Dinosaurs

[docB]

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This is one of those dinosaurs like renal dose dopamine, that IM people love to pimp on but don't understand or question. There is no issue with using NS with regards to hypercholomic acidosis.

This was inspired by the discussion about IVF for DKA thread. I've been running into a number of antiquated, discredited medical ideas being accepted as fact lately:
-Radiology wouldn't do a HIDA scan on a patient for 8 hours because I gave her morphine instead of demerol and the morphine constricts the sphincter of Oddi
-Surgeon complined to my director that I had given an appy pt narcotics and had obscurred the belly exam for him
-Aggressive use of bicarb drips in acidotic sepsis patients even though it shows no improvement in outcome and might increase cerebral edema
-Pt sent in from primary doc for "r/o neck fracture," pt arrived ambulatory by private car having been given a prescription for a soft cervical collar which he stopped and picked up on the way to the ER

I know older docs who are <5 yrs from retirement who say they won't change the way they do anything from here on in. Maybe that's why these things happen.

 

[Whisker Barrel Cortex]

Uh, there is a reason that nuc med does not want to do IDA scans on patients who have received morphine beforehand. Morphine does cause Sphincter of Oddi spasm, as has been shown by many studies. It is actually used during a IDA scan and having it beforehand will change these results.

Review article that describes how radiologists utilize morphine during a HIDA scan and why giving morphine pre-scan can effect the results:
http://radiographics.rsnajnls.org/c...tored_search=&FIRSTINDEX=0&sortspec=relevance

An article describing the use of morphine. If morphine given at 60 minutes does not cause filling of the gallbladder, the diagnosis is acute cholecystitis. If it does cause filling, abnormal gall bladder function is the diagnosis:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8623048

Use of morphine augmented cholescintigraphy:
http://jnm.snmjournals.org/cgi/cont...c8d1143a549247b5a1929829&keytype2=tf_ipsecsha


There are also many articles on medline that show that morphine does cause the sphincter to contract.

 

[Seaglass]

For that matter all narcotics cause Oddi "spasm" (Pubmed Review Article) and morphine doesn't cause much more than anything else. So Whisker you're saying you won't do a HIDA if they get any narcotics?

C

 

[Sheerstress]

Isn't Demerol an acceptable alternative to Morphine for IDA scans?

 

[Whisker Barrel Cortex]

I'd have to look into demerol as an alternative during the scan. To answer your question, I would prefer no narcotics for 4 hours at least prior to the procedure. However, as the link to the article above indicates, morphine does raise the sphincter of Oddi pressure more than other narcotics. I agree, 8hrs is too long, if that is what the OP meant.

 

[DocWagner]

Can you say C.R.A.P....just gives a radiologist another excuse to NOT do a procedure and go golfing! Sorry, I don't by the demerol argument...simply do not and in 5 years when Demerol is off hospital formulary, good ole MS04 will just have to do.

 

[docB]

Uh, there is a reason that nuc med does not want to do IDA scans on patients who have received morphine beforehand. Morphine does cause Sphincter of Oddi spasm, as has been shown by many studies. It is actually used during a IDA scan and having it beforehand will change these results.

Review article that describes how radiologists utilize morphine during a HIDA scan and why giving morphine pre-scan can effect the results:
http://radiographics.rsnajnls.org/c...tored_search=&FIRSTINDEX=0&sortspec=relevance

An article describing the use of morphine. If morphine given at 60 minutes does not cause filling of the gallbladder, the diagnosis is acute cholecystitis. If it does cause filling, abnormal gall bladder function is the diagnosis:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8623048

Use of morphine augmented cholescintigraphy:
http://jnm.snmjournals.org/cgi/cont...c8d1143a549247b5a1929829&keytype2=tf_ipsecsha


There are also many articles on medline that show that morphine does cause the sphincter to contract.

So what I would take from this is that HIDA should practically never be an ER study. It would only be of value in pts who are not in pain and do not need narcotics in the (?) 4 hours pre study. ER patients presenting in pain would not fit into this category. I also think it odd that of the 2 radiology groups I work with only one has this policy and the policy exists only at one of its shops.

 

[DrQuinn]

How about surgery residents who believe you can't give PRBCs through a line that had Lactated Ringer's going through it?

(See my thread in surgery of similar title a month ago).

Q, DO

 

[Whisker Barrel Cortex]

Can you say C.R.A.P....just gives a radiologist another excuse to NOT do a procedure and go golfing! Sorry, I don't by the demerol argument...simply do not and in 5 years when Demerol is off hospital formulary, good ole MS04 will just have to do.

Just to set the record straight, radiologists in practice work longer hours than ED physicians. They are just below general surgeons and anesthesiologists in number of hours worked. Radiology residents also work similar hours to ED residents, so please cut the C.R.A.P as you so eloquently put it. Maybe you are the dinosaur stuck in the day when radiologists were home at 3pm and there were few emergent studies. We work our asses off when we are in the hospital and when we are on call, so I do not appreciate your attitude.

Now onto an interesting discussion, through which I have learned a lot. Simply put, it is not a good idea to do a IDA scan when a patient has received narcotics, because the results won't be as complete. This doesn't mean its useless. We CAN rule out obstuction of the cystic duct (due to edema or stone) if the gallbladder fills. But if the narcotics you gave prevent emptying of the common duct into the small bowel, it may be hours before we can say whether the common duct is open when tracer is visualized in the small bowel, if it does so at all. And giving MSO4 basically negates the part of the study where we give MSO4, since its already in the blood stream. We only give it after the tracer has gotten into the small bowel in an attempt to fill a non-filling gallbladder.

I do believe that ultrasound is a much better examination for acute cholecystitis patients in the ED. The GB can be visualized, sonographic murphy's sign can be performed, ductal dilatation can be assessed, cholelithiasis can be visualized, all of which can be done well even in a patient on narcotics (of course Murphy's sign will be blunted, but usually still present). Also, non GB pathology can be examined. Just my opinion.

How often do most of you guys order IDAs in the ED? I geuss its institution dependent, but I haven't seen a single one from the ED at my institution.

 

[Whisker Barrel Cortex]

By the way, here is the average work hours in private practice for different specialties as collected by the AMA. So get off of your high horse DocWagner.

Obstetrics and Gynecology 61
Anesthesiology 61
Urology 60.5
Surgery 60
Radiology (diagnostic) 58
Orthopedic Surgery 58
Internal medicine 57
Neurology 55.5
Pediatrics 54
Otolaryngology 53.5
Family Practice 52.5
Psychiatry 48
Ophthalmology 47
Emergency Medicine 46
Dermatology 45.5
Pathology 45.5

 

[docB]

How often do most of you guys order IDAs in the ED? I geuss its institution dependent, but I haven't seen a single one from the ED at my institution.

Rarely. And then it's only after US and, in my opinion, is requested as a delaying tactic by surg so they don't need to respond immediately, just like many of the ABD CTs they want. The point of my OP was that morphine is first line for belly pain in the ER yet there are still those hangers on advocating Demerol or nothing for pain control.

 

[Katee80]

Why is everyone so against demerol? They say it causes siezures. How many have you seen in a healthy adult? Some people do not metabolize morphine or codiene very well. MSO4 should do? Bull. 4 hours in pain? holy cow!

If a med does not work well for the pt....change it.....whats the problem?

And don't be mean.

 

[stoic]

Why is everyone so against demerol? They say it causes siezures. How many have you seen in a healthy adult? Some people do not metabolize morphine or codiene very well. MSO4 should do? Bull. 4 hours in pain? holy cow!

If a med does not work well for the pt....change it.....whats the problem?

And don't be mean.

Demerol = legal heroin. HUGE abuse profile.

 

[mikecwru]

Why is everyone so against demerol? They say it causes siezures. How many have you seen in a healthy adult? Some people do not metabolize morphine or codiene very well. MSO4 should do? Bull. 4 hours in pain? holy cow!

If a med does not work well for the pt....change it.....whats the problem?

And don't be mean.

Because demerol is a poor analgesic, just gets you high, and seems more addictive. There are other meds.

mike

 

[Febrifuge]

If a med does not work well for the pt....change it.....whats the problem?

And don't be mean.

Two problems, as I see it: one, until the science and the technology advance, pain is and will be 100% a subjective thing. One person's 4/10 pain will be another person's 10/10. There is no good way to measure it from person to person, or from moment to moment in the same person. It's hard to study and hard to treat. Heck, not that long ago, the standard thinking was that pain is always a symptom of some underlying lesion or injury, and pain by itself isn't a treatable thing.

Two, giving patients what they want is sometimes (or often) not the same thing as giving them what they need. What feels bad is not necessarily bad, and what feels good is not necessarily good.

I just started jogging. I've started to wonder if a person can die from shin-splints. I hate life while I'm running, but I'm doing something that is good for me. Similarly, the fact that something takes away (or in the case of Demerol, masks) discomfort doesn't mean it's improving a person's health.

I've had intractable chronic pain in my lifetime, so I don't say it lightly and I don't agree with the camp that says we should just grin and bear it. But I also can't agree that pain is something no one should ever feel, and I don't think it's realistic to expect medicine to be able to take away 100% of one's pain. And certainly not with drugs.

 

[spyderdoc]

Why is everyone so against demerol? They say it causes siezures. How many have you seen in a healthy adult? Some people do not metabolize morphine or codiene very well. MSO4 should do? Bull. 4 hours in pain? holy cow!

If a med does not work well for the pt....change it.....whats the problem?

And don't be mean.

Again, this has been discussed in many threads....
Demerol causes a euphoria/high that people like. Any narcotic will treat pain. Morphine/Dilaudid/Fentanyl work just fine when titrated to control pain to an acceptable level. Demerol gives patients a great buzz. Patients seek Demerol more for secondary gain (the buzz) than for pain. When I was an intern, we had Demerol in the Pixis. About 2 months in, we removed it and stopped giving it. Our chronic pain visits (including sicklers!) declined significantly. Demerol is a bad medicine, period! I have never written for it during my entire medical career, except for one time---a terminal panc CA patient with tumor pinching off the SMA...Family was begging for me to give it to him, because he had days to live, I didn't care about making him an addict. Other than this one exception(which I was still reluctant to do), I will never write for it, period. If the patient is allergic to everything else but Demerol, I tell them they are out of luck...100% of the time, they say they can take dilaudid, or fentanyl....
The latest trend is patients coming in to the ER with a "note" from their neurologist saying that demerol is the only med that works for these patients.....Give me a break! I don't care if they have a note fom the president, they are not getting it. Period. Sorry to sound so harsh, esp to Katee, but there is a good reason that demerol is disappearing from the ER's...

Don't get me wrong, I treat pain very generously...Just NOT with Demerol...