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A View of the Epidemic: At the ER, New Complexities – Valley News

Lebanon Its hard to imagine someone more directly involved in the opioid epidemic through his work than Thomas Trimarco. Hes an emergency medicine physician at Dartmouth-Hitchcock Medical Center, where hes worked since 2012.

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

Dartmouth-Hitchcock officials couldnt 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 cant 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, weve 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 were seeing now is very significant. Instead of kind of an interesting, once-in-a-while case, its 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 dont think were 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 weve 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. Its certainly complicated and, perhaps, increased by the opioid epidemic that were 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, were really trained to diagnose and to stabilize the acute medical problem thats in front of us, and once that stabilization is achieved were 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 weve 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.

Aiming to break the cycle of addiction, emergency-room staff have started a peer-recovery coaching program.

We will identify patients who may benefit from this program and well call in a recovery coach to spend some time with that patient and offer some support to that patient, both for their current emergency department visit as well as, hopefully, going forward as they try to deal with the long-term addiction that theyre struggling with, he said.

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 dont think anybody is immune to this epidemic, he said. You see it in many different ways, both when youre working clinically and … it certainly spills over to our personal side as well.

Its 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 or 603-727-3213.

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A View of the Epidemic: At the ER, New Complexities – Valley News