[BigBri.net] The official Brian Fields site


The Opioid Crisis in America

I've seen this term tossed around recently and didn't pay much attention to it.  I knew that it was a problem, and had seen the first-hand effects in my resident clinic.  Mostly I dealt with patients written off as having chronic pain and now dependent on large doses of opiates. Some patients would come to my office asking me to continue their already existing 240 tablet monthly Norco prescriptions.  For most, my reluctance to continue that care plan led them to seek medical care elsewhere, but a select few stuck with me and I worked to address somatic complaints with non-narcotic treatments, wean them off the opiates, and address underlying psycho-social issues.  Looking back, it was one of the few things I miss about clinic and developing long-term relationships with patients.  Now that my practice as a Hospitalist is episodic, my personal investment in each patient feels smaller.

The White House has chimed in on this issue, in 2011 they published a plan outlining education, monitoring, and enforcement goals.  More recently, the White House blasted AstraZeneca's 5 million dollar Super Bowl ad touting a new treatment for opioid induced constipation.

Physicians have been under the magnifying glass also.  Just last year a Southern California physician was convicted of murder after several overdose deaths were linked to her loose prescribing habits, which were in turn fueled by greed in a clinic making several million dollars annually.

The thing that really got me thinking was a study presented during a palliative care lecture.  The premise was an elderly patient with stage 4 lung cancer and a family member at bedside insisting that the ER doc intubate her loved one.  68% of emergency physicians surveyed responded that performing the intubation would take less time than having a discussion about goals of care.  

So, is the traditional bureaucratic response to this problem appropriate?  Should we add more education, monitoring, enforcement, data gathering and analysis?


Practitioners in modern medical practice are already saddled with the ever-increasing complexity of electronic documentation, coding, billing, tracking, monitoring, and regulatory oversight.

We need to treat this as a SYMPTOM and not the disease.  It is my opinion that physician detachment, fueled by the fire of medical bureaucracy has forced physicians into a position where patient care comes second to the care they give the chart.  Time has become a commodity that physicians have to fight for.  Gone are the times of the independent medical practice.  The onerous burden of administration in medical practice has made us beholden to our corporate masters.  Decisions about patient workloads are now in the hands of people with MBAs who know almost nothing about patient care.

This physician disengagement has led us to a place where 68% of ER docs think it would be easier to intubate the dying patient than to talk about it, even though they thought it was the wrong thing to do!

I have seen the same phenomena creep into my practice.  It's annoying for me to spend 20 minutes explaining why I think Tylenol and Ibuprofen are appropriate for my patient's pain control after they leave the hospital.  It only takes me 30 seconds to fulfill my patient's narcotic wishes with a prescription.

I was hopeful listening to the Surgeon General's remarks today.  He talked about plans to address the opioid crisis, and his upcoming report on addiction and substance abuse:

“We’re going to stop treating addiction as a moral failing, and start seeing it for what it is: a chronic disease that must be treated with urgency and compassion…"

One of the tools that emerged to help prescribers is a PDMP, or prescription drug monitoring program.  This allows providers to look up pharmacy records online and see if patients are getting narcotics from other sources.  In Oregon, the program was so terribly implemented that it was almost not worth using.  The time and work required to log in, search, and find what you were looking for was not worth it.  

I hope that we can emphasize the importance of supporting physicians in this fight, because it is a valuable one. 

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I have to go potty!!!

We were flying to SoCal for my step- brother's wedding. We were late and had to run through the entire terminal. Devin stops 100 feet short of the gate and grabs his crotch: "I have to go potty!" he screams at the top of his lungs. I looked at my watch. The flight was scheduled for 6:20. It was 6:18. I yelled across the terminal: "Run, Devin, Run! You can go potty on the plane!" People began to stare. Devin didn't budge. In the end, we made it. Southwest rocks! they waited for us!

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I'm finishing up here in SoCal, and Lara moved into our new place in Oregon.

The truck took a while to get there, and Devin and Lara had to spend a night on the floor.

Our new place has a beautiful back yard with a creek that backs up to forest.

Devin was so excited when his toys came!

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SLO Days

We went for a walk in downtown SLO - we raced leaves down the creek and fed bread to the ducks. Devin saw some girls using sidewalk chalk, and just walked up and started talking to them. He charmed 'em, and next thing you know, they're all painting a birthday cake!

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How [not] to Intubate

right mainstem

A common mistake - the ETT was 24cm at the lip.  I heard diminished breath sounds on the left, we pulled it back and taped it.  After the CXR came back, we rechecked - it was 28cm at the lip.  No wonder the vent was alarming high pressures.


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New Plates

Here's Devin installing my new plates!


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ED Mnemonics

Here are a few mnemonics I picked up that helped me out...

HAD CLOTS: PERC Rule - Risk factors for PE
Hormone use
Age >50
DVT/PE History
Coughing Blood
Leg Swelling - Unilateral
O2 Sat < 95%
Surgery/Trauma History - Recent

AMPLE: Important history items in trauma patients
Past Medical/Surgical History
Last Meal/Last Menstrual Period

PHAILS: Toxins that cannot be decontaminated with charcoal

DUMB BELSS: Cholinergic Toxidrome

Differentials for Osmolar Gap
Diuretics (Mannitol, Sorbitol)
Ethylene Glycol

MUDPILES: Differentials for Anion Gap Acidosis
INH, Iron
Ethanol, Ethylene Glycol
Salicylates, Starvation, Solvents

Indications for dialysis
Electrolytes (Potassium)
Ingestion (Drugs)
Overload (Fluid)

I STUMBLED: Toxins that can be removed by hemodialysis
Ethylene Glycol

AEIOU TIPS: Differentials for Altered Mental Status
Toxins, Trauma, Tumor
Stroke, Seizure, Shock

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COMLEX II Percentile Table

The three-digit COMLEX score is often difficult to interpret.  This table converts your score to a percentile so you can gauge your performance against that of your peers. This table is based upon the 1995 to present three-digit score with a  mean of 500 and a standard deviation of 83.  Passing score is 400.


Bachelor Chow

I'm in Bakersfield right now, and I thought I'd write about one of my favorite pastimes: cooking.

While most of my bachelor meals consist of microwaved corn dogs dipped in sri racha, I do go on a culinary kick once in a while.  Here's a quick guide to one of my favorite dishes served up bachelor style.


Some posterize art with GIMP

One of my reservations in switching to Linux was Photoshop.  I really like Photoshop and I'm comfortable with it.  In order to get comfortable with GIMP, I decided to do a few little projects.  One of the filters that I really missed from photoshop was anisotropic filtering, but I found a wonderful filter for GIMP called Greycstoration.

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