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Cervical procedures and risk

Discussion in 'Pain Medicine' started by emd123, 12.30.11.

  1. Jcm800

    Jcm800

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    No local in cervical, for this reason.

    maybe it was intrathecal, maybe not. But if it was and there was no local, then the just got a prophylactic dose to prevent arachnoditis according to the japanese...

    avoid local.

  2. Jcm800

    Jcm800

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    agree, i always inject slowly, and patients complain a lot less compared to when i see more rapid injections
  3. epidural man

    epidural man ASA Member

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    I vote vagal...I see it all the time in cervical procedures - but whatever.

    I tell my fellows - "only two types of people put local in their interlaminar injections. Military trained, or those that trained over 20 yrs ago."

    The only guys at my place that put local in their interlaminars are those that satisfy that statement. It seems to be the case for others that I have talked to as well.

    No reason to do it. Agree with noble Lobel.
  4. specepic

    specepic

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    I place IV for all cervical cases d/t higher incidence of vagal with a needle in the neck ( is still not very common ime). I have been able to stop a vagal response in its tracks by opening the fluids wide-open. For lumbar, only for sedation cases, although I think ISIS rec's for TFESI?

    one issue that may be a little off topic, is I have frequently seen people on here discuss flipping the patient over when they're having a vagal response, which I do not do. I think their airway is safer prone and if they vomit it's going to the floor rather than in their lungs. now of course, if the patient full on codes or crashes, that is a different story. I discussed this with my anesthesia colleagues and they agree, leave the patient prone and let them recover from the vagal response

    0.02
  5. Tenesma

    Tenesma Senior Member

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    I absolutely turn them supine when they start to vagal, and typically the IVs that are placed are 20 or even 22 gauge - so opening wide open fluid with that gauge IV is not going to resuscitate anybody...

    flip them supine, lift/elevate their legs (works like a miracle) and make them inhale alcohol prep... works like a charm...

    if they aren't sedated, or aren't too sedated, they will protect their airway just as well prone or supine if they vomit - which most of them don't since they just get nauseated (and have an NPO empty belly).

    i think you are taking huge risks by leaving them supine
    1) you can't assess them as well
    2) hard to get a sense of how well they are recovering from the vagal
    3) if you wait long enough and they truly vagal and become unresponsive, it is a LOT harder to flip an unresponsive 250lbs pt than it is to have a fully responsive 250lbs pt flip themselves with your help

    Once a patient has vagaled - and I have determined that it was due to anxiety - I will typically offer to do the procedure in 30 minutes after a bolus of IV fluid and some IV sedation - but due to my crazy schedule, typically they just get rebooked for another day.
  6. brori

    brori

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    Had one--55yo male lumbar facet inj X2, no sedation, 2cc lidocaine for local skin wheal at the two sites--. Alcohol prep inhalation trick worked great (read about it on this forum a few years back, thanks Tenesma), supine then elevated legs, and then started an IV with NS (typically hadn't done IVs for SI joint or lumbar facets)
  7. emd123

    emd123

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    Neurocardiogenic syncope (formerly called vasovagal syncope) requires essentially no treatment whatsoever. Natures response is to drop the blood pressure, which lowers the cerebral perfusion pressure, which promptly causes a patient to faint, which promptly leaves them horizontal, which increases blood flow to the head, which increases cerebral perfusion pressure, which causes them to wake up which ends the episode in seconds or minutes

    Running around the room, sticking IVs in, starting high flow O2, giving crystalloid boluses is all fine and good and it makes everyone feel like they're doing something, but by the time you get your IV, get your bag of fluid, bolus the fluid, start the oxygen, and your saline volume reaches bolus volume, nature has done what it does anyway and your neurocardiogenic (vagal) episode is over. Of course, if you're not sure that what you're seeing is a vagal episode, you go down the resuscitation pathway until certain the episode is benign.

    In my former life, where I had the occasion to suture countless tattooed tough-guys, who frequently would faint at the site of a tiny needle coming at them, you know what we would do when they started to turn white-green, get sweaty and say, "I think I'm going to pass out"?

    You say, "Go ahead, pass out". You lay the patient down, supine, maybe even a little trendelenberg, and you keep on suturing. The treatment of the episode is "head down" and a few minutes of time. The rest is window dressing. People vagal and faint in the outside world all the time and the only harmful thing about it relates to what they're doing when and where they go down. Vagal in the grassy yard on a 73 degree day, you slump softly to the grass, no problem. The supine position itself, ends the episode. A few minutes go by and, by definition, the episode is self limited (prolonged episodes of unconsciousness and hypotension are by definition, not neurocardiogenic syncope). You vagal while taking a swim in the ocean at night: game over.

    Now, I must admit, being in the Interventional Pain world now, it does ratchet the sphincter tone up a few notches when all this occurs during and after a cervical epidural, that's for sure. That's why I think if you're not confident in basic resuscitation situations you shouldn't be sticking needles in peoples spines. You throw a xanax in there before the procedure, maybe the patient takes an extra pain pill beforehand to "take the edge off the shot", throw some volume in the cervical epidural space in a nervous patient, maybe a touch even throw in a touch of local, and it's hard to tell what's vagal and what's not.

    I've been taught, "No local in cervicals" and I don't use any. One guy I know uses a touch but he dilutes it enough that its likely subtherapeutic. For lumbars, okay maybe, but clearly its not the active ingredient and obviously not necessary for anything but giving the patient a sense that they had some immediate relief after the injection, for what that's worth.

    Be careful out there boys.
  8. specepic

    specepic

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    Agree. That is why I leave them prone. Treating a vagal episode aggressively is not an ACLS pathway. As you state, if you are unsure, or they are truly crashing, then treat appropriately.
  9. Tenesma

    Tenesma Senior Member

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    emd123 --- you make a few erroneous assumptions

    1) that when a patient is not feeling well while prone during a procedure: it is necessarily a vagal response. I have had 2 patients with symptomatic bradycardia - one of which I had to trans-cutaneously pace and transport to the ER and ended up needing a pacemaker. I have had one patient who had an MI (we had held plavix for 7 days for a cervical stim trial) on the table, and while he didn't become unresponsive, he acted like a vagal (nausea, clammy, thready pulse).... I have had another patient who (unbeknownst to me was hyper-ventilating) become unresponsive and then started having these weird hand/foot contractures (ended up being severely hypokalemic)... if you do enough procedures you will see a tiny bit of everything.
    2) these patients are already horizontal and are passing out --- so maybe lying horizontal is not enough to reverse a vagal response
    3) vagal responses are not all the same: some times it can extremely transient, in other cases it can last for a while... I had one guy who vagal'ed, we cancelled the procedure, brought him to the recovery area on a stretcher and I couldn't discharge him home for 3 hours, because every time he would sit up he would pass out again (i eventually gave him some ephedrine)...
    4) how does it look legally: guy passes out supine on your table - you just continue doing your procedure - guy remains unresponsive and doesn't do the "automatic emd123 wake-up", how are you going to explain that in court when the RN in the room will testify that you didn't do anything...

    now i will agree that IV fluids is probably not going to do that much - primarily because volume won't be that much through a small gauge needle... on the flip side, if the patient doesn't perk up w/ stimulation, supine/legs elevated, they automatically get an IV.... why? because I am an anesthesiologist - and part of my training is to be ready for plan B, plan C and plan D - instead of waiting for things to spiral out of control...
  10. Tenesma

    Tenesma Senior Member

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    specepic.... come on now...

    Bradycardia (seen in vagal episodes) is actually an ACLS pathway whether they are responsive or unresponsive.... try explaining that in court: stating that my "buddies in the surgeon's lounge said that keeping them prone so they don't inhale their vomit" ain't gonna cut it.

    Why even take the risk of waiting to see what happens?
  11. Pain Applicant1

    Pain Applicant1

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    -Hyperventilation can lead to
    -decreased CO2 can lead to
    -resp alk can lead to
    -acute secondary hypocalcemia can lead to
    -carpopedal spasms (weird hand/foot contractures)


    check calcium and monitor for QTc prolongation
  12. emd123

    emd123

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    I see your point, but I think you're misreading some assumptions into what I wrote:

    1. I never assumed that "when a patient is not feeling well while prone during a procedure: it is necessarily a vagal response".

    Let me be clear: I think Sweetalkr did the right thing in this situation. It sounds like he did a good job responding to this complication, primarily because it wasn't clear at the time whether or not it was a benign vagal episode. Which is why I wrote, "if you're not sure that what you're seeing is a vagal episode, you go down the resuscitation pathway until certain the episode is benign." Which is what Sweetalkr did, correctly so. I think that pretty clearly states that what appears vagal may not always be clear and you go down the resuscitation pathway until certain the episode is benign. And if it doesn't, let me acknowledge, you're right, not everything that appears to be benign/vagal will turn out to be benign and vagal. Especially during a cervical with local.

    But in defense of my post, my post was about vagal episodes. An MI is not a vagal episode. I never said treat ST elevation MIs like vagal episodes. Neither my post nor Sweetalkr's referred to MI's. I know how to treat MI's. That's a whole different thread. Sweetalkr's was about vagal vs. intrathecal injection of ropivicaine/dex.

    Persistent symptomatic bradycardia, is not a vagal episode.

    Also, people that have panic attacks, hyperventilate, blow their CO2 down which can cause carpopedal spasms from transient hypokalemia which is also self limited, and very common. UNLESS, they started out hypokalemic to begin with, then you can have a more prolonged situation, like you had; likely a transient drop in potassium on top of a pre-existing low K+. Of course, we don't routinely do pre-procedure labs, like in the OR, so how would you know?

    2. "these patients are already horizontal and are passing out --- so maybe lying horizontal is not enough to reverse a vagal response"

    You're right, it's not enough, like I said, 2 things are required: "treatment of the episode is 'head down' and a few minutes of time". It takes a few minutes. By definition, if its prolonged, you have a some underlying pathology that's mimicking a neurocardiogenic (vagal) episode. Bradycardic for 30 seconds? Probably vagal. Bradycardic for 15 min requiring transcutneous pacing, atropine and pressors? Not vagal. When you're bringing out the pacer pads, put on the full court press. Loss of consciousness during cervical epidural with Ropi (yikes), may not be "just vagal".

    Again, my post was about vagal episodes, not the entirety what can cause a patient to crash.

    3. "I couldn't discharge him home for 3 hours, because every time he would sit up he would pass out again (i eventually gave him some ephedrine)"

    This is interesting. I would say again, by definition, not a vagal episode if it lasted 3 hr and required ephedrine. It would be interesting if you could get some follow up here and post what they found out during his work up.

    I would suspect there may have been some underlying hypovolemia, anemia, orthostatic hypotension, electrolyte imbalance, occult infection or something else leading to 3 hours of persistent orthostatic symptoms. The procedure may have tipped him over the edge.

    4. "how does it look legally: guy passes out supine on your table - you just continue doing your procedure - guy remains unresponsive and doesn't do the 'automatic emd123 wake-up', how are you going to explain that in court when the RN in the room will testify that you didn't do anything"

    If I witnessed a patient truly having a vagal episode, which I have countless times, I would have no trouble defending myself legally because there would be no lawsuit.

    If an otherwise healthy patient passes out on my table before a procedure, during a panic attack associated with classic hyperventilation and carpalpedal spasms, would I do "nothing"? No. I'd do almost nothing. Like I said, I'd lay the patient down and observe for about 60 seconds. A little sternal rub, and time to start moaning groaning and to wake up. During or after a cervical? Different story. Local given in the cervical (which I don't do), a whole other story.

    The procedure I happened to be referring to was suturing. When people pass out during benign procedures like this, giving blood, etc, its almost always vagal and benign. I acknowledged that in the setting of a cervical epidural things are much different. Like I said,

    "in the Interventional Pain world now, it does ratchet the sphincter tone up a few notches when all this occurs during and after a cervical epidural, that's for sure"

    Let me be clear, I think Sweetalkr did the absolute right thing, like I said:

    "...if you're not sure that what you're seeing is a vagal episode, you go down the resuscitation pathway until certain the episode is benign."

    But, I'll stand by the fact that if someone truly vagals, and you're certain that they only vagaled, yes, you do absolutely (almost) nothing. At the red cross, when people faint at the sight of their own blood, what do the little old lady volunteers do? Lay down, juice, cookies, home in 30 minutes if able to walk across the room without being dizzy.

    Not all of our heroic treatments are benign either. Intubation can lead to aspiration. Pressors can trigger tachycardia and cardiac ischemia in patients prone to it. Being on a vent can lead to nasty hospital acquired pneumonia and sepsis.

    I may be a fellow when it comes to Interventional Pain, but this stuff I know inside and out, in my sleep.
    Last edited: 04.24.12
  13. Jcm800

    Jcm800

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    i used tp use etch wipes for nausea when doing anesthesia, especially OB nausea during C/S
  14. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Try vagaling in the yard down here in Georgia. Down for more than 60 seconds and the fire ants will make you wish you had a high spinal.
  15. emd123

    emd123

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    LoL
  16. SSdoc33

    SSdoc33

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    12,000 shots and counting.

    maybe 300 vagals, if not more. always flipped em, lifted their legs and there has never been a problem. not to say that there couldnt a problem, but just because you CAN resuscitate someone (hello, anesthesiologists out there) doesnt mean you SHOULD. i get the feeling that docs freak out from low heart rates or BPs when the body invariably corrects itself. we are not smarter than evolution, although we'd like to think we are.

    and i get it: low BP and HR etc, could lead to a cardiac problem, etc. i think you are more likely to cause a problem with the intervention (atropine, ephedrine, volume) than you will by letting things take care of themselves.
  17. Jcm800

    Jcm800

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    yeah, well ive done 12,001, and only had like 30-40 vagals, what are you doing to these patients...


  18. Tenesma

    Tenesma Senior Member

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    my point is: I completely disagree w/ the notion of leaving somebody prone during a "presumed" vagal episode (ie: Patient brady's down on the monitor, BP cuff can't get a measurement, pt gets clammy and states: "i don't feel right")... you are absolutely right that most of these self-resolve/correct w/ passage of time, but I ain't going to take that chance while they are prone...
  19. emd123

    emd123

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  20. emd123

    emd123

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    I agree totally. Supine. It's way easier to make a quick assessment of mental status, check carotid pulse, are the eyes open or not, etc.

    Also, quicker to put a nasal trumpet in, start bagging, assess extremities for access sites, and start coding if needed.

    "How the patient looks" is everything. Face down in a pain-table cutout makes that very tough to assess.
  21. powermd

    powermd Lifetime Donor

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    Are your patients NPO before procedures? Definitely seems to be more common in patients with an empty stomach. Sometimes I'll even recommend that someone who seems iffy before the injection have a few cups of water before proceeding.
  22. SSdoc33

    SSdoc33

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    i just threw that 3-400 number out there. dont really know the number maybe once a week or so.

    i dont give instructions to stay NPO. never had anyone barf -- yet. i will say that the ones who tend to do down usually havent eaten anything that day.
  23. bedrock

    bedrock Member

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    I don't make anyone NPO unless an IV sedation case.

    I limit PO intake to light foods and liquids and not within 90 minutes of procedure. That and about 70% of patients are prescribed a modest dose of PO Xanax/Valium to take before their procedure.

    Not starving/dehydrated and having a little benzo in your system will eliminate 90% of the vagal episodes.
  24. Jcm800

    Jcm800

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    damn skippy. all that vagal, i ask, "did you eat anything"
    "No i wasn't sure if i was suppose to or not..."
    "didn't we tell you NOT TO FAST, and eat something light for breakfast?"
    "Oh yeah, that might have helped"

    no sheet...
  25. Jcm800

    Jcm800

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    joking....
  26. emd123

    emd123

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    You're not by chance, telling them to eat gluten before all of your procedures, are you?:laugh:
  27. specepic

    specepic

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    I agree that is they are tanking objectively and subjectively you do not fool around. I have had 2 vagals in 2 years and it was young healthy pts who felt crappy (clammy/nausea) but had very acceptable VS. I stopped the case and talked to them and they perked up. I also open up the IVF on pts who look 'pre-vagal' before starting the case (wide eyed and pale coming in the room) and that seems to help.

    I am not advocating for prone assessment of a worsening situation.
  28. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    Stop sticking needles into men under 60 and you'll virtually eliminate all your vasovagals.
  29. Tenesma

    Tenesma Senior Member

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    interesting re NPO recommendations...

    all of my patients who have to lay prone definitely have to be NPO and any of my anxious patients who are not going to be prone also have to be NPO prior to the procedure...

    after having had to clear the smell of gastric contents in the procedure room a few times during fellowship and early in training - my policy is NPO - and so far, in the last 6 years, I haven't had ANYBODY puke up ANYTHING...
  30. pmrmd

    pmrmd

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    Are you seriously saying you demand someone be NPO for something like thoracic or lumbar facets? For how long?
  31. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

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    I've had one guy vomit in the past several years. He throws up each time we inject him, purely out of anxiety. With the Oakworks positioner, we just put the garbage under his face.
  32. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    4-5 over the last 6 years. Either pre-op or post-op. Never during procedures. My patients are courteous.
  33. drf

    drf New Member

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    I do NPO as well. Most of my pts could use 6 hours of not fattening up anyways.

    That stated, if someone forgets or has some toast, i generally do the case anyways.
  34. powermd

    powermd Lifetime Donor

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    Wow.. that's a strict policy. You make them NPO for a lumbar epidural? I guess I've been lucky so far in 3 years of practice. I had one guy retch a bunch of times over a trash can, but that's it. Thoracic epidural where I scraped the bone a few times trying to get access (unsuccessfully).

    I had one patient literally pass out in a seated position for a carpal tunnel injection. Pretty tough to get the legs up when they're slumping in a chair. Thankfully she woke with some slapping around as I summoned my staff.
  35. lobelsteve

    lobelsteve www.stevenlobel.com Lifetime Donor

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    Had a vagal guy ( he reports he passes out when he gets any shot) injected by the fellow in his first few weeks. Nice easy knee injection, seated in exam room. I gave it away and shouldn't have told the fellow what was going to happen. But it was a good review/exercise for a young pain doc...

    Ammonia salts, ice pack, lie down, recover.
  36. bedrock

    bedrock Member

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    Funny, That's what my former partner used to say.

    He was an anesthesiologist, and not to stereotype but I think the pain docs who went through an anesthesia residency are so conditioned to simply make every patient NPO for everything, that you don't consider if it's really necessary for bread and butter pain procedures with local or local/+ PO benzo.

    Patients really appreciate not being hungry and I think they tolerate procedures much better with a very light bit of food and water (but not within 2 hours of the procedure). They're more comfortable and it cuts down on vagal responses as well.

    Never had one patient even come close to vomiting-
  37. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    Agree 100% with this and above comments. Vagal response. Maybe panic attack. You are trying to be kind to the patient by using the local I'm sure, but it can cause issues as above.

    One tip for your population: it seems that contact with the ligamentum flavum triggers a lot of these vagal responses. Now, I put a couple drops of 1% when I am DORSAL to the ligamentum flavum before penetrating it on CLO view. It anecdotally decreases the vagal responses. Was talking with Dreyfuss about this and he does the same if I recall correctly.
  38. Ligament

    Ligament Interventional Pain Management SDN Advisor

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    I agree, but once I did have an ICU RN patient, did a ILCESIL, and she got off the table with chest pain. Had an acute MI on the table...sent to ER.
  39. emd123

    emd123

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    If you're sitting on a compensated coronary stenosis (80% coronary stenosis with colaterals), insert physiologic stressor + anxiety and shablamo! acute MI in progress.
    Last edited: 04.28.12
  40. 101N

    101N

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    So, after years of doing this, if they pass out I automatically shock them. If it was a vagal episode (99.999% of the time) they wake up pissed, but alive. But, if they are an acute coronary syndrome, I've done my best to save their life.
    Paddle burns, it comes with the territory:)
  41. Tenesma

    Tenesma Senior Member

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    I agree that my NPO policy is strict... and way overboard reaction to having had patients vomit early in my career... but since i haven't had one patient vomit since the policy makes me think I made the right decision - do you know how hard it is to get the smell of gastric contents to dissipate before the next patient comes in?
  42. powermd

    powermd Lifetime Donor

    Joined:
    03.30.03
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    Location:
    Northeast
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    Attending Physician
    Physician SDN 10+ Year Member
    Harder than getting the smell of stale smoke to dissipate from my office between patients?
  43. emd123

    emd123

    Joined:
    02.25.10
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    Attending Physician
    SDN 2+ Year Member
    Why don't you just get a taser gun? It would be way more effective for what your doing. And more entertaining. LOL.
  44. facets

    facets

    Joined:
    11.08.09
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    Location:
    arizona
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    Attending Physician
    SDN 2+ Year Member
    Try smelling salts (amononium ( Sp) pellets) they come in a capsule that you crush. I have one taped to the light switch so everyone knows where it is. Grab it and crush it under their nose, unless they have dropped dead, they will wake up.
  45. Pain Applicant1

    Pain Applicant1

    Joined:
    05.26.10
    Messages:
    595
    SDN 2+ Year Member
    Take this man's advice. I did and it works. Everyone knows where to grab the salts and it does perk up the patient, as well as everyone else.
  46. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor

    Joined:
    10.01.07
    Messages:
    4,185
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    Attending Physician
    SDN 5+ Year Member
    It also makes a good conversation piece when patients ask what that is taped above the exam table. An MOA started doing that for me, and we continue it.

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