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A View of the Epidemic: At the ER, New Complexities

  • Thomas Trimarco, director of emergency medical services at Dartmouth-Hitchcock Medical Center, speaks with Capt. Jim Wheatley at the Lebanon Fire Department in Lebanon, N.H., on Aug. 16, 2017. As part of his duties, Trimarco oversees and visits 27 area departments to assist with emergency medical training. "I'm really there because I want to be a resource for them," he said. (Valley News - Geoff Hansen) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Thomas Trimarco, the EMS Medical Director at Dartmouth-Hitchcock Medical Center, makes weekly visits to firehouses and also responds to calls once or twice a week as part of his duties. (Valley News - Geoff Hansen) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.



Valley News Staff Writer
Saturday, August 26, 2017

Lebanon — It’s hard to imagine someone more directly involved in the opioid epidemic through his work than Thomas Trimarco. He’s an emergency medicine physician at Dartmouth-Hitchcock Medical Center, where he’s worked since 2012.

Emergency rooms, of course, in some ways serve as one of the front lines in dealing with fallout from the epidemic. It’s where opioid users are taken when they’ve overdosed. It’s also a place where users might go to feign a condition in the hope of securing narcotics.

Dartmouth-Hitchcock officials couldn’t readily produce statistics on the number of opioid-related cases it handles in the emergency room, but Trimarco, 37, has no doubt it has increased substantially in the number of people he sees with serious, chronic conditions resulting from intravenous drug use, such as infections of the spine, heart and brain.

“Those can lead to significant problems that can’t necessarily be taken care of at the smaller, community hospitals,” said Trimarco, who also serves as medical director for 27 local emergency medical service agencies. “So, we’ve seen a significant increase in the amount of patients who are being transferred from (other) hospitals that are ending up in our emergency department and in our facility with these more serious, long-term complications.”

Such cases were once relatively uncommon, but “the amount that we’re seeing now is very significant. Instead of kind of an interesting, once-in-a-while case, it’s a pretty common case these days.”

While some patients come to the emergency room seeking drugs to feed their habit, Trimarco said DHMC has not seen an increase in such patients recently.

“I don’t think we’re known as a candy shop,” he said.

Because drug seekers often come in complaining of pain-related conditions, such as those that are commonly treated with opioids, it can sometimes be difficult for providers to determine whether a patient is seeking drugs to feed a habit or is in need of medication to treat an acute medical need, he said.

“We like to think the best of patients and surely we will give them the benefit of the doubt,” Trimarco said.

His job though is to evaluate a patient to determine what their medical need might be.

“Once we’ve eliminated the acute medical issue that might be going on other than the substance abuse ... We try to be upfront and honest about our ability to prescribe (opioids) for chronic pain issues out of the emergency department,” he said.

There are times when Trimarco has to speak firmly and bluntly with patients who just want to feed their habit.

“Most of the time the overall interaction is reasonable and goes well,” he said. But, “patients can get upset and angry when they are looking for what they think they need or deserve in coming into the emergency room.”

In some cases, patients may become violent, Trimarco said.

Trimarco was assaulted twice while working in an emergency room in Cincinnati, prior to coming to DHMC. In one instance, he was punched in the face, in the other he suffered a broken rib. Though both assaults predated the opioid epidemic, they did involve substance use, he said.

“Violence against health-care providers is a problem throughout this system and the nation,” he said. “It’s certainly complicated and, perhaps, increased by the opioid epidemic that we’re seeing. We are seeing more instances of risk to providers both in the ED as well as in the hospital over the last couple of years.”

Health care providers face another danger as a result of the epidemic: toxic substances. Even a trace amount of fentanyl or carfentinal — narcotics frequently used by addicts — could cause a fatal overdose. Such substances may lurk on patients’ clothing or belongings when they arrive in the emergency room or when emergency medical personnel arrive on a scene, Trimarco said.

“No longer can we just kind of dive in and start treating that patient,” he said.

If providers suspect patients may have toxic substances on them, they may need to remove and bag their clothing, or take a shower, Trimarco said.

He and the emergency room staff have to deal with overdoses and medical conditions related to intravenous drug use, but the epidemic has also forced him to question whether the standard emergency-room approach is adequate to the task.

“As emergency physicians, we’re really trained to diagnose and to stabilize the acute medical problem that’s in front of us, and once that stabilization is achieved we’re able to hopefully pass that patient along to another provider that would specialize in the longer term care of whatever the ailment, injury or illness is,” Trimarco said.

“What we’ve recognized, though, is the exposure that we have to a patient in the emergency department is sometimes the only chance that the health care system has to access these patients and to offer them this support that they may be in need of.”

Shifting to addressing patients’ longer-term needs, however, has come at a cost. What might previously have been a one- or two-hour visit can sometimes last much longer, which can mean longer waits for other patients, he said.

“It does have significant downstream effects for all of the other patients in the community who are coming in for emergency care, but these patients are as important as all of our other patients and we still prioritize them and all of our patients according to severity,” said Trimarco.

Providers approach those struggling with substance abuse differently than they did in the past, Trimarco said.

“I think we all do a little bit of a better job of recognizing the significant struggle that our patients are having dealing with substance abuse these days,” he said. “I think the patients are less stigmatized than they have been in the past, perhaps.”

In some cases, health-care providers also struggle with substance abuse.

“Before coming to D-H, I worked at a hospital and we had a young, tremendously talented nurse in our emergency department that died of an overdose, and so I don’t think anybody is immune to this epidemic,” he said. “You see it in many different ways, both when you’re working clinically and ... it certainly spills over to our personal side as well.”

“It’s a privilege to be able to see and treat patients in some of the worst times of their (lives), but at the same time that can take a toll on you and you certainly need to find a way to appropriately and positively deal with those stresses to be able to continue to do your job and serve the patients that we try to serve,” Trimarco said.

“Sometimes you just need a little bit of a breather,” he said. “A lot of times the issues that we see just constantly remind us of the blessings and the amazing things in our own lives.”

Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.

Clarification

Dartmouth-Hitchcock Medical Center offered a peer-recovery coaching program for people struggling with addiction through the emergency department earlier this year, but due to funding issues the program was discontinued. An earlier version of this story, which was based on an interview with Dr. Thomas Trimarco conducted before the program was ended, failed to update its status.