Medical Elephants in the ER – an ED Doc’s Rant!

There’s no other way to do it, someone needs to mention some of the elephants in the Emergency Room. Why are we afraid to discuss what we think?

Benzodiazepines and Z-drugs like Zopiclone prescribed long term. There isn’t a day goes by that I don’t come across people who have been prescribed Benzodiazepines or Zopiclone as a regular medication for several years. This is iatrogenic addiction; and any therapeutic benefit will have stopped after only a few weeks. The Royal College of Psychiatry recommends less than 4 weeks use, as does the National Institute of Clinical Excellence, who give some excellent advice on how to get iatrogenically addicted patients off these drugs.

Post Traumatic Stress Disorder. Please, stop diagnosing this to everyone who claims they’ve had a traumatic past, and if it’s going to be diagnosed at all, please let it be by a trained psychiatrist and not a therapist using a score sheet, medicine is far more complex than that! While I’m prepared to believe people who witnessed severe horrific events in the past can suffer from this, I’m not convinced by many. People regularly claim stressors like minor car accidents, divorce, and bereavement as the cause. Have you not noticed how the vast majority of people experiencing the same stressors don’t have a problem with PTSD? – There’s likely something else going on in their mad/bad world, and past events are being used as an excuse. Once you make this diagnosis, many will often cling to it like a badge of honour, slide into the sick role, and blame every bad personality trait on it. I believe it’s the ‘victim phenomenon’. True PTSD carries strong public empathy, and anyone suffering severe mental anguish due to real trauma such as seen in wars and disasters are held in high public regard (as they should be) and ‘are‘ real victims. But for others, what better way to not take responsibility for your actions than to seek and adopt this diagnosis, facilitated by the medical profession? “It’s not my fault I drink like a fish, beat my girlfriend, take drugs, and don’t want to work. I was in a car accident when I was 18 and have PTSD!”

Blaming Mad/Bad Behaviour on Head Injury. Exactly the same as above; while I’m prepared to believe significant brain trauma or diffuse brain injuries can cause behavioural problems, I don’t believe many of the diagnosed cases that I see. I once saw a neuro-psychiatrist’s report stating a thirty something year old man’s behavioural problems were likely the result of banging his head on the wall while bouncing on the bed when he was 7 years old, despite not even having to consult a doctor when it happened. Are we facilitating another excuse for people to externalise responsibility for their behaviour?

Prescribing Tramadol and Codeine together. I could write an essay on why not to use Tramadol at all, but of particular frustration is its use with opiates. Tramadol is a synthetic opiate (opioid), and Codeine is an true opiate. They work on similar receptors, but have different side effects. If you give both, you widen the potential side effects with little analgesic benefit (there is some)! Of similar madness is prescribing Codeine and Morphine. Why give a weak opiate and a strong opiate?

Signing people off work for depression and/or anxiety. Have you seen the statistics? The rate of suicide increases significantly once someone with mental health problems dis-engages from work, and their chances of getting back to work decreases. Work is good for mental health, sick notes are injurious.

Stop telling lies to people with Fibromyalgia. This is the one we worry about the most. Fibromyalgia patient groups are militant, and we appear too afraid to say what we think. The recommended treatment for Fibromyalgia is antidepressants and cognitive ‘behavioural’ therapy (CBT), but hey are told they are on special pain medications, and therapy that helps them learn how to cope with the pain. Also, is anyone going to face the elephant in the room; if this is a rheumatological disease, why do patients with fibromyalgia often cry, have multiple claimed drug allergies (that don’t make sense), have had multiple attendances for past problems, use strange non-specific phrases like “trapped nerves, pins-and-needles, and fibro-fog”, often have dizziness, IBS, or tinnitus, and describe other strange bodily sensations which are symptoms commonly seen in hypochondriasis? Are we frightened to say what we really think? If you think this is a rheumatological or neurological condition then fine, but, if you don’t, and you think this is a functional somatic syndrome then stop avoiding the truth as it is likely exacerbating their suffering and reaffirming the cycle of self validation“The suffering of these patients is exacerbated by a self-perpetuating, self-validating cycle in which these common, endemic, somatic symptoms are incorrectly attributed to serious abnormality.” Ann Intern Med. 1999 Jun 1;130(11):910-21. Functional somatic syndromes. Barsky AJ1, Borus JF.

Well, that’s one or two room elephants dealt with, and already I feel lighter. There must be a few more I can’t see; anyone else?

Teddy Marsh

Teddy is a medical author, and is interested in aspects of medical law and legislation. He likes to challenge conventions, and write about the topics that most avoid or simply refuse to acknowledge. In his own words he states he "prefers the simplicity of unpolished honesty no matter how much it irritates"

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