Someone please post an academic topic.

[RustedFox]

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I'm bored and want a small lecture on a relevant topic.

Someone please pick a topic and give some nuanced commentary, management pearls/pitfalls, or something else academic.

 

[xaelia]

Diagnosing SSPE is probably important, sadly. It seems as though they have an elevated risk for subsequent VTE, and will probably be candidates for anticoagulation rather than observation.

That said, it's a small study, and the risk for subsequent VTE is heterogenous – seems to go up with age, up if multiple SSPE are diagnosed. Probably still OK to send a young person (<65) home without commencing anticoagulation with an isolated SSPE and clean legs at index visit and follow-up. Over 65 and/or multiple SSPE, probably the balance of benefit vs. harm tilts towards anticoagulation.

ACP Journals

 

[WheezyBaby]

Diagnosing SSPE is probably important, sadly. It seems as though they have an elevated risk for subsequent VTE, and will probably be candidates for anticoagulation rather than observation.

That said, it's a small study, and the risk for subsequent VTE is heterogenous – seems to go up with age, up if multiple SSPE are diagnosed. Probably still OK to send a young person (<65) home without commencing anticoagulation with an isolated SSPE and clean legs at index visit and follow-up. Over 65 and/or multiple SSPE, probably the balance of benefit vs. harm tilts towards anticoagulation.

ACP Journals

I'm postcall. It took me about 30 seconds of thinking how subacute sclerosing panencephalitis and VTE were associated and why the hell it was pertinent to the ED to realize what you were actually talking about

 

[RustedFox]

Thanks.

Someone wax philosophical about something.

"Here's the thing about managing (XXX)... Yadda yadda yadda."

I've been off for 6 days now and my brain is itchy for medicine talk. That, and I'm really trying to encourage this forum to focus on the medicine; it's what we all still enjoy.

 

[WilcoWorld]

Hot off the presses for @RustedFox

Clinical question: The nurse comes to you about the elderly nursing home resident who's awaiting admission for a hip fracture. She's getting agitated, can we give her some ativan?

Answer: PLEASE DON'T

In residency I was taught that ativan is a very safe drug. Used alone it is hemodynamically stable and doesn't cause respiratory depression. Conversely, opioids kill people and you can only give little old ladies baby doses or else you'll totally zonk them out. THIS IS BACKWARDS. But, in the ED we don't see why. We see opioid OD's all the time, but fail to appreciate that none of those were people in acute pain who got weight-based morphine in a monitored setting. Contrariwise, when we give a dose or two of ativan in the ED, the nurse stops bothering us, and the patient goes upstairs - works for me!

What we don't see is that the elderly patient we gave ativan to often goes on to be in hypoactive delirium for 3 days, and then goes into agitated delirium until their pain gets adequately addressed.

Clinical pearl: Untreated pain is a leading cause of agitation and delirium in the elderly AND doses of 0.05-0.1mg/kg of IV morphine are well tolerated in elderly folks with OK to not-so-great renal function who are in acute pain. In the above-linked article the authors found ZERO increase in delirium (OR = 1.00) in patients who received opioids (but no benzos) while significant increases in delirium were observed in those who got benzos or benzos + opioids.

In summary: Benzodiazepines are a terrible analgesic. Do your hospitalists a favor - if you have an agitated elderly patient in the ED, make sure to treat pain before reaching for the benzos. By avoiding delirium you might shave a couple days off of their LoS, which may even decrease your ED boarding.

 

[RustedFox]

Hot off the presses for @RustedFox

Clinical question: The nurse comes to you about the elderly nursing home resident who's awaiting admission for a hip fracture. She's getting agitated, can we give her some ativan?

Answer: PLEASE DON'T

In residency I was taught that ativan is a very safe drug. Used alone it is hemodynamically stable and doesn't cause respiratory depression. Conversely, opioids kill people and you can only give little old ladies baby doses or else you'll totally zonk them out. THIS IS BACKWARDS. But, in the ED we don't see why. We see opioid OD's all the time, but fail to appreciate that none of those were people in acute pain who got weight-based morphine in a monitored setting. Contrariwise, when we give a dose or two of ativan in the ED, the nurse stops bothering us, and the patient goes upstairs - works for me!

What we don't see is that the elderly patient we gave ativan to often goes on to be in hypoactive delirium for 3 days, and then goes into agitated delirium until their pain gets adequately addressed.

Clinical pearl: Untreated pain is a leading cause of agitation and delirium in the elderly AND doses of 0.05-0.1mg/kg of IV morphine are well tolerated in elderly folks with OK to not-so-great renal function who are in acute pain. In the above-linked article the authors found ZERO increase in delirium (OR = 1.00) in patients who received opioids (but no benzos) while significant increases in delirium were observed in those who got benzos or benzos + opioids.

In summary: Benzodiazepines are a terrible analgesic. Do your hospitalists a favor - if you have an agitated elderly patient in the ED, make sure to treat pain before reaching for the benzos. By avoiding delirium you might shave a couple days off of their LoS, which may even decrease your ED boarding.

This is precisely what I was trying to inarticulately ask for.

 

[DrSnips]

By avoiding delirium you might shave a couple days off of their LoS, which may even decrease your ED boarding.

This is very true. Nursing facilities won't take patients on 1:1 obs, which is exactly what the floor RN will insist on for agitated delirium.

 

[thegenius]

Diagnosing SSPE is probably important, sadly. It seems as though they have an elevated risk for subsequent VTE, and will probably be candidates for anticoagulation rather than observation.

I'm postcall. It took me about 30 seconds of thinking how subacute sclerosing panencephalitis and VTE were associated and why the hell it was pertinent to the ED to realize what you were actually talking about

Me too! I didn't know at first what SSPE was, I thought it was some flesh eating man-brain parasite or something. And Xaelia writes "diagnosing it is probably important, sadly."

L M FOOKING ARSE OFF

 

[thegenius]

Hot off the presses for @RustedFox

Clinical question: The nurse comes to you about the elderly nursing home resident who's awaiting admission for a hip fracture. She's getting agitated, can we give her some ativan?

Answer: PLEASE DON'T

In residency I was taught that ativan is a very safe drug. Used alone it is hemodynamically stable and doesn't cause respiratory depression. Conversely, opioids kill people and you can only give little old ladies baby doses or else you'll totally zonk them out. THIS IS BACKWARDS. But, in the ED we don't see why. We see opioid OD's all the time, but fail to appreciate that none of those were people in acute pain who got weight-based morphine in a monitored setting. Contrariwise, when we give a dose or two of ativan in the ED, the nurse stops bothering us, and the patient goes upstairs - works for me!

What we don't see is that the elderly patient we gave ativan to often goes on to be in hypoactive delirium for 3 days, and then goes into agitated delirium until their pain gets adequately addressed.

Clinical pearl: Untreated pain is a leading cause of agitation and delirium in the elderly AND doses of 0.05-0.1mg/kg of IV morphine are well tolerated in elderly folks with OK to not-so-great renal function who are in acute pain. In the above-linked article the authors found ZERO increase in delirium (OR = 1.00) in patients who received opioids (but no benzos) while significant increases in delirium were observed in those who got benzos or benzos + opioids.

In summary: Benzodiazepines are a terrible analgesic. Do your hospitalists a favor - if you have an agitated elderly patient in the ED, make sure to treat pain before reaching for the benzos. By avoiding delirium you might shave a couple days off of their LoS, which may even decrease your ED boarding.

Good stuff Wilco

 

[dchristismi]

I have been ranting about this of late as well. I always write for teensy doses of benzos and much bigger doses of opiates and even my seasoned hospice nurses don't always get it. OLD PEOPLE ARE STOIC but their body language can give them away.

Here is a way to assess (nonverbal) (technically, demented but you can extrapolate to other perhaps delirious) people in a validated way:

Then you do the math.
Notice that it doesn't go past 10.

 

[xaelia]

Hah, I figured an ED group might think "PE" before "measles", but, oh well. 🙃

 

[Jabbed]

Afib RVR management:

1. I love giving Mag. It's probably the safest anti-arrhythmic and is so underused in my department. There's moderate evidence to support it as an adjunct. I'll order 4 g over 2 hours.
2. Why do people underdose diltiazem? 0.25 mg/kg followed by 0.35 mg/kg. I'll often tell the nurse to put it in a 50 cc bag and run it over 10 minutes. The highest dose that I've given at once was 50 mg and I've yet to have a patient become hypotensive during infusion.
3. Every now and then I'll mix diltiazem and metoprolol. HR 140 on dilt gtt? 2.5 mg metoprolol brings them down to 70 bpm.
4. I used to dig load people with CHF and AF RVR more often in residency.
5. I'll often think "Hm this hypotensive afib RVR who failed cardioversion would probably be better on a phenylephrine gtt". But then I put them on levophed anyway because I know that the intensivist will be judge me and change my orders 30 minutes later.

 

[thegenius]

Afib RVR management:

1. I love giving Mag. It's probably the safest anti-arrhythmic and is so underused in my department. There's moderate evidence to support it as an adjunct. I'll order 4 g over 2 hours.
2. Why do people underdose diltiazem? 0.25 mg/kg followed by 0.35 mg/kg. I'll often tell the nurse to put it in a 50 cc bag and run it over 10 minutes. The highest dose that I've given at once was 50 mg and I've yet to have a patient become hypotensive during infusion.
3. Every now and then I'll mix diltiazem and metoprolol. HR 140 on dilt gtt? 2.5 mg metoprolol brings them down to 70 bpm.
4. I used to dig load people with CHF and AF RVR more often in residency.
5. I'll often think "Hm this hypotensive afib RVR who failed cardioversion would probably be better on a phenylephrine gtt". But then I put them on levophed anyway because I know that the intensivist will be judge me and change my orders 30 minutes later.

I don't do #1 because I give adequate doses of the drug in #2. For the average person I start with 20 mg dilt IV, and then will go to 25 - 30 mg for the second dose.

Problem is sometimes these little old 82 yo ladies who are going at 165 and have a BP of 115/70. They weigh 50 kg and are not shocky. However when you give them diltiazem 0.25 mg / kg (like for instance ~15 mg), their BP becomes 82/51, everybody freaks out, and it takes like 6 hours for the systolic to climb above 100

 

[Jabbed]

I don't do #1 because I give adequate doses of the drug in #2. For the average person I start with 20 mg dilt IV, and then will go to 25 - 30 mg for the second dose.

Problem is sometimes these little old 82 yo ladies who are going at 165 and have a BP of 115/70. They weigh 50 kg and are not shocky. However when you give them diltiazem 0.25 mg / kg (like for instance ~15 mg), their BP becomes 82/51, everybody freaks out, and it takes like 6 hours for the systolic to climb above 100

Try the IV piggyback! It's voodoo but I swear by it.

 

[thegenius]

Try the IV piggyback! It's voodoo but I swear by it.

Dood it's not voodoo. I love it!!! But if I do that kind of thing it has to be "under the counter". I can't order it that way because Pharmacy says "THIS ISN'T A PROTOCOL."

So the nurse has to feel fine doing it. You don't put it on a pump, do you? Just let it drip in over 10 mins?

 

[Jabbed]

Dood it's not voodoo. I love it!!! But if I do that kind of thing it has to be "under the counter". I can't order it that way because Pharmacy says "THIS ISN'T A PROTOCOL."

So the nurse has to feel fine doing it. You don't put it on a pump, do you? Just let it drip in over 10 mins?

Ya I just have them run a 50 cc bag wide open. If they raise an eyebrow I just say "Well, it should be a 5-10 minute push so if you want to do that instead.."

 

[RustedFox]

Someone needs to do this brief AFib TED talk with acute CHF and it's heterogeneous disease states.

It's this kind of stuff that I'm talking about. Strike while the iron is hot, amigos.

 

[HoosierdaddyO]

I love haldol… I wish it was in the cities water supply sometimes.

2.5 to 5mg IM for anything related to GI (and obviously the psychotic fella flinging poop). But Haldol 5 mg IM has been my go to for intractable N and V, Gastroparesis, cannabinoid hyperemesis. I try to get the EKG in most if not all patients who I give it to ahead of time. But otherwise very safely tolerated and safe profile 🙂.

Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department - PubMed

The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

pubmed.ncbi.nlm.nih.gov

 

[thegenius]

I love haldol… I wish it was in the cities water supply sometimes.

2.5 to 5mg IM for anything related to GI (and obviously the psychotic fella flinging poop). But Haldol 5 mg IM has been my go to for intractable N and V, Gastroparesis, cannabinoid hyperemesis. I try to get the EKG in most if not all patients who I give it to ahead of time. But otherwise very safely tolerated and safe profile 🙂.

Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department - PubMed

The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

pubmed.ncbi.nlm.nih.gov

I should have used this yesterday. I admitted a DM gastroparesis after she was still intolerant of PO despite reglan 10 &
5, ativan, famotidine, PO GI cocktail, and 2L IVF.

 

[GassYous]

I love haldol… I wish it was in the cities water supply sometimes.

2.5 to 5mg IM for anything related to GI (and obviously the psychotic fella flinging poop). But Haldol 5 mg IM has been my go to for intractable N and V, Gastroparesis, cannabinoid hyperemesis. I try to get the EKG in most if not all patients who I give it to ahead of time. But otherwise very safely tolerated and safe profile 🙂.

Haloperidol undermining gastroparesis symptoms (HUGS) in the emergency department - PubMed

The rate of admission and ME was found to be significantly reduced in patients with GP secondary to diabetes mellitus who received HP. HP may represent an appropriate, effective, and safe alternative to traditional analgesia and antiemetic therapy in the ED management of GP associated N/V/AP.

pubmed.ncbi.nlm.nih.gov

Why not capsaicin cream for the pot smokers

 

[BoardingDoc]

Why not capsaicin cream for the pot smokers

Droperidol is easier and tends to work better in my experience. We see a lot of cannabinoid hyperemesis in my shop. Capsaicin works on maybe 60%. 1.25-2.5mg IV droperidol works on 95+%.

 

[southerndoc]

Droperidol is easier and tends to work better in my experience. We see a lot of cannabinoid hyperemesis in my shop. Capsaicin works on maybe 60%. 1.25-2.5mg IV droperidol works on 95+%.

Yep, use it all the time. Had a lady stuttering last night from her anxiety complaining of abdominal pain and nausea/vomiting. 0.625 of droperidol did the trick. Discharged shortly afterwards (already received labs from waiting room).

 

[thegenius]

Let's say Dr. Genius orders droperidol 1.25 mg IV for a young, seemingly healthy patient with n / v. 20 minutes later the pt goes into VT, is shocked several times and ended up intubated in the ICU. The subsequent EKG shows a prolonged QTc.

Is there precedent for Hospital Pharmacists to be successfully sued / settle for an adverse outcome from a drug ordered by a doctor at a hospital? I'm trying to figure out why our Pharmacy department is reticent to stock droperidol.

 

[southerndoc]

Let's say Dr. Genius orders droperidol 1.25 mg IV for a young, seemingly healthy patient with n / v. 20 minutes later the pt goes into VT, is shocked several times and ended up intubated in the ICU. The subsequent EKG shows a prolonged QTc.

Is there precedent for Hospital Pharmacists to be successfully sued / settle for an adverse outcome from a drug ordered by a doctor at a hospital? I'm trying to figure out why our Pharmacy department is reticent to stock droperidol.

I presented a lecture on droperidol to the paramedics. In my review of the literature and FDA reports of "adverse events," many of the deaths attributed to droperidol were complex patients with sepsis, traumatic brain injury, and end organ damage prior to administration of droperidol. It is highly unlikely that droperidol caused their death. Furthermore, the patients who did develop Torsades received doses I would never administer to a patient. One patient received almost 300 mg of droperidol in a 24 hour period before going into Torsades. The FDA blackboxed droperidol for 90 cases of prolongation of the QTc, all of which received >200 mg of droperidol. The majority of these had other reasons for QTc prolongation (cardiac disease, antiarrhythmics, etc.).

A large multi-center study of over 1,000 patients (Ann Emerg Med, 2015;66(3):230-238.e1) used 10-20 mg droperidol IV/IM and noted 1.3% had QTc prolongation with 50% of those having another cause for QTc prolongation. None developed Torsades.

In reality, droperidol is safe.

 

[bravotwozero]

Let's say Dr. Genius orders droperidol 1.25 mg IV for a young, seemingly healthy patient with n / v. 20 minutes later the pt goes into VT, is shocked several times and ended up intubated in the ICU. The subsequent EKG shows a prolonged QTc.

Is there precedent for Hospital Pharmacists to be successfully sued / settle for an adverse outcome from a drug ordered by a doctor at a hospital? I'm trying to figure out why our Pharmacy department is reticent to stock droperidol.

Cost is one issue. Been told by one of the medical directors it’s 12 times the cost of haldol!

 

[The kitchen sink]

Afib RVR management:

1. I love giving Mag. It's probably the safest anti-arrhythmic and is so underused in my department. There's moderate evidence to support it as an adjunct. I'll order 4 g over 2 hours.
2. Why do people underdose diltiazem? 0.25 mg/kg followed by 0.35 mg/kg. I'll often tell the nurse to put it in a 50 cc bag and run it over 10 minutes. The highest dose that I've given at once was 50 mg and I've yet to have a patient become hypotensive during infusion.
3. Every now and then I'll mix diltiazem and metoprolol. HR 140 on dilt gtt? 2.5 mg metoprolol brings them down to 70 bpm.
4. I used to dig load people with CHF and AF RVR more often in residency.
5. I'll often think "Hm this hypotensive afib RVR who failed cardioversion would probably be better on a phenylephrine gtt". But then I put them on levophed anyway because I know that the intensivist will be judge me and change my orders 30 minutes later.

#5: I had thought persistent tachycardia is precisely one of the reasons people theoretically trialed phenylephrine over norepinephrine for hypotense afib rvr.

The data is out here, certainly not a slam dunk though:

Does Switching Norepinephrine to Phenylephrine in Septic Shock Complicated by Atrial Fibrillation With Rapid Ventricular Response Improve Time to Rate Control? - PubMed

Our study suggests a potential clinical effect on achieving rate control when switching to phenylephrine cannot be excluded. It remains unclear if there is a benefit on mortality or length of stay outcomes in critically ill patients.

pubmed.ncbi.nlm.nih.gov

 

[WilcoWorld]

Let's say Dr. Genius orders droperidol 1.25 mg IV for a young, seemingly healthy patient with n / v. 20 minutes later the pt goes into VT, is shocked several times and ended up intubated in the ICU. The subsequent EKG shows a prolonged QTc.

Is there precedent for Hospital Pharmacists to be successfully sued / settle for an adverse outcome from a drug ordered by a doctor at a hospital? I'm trying to figure out why our Pharmacy department is reticent to stock droperidol.

When I last reviewed the literature, the doses of droperidol that were followed by adverse events were 10-20x what I'd use in the ED.

 

[WilcoWorld]

A large multi-center study of over 1,000 patients (Ann Emerg Med, 2015;66(3):230-238.e1) used 10-20 mg droperidol IV/IM and noted 1.3% had QTc prolongation with 50% of those having another cause for QTc prolongation. None developed Torsades.

That's what I'm talking about. I've never come CLOSE to 10mg, let alone 20mg of droperidol. Those are PACU doses.

 

[lymphocyte]

Afib RVR management:

1. I love giving Mag. It's probably the safest anti-arrhythmic and is so underused in my department. There's moderate evidence to support it as an adjunct. I'll order 4 g over 2 hours.

Completely agree. I give adjuvant Mg liberally in rapid AF. This is supported by a pragmatic multicenter RCT called LOMAGHI. The trial arm with the best outcome received 4.5g over 30 minutes. Often times I just push it at the beside. Works even better in post-operative AF.

LOMAGHI Trial: Magnesium Sulfate for Rapid Atrial Fibrillation? - REBEL EM - Emergency Medicine Blog

Recently, the LOMAGHI study was just published trying to answer the question of exact dose of magnesium sulfate to use for patients with rapid atrial fibrillation.

rebelem.com

 

[AlmostAnMD]

Cost is one issue. Been told by one of the medical directors it’s 12 times the cost of haldol!

I don't know if that's true but even if it is, it's 12 times the cost for 20 times the result imo

Dropping someone with just the right dose is more than just snowing the patient like Haldol, they just look at me and tell me they feel better. Then I discharge them.

Never pass up an opportunity to drop someone

 

[Vandalia]

Let's say Dr. Genius orders droperidol 1.25 mg IV for a young, seemingly healthy patient with n / v. 20 minutes later the pt goes into VT, is shocked several times and ended up intubated in the ICU. The subsequent EKG shows a prolonged QTc.

Is there precedent for Hospital Pharmacists to be successfully sued / settle for an adverse outcome from a drug ordered by a doctor at a hospital? I'm trying to figure out why our Pharmacy department is reticent to stock droperidol.

Why bother to sue the pharmacist when you can sue the hospital?

From what I am hearing the trend is to not even naming the physician in malpractice suits. Go after the deep pockets and don’t have a sympathetic physician as defendant.

 

[alpinism]

High dose nitroglycerin bolus in crashing heart failure patients.

That also includes patients with normal blood pressures.

I'll usually give 2mg but sometimes do up to 20mg boluses.

Haven't intubated a CHF patient in six years and almost everyone gets admitted to a floor bed on supplemental oxygen.

Nowadays I mostly hate working in the United States but one of the few joys I still have is watching the medicine residents face when they're freaking out asking for intubation and I'm like nope and push the meds and the patient is almost completely symptom free after a couple hours.

 

[Mr. Vandemar]

Do I get CME for reading this thread?

 

[Dred Pirate]

Let's say Dr. Genius orders droperidol 1.25 mg IV for a young, seemingly healthy patient with n / v. 20 minutes later the pt goes into VT, is shocked several times and ended up intubated in the ICU. The subsequent EKG shows a prolonged QTc.

Is there precedent for Hospital Pharmacists to be successfully sued / settle for an adverse outcome from a drug ordered by a doctor at a hospital? I'm trying to figure out why our Pharmacy department is reticent to stock droperidol.

data point of N=1 - I have a friend who was on a lawsuit for some completely stupid lawsuit and had to give a deposition for approving an order were the pt ended up leaving the ED and passing - I think the hospital settled even thou from what I know there was no basis for a lawsuit. That being said, there is a reason our malpractice insurance is only a couple of hundred bucks a year for $2 million coverage - bc we aren't the center of many lawsuits - even thought rph's are the most anal people I know and always insist "I want to keep my license" - other than narcotic diversion or just blantant idocracy, I don't know of any cases of a Rph losing their license while working in good faith.

On the droperidol talk - I personally love it as it seems to work for so must (agitation, headache, HV, and drama) - we only ask for EKG if using > 1.25mg as a dose, and even then I am not a big stickler based on the same comments as above in regards to the dose. I personally haven't ever seen a bad outcome - and the follow up ekg's haven't been concerning in cases that I have seen - and as far as I know - my hospital hasn't had a bad outcome (and hopefully I didn't jinx it).

I honestly don't know the cost of it, it was cheap before they manufacturer quick making it years ago, and now that it is back - I know big pharma likes to play games with the price of these drugs, but I have never been told that it is expensive at all - and we have had a lot of cost containment plans, so if it was expensive, I am sure it would have been on somebody's radar. I will try to remember to look it up when I am back at work.

I think so many people have a knee jerk reaction to the black box warning without looking into what caused it and don't realize the doses that were given in the cases. Heck, I worked with an old school guy that retired a few years back that worked in a psych hospital 40-50 years ago and he said they would give like 50-75 mg of haldol all the time. That being said, there is probably a reason we don't do that anymore.

 

[WilcoWorld]

High dose nitroglycerin bolus in crashing heart failure patients.

That also includes patients with normal blood pressures.

I'll usually give 2mg but sometimes do up to 20mg boluses.

Haven't intubated a CHF patient in six years and almost everyone gets admitted to a floor bed on supplemental oxygen.

Nowadays I mostly hate working in the United States but one of the few joys I still have is watching the medicine residents face when they're freaking out asking for intubation and I'm like nope and push the meds and the patient is almost completely symptom free after a couple hours.

20mg of nitro?!?! Is that a typo?

I love high dose NTG for sick heart failure patients, but 20,000mcg makes even me do a double take.

 

[gutonc]

Why bother to sue the pharmacist when you can sue the hospital?

From what I am hearing the trend is to not even naming the physician in malpractice suits. Go after the deep pockets and don’t have a sympathetic physician as defendant.

Totally unrelated to the case at hand, or the OP, but I have personally experienced this twice now. I'm peripheral in both cases (saw patient once or twice for 2nd opinion, pursued treatment with another physician) but plaintiffs aren't naming individual physicians in the suits, just the hospital.

 

[WheezyBaby]

Hah, I figured an ED group might think "PE" before "measles", but, oh well. 🙃

I'm not ED, I'm sure your target audience wasn't confused!




Weingart has a great lecture on SCAPE and high dose nitro pushes, don't remember what he "maxed" at though

 

[RustedFox]

I'm not ED, I'm sure your target audience wasn't confused!




Weingart has a great lecture on SCAPE and high dose nitro pushes, don't remember what he "maxed" at though

What are you ? Peds?

 

[southerndoc]

Cost is one issue. Been told by one of the medical directors it’s 12 times the cost of haldol!

$4 for 2.5 mg of droperidol vs $3.75 for a 5 mg vial of haloperidol.

Yea, it's more expensive but not 12 times the cost of haloperidol.

 

[southerndoc]

Totally unrelated to the case at hand, or the OP, but I have personally experienced this twice now. I'm peripheral in both cases (saw patient once or twice for 2nd opinion, pursued treatment with another physician) but plaintiffs aren't naming individual physicians in the suits, just the hospital.

Counsel for the plaintiff does this when unbeknownst to you, they try to use you as a witness against the hospital. Most ED docs have a $1/3 policy. Not naming you is leaving money on the table. Be careful though, your deposition could get you named into litigation (i.e., they don't name you initially, you think you're in the free and clear, give a deposition and say something you shouldn't, and then you get named). Always make sure you have representation for yourself provided by your malpractice carrier and not the hospital unless you are employed by the hospital.

 

[gutonc]

Counsel for the plaintiff does this when unbeknownst to you, they try to use you as a witness against the hospital. Most ED docs have a $1/3 policy. Not naming you is leaving money on the table. Be careful though, your deposition could get you named into litigation (i.e., they don't name you initially, you think you're in the free and clear, give a deposition and say something you shouldn't, and then you get named). Always make sure you have representation for yourself provided by your malpractice carrier and not the hospital unless you are employed by the hospital.

The only reason I've heard about either of these is through hospital risk management. In neither case have I been deposed or spoken to plaintiff or their counsel. I do a lot of dumb s***, but talking to lawyers who aren't mine, without mine present, isn't on the list.

 

[Vandalia]

Counsel for the plaintiff does this when unbeknownst to you, they try to use you as a witness against the hospital. Most ED docs have a $1/3 policy. Not naming you is leaving money on the table. Be careful though, your deposition could get you named into litigation (i.e., they don't name you initially, you think you're in the free and clear, give a deposition and say something you shouldn't, and then you get named). Always make sure you have representation for yourself provided by your malpractice carrier and not the hospital unless you are employed by the hospital.

There is nothing to leave on the table. You do not get any more damages by suing more people.

No plaintiff can recover more than their actual damages. An attorney sues multiple physician defendants to add up all the $1M policy limits. That is not necessary when the hospital is a defendant because their assets - heck, their cash reserves - are enough to simply write a check for damages. A physician's liability is capped at the policy limit; even though a hospital has insurance, it bears no relation to their ability to pay and what an attorney will seek. An attorney does not want to get into a situation where they won a $10M verdict and liability was split 50/50 with the hospital and the physician. Ah! but they could only get $1M from the physician. So they left $4M on the table by suing the physician. Far better to sue just the hospital and have them write a $10M check. (Reality is a little more complicated.)

The only exception would be if the hospital is bankrupt or near to it.

 

[southerndoc]

There is nothing to leave on the table. You do not get any more damages by suing more people.

No plaintiff can recover more than their actual damages. An attorney sues multiple physician defendants to add up all the $1M policy limits. That is not necessary when the hospital is a defendant because their assets - heck, their cash reserves - are enough to simply write a check for damages. A physician's liability is capped at the policy limit; even though a hospital has insurance, it bears no relation to their ability to pay and what an attorney will seek. An attorney does not want to get into a situation where they won a $10M verdict and liability was split 50/50 with the hospital and the physician. Ah! but they could only get $1M from the physician. So they left $4M on the table by suing the physician. Far better to sue just the hospital and have them write a $10M check. (Reality is a little more complicated.)

The only exception would be if the hospital is bankrupt or near to it.

I disagree. This has not been my experience from my own litigation as well as being an expert witness/peer reviewer.

Hospitals usually carry $7 million per occurrence policies. The number of verdicts that are exceeding $10 million has been increasing, so every policy is a target. Obviously if it's a $300,000 case it makes no sense to add the physician, unless there is a claim that the physician had a lot of responsibility. Respondeat superior does not apply to independent contractors in most states, so if an emergency physician as an IC discharges a patient that had a catastrophic outcome, then there is shared liability (or sole liability in some circumstances).

If parties come to the table to mediate into a settlement, it gives plaintiff's counsel more power to force a higher settlement from the hospital (i.e., hospital pays more money to have plaintiff drop the physician as an act of good faith by the hospital).

EDIT: @Vandalia I forgot to mention that you said if the physician is named and is deemed 50% responsible, then the plaintiff may not get everything because of per occurrence limits on the physician's insurance. In most states, if the hospital is deemed 50% responsible and an unnamed party or the patient him/herself is deemed 50% responsible, then the hospital is only liable for 50% of the verdict. In other words, if the hospital is successfully litigated, gets a judgement of $10 million, but an unnamed physician is deemed 50% responsible, then the hospital's insurer is only obligated to pay $5 million. The plaintiff left money on the table by not naming the physician. The physician's policy would've only paid $1 mil, and in most cases counsel for the plaintiff doesn't go after personal assets.

 

[WilcoWorld]

I'm not ED, I'm sure your target audience wasn't confused!




Weingart has a great lecture on SCAPE and high dose nitro pushes, don't remember what he "maxed" at though

Looks like he recommended a 400mcg/min x 2 min load, which is a practice that I preach to my residents. That's 0.8mg - 1/25th of the 20mg cited above. 2mg seems believable to me (500mcg SL q5 x 3 is a standard order and that adds up to 1.5mg), though the nurses would probably give me a side eye.

20mg sounds like a typo.

 

[DrSnips]

An attorney does not want to get into a situation where they won a $10M verdict and liability was split 50/50 with the hospital and the physician. Ah! but they could only get $1M from the physician. So they left $4M on the table by suing the physician.

Wouldn't the $4 million come out of the physician's pocket in that case? (Or if personal assets are less than $4 million then however much they have)

 

[WheezyBaby]

What are you ? Peds?

Medpeds / PICU

 

[thegenius]

High dose nitroglycerin bolus in crashing heart failure patients.

That also includes patients with normal blood pressures.

I'll usually give 2mg but sometimes do up to 20mg boluses.

Haven't intubated a CHF patient in six years and almost everyone gets admitted to a floor bed on supplemental oxygen.

Nowadays I mostly hate working in the United States but one of the few joys I still have is watching the medicine residents face when they're freaking out asking for intubation and I'm like nope and push the meds and the patient is almost completely symptom free after a couple hours.

You do not give 2mg or even 20 mg nitroglycerin at once? 20 mg?

The standard dosing is 0.4 mg every 5 mins or so. I’ll occasionally start drips at 100 mcg/min/hr but that is rare.

 

[Apollyon]

100 mcg/min/hr

Minutes and hours are the same units. Did you mean mcg/kg/min?

 

[lucid_leprechaun]

Looks like he recommended a 400mcg/min x 2 min load, which is a practice that I preach to my residents. That's 0.8mg - 1/25th of the 20mg cited above. 2mg seems believable to me (500mcg SL q5 x 3 is a standard order and that adds up to 1.5mg), though the nurses would probably give me a side eye.

20mg sounds like a typo.

There was a study recently on high dose nitro in CHF

High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study - PubMed

Use of our specific SCAPE treatment algorithm, which included high-dose NTG and NIV, was safe and provided rapid resolution of symptoms.

pubmed.ncbi.nlm.nih.gov

But in my opinion is kind of silly. Put them on PPV with typical high dose nitro dosing and appropriate after load reduction (in my mind 200-400 mcg/min infusion. Super high dose nitro is a treatment for a problem we don’t actually have. These patients typically improve very quickly with SOC.

 

[thegenius]

Minutes and hours are the same units. Did you mean mcg/kg/min?

yea yea