robots, even though I’ve seen some do their best to act that way. At the end of the day, we are still human beings with feelings. So how did I handle it personally? I cried. I pulled the nurse working that section in the office and I lost it. I cried. It was the proverbial straw breaking the camel’s back. After the long day I had already endured, to witness an adult strike a 10 year old was just too much to handle. I cried after work while with my girlfriend. I’m sure there are those of you who like me got hit when we were punished as children. Some of you may think “He did something to deserve it”. For me that’s neither here nor there. If you can, or think you can, witness a child getting hit in the face/head and not have some kind of emotional response then I say there is something very wrong with you. If you can witness such an act and repress your emotions entirely, then I say you are not handling yourself in a healthy way. If you sit there and read this and think that I am unprofessional for letting this affect me emotionally, then please email so I can explain to you why you need to leave medicine or retire.
While we do need to remain calm and professional during any time of crisis with our patients, we are still human and we still need to find other time to address our emotions, let ourselves feel our emotions. We cannot bottle them up or ignore them. We can’t hide behind bravado and hubris saying to ourselves, “I’m a professional, I’m a man, I don’t cry”. When the kettle boils over, we need to find a healthy way to experience our emotions, whether it be leaning on a co-worker/colleague, friend, or partner, writing about it, or meditation. Finally, we need to find ways to minimize when the kettle boils over which is something I will try to work on from here on out.
Unlike some of my colleagues, I am not one to rally the troops and go on the offensive about the benefits of immunizations. I prefer to think I fall somewhere in the middle. While I fully support the benefits of immunizations, I also support a person’s right to choose. Consequently, I rarely get on a soap box and pontificate on the topic. However, given this year’s flu season to date, I find I must abandon my usual centrist stance on the topic. Though admittedly anecdotal, I’m hoping what I’m about to relate will make the reader capable of making a more informed decision on the issue.
While the politicians in Washington spent a good part of Fall 2014 scaring the country about an ebola outbreak that never happened, the influenza virus has decided to take advantage of the distraction and do some real damage. I have seen more influenza cases and admitted more patient’s for the flu than possibly in my last ten years of practicing medicine. All of these patients have one thing in common:
None of them had a flu shot.
I’ll say that again, none of them had a flu shot. I know this because I ask my patients (or their respective parent) and it’s one of those questions that people have little reason to lie about. Now, while most adults who contract the flu will be fine, with or without being prescribe an anti-viral, the bigger concern comes with infants, children, elderly, and the immunocompromised. These patients are at an increased risk of complications and death from the flu. As already stated, I have admitted more patient’s for influenza this year than the past ten. These patients, particularly infants and elderly, are presenting to us extremely sick. Dehydration is common. Co-existing pneumonia’s are not unusual. These populations are unable to handle the flu well and usually contract it from an adult who can.
Is the flu vaccine a guarantee? No, there are none. IT IS our best defense against getting the flu and the complications that can arise from it. If you want a guarantee, buy a toaster. Given that we are well into the flu season, if you have already been exposed to the flu virus before getting the vaccine, you may still get the flu. However, the vaccine will NOT make the illness worse.
As I said, I’m not going to go on an exhaustive campaign and demand everyone get the flu shot. This is still America, you can still make choices. All I ask is that you seriously consider the information I have presented here and consider the health of not only yourself but of those around you. I hope that you will see the benefit and protection from getting the flu vaccine.
We are well into football season and I have already seen my fair share of sports related head injuries with and without concussions in the Emergency Department. As I have also had family, friends, and aquaintances ask me from time to time what constitutes a concussion or if their child needs a cat scan of their head, I figured this would be a good time to do an article on the topic of head injuries, concussions, and who typically needs a cat scan.
Disclaimer: This article is not intended to be used as a substitute for medical advice or in place of a medical evaluation in the event of a head injury. It is intended for informational / educational purposes only. Always seek medical attention/advice from your primary doctor in the event of a head injury. If there is any doubt to the severity of the injury, you cannot get in contact with your primary care doctor, or your primary advises you, call 911 and/or proceed to the nearest Emergency Department. Please read this site’s full disclaimer on the main page.
While concussions do not occur with every head injury, they are invariably a concern. In addition, while sports are not the only mechanism by which head injuries occur (i.e. Motor Vehicle Accidents, falls from a significant height), their incidence does tend to increase during football and hockey seasons where the number of people participating in contact sports increases. The information below will concentrate on sports related concussions, most of the information, with the exception of pre-season screening, can apply to concussions due to any mechanism.
So what is a concussion? The medical definition of a concussion is a head injury with a temporary loss of brain function. Concussions cause a variety of physical, cognitive, and emotional symptoms, which may not be recognized if subtle. Anatomically, the brain floats in cerebrospinal fluid within the skull, so when head injury occurs, the brain will slosh back and forth. This can cause the brain to actually impact the inside of the skull causing blunt injuries to the opposite side of initial impact (medically know as a coup contra-coup injury) as well as rotational forces on the brain. One of the most important aspects is that a concussion is a clinical diagnosis. This means that a concussion is diagnosed base on the history / mechanism of injury and the physical exam. It is not based on imaging which we will get into later. The general guidelines for concussions can be divided into three areas; Prevention, Recognition, and Recovery. It is also important to note that concussion guidelines may differ state to state. It is important to be familiar with your state’s guidelines. The New Jersey guidelines for sports related concussions can be found here:
Prevention of concussions consists of:
1. Pre-season baseline testing: This gives each athlete a picture of their baseline mental status which can then be compared to repeat tests following a head injury during the season
2. Education of student athletes on concussion prevention
3. Reinforcement of early identification and treatment of concussions to improve recovery
4. Immediate removal of any student athlete who exhibits signs and symptoms of a concussion and they may not return to play that day
Recognizing a concussion further consists of two parts, signs and symptoms.
Signs are issues observed by the coach, trainer, team physician, or school nurse and may include:
1. Appearing dazed, stunned, or disoriented
2. Forgets plays, or demonstrates short term memory difficulty
3. Exhibits difficulties with balance or coordination
4. Answers questions slowly or inaccurately
5. Loses consciousness
Symptoms are issues reported by the athlete and may include:
3. Balance problems or dizziness
4. Double vision or changes in vision
5. Sensitivity to light or sound/noise
6. Feeling sluggish or foggy
7. Difficulty with concentration and short term memory
8. Sleep disturbance
In the event of a head injury associated with the above signs and symptoms the athlete…
1. Should be immediately removed from competition or practice
2. Should be evaluated immediately by a physician or school’s licensed health care provider
3. Should have 911 called and be taken to the nearest Emergency Department for evaluation if symptoms worsen, patient experiences a loss of consciousness, patient complains of neck pain, there is not physician / health care provider on scene, or if recommended by on scene physician / health care provider
Recovery from a concussion is a slow, graduated process that involves input from everyone involved in the student athletes care including but not limited to a physician trained in the treatment of concussions, school nurse, athletic trainer, and coaches. It includes a slow re-introduction to not only athletics but also day to day school activities, as mental and cognitive stress are just as important to limit as physical stress. Both mental and physical stressors can adversely affect the athlete and delay recovery.
In general, any student must remain symptom free for at least a week since their last symptom before returning to competition. For example, if the last concussion symptom an athlete experiences is vomiting and only three days pass before vomiting returns, the one week clock starts again. The athlete must wait a week from the resolution of the second episode of vomiting. This is because the greatest risk of long term brain injury occurs if an athlete sustains a second head injury while still recovering from a concussion. The basic tenants of recovery include:
1. The athlete is advised, while experiencing symptoms and signs of a sports-related concussion or other head injury, to have complete physical, cognitive, emotional, and social rest (Minimize mental exertion, limiting overstimulation, multi-tasking etc.)
2. Upon resolution of signs/symptoms and re-evaluation by a physician trained in the treatment of concussions, the athlete requires written clearance that the athlete is without symptoms at rest and may start the graduated return to play protocol. This protocol should also include changes in daily school activities to lessen any mental / cognitive stressors
3. If any concussion symptoms return during the graduated return to play protocol, the athlete is to return to the previous level of activity that did not cause symptoms
4. If any concussion symptoms return after being cleared for normal physical activity, the athlete is to be removed from any further exertional activities and re-evaluated by their physician
5. Medical clearance to return to normal training activities is done by consultation between the athlete’s physician, athletic trainer, team physician, and school nurse
While research into concussions is always ongoing, we know a great deal more than we did even twenty years ago. Adherence to these guidelines is vital to protect student athletes and allow them the chance to make a full recovery and prevent / minimize long term cognitive issues.
It’s difficult to talk about head injuries and concussions without also discussing Cat Scans of the brain. While many head injuries, sports related and otherwise, will get a Cat Scan of the brain it is important to know that a much smaller percentage of head injuries actually need one. As mentioned earlier, a concussion is a clinical diagnosis which means to diagnosis a concussion, a Cat Scan is not required. There is no abnormality seen on a Cat Scan that a physician or health care provider will point to and say “there is the concussion”. However, there are times when a Cat Scan is needed to rule out other, more worrisome, conditions associated with head injuries. Like concussions, the need for CT scans of the brain has been well studied and as a result there is an excellent understanding for when they are needed, and also medical guidelines for them as well. As you will see, the red flags we associate with other more serious traumatic brain injuries have overlap with concussion symptoms. This is why in the setting of concussions, sometimes CT scans are needed, and sometimes they are not.
In keeping with our talk on concussions, the guidelines for head CT’s we will be reviewing will be specific to children and teenagers. These guidelines cannot be used for the elderly, patient’s on blood thinners, or patient’s with these symptoms in the absence of a head injury. The signs and symptoms that parents, coaches, team physicians, school nurses, and teachers should be aware are divided into two age groups, under 2 years old and over 2 years old. While young children and toddlers are not participating in contact sports, they are still prone to head injuries via other mechanisms that require evaluation.
Head Injury Over 2 Years Old
Requires a CT Scan of the brain:
1. Bruising around both eyes (raccoon eyes) or behind the ears (Battle Signs)
2. Altered Mental Status: Agitation, slow response, repetitive questions, amnesia, excessive sleepiness
CT Scan of brain vs. Observation:
2. Loss of Consciousness
3. Severe Headache
4. Severe Mechanism Of Injury: Fall from more than 5ft, MVA with ejection from vehicle / roll over / fatality, bike/pedestrian MVA w/o helmet, struck by high impact object
In these cases, the decision to do a CT scan vs observing is shared between the health care provider and parent/patient. The factors involved are multiple vs. isolated mechanisms, worsening findings during observation, abnormal neurological exam, physician experience, and parental preference.
Head Injury Under 2 Years Old
Requires a CT Scan of the brain:
1. Palpable skull fracture or obvious deformity to skull
2. Altered Mental Status: Agitation, slow response, repetitive questions, excessive sleepiness
CT Scan of brain vs. Observation:
2. Loss of Consciousness greater than 5 seconds
3. Scalp hematoma (except frontal)
4. Not acting normally per parent
5. Severe Mechanism Of Injury: Fall from more than 3ft, MVA with ejection from vehicle / roll over / fatality, bike/pedestrian MVA w/o helmet, struck by high impact object
In these cases, the decision to do a CT scan vs observing is shared between the health care provider and parent/patient. The factors involved are multiple vs. isolated mechanisms, worsening findings during observation, abnormal neurological exam, physician experience, parental preference, or patient less than 3 months old.
Again, this information is not to take the place of medical advice or examination by a health care provider. In the absence of these findings a phone consultation to your pediatrician should at least be done. Keep in mind your pediatrician may still ask that you have your child evaluated in the ER as they cannot do a full evaluation by phone. The material presented here is for informational purposes only and intended to educate and help those understand the factors that go into medical evaluation of concussions and deciding whether a patient needs a CT scan. As a parent, if there is ever any doubt, call 911 or bring you child to the Emergency Department. As health care providers, we would prefer to take the time to reassure patients and parents or observe them in the ER rather than have someone stress over whether or not to come to the ER.