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Discussion in 'Emergency Medicine' started by Angry Birds, Apr 15, 2018.
So, what's your personal practice on this?
If I got a bad abrasion, I'd use drops.
I mean, do you discharge patients with the remainder of the Tetracaine bottle?
Only if they won't leave.
Likely no harm according to the new evidence I've seen (I think EMRAP had a segment a few years ago), but still standard of care and all over the textbooks NOT to.
I don't prescribe it.
I don't prescribe it but for patients with a legit abrasion who seem smart enough to follow basic instructions I explain how its used, the theoretical risks, why I will not be giving them a prescription for it, and then I leave the rest of the little bottle at bedside and tell them "I can't send you home with this but no one is going to come looking for the rest of it, wink wink". Small sample size but no one has returned with an ulcer yet and I would certainly use it personally if I had an abrasion.
I went to one of those CMEs that Rick Bukata runs, and one of the speakers said they had a colleague that gave out the bottle, and the pt used it so liberally, they eroded away their cornea, and needed a transplant. Doc got sued, and lost. Yet, he still does that - leaves the bottle there with a wink.
If I got sued, I would not continue to do the same thing the same way (and I'm not talking t-PA for or against CVA); however, that guy is one, and I work with a total idiot that is another (sued, didn't change practice). That's why I call him "the Walking Lawsuit". Every step seems like malpractice.
I wouldn't. I had corneal cross-linking (ue a big corneal abrasion) and my surgeon didn't give it to me. So why would I give it to a person with a small abrasion...
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as an anesthesiologist i see corneal abrasions with some frequency postoperatively, when pt rubs their eyes in pacu or someone forgets to put the eye tape before intubating.
single dose under supervision yes.
allow patient to bring home to self medicate? hell no
As others have noted, there is zero evidence that using topical anesthetics for 24 hours leads to harm. There have been 2 small papers from the same authors reporting no difference when compared to placebo. As far as textbooks, I've grown more cynical about the accuracy of books over the years as they are not peer-reviewed and often contain outdated information. I also leave the bottle in the room. That way, you are off the hook if the patient sues you because your attorney will ask on cross-examination, "Did you know that it was wrong to steal?"
I tell them to use saline rewetting drops. Seems to have same efficacy based on the lit.
I also tell them to suck it up. I didn't get tetracaine after my lasik, and that's one giant corneal abrasion too. They can take tylenol and motrin.
From the reddit legal advice sub-forum:
Regardless of the above using topical anesthetics for 24 hrs provides significant pain relief and has essentially zero chance of causing corneal damage.
The key is to only give a 24 hr supply (3cc of 0.5% or 0.o5% proparacaine).
Topical Anesthetic Use on Corneal Abrasions - R.E.B.E.L. EM - Emergency Medicine Blog
Although I care about the actual evidence, I care more about what is still considered standard of care at this time. Not giving topical anesthetics for corneal abrasion is clear standard of care and it's one of those things that is all good....until it's not. Why give the sharks an easy malpractice case?
The corneal epithelium regenerates rapidly. They will feel almost 100% better in 48 hours or less.
This is a great example of what we have to deal with on an everyday basis. In addition to convincing our patients that they don't need an xray, CT scan, blood work, IV fluids, we have to be able to defend our actions to other doctors, nurses, EMTs, laypersons. Not to mention the ED Director, chairperson, admin, etc.
There's no reason to do this. There are other ways to control this pain that have zero risk. I'm not saying corneal abrasions can't hurt, because they do, but let's face it, it's a scratch. A scratch. That's it.
And they heal fast.
Plus, there's lots of evidence local anesthetics are tissue toxic. They can kill chondrocytes in joints, etc. Yes, it's sad that potential lawsuits, frivolous or not, have to dominate every thing we do (and don't do), but that's the reality we live in. It's best to just accept that, rather than fight it. So, your patient can't have eye tetracaine, no matter how reasoned or self controlled he is, because plaintiffs' lawyers that haven't gone to medical school have taken that option away from him. That doesn't seem too hard a reality to accept. If a drug or a treatment has it's own commercial with a 1-800 number run by plaintiffs' attorneys, it's probably best to find an alternative that's not such easy lawyer-bait.
Also aware of literature backing short-term use of this, but I will never send anyone home with such things nor suggest they pocket the bottle in the ED until it is standard of care, if that ever happens. As above, if I'm going to have a target on my back, I want it to be for something more defensible than something not yet fully accepted.
(Incidentally, I know of a case where someone swiped the bottle from the ED. Many days of use. May or may not have been using what he was supposed to have been using. Attempted to sue the physician, stating "they never told me I couldn't use it at home so I took the bottle with me." Never went anywhere. But that it even became a story is a sad commentary on some of our medicolegal world.)
Personally I will never do this. Specifically because I know patients won’t follow directions and likely overuse the drops as noted in the cases above.
That Reddit thread sealed the deal for me. I will never let them take it home!
To be fair, if you read the comments on the reddit thread, basically everyone is telling the original poster he's an idiot with no standing to sue.
Yeah I feel ya. Issue is that the ophthalmologist will sell us out too. I had one that called me and yelled at me even though it was just the remainder of the very small bottle (<3 cc).
I don't ever send them home or Rx proparacaine/tetracaine drops though I am encouraged by some of the more recent literature supporting what I suspected all along which was no real change in outcome for short term use. For the bad ones, I'm generally Rx'ing abx, ketorolac drops +/- cyclopentalate.
That being said, I suffered my first major corneal abrasion (we've all had minor ones) recently and had a 40% abrasion and I've got to say that was one of the most painful and aggravating things I've ever had to deal with and I've got a major pain tolerance. It was this constant, intrusive, debilitating pain that kept me from even being able to fall asleep. I couldn't leave the house for 2 days, nor look at a computer screen or tv, I had to keep my windows closed and couldn't drive. The only way I could work was to use proparacaine drops every 20 mins and wear an eye patch. Luckily, the cornea heals extremely fast. However, that experience made me a little more empathetic to my pt's suffering from corneal abrasions. So... going forward I may be one of those types that explains to them why we don't Rx it but "wink wink", I'm going to leave it on the counter, etc..
However, our ophthalmologists here are not impressed with any of the new literature and def don't prescribe it. It's also def not standard of care among EPs, so I'd say if you are going to Rx, you do so at your own risk.
We've had this argument, on this website, before.
ER docs pushing for tetracaine for corneal abrasions!
We just had an *adverse event* with this.
Doc says it's cool to take home the tetracaine. "Heres the literature!" Homeboy takes it home. Uses several drops every hour and ulcerates his cornea.
Big kerfuffle. Good doc. Not playing this game.
Any idea how long the patient used the drops for? I suppose that's the unaccounted for variable that we don't pay attention to - patient stupidity. Will come back to bite you every time.
Word on the street is 2 days of hourly drops... but more importantly, you hit it right on the head:
Attention all medical students.
Your patients are idiots.
Yep. Five-star [email protected]
And the subsection of patients that we see in the ER are especially prone to being incorrigible r-tards.
Get used to it.
It highlights a bizarre phenomenon in medical education.
When you're a MS4/EM1... you say to yourself; "I don't know my @sshole from a hole in the ground. I better button up and pay attention." Somewhere in that line of thought, you also figure that your patients know more than you do, or (even worse, these days) because "patient satisfaction" is important, that they should serve as some kind of reference/guide for how things *should be* done.
Patients are generally 90% dumbass. The earlier you learn that, the better.
Aren’t you supposed to dilute it or something? Like 1:10?
I'm going to start a spinoff thread entitled: "Things patients say" (or something similar). Or hell; somebody start it up when you're hot and ready.
Last week, heard in my ER, to family member of snowbird:
"Your flu swab is positive for Influenza B. It's a bit late in flu season; but this is why you're having these symptoms."
(Family member, to be read in a Noo Yawk accent) "So, a Z-pack will help us then."
"No. The flu is a virus; you can't ki..."
"Listen, she got a Z-pack last year and was better in 3 days."
hah, i'm sure anyone who just reads that has to instantly suppress the urge to facepalm.