After 35 years I couldn’t do it anymore. All of it, the pandemic and the situation as you just describe, it broke me. Thankfully and due to a sheer stroke of good fortune I had been seeing patients in an Addiction Clinic once a week for years. . This led to Board Certification in Addiction Medicine and a new, satisfying career. Lucky. Very lucky.
Thank you Ed for articulating my thoughts before, during and after every shift. I have been telling everyone I can that emergency department and health care in general is collapsing in front of us and nobody is doing a damn thing. People I interact with outside healthcare/medicine don't want to hear it. I have been fortunate enough to avoid sick or requiring services of the emergency department/hospitals. Since they do not have to see it on a regular basis they tend to shut their eyes to it. We all need to keep yelling from the rooftops and just hope at some point someone will take notice. Thank you for all you do.
Adam, thank you so much for reminding me that I'm not just an old curmudgeon! It amazes me that this isn't on the news every single day. It's unbelievable. My hospital is opening two new cath labs next month. Big deal, ceremony, etc. But I still can't get complicated patients admitted or transferred and it's just a shrug of the shoulders. Part of me wants to quit. Part of me wants to go down swinging on this because we'll need care and so will our kids and grandkids!
In addition to all of the issues you present, we here in one of the well known hospital systems in the Lowcountry of your state are contending with a CMG takeover of some of the last remaining democratic groups in the state.
The hospital system claims a need for "cost savings." In the mean time the system is looking to spend almost $1B to build a new hospital.
Our wait times have skyrocketed. Our nurse manager just quit after the loss of 10 experienced ED RNs in the last 12 months.
We are told we are "doing a great job and given occasional pizza.
It used to be the best job in the world. I used to say I can't believe they pay me for this. now it just seems to become more hopeless each day.
Even my very young partners are looking for escape ramps.
Maybe the huge increase in residency slots are required as we will have such rapid turnover of young docs in the coming years.
The sheer weight of all this on medical staff must be unimaginable. It takes a lot of strength and emotional labor to go through these things in the first place, and then share about them afterward. Before I say anything else, I want to thank you for giving folks like me outside of the medical community a look into your world.
That said, a portion of your writing struck me as somewhat alarming. It’s the section about drug addiction, which bleeds (logically) into the ongoing mental health crisis.
Bear in mind I’m not a part of the medical community, but to me, that section about addiction seemed to lean pretty aggressively against said patients.
In all other sections, you talk about the complexity of health and treatment, how bigger-picture aspects of society ultimately influence them. You had a clear outpouring of empathy that vanished almost entirely once addiction came into play.
Here’s my reasoning for saying that: your language dramatically shifted from things happening TO patients, to patients THEMSELVES actively causing the problems in your ER and in their own lives. (my apologies for using all caps, no italics option)
- Examples of the former: “Lack of fitness, lack of healthy diets, obesity, all of these take a toll and create complicated patients”, “They are defined by heart attacks and strokes”, etc.
- Examples of the latter: “they’re just buying heroin and fentanyl”, “They fill our ERs”, “most circle back to the drugs.”
Then, you go back to your original storytelling method, mentioning the problems as occurrences instead of actions (“Mental illness fills our rooms”, “violence plagues the ER”).
I don’t know if this was intentional or not, but it’s concerning nonetheless.
It seemingly frames patients struggling with addiction as being 100% to blame for the specific issues related to their ER visits. Obviously, the individuals who come in have some level of control over their situation, but as a medical professional, I’m (hopefully) sure you understand the insane complexities of addiction. People don’t wake up and say “today, I will overdose on heroin and end up in an emergency room”, but your casual language here could be interpreted to say as much.
Are “complicated” patients considered “simple” if their problems don’t stem from unhealthy diets and obesity (as you mentioned earlier), but rather from addiction?
Should we place blame on these people (often the living end results of economic turmoil and untreated mental health crises) and throw a simple “addict” label on them? Or should we see them as people, as complicated patients? For the other issues in your piece, you chose the former. When it came to addiction, you seemed to have chosen the latter.
After (what could be interpreted as) assigning responsibility for ER-related issues to addiction patients themselves, you say the following: “They lose limbs, they die. Until then, they are brought by family members ‘because she needs help,’ and some go to rehab but most circle back to the drugs.”
The specific quote of “because she needs help” seems very down the nose in this context—it comes across almost as mockery. Yes, it seems illogical to ask the ER for help with addiction, but let’s not pretend that people always think clearly in times of desperation. And sadly, you see people in desperation every day. I don’t think it’s fair to hold people in these situations to the same decision-making standards you’re capable of as a practitioner who has to see this stuff constantly. I empathize with your frustration and I don’t know if this was intentional, but it arguably reads that way.
Then, you mention how “some go to rehab but most circle back to the drugs.” Throughout this entire section, from “Still another population is addicted” to the finishing quote I just mentioned, your dialogue doesn’t seem to follow the ER, it begrudgingly follows the cycle of addiction like it’s an intentional act.
Perhaps that was the whole point of that section. Addiction is an ugly and complicated cycle, after all, and it causes anger. I’m angry about it, too. I wish it wasn’t killing people and ruining lives in the way you describe—I just don’t think it’s as casual as you make it out to be here. And I don’t believe the blame should be piled onto the individual.
Yes, personal accountability matters, but so does viewing these patients as people rather than “addicts” as you refer to them at the beginning of your piece.
I don’t say all of this as a “gotcha” or anything like that. I don’t want to be the language police. And I certainly don’t want to pretend like I understand the difficulties you and other medical professionals face every day. I simply hope you will give the issue of addiction the same amount of nuance and sympathy as you gave the rest of the ailments/problems in this article.
Thomas, I've been meaning to thank you for your comments. I think sometimes that I have a hard time switching from writing to physicians (which I do regularly) to writing to the public and patients. When writing to physicians there's a kind of understood subtext that we know the struggles of the addicted but get frustrated with the situations on many levels. This can come across as cynicism and cruelty (and can be those) but often is just exhaustion. I made some changes to the post in another iteration of it which was published by MedPage. I'll send you a link. Thank you for your honest and appropriate critique!
One nitpick, though, Doc: When we give that patient Narcan we may well save their life, but we’re also throwing them into acute withdrawal. Not fatal, but not pleasant either.
I’m a PA, Dr. Leap. I spent 14 years in academic Emergency Medicine. I sometimes miss the work, but the average ED these days is a circle of hell that Danté would find too implausible to include.
After 35 years I couldn’t do it anymore. All of it, the pandemic and the situation as you just describe, it broke me. Thankfully and due to a sheer stroke of good fortune I had been seeing patients in an Addiction Clinic once a week for years. . This led to Board Certification in Addiction Medicine and a new, satisfying career. Lucky. Very lucky.
Thank you Ed for articulating my thoughts before, during and after every shift. I have been telling everyone I can that emergency department and health care in general is collapsing in front of us and nobody is doing a damn thing. People I interact with outside healthcare/medicine don't want to hear it. I have been fortunate enough to avoid sick or requiring services of the emergency department/hospitals. Since they do not have to see it on a regular basis they tend to shut their eyes to it. We all need to keep yelling from the rooftops and just hope at some point someone will take notice. Thank you for all you do.
Adam, thank you so much for reminding me that I'm not just an old curmudgeon! It amazes me that this isn't on the news every single day. It's unbelievable. My hospital is opening two new cath labs next month. Big deal, ceremony, etc. But I still can't get complicated patients admitted or transferred and it's just a shrug of the shoulders. Part of me wants to quit. Part of me wants to go down swinging on this because we'll need care and so will our kids and grandkids!
In addition to all of the issues you present, we here in one of the well known hospital systems in the Lowcountry of your state are contending with a CMG takeover of some of the last remaining democratic groups in the state.
The hospital system claims a need for "cost savings." In the mean time the system is looking to spend almost $1B to build a new hospital.
Our wait times have skyrocketed. Our nurse manager just quit after the loss of 10 experienced ED RNs in the last 12 months.
We are told we are "doing a great job and given occasional pizza.
It used to be the best job in the world. I used to say I can't believe they pay me for this. now it just seems to become more hopeless each day.
Even my very young partners are looking for escape ramps.
Maybe the huge increase in residency slots are required as we will have such rapid turnover of young docs in the coming years.
Excellent, yet horrifyingly accurate piece.
The sheer weight of all this on medical staff must be unimaginable. It takes a lot of strength and emotional labor to go through these things in the first place, and then share about them afterward. Before I say anything else, I want to thank you for giving folks like me outside of the medical community a look into your world.
That said, a portion of your writing struck me as somewhat alarming. It’s the section about drug addiction, which bleeds (logically) into the ongoing mental health crisis.
Bear in mind I’m not a part of the medical community, but to me, that section about addiction seemed to lean pretty aggressively against said patients.
In all other sections, you talk about the complexity of health and treatment, how bigger-picture aspects of society ultimately influence them. You had a clear outpouring of empathy that vanished almost entirely once addiction came into play.
Here’s my reasoning for saying that: your language dramatically shifted from things happening TO patients, to patients THEMSELVES actively causing the problems in your ER and in their own lives. (my apologies for using all caps, no italics option)
- Examples of the former: “Lack of fitness, lack of healthy diets, obesity, all of these take a toll and create complicated patients”, “They are defined by heart attacks and strokes”, etc.
- Examples of the latter: “they’re just buying heroin and fentanyl”, “They fill our ERs”, “most circle back to the drugs.”
Then, you go back to your original storytelling method, mentioning the problems as occurrences instead of actions (“Mental illness fills our rooms”, “violence plagues the ER”).
I don’t know if this was intentional or not, but it’s concerning nonetheless.
It seemingly frames patients struggling with addiction as being 100% to blame for the specific issues related to their ER visits. Obviously, the individuals who come in have some level of control over their situation, but as a medical professional, I’m (hopefully) sure you understand the insane complexities of addiction. People don’t wake up and say “today, I will overdose on heroin and end up in an emergency room”, but your casual language here could be interpreted to say as much.
Are “complicated” patients considered “simple” if their problems don’t stem from unhealthy diets and obesity (as you mentioned earlier), but rather from addiction?
Should we place blame on these people (often the living end results of economic turmoil and untreated mental health crises) and throw a simple “addict” label on them? Or should we see them as people, as complicated patients? For the other issues in your piece, you chose the former. When it came to addiction, you seemed to have chosen the latter.
After (what could be interpreted as) assigning responsibility for ER-related issues to addiction patients themselves, you say the following: “They lose limbs, they die. Until then, they are brought by family members ‘because she needs help,’ and some go to rehab but most circle back to the drugs.”
The specific quote of “because she needs help” seems very down the nose in this context—it comes across almost as mockery. Yes, it seems illogical to ask the ER for help with addiction, but let’s not pretend that people always think clearly in times of desperation. And sadly, you see people in desperation every day. I don’t think it’s fair to hold people in these situations to the same decision-making standards you’re capable of as a practitioner who has to see this stuff constantly. I empathize with your frustration and I don’t know if this was intentional, but it arguably reads that way.
Then, you mention how “some go to rehab but most circle back to the drugs.” Throughout this entire section, from “Still another population is addicted” to the finishing quote I just mentioned, your dialogue doesn’t seem to follow the ER, it begrudgingly follows the cycle of addiction like it’s an intentional act.
Perhaps that was the whole point of that section. Addiction is an ugly and complicated cycle, after all, and it causes anger. I’m angry about it, too. I wish it wasn’t killing people and ruining lives in the way you describe—I just don’t think it’s as casual as you make it out to be here. And I don’t believe the blame should be piled onto the individual.
Yes, personal accountability matters, but so does viewing these patients as people rather than “addicts” as you refer to them at the beginning of your piece.
I don’t say all of this as a “gotcha” or anything like that. I don’t want to be the language police. And I certainly don’t want to pretend like I understand the difficulties you and other medical professionals face every day. I simply hope you will give the issue of addiction the same amount of nuance and sympathy as you gave the rest of the ailments/problems in this article.
Thomas, I've been meaning to thank you for your comments. I think sometimes that I have a hard time switching from writing to physicians (which I do regularly) to writing to the public and patients. When writing to physicians there's a kind of understood subtext that we know the struggles of the addicted but get frustrated with the situations on many levels. This can come across as cynicism and cruelty (and can be those) but often is just exhaustion. I made some changes to the post in another iteration of it which was published by MedPage. I'll send you a link. Thank you for your honest and appropriate critique!
This was why I left EM. I couldn’t do it anymore.
One nitpick, though, Doc: When we give that patient Narcan we may well save their life, but we’re also throwing them into acute withdrawal. Not fatal, but not pleasant either.
I sometimes forget I'm not writing just to colleagues. Thanks for the reminder.
I’m a PA, Dr. Leap. I spent 14 years in academic Emergency Medicine. I sometimes miss the work, but the average ED these days is a circle of hell that Danté would find too implausible to include.
Can't win, either way. I'll keep giving narcan.
the unbearable sadness of being