As a Community Leader of EMTLife.com I read over most posts. I see patterns. Medics know their drugs, but when it comes to understanding the drugs their patients are prescribed, they’re lost. Of course, we’re specialists living in a very narrow tunnel. For the most part we’re taught about the actions and reactions of the drugs we use, very often of how they affect each other. But with medicine as it is, that’s only the tip of the iceberg. Before we ever get to our patients, they are often loaded up with more combinations of medications than you can write on the palm of your hand with a fine-point pen in 6 pt. type.
Even back in my stone-age days I recall often just shoveling meds into a sack and dragging them along with the patient to the E.R. Sure, I’d know a couple, and they would be helpful to understand what the patient had, but when it came to how their combinations were affecting each other, I was oblivious. I imagine that that has not changed over the years, and with the pharm companies encouraging people more and more to try this for that (under your doctor’s order, of course) that sack is likely getting heavier.
This aspect of modern medicine didn’t become apparent to me until the other day. As a medic way back when, it was something I didn’t consider much, and now as I’ve been reading through threads I’ve begun to wonder. So many “scenarios” that the contributing medics present include arrythmias that stump them. Although every other element of their patients’ presentations generally fall into line with their most dominant afflictions, they note — and call out for help in interpretation of– anomalies in their 12-leads; things that don’t quite conform to the bulk of the story.
Of course, the same pattern holds true with sudden unexplained spikes in BP or crashing pulse rates or even respiratory changes happening so rapidly and out of step with their conditions that the medics are stymied.
Oddly enough, being a Tour Guide on Maui exposes me to more inside information on how today’s medicine works than I got as a paramedic! A light went on in my head the other day about something I hadn’t really noticed as clearly before. One of my clients was an Internist working out of the University of Wisconsin Medical Center. He had come up from India, was trained in Britain, worked for a number of years in the squalid conditions of an African backwater (seeing 100 + patients a day and working with severely limited resources!) and now is pleased to have a relaxed practice where he only sees about fifty patients a day.
As outrageous as that sounds, he really does have it easy. The average amount of time (U.S.) that an MD spends with his patient is about 8 minutes. (His days are usually 10 or more hours.) And, according to this MD and many others I’ve spoken to those minutes are usually spent in the prescription of drugs, the recomendations for testing of one sort or another and the explaining of same to the patient (as best he can; and let’s face it, often leaving the patient befuddled).
What he mentioned, however, set my sirens going. He said something like, “My biggest challenge when I intake a new patient is seeing that they present with a huge mix of medications; all for the same disease or problem. The first thing I do is work on narrowing tratment down to no more than two of those meds.”
I found that curious so I asked, “Why?”
“Simple,” he replied, “I can figure out how two meds may affect each other, but when it comes to more, I often don’t have a clue. And I have to wean them off of one at a time until I can establish a stable baseline to work from.”
He went on to say that these combinations and their effects on each other don’t even include the slew of OTC medications patients put themselves on. But this next statement is the thing that got me to write this blog:
Nobody knows how all these combinations affect each other!
Could that possibly mean the pharmaceutical firms as well? To the best of my knowledge, they are geared up to test one drug at a time, and with certain pat warnings against not combining things like MAO inhibitors with, for example, certain anti-depressants and the like. But they’re not actually dealing with the real world where each patient is being exposed to many different combinations.
And it didn’t stop there, either, because that led into a discussion of how the prescription of meds to tackle individual symptoms are largely a way for Medicine to show that it knows what it’s doing when in actuality, the patient is just seeking human connection!
But wait a minute, that’s off topic.
Or is it?
Many people with multiple ailments (real or imagined) end up seeking out one doctor for each, often in the absence of anyone coordinating their overall treatment plan. Very often, the patient feels no need to tell the heart specialist what their arthritis specialist is giving them. (Think in terms of analgesics that thin the blood.) Their primary concern is reassurance and if that comes in the form of being prescribed yet another pill, then Hey! let’s get it on board.
In the back of the ambulance, however, when we’re called on to figure out some sort of an emergency treatment plan, we’re more in the dark than anyone, precisely because if the doctors wouldn’t be able to call how this affects that, and the pharm companies aren’t taking their studies to the next logical step, how could we be expected to?
Now the first place this sent me to is (and I’m curious what Rogue would have to say about this) is:
If we’re going to be true professionals, we need to be able to go through a list of medications that a patient has taken That Day and identify possible drug interactions that may be contributing to their chief complaint, or throwing off the presentation of symptoms that we are called to treat. After all, isn’t that what we do; treat the symptoms and not the underlying disease?
This is not only to get the patient to the ER in better shape than when we arrived on scene, but to make sure whatever WE give him or her doesn’t make things worse.
So let me ask you all a few questions:
* Have you followed up on your own cases to find that major contributing factors to the exacerbation of the emergency you were called on to deal with happened to be drug interactions from your patients’ prescribed meds (or even OTC, for that matter)?
* Or is that really not our job because we’re not expected to think that much?
* Would a better understanding of pharmacology and drug interactions be something You would be willing to invest time and energy into getting?
Inquiring minds want to know!
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