tPA for cardiac arrest

rxfudd said:

So I had a painfully sad case tonight of a 26 year old girl who came in with full cardiopulmonary arrest. Healthy, last seen completely normal by her boyfriend a few minutes before she went to sleep. He heard her gasping for air and went into the bedroom to find her unresponsive and cyanotic in her bed.

Time to EMS was about 10 minutes, she was in vfib and was shocked into asystole. She was in asystole in the ER (down time now about 25 minutes), but converted to vfib after 1 round epi/atropine. We shocked two more times and gave 2 more rounds of drugs (plus amio and bicarb), still in vfib.

We get a history from EMS that she was on OCPs and a smoker. At this point, down time is about 45 minutes. We decide we should try tPA as a last ditch effort, and both myself and the attending were surprised to find out we don't have it in the Pyxis. Pharmacy says it will take 10 minutes to prepare it. After deciding that she her meaningful recovery after one hour of downtime was about zero, we shocked once more and then called it.

Odds are that she would have had no meaningful recovery even if we had given tPA and it had worked. But I find it very difficult to understand why we didn't have it ready to go in the ER. It's one of those drugs where, when you really need it, you need it now.

How many of you know for certain that you have it in your ER? Ever used it in a code? Ever see it work (i.e. walking, talking, and functioning)? It seems to me this should be stocked in every crash cart...

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Same thing at the ER I work in. I have seen it used in a code only once no change in patients outcome.

We have it in our ED (which is at a stroke center). I pushed it yesterday for a stroke. Took about a minute or two to draw up.

I've heard anecdotal evidence of it working in oatients who went from dyspneic to PEA in front of the staff's eyes, but never in a patient who came in without a pulse.

One of the contraindications of TPA is chest compressions >10 minutes.

There are a couple case reports that report successful thrombolysis and resuscitation, but most of those were not neurologically intact. One of the EMS agencies in my area did a study about ten years ago and found no improvement in outcome. The study was halted because of insufficient funding and failure to demonstrate improvement in survival (further funding was dependent on showing a trend of survival).

Most ED's do not stock TPA.

I'm from the pharmacy (although on the ED rotation now) and we stock tPA in our resus room for stroke patients.

It's recombinant so it can't be sent in the tube system/has to be hand delivered so it's often difficult to get it down to the ED in a truly STAT manner. I think that's why we have at least 150mg in the accudose at all times, and a pharmacist down there who can mix it from 1500-0130.

They used it yesterday in a stroke patient who was pretty hesitant - within 10 minutes he was a new man, it was pretty impressive.

njac said:

I'm from the pharmacy (although on the ED rotation now) and we stock tPA in our resus room for stroke patients.

It's recombinant so it can't be sent in the tube system/has to be hand delivered so it's often difficult to get it down to the ED in a truly STAT manner. I think that's why we have at least 150mg in the accudose at all times, and a pharmacist down there who can mix it from 1500-0130.

They used it yesterday in a stroke patient who was pretty hesitant - within 10 minutes he was a new man, it was pretty impressive.

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Land of Entrapment, eh? I think we're talking about the same patient.

The odds are good that if the PE is massive enough to cause cardiac arrest, it probably won't resolve with TPA. Blood flow probably isn't sufficient with just chet compressions to circulate the TPA and provide enough shear force to break up the clot.

southerndoc said:

One of the contraindications of TPA is chest compressions >10 minutes.

There are a couple case reports that report successful thrombolysis and resuscitation, but most of those were not neurologically intact. One of the EMS agencies in my area did a study about ten years ago and found no improvement in outcome. The study was halted because of insufficient funding and failure to demonstrate improvement in survival (further funding was dependent on showing a trend of survival).

Most ED's do not stock TPA.

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WilcoWorld said:

Land of Entrapment, eh? I think we're talking about the same patient.

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That was pretty impressive.

A couple months ago (when our last batch of residents was still here) we had a patient with a presumed PE - chest pain on long drive, I think there was a clot seen on the TTE. They started a tPA drip while he was worried but talking and walking. A couple hours later I happened to be in the MICU where he was coding. So n=1, but it wasn't effective.

rxfudd said:

So I had a painfully sad case tonight of a 26 year old girl who came in with full cardiopulmonary arrest. Healthy, last seen completely normal by her boyfriend a few minutes before she went to sleep. He heard her gasping for air and went into the bedroom to find her unresponsive and cyanotic in her bed.

Time to EMS was about 10 minutes, she was in vfib and was shocked into asystole. She was in asystole in the ER (down time now about 25 minutes), but converted to vfib after 1 round epi/atropine. We shocked two more times and gave 2 more rounds of drugs (plus amio and bicarb), still in vfib.

We get a history from EMS that she was on OCPs and a smoker. At this point, down time is about 45 minutes. We decide we should try tPA as a last ditch effort, and both myself and the attending were surprised to find out we don't have it in the Pyxis. Pharmacy says it will take 10 minutes to prepare it. After deciding that she her meaningful recovery after one hour of downtime was about zero, we shocked once more and then called it.

Odds are that she would have had no meaningful recovery even if we had given tPA and it had worked. But I find it very difficult to understand why we didn't have it ready to go in the ER. It's one of those drugs where, when you really need it, you need it now.

How many of you know for certain that you have it in your ER? Ever used it in a code? Ever see it work (i.e. ultimately walking, talking, and functioning)? I know that the evidence is lacking for it's use in suspected massive PE, but it seems to me this should be stocked in a crash cart...

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If your downtime was already 45 minutes, I'm not sure that any intervention at that point would have made the difference in a meaningful recovery.

As a related question, how much 'down time' is required before people start thinking about calling the code? It will probably depend on age and circumstances, but does anyone have a general rule?

Personally, if a patient has >10 continuous minutes of a non-perfusing rhythm, then I am thinking about calling it. In a 26 year old, I'll probably go longer and try some additional interventions. Even if the patient doesn't ultimately survive, some end up being organ donors. On the other hand, an 86 year old, I'll probably call it early.

What's the word out there?

Severe dementia or terminal illness (like lung cancer) usually 2 rounds epi/atropine then call it.

80+ with no severe comorbidities 10 minutes (in addition to EMS)

60+ with no severe comorbidities 30 minutes

<60 up to an hour depending on the clinical circumstances.

I actually saw one approx 40 year old brought in by EMS who had actual lividity. We halted all efforts immediately.

rxfudd said:

So I had a painfully sad case tonight of a 26 year old girl who came in with full cardiopulmonary arrest. Healthy, last seen completely normal by her boyfriend a few minutes before she went to sleep. He heard her gasping for air and went into the bedroom to find her unresponsive and cyanotic in her bed.

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Did you get the autopsy results yet? Maybe he just saw agonal breathing?

rxfudd said:

Probably early next week

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Let us know the results, if you can. At any rate, I'm sorry to hear about how it turned out.

I have given tpa in situations like this before. Its a last ditch but what else are you going to do?
haven't had one of those impressive cardiac arrest stories yet with tpa.

I have been fortunate that the places I have worked, I have had tpa.
chest compressions are a relative contraindication, and again, I have given it several times because the situation was dramatic (close to yours) and its hard to just give up wihtout trying.

The data is poor. Its kind of like cracking a chest. IF it works, its nice and dramatic and impressive. If it doesn't (which it rarely does), you still feel like you could have done SOMETHING even though you did 'everything'.

Sorry to hear such a sad case.

roja said:

I have given tpa in situations like this before. Its a last ditch but what else are you going to do?
haven't had one of those impressive cardiac arrest stories yet with tpa.

I have been fortunate that the places I have worked, I have had tpa.
chest compressions are a relative contraindication, and again, I have given it several times because the situation was dramatic (close to yours) and its hard to just give up wihtout trying.

The data is poor. Its kind of like cracking a chest. IF it works, its nice and dramatic and impressive. If it doesn't (which it rarely does), you still feel like you could have done SOMETHING even though you did 'everything'.

Sorry to hear such a sad case.

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I'm against it unless there is clear evidence of it providing benefit. It's a drug that is horrendously expensive, and is "wasted" in the full arrest scenario without clear evidence of AMI as the causative event.

GeneralVeers said:

I'm against it unless there is clear evidence of it providing benefit. It's a drug that is horrendously expensive, and is "wasted" in the full arrest scenario without clear evidence of AMI as the causative event.

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I agree that it's a pretty expensive drug to try without good reason. But I think that we're talking about treating PEA presumed to be due to PE, rather than treating AMI with tPA (not that that's clearly beneficial).

While we're on the topic of throwing the kitchen sink at codes, does anyone have much experience with using Glucagon in codes in patients on beta blockers?

GeneralVeers said:

I'm against it unless there is clear evidence of it providing benefit. It's a drug that is horrendously expensive, and is "wasted" in the full arrest scenario without clear evidence of AMI as the causative event.

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I tend to agree. But young people or people who start talking to you after a vfib arrest and then arrest again... those rare really impressive cases where you do feel like you need to give it everything.

I hate kitchen sinks. But sometimes I think its worth a try.

WilcoWorld said:

I agree that it's a pretty expensive drug to try without good reason. But I think that we're talking about treating PEA presumed to be due to PE, rather than treating AMI with tPA (not that that's clearly beneficial).

While we're on the topic of throwing the kitchen sink at codes, does anyone have much experience with using Glucagon in codes in patients on beta blockers?

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we gave it to an angioedema patient (allergic rxn to something unknown at that time) before we gave her epi last night.

Had a case in residency where we had an ICU patient with an echo proven clot dangling out there dangerously close. (I don't remember exactly where it was, but it wouldn't have taken much to create a saddle situation, and she was so stinking sick that no one would do anything about it.) The sign-out plan that night was if she went into PEA to push 100 of TPA and pray. We learned that the pharmacy could have it to her bedside in about 8-10 minutes if we called right when we needed it.

Not ideal, but she was a disaster in progress and it was our planned last hurrah. We didn't need to use it.

dchristismi said:

Had a case in residency where we had an ICU patient with an echo proven clot dangling out there dangerously close. (I don't remember exactly where it was, but it wouldn't have taken much to create a saddle situation, and she was so stinking sick that no one would do anything about it.) The sign-out plan that night was if she went into PEA to push 100 of TPA and pray. We learned that the pharmacy could have it to her bedside in about 8-10 minutes if we called right when we needed it.

Not ideal, but she was a disaster in progress and it was our planned last hurrah. We didn't need to use it.

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In a situation like this, why wouldn't you administer TPA before the patient coded?

There are a lot of emergency physicians and intensivists who are against administering thrombolytics to PE patients. If there is a significant clot burden (saddle embolus, multiple large PE's) with evidence for right ventricular strain, then the patient should receive thrombolytics. Some physicians will only administer thrombolytics when there is hypotension or hypoxemia present, but patients with significant clot burden have a poor quality of life in the long-term because of right ventricular dysfunction due to secondary pulmonary hypertension.

A patient that's in his or her 20's or 30's and has a large clot burden should receive thrombolytics to prevent disability. If you don't, then 10 years later these patients will find themselves unable to walk across a room without severe dyspnea.

WilcoWorld said:

While we're on the topic of throwing the kitchen sink at codes, does anyone have much experience with using Glucagon in codes in patients on beta blockers?

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Would that be beneficial? I thought epi was given for codes more for its alpha effects than for beta effects. I don't think glucagon will cause alpha effects as it increases cAMP levels, and alpha receptors work on IP3, Calcium, and DAG levels.

southerndoc said:

In a situation like this, why wouldn't you administer TPA before the patient coded?

There are a lot of emergency physicians and intensivists who are against administering thrombolytics to PE patients. If there is a significant clot burden (saddle embolus, multiple large PE's) with evidence for right ventricular strain, then the patient should receive thrombolytics. Some physicians will only administer thrombolytics when there is hypotension or hypoxemia present, but patients with significant clot burden have a poor quality of life in the long-term because of right ventricular dysfunction due to secondary pulmonary hypertension.

A patient that's in his or her 20's or 30's and has a large clot burden should receive thrombolytics to prevent disability. If you don't, then 10 years later these patients will find themselves unable to walk across a room without severe dyspnea.

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What evidence do you have that tPA is beneficial in submassive PE (+ Echo findings, but without hemodynamic instability or hypoxia)? The only RCT I am aware of is the one by Goldhaber and that had no mortality or other clinically significant benefit. And that's not to mention some serious methodologic concerns I have with it.

This particular ICU patient (who initially presented in florid DIC) was 3 months into a very long course of vanc-intermediate-resistant endocarditis, and had showered septic emboli everywhere, including her brain. Anticoagulation was something we were trying to avoid for this reason... TPA being only a last-last-ditch effort. She spent 5 months at death's door, but somehow they managed to pull her through it. Well, last I heard.

WilcoWorld said:

What evidence do you have that tPA is beneficial in submassive PE (+ Echo findings, but without hemodynamic instability or hypoxia)? The only RCT I am aware of is the one by Goldhaber and that had no mortality or other clinically significant benefit. And that's not to mention some serious methodologic concerns I have with it.

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I'm guessing the same amount of evidence as administering TPA or glucagon in codes.

At any rate, you should take a look at the work done by Konstantinidis (however you spell it). Published in NEJM a while ago -- 2000 or so. Study wasn't powered to assess mortality, but it did show significant reductions in needs for intubation, progression of hypoxemia, etc.

I suspect this will be the new stroke dilemma. Patients who have PE and don't receive TPA and who subsequently develop pulmonary hypertension with reduced exercise tolerance will be suing EM physicians just like stroke patients who do not receive TPA are suing. Disagree all you want, but it's likely that lawyers will latch onto the idea. Gotta love our society.

southerndoc said:

I'm guessing the same amount of evidence as administering TPA or glucagon in codes.

At any rate, you should take a look at the work done by Konstantinidis (however you spell it). Published in NEJM a while ago -- 2000 or so. Study wasn't powered to assess mortality, but it did show significant reductions in needs for intubation, progression of hypoxemia, etc.

I suspect this will be the new stroke dilemma. Patients who have PE and don't receive TPA and who subsequently develop pulmonary hypertension with reduced exercise tolerance will be suing EM physicians just like stroke patients who do not receive TPA are suing. Disagree all you want, but it's likely that lawyers will latch onto the idea. Gotta love our society.

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Just to be clear I was not advocating glucagon - I was asking what people's experience was.

But the article by Konstantinides that you are referring to was the one I mentioned (Goldhaber wrote an editorial, not the article - mia culpa). That study was:
a) Underpowered to detect intracranial hemorrhage (which any study on tPA must consider) and thus likely underestimated mortality in the treatment arm.
b) The benefit showed was a combined outcome. It was a decreased rate of "escalation of therapy" which you described as "intubation, progression of hypoxemia, etc". Intubations, pressors, mortality - none of those added up to a benefit in that study. The statistically significant benefit was in the "etc" group, and that was for secondary thrombolysis. So what this is saying is that if you don't give tPA for PE, then someone might later decide to give you tPA for PE. That's not a benefit! The treatment arm wasn't doing any better, they simply had already gotten tPA, so when they continued to not do well that "escalation of therapy" wasn't available to them so they didn't get it.
c) If you'll notice, the group who didn't get tPA initially got tPA if they didn't improve. Thus the people deciding who needed this "escalation of therapy" knew who was treatment & who was control. This raises serious questions about blinding.

That study was crap, it didn't convince me at all.

As for the fear of being sued; There is a big difference between this unproven, not standard of care measure and thrombolysis in stroke, which, in addidtion to having a lot of supporting data, is standard of care.

WilcoWorld said:

As for the fear of being sued; There is a big difference between this unproven, not standard of care measure and thrombolysis in stroke, which, in addidtion to having a lot of supporting data, is standard of care.

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Many physicians view the evidence supporting TPA in stroke the same way you view evidence supporting TPA in PE. Each has its own design problems and limitations.

Give it time and you'll see that TPA in PE will become a standard of care. If it's not the standard of care in 10 years, then come back here, dig up this thread, and say "I told you so!"

I gave TPA to a 35 min PEA arrest. The patient walked out of the hospital (she had b/l saddle PE which was suspected based on our bedside ED echo). Her pulse was in and out from the start of the code and was given excellent compressions.

I told the family that I could retire happily. She sent us chocolates for Christmas with the most to the point note, "To the ER staff, thank you for saving my life".

Consider it in PEA codes. GIVE it in PEA codes with a large RV, it will likely make a passage in the clot if it's a PE. ICU study of pt's with known PE that go into PEA arrest had 50% survival.

If someone arrives in asystole it won't work, but I don't think you'll be faulted for trying. We do carry TPA in our PIXIS an do give early in codes, has worked a few times for PE's, but none so dramatic as the above case.

southerndoc said:

One of the contraindications of TPA is chest compressions >10 minutes.

There are a couple case reports that report successful thrombolysis and resuscitation, but most of those were not neurologically intact. One of the EMS agencies in my area did a study about ten years ago and found no improvement in outcome. The study was halted because of insufficient funding and failure to demonstrate improvement in survival (further funding was dependent on showing a trend of survival).

Most ED's do not stock TPA.

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We certainly stock TNK. You should have a clot box in the ED unless you have 24/7 hour cath lab coverage rapidly available and you've made a decision not to lyse strokes. I recently had a woman with RV and Inf MI arrest and CPR in field. Had several rhythms (VF, VT, 3rd degree block) and intermitent CPR in ED, then into PEA. Was trying to get her to the cath lab, but they had to come in. Gave TNK, she came back a little, got to the lab, found to have recanalized her RCA, got a stent, IABP for two days and walked out five days after admission. Total CPR time almost an hour. I was stunned.

BKN said:

We certainly stock TNK. You should have a clot box in the ED unless you have 24/7 hour cath lab coverage rapidly available and you've made a decision not to lyse strokes. I recently had a woman with RV and Inf MI arrest and CPR in field. Had several rhythms (VF, VT, 3rd degree block) and intermitent CPR in ED, then into PEA. Was trying to get her to the cath lab, but they had to come in. Gave TNK, she came back a little, got to the lab, found to have recanalized her RCA, got a stent, IABP for two days and walked out five days after admission. Total CPR time almost an hour. I was stunned.

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Wow....was therapeutic hypothermia involved in the post-arrest resuscitation?

leviathan said:

Wow....was therapeutic hypothermia involved in the post-arrest resuscitation?

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no.

njac said:

I'm from the pharmacy (although on the ED rotation now) and we stock tPA in our resus room for stroke patients.

It's recombinant so it can't be sent in the tube system/has to be hand delivered so it's often difficult to get it down to the ED in a truly STAT manner. I think that's why we have at least 150mg in the accudose at all times, and a pharmacist down there who can mix it from 1500-0130.

They used it yesterday in a stroke patient who was pretty hesitant - within 10 minutes he was a new man, it was pretty impressive.

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Or the patient could have just had a TIA.

napster said:

Or the patient could have just had a TIA.

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That was briefly discussed in this thread a few months ago. It's not a black and white clearly cut issue (at least in my own anecdotal, individual, non-RCT experience).

I gave tPA a couple of months ago to a young (38yo) woman with multiple PE risk factors, clearly hypoxic, who arrested in front of me on the EMS stretcher. After two unsuccessful cycles we pushed tPA (it is in our Pyxis) and got ROSC, started heparin, but she re-coded upstairs in the ICU and efforts were terminated at the request of the family.

I agree with previous posters that the amount of time before "calling it" is variable and depends on age, morbidity, circumstances, length of quality CPR. My outer limit is generally 30 minutes of continuous coding.

Young female p/w cardiac arrest. Tpa given then prolonged CPR. Survived without neuro deficits.

N=1

Dr.McNinja said:

Had a diagnosed PE that arrested, gave tPA. They basically bled out their blood volume from everything after the bolus. Frothy blood in the ETT, pouring out of their nose, their eyes. Lived to the ICU to basically die there from acidosis.

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-1

pinipig523 said:

Young female p/w cardiac arrest. Tpa given then prolonged CPR. Survived without neuro deficits.

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+1

= 0. So, back to even. What can you do? If you're coding the patient, can you make it worse?

(Although I did notice the necrobump, but forgot to mention it. That happens when you get old.)

Apollyon said:

-1
+1
= 0. So, back to even. What can you do? If you're coding the patient, can you make it worse?

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Sure, by billing the widow/government/insurance for an expensive medication in a futile resuscitation to increase everyone's healthcare costs.

xaelia said:

Sure, by billing the widow/government/insurance for an expensive medication in a futile resuscitation to increase everyone's healthcare costs.

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It's definitely a sliding scale. If they look reasonably healthy and I saw them arrest then I go until I can't get them out of asystole, or until their pulse goes away as soon as they're not getting epi boluses. Out of hospital cardiac arrest I usually work for a round and then call it. But that's partly due to our EMS system, where massively prolonged field times are the norm. Last patient in cardiac arrest that came in had an arrest to scene arrival of 5 minutes , and was brought to the ED after being worked for almost an hour.

In residency, we did have a young healthy woman that arrested while on the scanner (which showed occlusive saddle embolus). Got tPa and CPR and came back, but the CPR had cracked her ribs and ended up causing a splenic lac which started her dropping her pressure. Our surgeon (who balls had to be carried in a wheelbarrow, as my attending put it) took her to the OR, removed the spleen, and she walked out of the hospital neuro intact in 3 days.

xaelia said:

Sure, by billing the widow/government/insurance for an expensive medication in a futile resuscitation to increase everyone's healthcare costs.

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"Lies, damn lies, and statistics" - I've never done it, but, in selected cases, it (anecdotally) seems to work, which, ipso facto, makes it not futile.

It's one thing to give a slug of t-PA to a cancer-ridden 60 y/o in arrest, who then has blood coming out the ass, ears, eyes, and the fingernails, but, for a 30 y/o otherwise should not be dead female - anecdote is that I'll consider it.

In the grand scheme of things, if you think the $3000 or whatever (as it was $2000/dose in 2006) is breaking the system, then you don't do it. As of now, no one is going to hold you responsible, and, if you can say to yourself that night, before you go to bed, that you did everything you could, and you saved someone or some organization a few thousand dollars, and the patient was dead anyways, and that you were cost-effective and not going for that last gasp, possible miracle, and you're OK with that, then you're good.

Eh, had a 40s year old dissection with ~T6 paralysis last night that I was certain was going to die. CT surgery at bedside knew his dissection was non-survivable. And then the patient proved us right by coding...but had ROSC after one round of CPR and epi - so we did a pericardiocentesis for the tamponade from hemopericardium - and then had relatively stable VS on phenylephrine and esmolol for almost an hour. So we sent him to the ICU.

And then coded in the elevator on the way to the CVICU and was declared a half hour later.

And yes, I feel worse today that we continued to provide expensive, futile care for an additional hour+ after diagnosing him with terminal illness - because of the additional financial burden to the family, and because the resource utilization required for that patient detracted from the care of other patients in the ED and the hospital.

Though, I am still pumped one of our 3rd years was able to successfully perform an u/s guided parasternal pericardiocentesis before she graduated.

Ah, well.

So, you're saying that people are dollars only, then? Heroic = futile? You actually feel bad that money was spent on a faint hope?

When did you sell your soul? When are you going into administration, or working for an insurance company?

Or did you discuss DNR with the patient and family? If you were able to get CTS to the bedside, I might think you had time.

I just want it clear - you are bitching about heroic measures, because of the money - nothing more, correct? You just say that, and I'll not say another word.

I equate people to dollars only in the sense that expensive/resource intensive, heroic measures on one patient remove those resources from a finite pool available to deliver care to all individuals.

I think it's clear in the coming years the major cultural shift will be, by necessity, to make do with less. So, where do you start? With which patients? How can the limited available resources be distributed to have the highest yield to society as a whole?

If I hadn't been at an academic medical center with educational benefits to the residents, I would have terminated resuscitative efforts at the first CPR after CTS communicated their prognosis and plan for non-intervention.

I.e., "This patient has suffered a vascular catastrophe incompatible with life. CTS believes his condition to be irreversibly terminal. He has lost pulses and has no realistic chance of survival. Does anyone have an objection to termination?"

xaelia said:

I equate people to dollars only in the sense that expensive/resource intensive, heroic measures on one patient remove those resources from a finite pool available to deliver care to all individuals.

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So critical care patients just aren't worth it? That is certainly what it sounds like from this passage. Not all patients need the same, but some do need more. You're beating around the bush - just say it - "let them die, because they are going to, anyways". Just say it.

xaelia said:

I think it's clear in the coming years the major cultural shift will be, by necessity, to make do with less. So, where do you start? With which patients? How can the limited available resources be distributed to have the highest yield to society as a whole?

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Again, you are comfortable with the sliding slope - you are ready to widen the group who you are certain are going to die? What you are saying is no different than today, in the ED, at least - limited resources distributed. When there is one doctor (or provider) on, there cannot be any fewer. Do you decide to cut corners because of the volume? What is morally right?

xaelia said:

If I hadn't been at an academic medical center with educational benefits to the residents, I would have terminated resuscitative efforts at the first CPR after CTS communicated their prognosis and plan for non-intervention.

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You can't have it both ways - you can't bitch about the cost, but then say "educational benefits". That was NOT your point in your post about the T6 guy. Your point there was about $$. Did you explicitly tell the residents that you would not work it if there weren't residents there, and, then, because of the cost?

Listen - if you are a "true believer" and can stand up straight and say what you are saying in a loud, clear voice, and you can sleep the good sleep of the righteous, then good on ya - honestly. If you can't do that, though - that is at which I am getting.

Dr.McNinja said:

But to argue to go balls to the wall "just when you feel like it" doesn't hold water.

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That's not what I'm saying. It's wholesale moving the setpoint, not randomly deciding "yes" on this one and "no" on that one, which is what "just when you feel like it" means to me.