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.

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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.

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Sep 27, 2022·edited Sep 27, 2022

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.

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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.

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the unbearable sadness of being

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