Frequent Flyers with Migraines

[TxNerdyNerd101]

Does anyone start off their ED notes with, "Mrs Jones is a very pleasant 38 yo female..."? Seems like it might be a good idea.

I know I write stuff like that for parents who are taking their kids home... "Upon reassessment, Little Joey is improved. Discussed diagnosis and follow up with parents who appear reliable..." etc.

It doesn't matter if you compliment and then critique - "she's nice, but she's xyz...," - a lawyer is going to turn that around on you.

Lawyer: So Dr. Bam, you stated Mrs. Innocent was a pleasant woman, but you didn't really think that, did you? You thought she was a drug addict, didn't you? That's why she died, right? Because you were biased and were negligent in treating her condition, right? **continues verbal assault**

If you think she's pleasant (and you're trying to cya), state what gives you that opinion. If you think she's seeking drugs, state what makes you think that. If you leave things open-ended, a lawyer is going to fill in the gaps for you.

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[TooMuchResearch]

Epic blows in the name sex age per my template. I don't modify it.

 

[BAM!]

It doesn't matter if you compliment and then critique - "she's nice, but she's xyz...," - a lawyer is going to turn that around on you.

Lawyer: So Dr. Bam, you stated Mrs. Innocent was a pleasant woman, but you didn't really think that, did you? You thought she was a drug addict, didn't you? That's why she died, right? Because you were biased and were negligent in treating her condition, right? **continues verbal assault**

If you think she's pleasant (and you're trying to cya), state what gives you that opinion. If you think she's seeking drugs, state what makes you think that. If you leave things open-ended, a lawyer is going to fill in the gaps for you.

Well of course. No one is going to write, She is a pleasant drug seeking malingerer.

But on the other hand, I have never read an ED note that describes a patient as pleasant. However I've read truckloads of consultant charts and hospitalist charts that say this. Perhaps we should be implementing this. I don't think it would hurt, even if you don't believe it. Of course with an unhappy patient you might write something different, like, "Mrs Jones is an unfortunate but likable woman who is understandably upset because of her severe back pain," etc.

Also, the 60 you send home that dies from an unrelated MI isn't going to sue you. It's their family members. Perhaps while reading your charting they might be on your side if you write good things about their mother. Not only by avoiding pejorative terms, but also by complimenting their demeanor and being understanding of their ailments.

I just curious if anyone does the second part of this... complimenting patients. I certainly don't but am open to start doing so if it will help me chart more defensively.

Or maybe my colleagues will just make fun of me

 

[Janders]

I do occasionally right "pleasant" or similar things in my opening sentence. consultants rubbed off on me?

I do often put something personal / social that serves to personalize the note up in the HPI or MDM. It helps me remember them, and I suppose if the chart get pulled in the future it serves as evidence I actually spoke to the patient for more than 5 seconds. Examples "a very pleasant, chronically illl retired pilot from the area" "a pleasant 80yo widower who presents alongside his loving family whom he lives with" "75M, long standing COPD, retired korean war combat veteran who presents with his loving wife who is his full time caretaker".

Not every chart, but with Dragon I do fall into the friendly / superfluous on occasion. I think one of our surgeons, who is adored, rubbed off on me. His notes always have a line or two like this, that come off more sincere than pure BS flattery.

 

[gotname]

Anyone use triptans?

I usually get 2L IV fluids, 15mg toradol & 25mg phenergan. A triptan script upon discharge if really, really bad migraine.

I just curious if anyone does the second part of this... complimenting patients. I certainly don't but am open to start doing so if it will help me chart more defensively.

A lot of the physicians at the ED I go to do it. As a patient, it's nice to be called "pleasant" but what I appreciate most in doctor (ED or otherwise) notes is sincerity and accuracy. What these particular doctors say to me etc. is what they put down. Most importantly, they always make an effort to provide care. That's what matters...at least to me.

From some of the comments, it seems as if one needs to chart well but not only to potentially protect him/herself but the patient as well. Sounds like a delicate task.

 

[Birdstrike]

Does anyone start off their ED notes with, "Mrs Jones is a very pleasant 38 yo female..."? Seems like it might be a good idea.

I know I write stuff like that for parents who are taking their kids home... "Upon reassessment, Little Joey is improved. Discussed diagnosis and follow up with parents who appear reliable..." etc.

I haven't seen it for ED notes much (if ever) but more often with consultants notes.

 

[GeneralVeers]

I never write this. It has nothing to do with why the patient is there and is medically irrelevant. I simply describe why they patient has visited, what I've witnessed, what the tests show and the diagnosis plan. I never use negative adjectives like "unpleasant, hostile, etc". I will put "patient has evidence of drug-seeking behavior" then state the reasons for why.

 

[gotname]

I simply describe why they patient has visited, what I've witnessed, what the tests show and the diagnosis plan.

Yes, this.

Both positive and negative bias can prove problematic for the patient or physician in the future.

 

[TxNerdyNerd101]

Well of course. No one is going to write, She is a pleasant drug seeking malingerer.
....
Of course with an unhappy patient you might write something different, like, "Mrs Jones is an unfortunate but likable woman who is understandably upset because of her severe back pain," etc.
....
Also, the 60 you send home that dies from an unrelated MI isn't going to sue you. It's their family members. Perhaps while reading your charting they might be on your side if you write good things about their mother. Not only by avoiding pejorative terms, but also by complimenting their demeanor and being understanding of their ailments.

The family is not going to give a rats about whether you complimented their dead mother. However, stating that she is "understandably upset because of her severe back pain" is a great example of explaining WHY you think WHAT you think about someone's demeanor. I'm no longer in the medical field, and I know healthcare providers have a lot on their plates in the ED, but subjective terms can be problematic. And I'm saying all this in love...and from a lawyer's point of view....

 

[TxNerdyNerd101]

I never write this. It has nothing to do with why the patient is there and is medically irrelevant. I simply describe why they patient has visited, what I've witnessed, what the tests show and the diagnosis plan. I never use negative adjectives like "unpleasant, hostile, etc". I will put "patient has evidence of drug-seeking behavior" then state the reasons for why.

And I would say it's perfectly acceptable to state "patient has evidence of drug-seeking behavior" and then explain why you think that. It's the explaining part that's critical.

 

[sawboned]

We too were plagued by a deluge of migraine patients - most of whom routinely received opiates due to long standing custom.

This changed almost overnight with the adoption of a chronic/recurrent pain policy, discouraging opiates for chronic condition including migraines.

My approach:

Cervical paraspinous muscle injection with bupivacaine, as described above
500ml crystaloid bolus
Compazine 10mg IV +/- diphenhydramine. (Would substitute Droperidol IV when available)
Decadron 5mg IV
If these fail, contraindicated, allergy, etc -
Ketamine 0.1 mg/kg slow push IV, repeated in 30 mins prn. 7 mg in the typical adult seems just about optimal, balancing dysphoria/sedation with analgesia/pain amnesia.

Try it!

 

[Gingerlily]

Magnesium is a 2-hour infusion at my shop...

My cocktail:

- ketorolac 30 mg IV
- diphenhydramine 12.5 mg IV
- prochlorperazine 10 mg or metoclopramide 10 mg IV
- dexamethasone 10 mg IV (if it's been going on for a while)
- 1 L NS

That cures just about any migraine in <30 minutes. No labs. If it doesn't cure them, then we're considering other options (drug seeking, SAH, etc.) and somebody is probably getting a CT/LP. Those that come in saying they usually get "2 of Dilauda" get no opiates.

Weighing in as a migraine patient here myself. It's been more than two years since I had to go to the ER for a headache which is absolutely amazing.

The times I have gone to the Emergency Department were usually periods where the pain had lingered in its current strength for at least 48 hours, and also where nausea and vomiting were pat of the experience.

The 'cocktail' you've outlined here is pretty fabulous, especially for patients who are actively working with a neurologist with hospital privileges in your building.

The only thing I'd add is at least one bag of fluid to replace dehydration along with the metoclopramide.

It can sometimes be useful to add a light dose for panic/muscle relaxation, as the patients stress by this point is likely off the charts. A shot of Ativan or Klonapin or whatever will help release muscles and help patients calm.

 

[RustedFox]

Weighing in as a migraine patient here myself. It's been more than two years since I had to go to the ER for a headache which is absolutely amazing.

The times I have gone to the Emergency Department were usually periods where the pain had lingered in its current strength for at least 48 hours, and also where nausea and vomiting were pat of the experience.

The 'cocktail' you've outlined here is pretty fabulous, especially for patients who are actively working with a neurologist with hospital privileges in your building.

The only thing I'd add is at least one bag of fluid to replace dehydration along with the metoclopramide.

It can sometimes be useful to add a light dose for panic/muscle relaxation, as the patients stress by this point is likely off the charts. A shot of Ativan or Klonapin or whatever will help release muscles and help patients calm.

1. The fluid is in the recipe. (1 L NS)
2. No to the benzos; now we're just swapping abused drug classes.

 

[sonofva]

If someone needs a workup for a new headache (CT, LP, etc), I'll give them a headache cocktail through the IV with compazine/benadryl, etc...

If they have their usual headache with no 'red flags,' I give them home headache cocktail of naproxen x 2, benadryl 25mg x2, and reglan 10 mg x2 (PO for all), tell them to take the meds 6 hrs apart, and follow up with PCM/neurologist if not improved. I then tell them to beat it...

edit: to clarify, take 1 of each all at once, then another one of each in 6 hours.

 

[bravotwozero]

Anyone try 1 gram of IV Depakene (depakon?)? Neurologists try this for migraines, I had one tell me to use this for her patient in the ED, seemed to work great for her.

 

[Psai]

Weighing in as a migraine patient here myself. It's been more than two years since I had to go to the ER for a headache which is absolutely amazing.

The times I have gone to the Emergency Department were usually periods where the pain had lingered in its current strength for at least 48 hours, and also where nausea and vomiting were pat of the experience.

The 'cocktail' you've outlined here is pretty fabulous, especially for patients who are actively working with a neurologist with hospital privileges in your building.

The only thing I'd add is at least one bag of fluid to replace dehydration along with the metoclopramide.

It can sometimes be useful to add a light dose for panic/muscle relaxation, as the patients stress by this point is likely off the charts. A shot of Ativan or Klonapin or whatever will help release muscles and help patients calm.

Nice try, frequent flyer

 

[USCDiver]

Anyone try 1 gram of IV Depakene (depakon?)? Neurologists try this for migraines, I had one tell me to use this for her patient in the ED, seemed to work great for her.

I’ve used 500mg infusion before, usually third line after toradol and decadron. Sometimes when a patient suggests they only get relief with the “D-word” I suggest Decadron or maybe Depakote!

 

[Psai]

I’ve used 500mg infusion before, usually third line after toradol and decadron. Sometimes when a patient suggests they only get relief with the “D-word” I suggest Decadron or maybe Depakote!

What about dolobid

 

[WilcoWorld]

I’ve used 500mg infusion before, usually third line after toradol and decadron. Sometimes when a patient suggests they only get relief with the “D-word” I suggest Decadron or maybe Depakote!

What about dolobid

None of them beat Droperidol. Bonus, it has evidence!

 

[Rendar5]

Anyone try 1 gram of IV Depakene (depakon?)? Neurologists try this for migraines, I had one tell me to use this for her patient in the ED, seemed to work great for her.

I've used depakote for migraines and it is actually an on label use unlike keppra I believe which I also use. On those who truly say nothing works ever and deny everything I give 20mg I've ketamine and it drops to a 2-3. They say they feel weird but it doesn't give them euphoria. Or so it seems at those low doses.

 

[KGflyboy]

What about dolobid

That's my favorite. I actually saw an old note written on patient that actually quoted the patient for requesting "dilauda." I personally wouldn't write that, but it gave me a quick laugh.

 

[Janders]

I do something a la this:

http://www.painmedicinenews.com/aimages/2015/PMN0915_13.pdf

So IF needing IV:
reglan or compazine + benadryl + toradol + 1L NS IVF
next line, some of these:
Magnesium infusion, decadron IV, Valproate
next line, consider:
DHE, Zofran, Sumatriptan or Haldol iv. We can't get any droperidol in stock.

Never opiates. Very very very rarely benzo.

 

[deuist]

Cervical neck injections (aka, occipital nerve blocks) with bupivicaine work on occasion. I have also used ketamine 0.3 mg/kg with success. Unfortunately I have also had 2 emergence reactions with such a low dose that I shy away from it. Depending on your hospital, you may need to fill out procedural sedation paperwork, which makes the medication a no-go for most docs.

 

[deleted109597]

Cervical neck injections (aka, occipital nerve blocks) with bupivicaine work on occasion. I have also used ketamine 0.3 mg/kg with success. Unfortunately I have also had 2 emergence reactions with such a low dose that I shy away from it. Depending on your hospital, you may need to fill out procedural sedation paperwork, which makes the medication a no-go for most docs.

Unless they go and change the procedural sedation policy so that it is the intent and not the drug itself. GI always uses fent/versed based on some BS belief of short half-life and lack of negative outcomes (they kill people regularly). But fentanyl and versed don't require it (although some places require some BS "not within x minutes of each other" policy)

 

[turkeyjerky]

Cervical neck injections (aka, occipital nerve blocks) with bupivicaine work on occasion. I have also used ketamine 0.3 mg/kg with success. Unfortunately I have also had 2 emergence reactions with such a low dose that I shy away from it. Depending on your hospital, you may need to fill out procedural sedation paperwork, which makes the medication a no-go for most docs.

Occipital nerve blocks and paracervical IM injections are different procedures for different headache syndromes.

I'm not aware of any data on ketamine for headaches, so I would avoid it (unless there's more recent stuff that I haven't seen, would appreciate a reference). Propofol, does however have some data behind it and I'd be interested to see if anyone here has used it.

Honestly, by the time you're getting to a third line treatment, I'm either admitting (if they look visibly uncomfortable) or telling them to man up and f/u with their neurologist (a lot of these are chronic migraines with a component of analgesic overuse and will not be responsive to any acute treatment--the goal of care then is restoration of function rather than pain relief)

 

[Rendar5]

Occipital nerve blocks and paracervical IM injections are different procedures for different headache syndromes.

I'm not aware of any data on ketamine for headaches, so I would avoid it (unless there's more recent stuff that I haven't seen, would appreciate a reference). Propofol, does however have some data behind it and I'd be interested to see if anyone here has used it.

Honestly, by the time you're getting to a third line treatment, I'm either admitting (if they look visibly uncomfortable) or telling them to man up and f/u with their neurologist (a lot of these are chronic migraines with a component of analgesic overuse and will not be responsive to any acute treatment--the goal of care then is restoration of function rather than pain relief)

Ketamine is just an analgesic. Im not using it for any special properties for migraines like depakote and compazine, just using as a non opiate which is what a lot of opiate free emergency rooms use it as.

 

[deuist]

Occipital nerve blocks and paracervical IM injections are different procedures for different headache syndromes

I go higher than Larry Mellick recommends. I haven't had much success going to C6/C7, but instead go to C3/C4.

I'm not aware of any data on ketamine for headaches

Start searching PubMed.

 

[Birdstrike]

I go higher than Larry Mellick recommends. I haven't had much success going to C6/C7, but instead go to C3/C4.



Start searching PubMed.

I'm familiar with the article you're referring to. Although there's some decent information in it, what's he's referring to are simply trigger point injections. They can give short term relief for pain from focal muscle spasm (trigger points) and help for headaches, if the headache pain is referred from the cervical muscles. Also, remember that the procedure is separately billable under 20552 or 20553 in addition to your E&M code. It doesn't pay much; $56 for one site, $65 for 3 or more, from Medicare. But be careful injecting up around C3/4 or anywhere in the cervical region with bupivicaine or any other local. A 1.5 inch needle can get you into the epidural space in some patients, and if you do it, you'll be intubating. I say this as someone who's an expert in all types of pain related cervical injections (imaged guided and other), having done an accredited Pain fellowship, and being board certified in Pain Medicine by the ABMS (same test the Anesthesia/Pain & PMR/Pain people take). As a side note, when reading about Pain Medicine subjects, be aware there are a lot of people that claim to have "board certification" in Pain, that have never done an accredited fellowship and claim certification from fake boards; many of these are published but lack valid Board Certification. The only legitimate and accredited Pain Board certification, is the one by AMBS, just like in EM and all of the other specialities and subspecialties.

Occipital nerve blocks are a totally different injection (also easy to do) but are specifically for occipital neuralgia headaches.

I do these and many other pain injections all the time, because I do Pain full time now, but honestly, I don't know how much utility there is in doing them in the ED. You can do them, they're not hard to do, but don't let any of them allow you to lose focus from what should always be your goal regarding headaches in the ED: Ruling out intracranial catastrophes.

 

[GeneralVeers]

I never do injections for headache. In the time it would take to explain to the patient, get the supplies set up, and perform the procedure, I probably could have seen at least two other patients. Why do a time-consuming procedure, when I can Set-It And Forget It by ordering IV headache meds, and 90% of the time have it work.

 

[deuist]

. A 1.5 inch needle can get you into the epidural space in some patients

Even at 2.5 cm lateral of the midline?

I don't know how much utility there is in doing them in the ED

After Reglan, Toradol, fluids, and Benadryl didn't work, that's when I reach for the bupivicaine. I still use CT/LP as indicated. I just want people to feel better so that they can leave the department.

I never do injections for headache. In the time it would take to explain to the patient, get the supplies set up, and perform the procedure, I probably could have seen at least two other patients.

Same reason I do trigger point injections for low back pain: some people aren't going to feel better with NSAID's and muscle relaxers. I try to avoid opiates in non-traumatic pain. If I can get patients feeling good enough to leave without an opiate script, I call that a victory.

 

[Birdstrike]

Even at 2.5 cm lateral of the midline?

Unlikely that far out lateral. You could end up blocking a nerve root, though. What gauge & length needle are you using?

Same reason I do trigger point injections for low back pain:

You’re billing the 20552/3 code for them, right?

I try to avoid opiates in non-traumatic pain.

Good. You should avoid them. I don’t start opiates in opiate-naive chronic non-cancer pain patients. Not even tramadol.

If I can get patients feeling good enough to leave without an opiate script, I call that a victory.

I could not agree more.
The key to fixing the opiate crisis, is with the next generation, and not starting people on opiates and not making the next 20-30 years of people dependent. Often the first script in the ER, by a PCP or a surgeon is the one that does it. Getting the non-medication abusing, chronic opiate-dependent patients off opiates is going to be much harder.

 

[deuist]

Unlikely that far out lateral. You could end up blocking a nerve root, though. What gauge & length needle are you using?

25 or 27 gauge, 1.5" long needle. I inject 1.5 mL of bupivicaine 0.5%. The only complication I have ever experienced is when 2 patients stated that they felt dizzy afterward. The majority either feel relief, with about 20% experiencing no effect of any kind.

You’re billing the 20552/3 code for them, right?

I work for a CMG who takes care of all of the billing and coding. I have no idea what is happening behind the scenes since I am paid hourly.

Often the first script in the ER, by a PCP or a surgeon is the one that does it

I thought that the evidence showed that only a minority of opiate addicts started their addiction with their physician. The bulk abuse drugs from the beginning by using their friends' and family members' pills.

 

[Birdstrike]

25 or 27 gauge, 1.5" long needle.

Try 30 gauge 0.5” needles for this. Can’t get in any trouble and hurts less.

I thought that the evidence showed that only a minority of opiate addicts started their addiction with their physician. The bulk abuse drugs from the beginning by using their friends' and family members' pills.

I’m not sure what the actual numbers are on this, but regardless, there’s still no need to add to to them. I don’t know if it makes it any better, if an opiate script to an opiate naive patient leads to addiction in that patient, or a friend or family member. Does it?

Regardless, it’s just a thought. I’m not judging. Do what you think is right for your patients. But, it’s my personal opinion that there’s more potential harm with the first script to an opiate naive patient, than with the 1,000th script to the person already dependent on opiates for years. In one, a dependency has been created in someone who’s previsouly had an opiate free life. You’re much more likely to help that person by not creating a dependency, than you are by trying to pry a years-long opiate dependent patient await from opiates.

In other words, it’s much easier to prevent an opiate dependency (zero withdrawal, people don’t miss what they never had) than it is to stop one that’s entrenched.

 

[deleted109597]

I'm all for not giving opiates, but I'm still not on board with the cervical blocks. Something about that asystole that they caused that one time.
There's some neurologist out there selling a device that supposedly makes it easier. I didn't buy one. He seemed to imply that the billing is pretty good for privately insured patients.

 

[WilcoWorld]

I'm all for not giving opiates, but I'm still not on board with the cervical blocks. Something about that asystole that they caused that one time.
There's some neurologist out there selling a device that supposedly makes it easier. I didn't buy one. He seemed to imply that the billing is pretty good for privately insured patients.

reference please

edit: I found a case report of this with epidural injection - I don't think that this is what most of us are discussing.

 

[Gastrapathy]

Unless they go and change the procedural sedation policy so that it is the intent and not the drug itself. GI always uses fent/versed based on some BS belief of short half-life and lack of negative outcomes (they kill people regularly). But fentanyl and versed don't require it (although some places require some BS "not within x minutes of each other" policy)

WTF?

 

[deleted109597]

WTF?

GI (or the nurses assisting them) have killed more people in the GI suite with fentanyl and versed (or dilaudid) than procedural sedation in the ED. This isn't a dig. It's just a fact.

 

[deleted109597]

reference please

edit: I found a case report of this with epidural injection - I don't think that this is what most of us are discussing.

Emergentology: A Needle in the Neck : Emergency Medicine News
Well I heard it from Larry Mellick (via Graham Walker)

Dr. Mellick told me that he has had a few patients with vagal responses after the injection. A colleague's patient with a severe vasovagal response had a brief cardiac arrest after injection, but he did not think it was intra-arterial. He, of course, always recommends double- or triple-checking that you're not in a vessel first. (Obviously, this is a scary outcome, but other medicines that we give all the time have similar risks.)

 

[Gastrapathy]

GI (or the nurses assisting them) have killed more people in the GI suite with fentanyl and versed (or dilaudid) than procedural sedation in the ED. This isn't a dig. It's just a fact.

If it's a fact, I'm sure you have proof. I know the moderate sedation literature pretty well.

My group does 30,000+ sedated procedures/year. Only periprocedural death in last 10 years was a GETA case in a septic patient. I don't criticize ER docs when I see them do crazy **** to my patients but this is a ridiculous claim.

 

[deleted109597]

If it's a fact, I'm sure you have proof. I know the moderate sedation literature pretty well.

My group does 30,000+ sedated procedures/year. Only periprocedural death in last 10 years was a GETA case in a septic patient. I don't criticize ER docs when I see them do crazy **** to my patients but this is a ridiculous claim.

I'm not saying you guys are killing them on purpose. But I've worked at 3 hospitals, and all 3 had sentinel events in the GI suite, not anywhere else. And since it often affects our ability to provide procedural sedation, it's a touchy subject. Simply put, the rate is higher in GI than in the ER. You can argue all day that we are less likely to do ASA 4 patients or whatever, but in the end, the data is the data. Your group appears to be an outlier based on the literature I've looked at, which would have a death rate nearly 150 times that. 1 death in 10 years with 300,000 procedures? I hope you've written that up. That's some amazing work.

Procedural sedation in adults outside the operating room

Serious complications attributable to PSA rarely occur [43,44]. According to a systematic review of 55 studies including 9652 cases of PSA performed in the emergency department, the rate of severe adverse events requiring an emergency intervention is exceedingly low [44]. Adverse outcomes may include respiratory depression with hypoxia or hypercarbia, cardiovascular instability, vomiting and aspiration, emergence reactions, and inadequate sedation preventing completion of the procedure [10]. However, significant respiratory compromise, the most concerning potential complication, develops in well less than 1 percent of cases. Among the studies included, the review identified one case of aspiration in 2370 sedations (1.2 per 1000), one case of laryngospasm in 883 sedations (4.2 per 1000), and two intubations in 3636 sedations (1.6 per 1000).

Adverse events related to procedural sedation for gastrointestinal endoscopy

The overall incidence of cardiopulmonary adverse events is low, but important. In a prospective survey of 14,149 upper endoscopies and a retrospective study of 21,011 procedures, the rate of early cardiopulmonary events was 2 to 5.4 per 1000 cases, and the mortality rate, which included cases of aspiration pneumonia, pulmonary embolism, and myocardial infarction, was 0.3 to 0.5 per 1000 cases [5,6].

 

[Gastrapathy]

That is data from 1991. It included PE and other unrelated diagnoses as a sedation complication. Pulse oximetry wasn't in wide use, let alone capnography.

If you approach the data the way surgeons do (any death in 60 days after the procedure, readmission, repeat procedures), complication rates are higher but dying in endoscopy from sedation is incredibly rare in 2017. That's why it's a sentinel event.

 

[Birdstrike]

Emergentology: A Needle in the Neck : Emergency Medicine News
Well I heard it from Larry Mellick (via Graham Walker)

Like I said above, you can get in trouble using a 1.5” needle by going inadvertently epidural (respiratory arrest due to high spinal block) in a thin patient. Also, out laterally, you could also, in theory, accidentally inject into the vertebral artery (would like cause seizures, not likely full arrest). Negative aspiration, doesn’t always rule out intravascular needle location, especially if the needle hub is up against the vessel wall. The example given above about someone arresting from a vagal episode, would be more related to the vagal episode and underlying propensity heart arrhythmia, and less to do with anything injected.

I definitely advocate only injecting in the neck, if you’re confident you know what you’re doing. Personally, I have the training to put a needle 1mm from the cervical spinal cord and feel very comfortable about it, but not everyone does.

 

[deleted109597]

If you approach the data the way surgeons do (any death in 60 days after the procedure, readmission, repeat procedures), complication rates are higher but dying in endoscopy from sedation is incredibly rare in 2017. That's why it's a sentinel event.

It may be old data, but there's still a reason for my statement. I have not seen any sentinel events in the ED. I've personally seen (been part of the committee agonizing over it anyway) 3 in GI since 2011.

 

[Gastrapathy]

It may be old data, but there's still a reason for my statement. I have not seen any sentinel events in the ED. I've personally seen (been part of the committee agonizing over it anyway) 3 in GI since 2011.

Well, the JC hasn't had trouble finding ED sentinel events. 2002 report said half of all hospital sentinel events occurred in ED. The current data includes ED in hospital group so it's harder to measure. But sure, EDs are way safer than endoscopy if you happen to work at that hospital.

 

[deleted109597]

Well, the JC hasn't had trouble finding ED sentinel events. 2002 report said half of all hospital sentinel events occurred in ED. The current data includes ED in hospital group so it's harder to measure. But sure, EDs are way safer than endoscopy if you happen to work at that hospital.

So my "old data" isn't valid, but yours is. Check.
Endoscopy is entirely different than ED procedural sedation. The time frames are much, much longer. This is why it's more dangerous. Also that whole "opening the sphincter" thing.

 

[n2b8me]

At my shop, headache seems to be the most common complaint among habitual visitors. Headaches seem to rival and even outnumber our back painers. We have several customers who present 3+ times weekly, twice in the same 12 hr shift, 200+ visits per year. Naturally, toradol, other NSAIDS and every triptan under the sun are listed as an allergy. Although it seems at times instinctive to order them their shot of dilaudid and phenergan, this is sometimes more of a knee jerk reaction in order to dispo them quickly and move them along. Our migraineurs come in 2 forms: about 25% occasionally see their neurologist and are the ones taking handfulls of preventative meds like topamax and neurontin. These are the folks that always utter the line "my neurologist told me that if my headache gets bad just to go to the ER." The second are the other problematic 75% who, despite having "migraines" for years on end have never actually seen a neurologist nor seem to have any motivation to visit one. I welcome your thoughts and input. Do your ED's have narcotic policies for frequent flyer headache patients? Does case management ever get involved with these folks in trying to funnel them into a neuro clinic? Do you acquiesce and just give them their shot and send them on their way? Do you just offer compazine, reglan, benadryl IM, etc and take a stand?

For what its worth: a widely used orderset in a nonprofit, integrated, managed care system... the way most people use it is to order EVERYTHING upon patient assignment.

ED/HBS HEADACHE ORDER SET:

1. IVF - 2L NS wide open
2. O2 via NC
3. reglan 10mg IV (1st line) or zofran 4mg iv (if reglan intolerant)
4. DHE 1 mg (dilute in 50 cc saline and administer over 3-5 min after premed w reglan)
5. decadron 10mg iv
6. magnesium 1g iv
7. toradol 15mg im/iv
8. send referral to neuro HA clinic/neurologist if not previosuly evaluated/advise HA journal - can send home with DHE SQ or intranasal/ include antiemetic prior to use
9. NO NARCOTICS

 

[Gastrapathy]

So my "old data" isn't valid, but yours is. Check.
Endoscopy is entirely different than ED procedural sedation. The time frames are much, much longer. This is why it's more dangerous. Also that whole "opening the sphincter" thing.

Endoscopy and sedation for endoscopy are incredibly safe. You seem to believe otherwise. You're wrong. I have no idea what you're talking about.

It must be frustrating to know everything about everyone else's job.

Gotta say it's disappointing that a moderator would so casually disparage my specialty. Pretty poor example.

 

[Rendar5]

Endoscopy and sedation for endoscopy are incredibly safe. You seem to believe otherwise. You're wrong. I have no idea what you're talking about.

It must be frustrating to know everything about everyone else's job.

Gotta say it's disappointing that a moderator would so casually disparage my specialty. Pretty poor example.

He mentioned 1 death every 2 years. It’s safe but not perfect at his particular institution.

 

[Gastrapathy]

He mentioned 1 death every 2 years. It’s safe but not perfect at his particular institution.

He wrote "they [GI] kill people regularly" etc.

That is false, disparages my profession in public, and given that there is no specialty that comes under more unfair criticism than EM, you'd think most emergency physicians would know better.

Not classy and not true but I guess those qualities aren't that important anymore.

 

[Birdstrike]

For what its worth: a widely used orderset in a nonprofit, integrated, managed care system... the way most people use it is to order EVERYTHING upon patient assignment.

ED/HBS HEADACHE ORDER SET:

1. IVF - 2L NS wide open
2. O2 via NC
3. reglan 10mg IV (1st line) or zofran 4mg iv (if reglan intolerant)
4. DHE 1 mg (dilute in 50 cc saline and administer over 3-5 min after premed w reglan)
5. decadron 10mg iv
6. magnesium 1g iv
7. toradol 15mg im/iv
8. send referral to neuro HA clinic/neurologist if not previosuly evaluated/advise HA journal - can send home with DHE SQ or intranasal/ include antiemetic prior to use
9. NO NARCOTICS

Wow. You do all that for headaches in the ED?
Damn.