I'm Quitting

[CliveStaples]

So a bit of background. I'm a pretty young attending, working a community job that I actually enjoy. Hospital admin seems to support us, the ER director seems to have a good relationship with them, we know the metrics they care about but it isn't tied to our compensation in any way so it's more of a gentleman's agreement than anything malignant (I.e. be productive and play nice, please). Sure, we have had our fair share of COVID related stress between the initial loss of volume and now the increase in sick respiratory distress volume and ICU boarding, but I generally have a pretty positive outlook.

But yesterday broke me.

I come walking into my work station, bright eyed and carrying a sack lunch that will be a bright spot on what is bound to be a busy Tuesday afternoon. As I approach my computer, I spy the mess of papers sitting around it. It's the usual stuff, like who is on call for what service. Today though, there's a new list of medications we have on shortage, along with a recommendation of alternatives. I decide to take a peak.

"IV Doxycycline Shortage: Please consider use of PO Doxycycline or alternative antibiotic regimens"

Now I personally love Doxycycline but I can't say I administer a lot of IV Doxy, so no skin off my back.

"IV Hydralazine Shortage: Please consider IV Captopril or Clonidine"

This one isn't new. I've been out of Hydralazine for weeks now. This was particularly frustrating when we are were on IV Labetalol shortage since I'm not particularly bright and I prefer to use the same drugs I always use. I groaned and looked at the last item on the list.

"IV/IM Haloperidol Shortage. Please consider Geodon."

At this, my heart stops. I look over it a second time, making sure my eyes don't deceive me. No more Haldol? As my palms start to sweat, I start running over the clinical scenarios in my mind. Acute agitation? No more Haldol. 50yo diabetic presenting with gastropresis for the umpteenth time? No more Haldol. Female abdominal pain of unknown etiology with multiple negative workups? No more Haldol. Hell, I'm about at the point where it's going into my Sepsis order set. Haloperidol is my 5th pressor.

As we speak, I'm calling the CEO and my director down for an emergency meeting and to sign my resignation. I don't think I'll be able to work under these conditions any more. Maybe this is how you old guys and girls felt when Droperidol went the way of the dinosaur, but I'm not built of as strong stuff as you all. It's been a good career, but I just didn't go to a Powerhouse Program that could teach me how to work under such austere conditions. Good luck working in this new future, my friends.

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[Birdstrike]

So a bit of background. I'm a pretty young attending, working a community job that I actually enjoy. Hospital admin seems to support us, the ER director seems to have a good relationship with them, we know the metrics they care about but it isn't tied to our compensation in any way so it's more of a gentleman's agreement than anything malignant (I.e. be productive and play nice, please). Sure, we have had our fair share of COVID related stress between the initial loss of volume and now the increase in sick respiratory distress volume and ICU boarding, but I generally have a pretty positive outlook.

But yesterday broke me.

I come walking into my work station, bright eyed and carrying a sack lunch that will be a bright spot on what is bound to be a busy Tuesday afternoon. As I approach my computer, I spy the mess of papers sitting around it. It's the usual stuff, like who is on call for what service. Today though, there's a new list of medications we have on shortage, along with a recommendation of alternatives. I decide to take a peak.

"IV Doxycycline Shortage: Please consider use of PO Doxycycline or alternative antibiotic regimens"

Now I personally love Doxycycline but I can't say I administer a lot of IV Doxy, so no skin off my back.

"IV Hydralazine Shortage: Please consider IV Captopril or Clonidine"

This one isn't new. I've been out of Hydralazine for weeks now. This was particularly frustrating when we are were on IV Labetalol shortage since I'm not particularly bright and I prefer to use the same drugs I always use. I groaned and looked at the last item on the list.

"IV/IM Haloperidol Shortage. Please consider Geodon."

At this, my heart stops. I look over it a second time, making sure my eyes don't deceive me. No more Haldol? As my palms start to sweat, I start running over the clinical scenarios in my mind. Acute agitation? No more Haldol. 50yo diabetic presenting with gastropresis for the umpteenth time? No more Haldol. Female abdominal pain of unknown etiology with multiple negative workups? No more Haldol. Hell, I'm about at the point where it's going into my Sepsis order set. Haloperidol is my 5th pressor.

As we speak, I'm calling the CEO and my director down for an emergency meeting and to sign my resignation. I don't think I'll be able to work under these conditions any more. Maybe this is how you old guys and girls felt when Droperidol went the way of the dinosaur, but I'm not built of as strong stuff as you all. It's been a good career, but I just didn't go to a Powerhouse Program that could teach me how to work under such austere conditions. Good luck working in this new future, my friends.

Me, 10 years ago. Ever wonder how I got the name, Birdstrike?

 

[AlmostAnMD]

Me, 10 years ago. Ever wonder how I got the name, Birdstrike?

I've always meant to ask you. If you left a decade ago, why stick around this forum? I mean I left residency and med school and have essentially no desire to post on those forums. If I left EM I'd probably leave this site entirely. Also, stuff has probably changed so much over the last ten years it would be difficult in some situations to even get advice from you about certain things. Just curious.

 

[Birdstrike]

I've always meant to ask you. If you left a decade ago, why stick around this forum? I mean I left residency and med school and have essentially no desire to post on those forums. If I left EM I'd probably leave this site entirely. Also, stuff has probably changed so much over the last ten years it would be difficult in some situations to even get advice from you about certain things. Just curious.

If it wasn't for the regular private messages from disillusioned ER doctors asking for help (and offering profuse thanks) on how to cure their burnout once and for all, and for advice on an EM subspecialty I know a tremendous amount about that 99.9% of EM physicians know nothing about, it might not waste my time. Or maybe it's a less noble antidote for periodic moments of boredom when on the toilet, I'm not quite sure.

Would you rather I not post here?

 

[AlmostAnMD]

Oh no, wouldn't tell anyone to never post here (barring some non-em folk that never were). Was just curious, didn't mean to offend.

 

[Birdstrike]

Oh no, wouldn't tell anyone to never post here (barring some non-em folk that never were). Was just curious, didn't mean to offend.

One one hand, I think your implication is 100% right, that I probably shouldn't waste any time here. On the other hand, I'm ABEM certified (still) and practice an EM subspecialty full time. I'm not sure that means, "I've left" and that there's something improper that I post in an interest group in my base specialty, like you're implying, but I digress.

But you're mostly right and I have considered deleting my account numerous times over the years to save time. And you almost got me to, just now. But what's keeping from doing that is I'd hate to miss the next private message I get regularly, that go like this,

"Hey man, I got into a fellowship! I can't believe it! Thanks for all your help!" or,

"Wanted to let you know I just landed an awesome job, my life is so much better now! Thanks for all the help," or,

"Thanks for the info! There's so little of it out there on this subject. Can we stay in touch?"

 

[namethatsmell]

"IV/IM Haloperidol Shortage. Please consider Geodon."

At this, my heart stops. I look over it a second time, making sure my eyes don't deceive me. No more Haldol? As my palms start to sweat, I start running over the clinical scenarios in my mind. Acute agitation? No more Haldol. 50yo diabetic presenting with gastropresis for the umpteenth time? No more Haldol. Female abdominal pain of unknown etiology with multiple negative workups? No more Haldol. Hell, I'm about at the point where it's going into my Sepsis order set. Haloperidol is my 5th pressor.

This bit of gold needs to be published somewhere.

 

[AlmostAnMD]

And you almost got me to, just now.

Yikes! Not the intention, especially for lost souls that you help. Obviously you bring quite a bit here, but was just wondering what still brought you here, if that made sense, and you answered the question. No no, please don't go away on mine or anyone else's account

 

[Birdstrike]

Yikes! Not the intention, especially for lost souls that you help. Obviously you bring quite a bit here, but was just wondering what still brought you here, if that made sense, and you answered the question. No no, please don't go away on mine or anyone else's account

No worries. It's all good. And thank you.

As an aside. What stage of your career are you in? I only ask because with most people I get a sense of that, but with you it's hard to judge because of your screen name. You don't have to answer if you want. Just curious. You seem further along than "almost an MD."

 

[GeneralVeers]

I almost quit in 2013 when we lost Droperidol. Losing Haldol would make the ED untenable for me, as I'd have no way of stopping the noise.

 

[AlmostAnMD]

No worries. It's all good. And thank you.

As an aside. What stage of your career are you in? I only ask because with most people I get a sense of that, but with you it's hard to judge because of your screen name. You don't have to answer if you want. Just curious. You seem further along than "almost an MD."

Early. Just graduated in 2019. Burnout yet to set in, but the SDG I'm in seems quite nice by most comparisons so maybe it'll last. who knows. My screen name is now a running joke, albeit a bad one.

I almost quit in 2013 when we lost Droperidol. Losing Haldol would make the ED untenable for me, as I'd have no way of stopping the noise.

By popular demand, our group just got it back! It's a miracle drug. Should be unconstitutional to have an ED without it imo, especially if you find the right people for it.

 

[d2305]

Me, 10 years ago. Ever wonder how I got the name, Birdstrike?

I always thought you were a pilot.

 

[GeneralVeers]

I always thought you were a pilot.

I thought he just hit a window too hard.....

 

[RustedFox]

No; he was taking a poop when he first posted. Didn't you read his other messages?

 

[Angry Birds]

Me, 10 years ago. Ever wonder how I got the name, Birdstrike?

I thought it was cuz you always struck down angry birds

 

[Angry Birds]

On a serious note I gave Haldol to calm down a hysterical patient only to realize later that she was having akathisia from her meds. Lets just say that Haldol made her go bat sh** crazy and had the opposite effect of why I love it so much. Now I fear the nurses will refuse to give it... all my hard work normalizing this med in our ER gone down the drain

 

[PianoMedic]

Early. Just graduated in 2019. Burnout yet to set in, but the SDG I'm in seems quite nice by most comparisons so maybe it'll last. who knows. My screen name is now a running joke, albeit a bad one.



By popular demand, our group just got it back! It's a miracle drug. Should be unconstitutional to have an ED without it imo, especially if you find the right people for it.

I don’t really find much difficulty finding the right patients to give droperidol too... Migraine? Drop. Nausea/vomiting? Drop. Belly pain? Drop. Crazy/agitated/otherwise supratentorial? Drop. We’re chronically on a slight shortage of it now and it has to come from pharmacy, but I’m ordering it often. Love it and very glad it is back.

 

[njac]

Early. Just graduated in 2019. Burnout yet to set in, but the SDG I'm in seems quite nice by most comparisons so maybe it'll last. who knows. My screen name is now a running joke, albeit a bad one.



By popular demand, our group just got it back! It's a miracle drug. Should be unconstitutional to have an ED without it imo, especially if you find the right people for it.

It’s back on the market, but on shortage,

We’re down to 20 vials. Every time they order it I have to ask “because you need to or because you want to” which sucks.

But we still have plenty of haldol.

 

[BAM!]

I started residency in 2010 and Droperidol was not an option for us. I have only heard about its glory.

For those who recently gained access to this drug, how did you get it? Was there any red tape or justifications that needed to be had? If so, what were they and what were the arguments?

 

[dadaddadaBATMAN]

I started residency in 2010 and Droperidol was not an option for us. I have only heard about its glory.

For those who recently gained access to this drug, how did you get it? Was there any red tape or justifications that needed to be had? If so, what were they and what were the arguments?

I’m not sure why we have it, but we do not speak it’s name lest it leave us forevermore, back to the dark times of haldol

In all seriousness one of our docs is an old school guy who I think pushed for it when it came back in vogue, and it’s a good drug. Like haldol but faster with stopping the noises.

I believe there is some literature on its use as a chemical restraint: compared haldol, droperidol and bdzs and droperidol has fastest onset and least adverse events. That would be a good justification to have it around.

 

[d2305]

I think its QT prolongation effect is negligible.

 

[dadaddadaBATMAN]

I think its QT prolongation effect is negligible.

In all fairness so is zofrans but we can’t shut up about it

 

[Mushdoc]

Send this and this to your pharmacist

Effectiveness and safety of droperidol in a United States emergency department - PubMed

Droperidol Is Back (and Here's What You Need to Know) - ACEP Now

ACEP Now offers real-time clinical news, news from the American College of Emergency Physicians, and news on practice trends and health care reform for the emergency medicine physician. ACEP Now is an official publication of the American College of Emergency Physicians.

www.acepnow.com

 

[WilcoWorld]

I started residency in 2010 and Droperidol was not an option for us. I have only heard about its glory.

For those who recently gained access to this drug, how did you get it? Was there any red tape or justifications that needed to be had? If so, what were they and what were the arguments?

Here's an easy read on the history and uses of droperidol in the ED.

Bonuses:
1 - They reference MDRAP as an indication (MDRAP = "multidrug-resistent abdominal pain")
2 - The 2nd citation is a thread on this forum!

 

[BAM!]

Thanks for all the tips. i emailed the pharmacist directors. Let's see what happens.

 

[njac]

Thanks for all the tips. i emailed the pharmacist directors. Let's see what happens.

Good luck.

Droperidol is also currently on shortage but maybe they can get it queued up for when it’s available again.

 

[Old_Mil]

I've always meant to ask you. If you left a decade ago, why stick around this forum? I mean I left residency and med school and have essentially no desire to post on those forums. If I left EM I'd probably leave this site entirely. Also, stuff has probably changed so much over the last ten years it would be difficult in some situations to even get advice from you about certain things. Just curious.

Having cynical attendings such as myself and Birdstrike around is critical to the health of the medicine because it lets all the premeds, medical students, residents, and new attendings have a preview of their future.

 

[Mad Jack]

One one hand, I think your implication is 100% right, that I probably shouldn't waste any time here. On the other hand, I'm ABEM certified (still) and practice an EM subspecialty full time. I'm not sure that means, "I've left" and that there's something improper that I post in an interest group in my base specialty, like you're implying, but I digress.

But you're mostly right and I have considered deleting my account numerous times over the years to save time. And you almost got me to, just now. But what's keeping from doing that is I'd hate to miss the next private message I get regularly, that go like this,

"Hey man, I got into a fellowship! I can't believe it! Thanks for all your help!" or,

"Wanted to let you know I just landed an awesome job, my life is so much better now! Thanks for all the help," or,

"Thanks for the info! There's so little of it out there on this subject. Can we stay in touch?"

Time spent helping others is never wasted

 

[Apollyon]

Time spent helping others is never wasted

Man, you should consider becoming a psychiatrist!

 

[Old_Mil]

I almost quit in 2013 when we lost Droperidol. Losing Haldol would make the ED untenable for me, as I'd have no way of stopping the noise.

Try noise cancelling headphones. They bring the added benefit of not hearing floor codes as they are paged overhead.

 

[southerndoc]

I love droperidol. I also use Haldol when we're low on droperidol.

For gastroparesis, cannibanoid hyperemesis syndrome, etc., droperidol has been a blessing. If someone doesn't have it, Haldol is a close second.

If someone practices in a place that doesn't have either, then I guess you can give enough Compazine that the patient gets the wiggles and bolts. That makes your life easier than dealing with someone violently vomiting with a noise:emesis ratio >1.

 

[GassYous]

I love droperidol. I also use Haldol when we're low on droperidol.

For gastroparesis, cannibanoid hyperemesis syndrome, etc., droperidol has been a blessing. If someone doesn't have it, Haldol is a close second.

If someone practices in a place that doesn't have either, then I guess you can give enough Compazine that the patient gets the wiggles and bolts. That makes your life easier than dealing with someone violently vomiting with a noise:emesis ratio >1.

Just give the marijuana people some capsaicin cream

 

[bravotwozero]

supposedly droperidol is significantly, like 11x more, expensive than haldol, so our hospital system declined to stock it.

 

[Fox800]

supposedly droperidol is significantly, like 11x more, expensive than haldol, so our hospital system declined to stock it.

If it works and gets the pt out of the hospital 1-2 hours faster, then it's worth the cost.

But that would, like, require thinking.

 

[WilcoWorld]

supposedly droperidol is significantly, like 11x more, expensive than haldol, so our hospital system declined to stock it.

They're both dirt cheap. 12 x a nickel is still just $0.60

 

[Fox800]

They're both dirt cheap. 12 x a nickel is still just $0.60

I bring this up when hospitals say that IV acetaminophen is too expensive when patient's can't take PO.

Dude, if I'm in the ED, I'd pay the extra $10 to have Tylenol through my IV instead of shoved up my @$$, but that's just me.

 

[GeneralVeers]

If it works and gets the pt out of the hospital 1-2 hours faster, then it's worth the cost.

But that would, like, require thinking.

You mean like employing a 24-hour case manager for $500/day who could probably prevent 5-6 hospital admissions? Hospitals never seem to view the larger picture amongst a sea of nickels and dimes.

 

[chocomorsel]

I bring this up when hospitals say that IV acetaminophen is too expensive when patient's can't take PO.

Dude, if I'm in the ED, I'd pay the extra $10 to have Tylenol through my IV instead of shoved up my @$$, but that's just me.

Doesn’t matter how much it costs in the ED. When You don’t intend on paying.
But I suspect it’s more in the realm of hundreds of dollars. Not tens.

 

[chocomorsel]

You mean like employing a 24-hour case manager for $500/day who could probably prevent 5-6 hospital admissions? Hospitals never seem to view the larger picture amongst a sea of nickels and dimes.

This honestly sounds like a great idea. Have you suggested it to the C suite and they declined? I guess they’re thinking no admissions equals no money. But a lot of those freeloaders means no money anyway.

 

[GeneralVeers]

This honestly sounds like a great idea. Have you suggested it to the C suite and they declined? I guess they’re thinking no admissions equals no money. But a lot of those freeloaders means no money anyway.

I try not to talk to the C suite. Not being noticed is part of thr survival imperative.

 

[AlmostAnMD]

Doesn’t matter how much it costs in the ED. When You don’t intend on paying.
But I suspect it’s more in the realm of hundreds of dollars. Not tens.

A pharmacist told me a few years ago a single 1g dose was $1,500

I have no way of knowing if that's an accurate statement

If it isn't I'm going to be pissed because I never ordered it again

 

[Birdstrike]

So, @CliveStaples, did you end up quitting? Did things get better and you no longer need to quit? Are you at a new job, where the future is looking brighter? Just wondering, because I don't see that you followed up after your OP.

 

[Birdstrike]

A pharmacist told me a few years ago a single 1g dose was $1,500

I have no way of knowing if that's an accurate statement

If it isn't I'm going to be pissed because I never ordered it again

It's worth keeping in my the "cost" versus "price." I'm not 100% sure of the exact cost to produce one dose of IV acetaminophen, but it has to be less than the GoodRx price of 52 cents per dose. But the price? That might be $0.52 like on good Rx, or it could be $1,000 if you repackage/reformulate/rebrand it and tell everyone its the latest/greatest best thing since sliced bread and because this version is "so, so hard to make," but is really the same liquid crap as the 52 cent solid stuff.

Yes, the patient gets a bill for $1,000 which is sad. But nowhere in any objective reality does the medication have to "cost" what they're pricing it at. It's one of the many areas in which our system needs improvement at best, or a total revamp, at worst. The rules of supply and demand are distorted by politics, regulations, government and insurance games. It's a free market, that's not free.

I don't know what the solution is, but I know we can do better.

 

[southerndoc]

A pharmacist told me a few years ago a single 1g dose was $1,500

I have no way of knowing if that's an accurate statement

If it isn't I'm going to be pissed because I never ordered it again

The cost of Ofirmev is $40 per dose (roughly 50 cents per 10 mg). It was previously higher, but I don't think it was ever above $2 per 10 mg. Hospitals, however, usually charge $700-1500 per dose to the patient/insurers.

 

[AlmostAnMD]

The cost of Ofirmev is $40 per dose (roughly 50 cents per 10 mg). It was previously higher, but I don't think it was ever above $2 per 10 mg. Hospitals, however, usually charge $700-1500 per dose to the patient/insurers.

This nuance is irrelevant to me. I'm bending the patient over enough as it is per visit. I don't need to stop using lube and use IV tylenol. Or I can just wear a cape to work and grow an evil moustache and start giving Andexxa to every minor GI bleed on eliquis.

 

[Birdstrike]

The cost of Ofirmev is $40 per dose (roughly 50 cents per 10 mg). It was previously higher, but I don't think it was ever above $2 per 10 mg. Hospitals, however, usually charge $700-1500 per dose to the patient/insurers.

I'd like to know what is the cost to produce per dose. But that's probably proprietary and not public information, for good reason. Chances are it's far, far, below that $40 mark, and certainly thousands of a percent below the $700-$1,500 charge. My bet is it's less than a dollar. How many more times will they rebrand a drug discovered in 1878 as an excuse to sucker us into paying thousands percent's more for the same old stale donut?

 

[Fox800]

Doesn’t matter how much it costs in the ED. When You don’t intend on paying.
But I suspect it’s more in the realm of hundreds of dollars. Not tens.

The amount the hospital bills is not the same as the average unit cost to the hospital.

 

[southerndoc]

I'd like to know what is the cost to produce per dose. But that's probably proprietary and not public information, for good reason. Chances are it's far, far, below that $40 mark, and certainly thousands of a percent below the $700-$1,500 charge. My bet is it's less than a dollar. How many more times will they rebrand a drug discovered in 1878 as an excuse to sucker us into paying thousands percent's more for the same old stale donut?

Based on work with other drugs (analysis for hedge fund consulting work), I'd say it's probably around 5-10 cents per 10 mg when you factor in cost to develop, cost to manufacture, and cost of supply chain (shipping, storing, etc.). Usually there is a 5-10 times markup for most pharmaceutical companies, but some charge much much more.

 

[CliveStaples]

So, @CliveStaples, did you end up quitting? Did things get better and you no longer need to quit? Are you at a new job, where the future is looking brighter? Just wondering, because I don't see that you followed up after your OP.

I persevered, and we now have magical Haldol back in stock. Used it today on a patient having "seizures" who was able to stop their convulsing long enough to transfer themselves from the EMS stretcher to the bed. I don't know how I failed to mention its antiepileptic activities before.

Now my most frustrating aspect of the job is the fluctuating hours with how ridiculously labile our volume has been over the past couple months. I just want to work full time and not be worried about not getting enough hours and having to pick up PRN at other facilities. Is that so much to ask for?