The PITT

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Point of clarification:

Here's the exchange that got me to eyeroll:

EMS: "50mcg of fentanyl didn't touch her."
Surgeon: "Give her 4 of morphine."
ER resident: "NoO! It COULD depress her mental status."

Me: Puh-lease.
 
EMhawkeye said:
Europe manages hip fractures without opioids and just IV tylenol.
Many Americans have very altered perceptions of pain and analgesia. Or they have a fundamental misunderstanding of the purpose of pain meds being to make pain tolerable and not zonk you out so much you can’t perceive it.
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the fact that 80% of the world's opioids are consumed in North America says a lot about American's perception of pain vs the rest of humanity.
 
thegenius said:
I can't imagine this will be any different than all the other "realistic" ER shows.
The only thing that would make me watch it, is the producers also made West Wing, the best political drama series of the past few decades.
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Oh heck yeah. West Wing was one of the best TV shows that’s ever been made, certainly the best in the political genre (obviously just my opinion). I will say the show was not nearly as good when Aaron Sorkin left, but it was still great.
 
EMhawkeye said:
Europe manages hip fractures without opioids and just IV tylenol.
Many Americans have very altered perceptions of pain and analgesia. Or they have a fundamental misunderstanding of the purpose of pain meds being to make pain tolerable and not zonk you out so much you can’t perceive it.
Click to expand...
Mount Asclepius said:
I’ve come full circle on Morphine. Initially I was persuaded we were under dosing and they just needed 8-10 mg for proper dosing. The focus on ALTO and even MME reduction has me back to giving doses of 2-4 mg, or alternatively just 0.2 mg of Dilaudid instead of 1 mg when I would have previously thought that was trivial. I’ve been pleasantly surprised that just taking the edge off of patients pain achieving tolerable and stopping the screaming from the room across from the doc box is all that is needed for patient, staff and physician satisfaction. People can live with a little pain and I prefer that to the delirium or respiratory depression from over medication. Moving past pain as a vital sign though was key to this change. They mandated treating pain, and now they mandate not treating. Lovely migration to the extremes…
Click to expand...

Americans feel entitled to not having any adverse symptoms at any time: pain, nausea, mild thirst/hunger.

That being said, as long as patient sat is part of my pay, I will be giving the things
 
This show is pretty good so far. I went in with very low expectations so the medicine actually being pretty spot on is impressive. Obviously the acuity shown between 7a and 9a is outside the realm of reality but they're also showing us an ED with a physician in triage and so boarded up that only higher acuity patients are making it back.

I'll be curious to find out how they managed to keep the medicine and the character's challenges (boarding, patient satisfaction, burnout, etc.) so close to reality.

For Scrubs, a show famous for the accuracy of its depiction of medicine, the authenticity was because Bill Lawrence (the creator of the show) used his best friend from college, a Cardiologist, as the show's medical advisor. I believe that as opposed to hiring an advisor that he could get to ignore as soon as is inconvenient to the narrative of the show, using someone he had a real personal friendship with is what contributed to the accuracy.

There's a real life ER doc or group of ER docs that are behind a lot of the writing of this show and I'd love to find out how they pulled it off so well, at least for two episodes.
 
Mount Asclepius said:
I’ve come full circle on Morphine. Initially I was persuaded we were under dosing and they just needed 8-10 mg for proper dosing. The focus on ALTO and even MME reduction has me back to giving doses of 2-4 mg, or alternatively just 0.2 mg of Dilaudid instead of 1 mg when I would have previously thought that was trivial. I’ve been pleasantly surprised that just taking the edge off of patients pain achieving tolerable and stopping the screaming from the room across from the doc box is all that is needed for patient, staff and physician satisfaction. People can live with a little pain and I prefer that to the delirium or respiratory depression from over medication. Moving past pain as a vital sign though was key to this change. They mandated treating pain, and now they mandate not treating. Lovely migration to the extremes…
Click to expand...
I still weight base dose my opioids but I was taught it’s 0.1mg/kg in residency when it is actually 0.05-0.1mg/kg. So I have also reduced my overall amounts but find I still can’t go below that for most conditions actually warranting opioids. Average patient translates to 3-6mg morphine. 2mg for elderly as trial dose
 
RustedFox said:
LoL.
But DiVeRsiTy.
That's the reason I'm not in the NBA and I'm just an ER doc; because the NBA needs diversity. It's the solution to all things at all times. If only the NBA had DEI requirements, the underrepresented would have what they are entitled to and everything would be fair.

Say otherwise and you're a bigot.
Click to expand...
You should watch New Amsterdam. One episode the racism is so bad that it caused a kid to get cancer.

Scrubs is my all time favorite show.

I thought the show ER was pretty good though. I'll have to check out this new one.
 
Rendar5 said:
I still weight base dose my opioids but I was taught it’s 0.1mg/kg in residency when it is actually 0.05-0.1mg/kg. So I have also reduced my overall amounts but find I still can’t go below that for most conditions actually warranting opioids. Average patient translates to 3-6mg morphine. 2mg for elderly as trial dose
Click to expand...
I always nurse-base dose mine. Our morphine comes in 4 mg vials and hydromorphone in 1 mg vials. Never order 1.5 of hydromorphone or 6 mg of morphine. 0.5, 1 or 2 of hydromorphone or 2, 4 or 8 of morphine it is.

I try to eliminate nurses needing to waste it as much as possible because it slows them down to get a second signoff/witness. Obviously the elderly get a lowered dose, but I'd rather order 4 of morphine instead of 6 because the patient gets it quicker. It's easier and quicker for a repeat dosage than it is a "middle" dose with a waste.
 
RustedFox said:
You know what grabbed my eye?
The brand spanking new intern somehow instantly knew the EMR and clicked around it with ease.
Click to expand...
When I was a new intern one of our hospitals had “CHolace” and “Colace” both as meds that could be ordered. I spent the whole first year of residency sending constipated/hemorrhoid people home with scripts for “CHolase” until finally an outpatient pharmacist called my cell phone and told me to stop ordering it.

Turns out “CHolase” is an herbal supplement that contains garlic and cayenne pepper. Probably not the most helpful for constipation or hemorrhoids…
 
The Knife & Gun Club said:
When I was a new intern one of our hospitals had “CHolace” and “Colace” both as meds that could be ordered. I spent the whole first year of residency sending constipated/hemorrhoid people home with scripts for “CHolase” until finally an outpatient pharmacist called my cell phone and told me to stop ordering it.

Turns out “CHolase” is an herbal supplement that contains garlic and cayenne pepper. Probably not the most helpful for constipation or hemorrhoids…
Click to expand...

Good thing colace doesn’t really work lol
 
The Knife & Gun Club said:
When I was a new intern one of our hospitals had “CHolace” and “Colace” both as meds that could be ordered. I spent the whole first year of residency sending constipated/hemorrhoid people home with scripts for “CHolase” until finally an outpatient pharmacist called my cell phone and told me to stop ordering it.

Turns out “CHolase” is an herbal supplement that contains garlic and cayenne pepper. Probably not the most helpful for constipation or hemorrhoids…
Click to expand...
You actually probably did a lot more good than harm. I bet those people never came back to the ED for constipation/hemorrhoids.
 
JacobMcCandles said:
You actually probably did a lot more good than harm. I bet those people never came back to the ED for constipation/hemorrhoids.
Click to expand...
One of my co-residents got fired from his urgent care moonlighting gig for prescribing capsaicin cream for hemorrhoids.

The guy had to go to the ED and get multiple doses of morphine for pain control.

Pt just filled his hand with the stuff and slathered it on there.
 
RustedFox said:
I eyerolled hard at doing an extemity block on that leg and fights over 4mg morphine.
Click to expand...

...but not the scene where surgery is like, "We'll admit this guy for observation" and Carter goes, "Naw, I'll take the liability of discharging him instead"?
 
thegenius said:
I don't anticipate ever watching it becuase I'm not paying to get HBO Max
Click to expand...
honestly, it might be the single best streaming service - especially because of the massive amount of tv channels it just happens to have included because of the discovery/WB merger element.

it might also be one of the worst layouts with 90-95% of the screen space dedicated to HBO and Max products and a tiny out of the way area where you can open "other brands" and suddenly realize that its like 10 different streaming services. Plus its movie library is... like... actual movies youve heard of and would want to watch.
 
Lexdiamondz said:
the fact that 80% of the world's opioids are consumed in North America says a lot about American's perception of pain vs the rest of humanity.
Click to expand...
there were a few comments on this, but ill pick yours for the reply just so I'm quoting somebody.

Working in NYC and Miami I get to see this a lot with true recent immigrants. I also did a Haitian medical charity mission and I'm sure plenty of people who have done medical charity abroad can say the same thing: most people in the world have ZERO exposure to opiates and find them, even in small doses, overwhelmingly sedating and temporarily delirium-inducing. 2mg of morphine was often too much for the Haitians with various maladies that I would often give 4mg to in the US and expect to need to redose 15 minutes later. Same thing holds for recent immigrants Ive run into here in the US who are just visiting the country but are originally from the caribbean, south america, africa, or eastern europe (dont have the same experience with western europe and i dont see many asian tourists). They can very easily control diseases otherwise considered debilitating with nsaids and tylenol. I *love* the occasional sickle cell case from an african immigrant becuase they actively refuse opiates and are very clearly theyve never received any and dont intend to start today.

We just acclimate our population early, even if its just with benign things like a few percocet for a wisdom tooth at 16-18.
 
CliveStaples said:
This show is pretty good so far. I went in with very low expectations so the medicine actually being pretty spot on is impressive. Obviously the acuity shown between 7a and 9a is outside the realm of reality but they're also showing us an ED with a physician in triage and so boarded up that only higher acuity patients are making it back.

I'll be curious to find out how they managed to keep the medicine and the character's challenges (boarding, patient satisfaction, burnout, etc.) so close to reality.

For Scrubs, a show famous for the accuracy of its depiction of medicine, the authenticity was because Bill Lawrence (the creator of the show) used his best friend from college, a Cardiologist, as the show's medical advisor. I believe that as opposed to hiring an advisor that he could get to ignore as soon as is inconvenient to the narrative of the show, using someone he had a real personal friendship with is what contributed to the accuracy.

There's a real life ER doc or group of ER docs that are behind a lot of the writing of this show and I'd love to find out how they pulled it off so well, at least for two episodes.
Click to expand...
stupid but fun fact about medical advisors. On the show ER the producers hated intubations because no one on TV could figure out what was going on and the producers asked the medical advisors if there wasn't some way to get the image to appear on the monitors so it would look good for TV. Video laryngoscopy just didn't exist at that point. The medical advisor at the time (I cant recall which one) explained this demand to his/her coworker Rich Levitan, who went on to create the first video laryngoscopy device after realizing this could be a great teaching device (though it never got much commercial success because it was weirdly designed). And now he is running airway bootcamps because he made airways, airway education, and fancy airway devices his whole 'thing.' AND the depiction of a video laryngoscopy when it did air on ER is what inspired John Pacey to create the glidescope shortly after Levitan's less successful version came out and THAT design has had tons of success.

Source: Rich Levitan himself told the story to my residency every year. He is amazing but is still a bit grumpy that his model was first to market but never took off.
 
IMG_1428.jpeg
 
While the medicine may be more scientifically accurate then we are used to on TV, how is this realistic as far as all happening in one shift?
Where are the 20 urgent care level sniffles before you get to the one legitimately sick patient?
The ones who foot the taxpayers a huge bill for a work note? Or the dramatic twenty something with flu like symptoms for one day who's asking for last rites?
 
EMhawkeye said:
While the medicine may be more scientifically accurate then we are used to on TV, how is this realistic as far as all happening in one shift?
Where are the 20 urgent care level sniffles before you get to the one legitimately sick patient?
The ones who foot the taxpayers a huge bill for a work note? Or the dramatic twenty something with flu like symptoms for one day who's asking for last rites?
Click to expand...
It sounded like they were all stuck in the waiting room. They alluded in the last episode there was a doc in triage.
 
Siggy said:
...but not the scene where surgery is like, "We'll admit this guy for observation" and Carter goes, "Naw, I'll take the liability of discharging him instead"?
Click to expand...
I have this conversation plenty of times with consulting services.

“We could admit for observation if you think it’s necessary.”

“Nah, definitely not necessary.”

What the heck are they gonna do in hospital with a through and through extremity GSW with a negative CTA? I discharge those all the time.
 
Zebra Hunter said:
I have this conversation plenty of times with consulting services.

“We could admit for observation if you think it’s necessary.”

“Nah, definitely not necessary.”

What the heck are they gonna do in hospital with a through and through extremity GSW with a negative CTA? I discharge those all the time.
Click to expand...
Get a “crit q2 times 3” like they did in the show.

#7hourdispo
 
What do you think will happen when the guy with chest pain in the WR gets DC’ed from the WR?
 
southerndoc said:
I always nurse-base dose mine. Our morphine comes in 4 mg vials and hydromorphone in 1 mg vials. Never order 1.5 of hydromorphone or 6 mg of morphine. 0.5, 1 or 2 of hydromorphone or 2, 4 or 8 of morphine it is.

I try to eliminate nurses needing to waste it as much as possible because it slows them down to get a second signoff/witness. Obviously the elderly get a lowered dose, but I'd rather order 4 of morphine instead of 6 because the patient gets it quicker. It's easier and quicker for a repeat dosage than it is a "middle" dose with a waste.
Click to expand...
as a ED pharmacist - this is something I appreciate lol- I hate the paperwork/time needed to waste partial doses. Round down and redose prn
 
Dred Pirate said:
as a ED pharmacist - this is something I appreciate lol- I hate the paperwork/time needed to waste partial doses. Round down and redose prn
Click to expand...
While I do weight base, I will weight base and then round it to the nearest full or half dose. I can usually find something within he weight based range (0.05-0.10mg/kg). I did love that in my residency, they’re pretty smart because they had 2 mg and 5 mg aloquots. We could give 2, 4, 5, 7, and 10mg doses easily
 
Is chest pain guy being worked up in the waiting room an actual story line? I’ll be legitimately impressed by the accuracy if so.
 
hoot504 said:
Is chest pain guy being worked up in the waiting room an actual story line? I’ll be legitimately impressed by the accuracy if so.
Click to expand...

Yeah, and he's pissed that he's had orders from triage and hasn't seen a doc properly yet.
They just drew his 2 hour trop and sent him back to the WR.
 
Welp. That’s the ballgame. I think I actually miss the wildly inaccurate shows that make us look good.
 
I actually really like the concept of the show demonstrating "real" Emergency Medicine as it relates to crowding/boarding, the things we all do to compensate for it, and the consequences.

It's still glorifying the things we actually do (from trauma resuscitations to family discussions to pulling out bugs from ears and sewing up simple lacs).
 
hoot504 said:
Welp. That’s the ballgame. I think I actually miss the wildly inaccurate shows that make us look good.
Click to expand...

It's even better.
In Episode 1, admin comes to the department and gives our main character hell about his satisfaction scores. He replies with: "Maybe we shouldn't be seeing people from the waiting room. Hire more nurses and free up beds in the ER."
 
Please tell me there’s a throw away line some place with a nurse telling the doc they only have 30 minutes left to order abx and cultures or else everyone’s getting an email.
 
hoot504 said:
Please tell me there’s a throw away line some place with a nurse telling the doc they only have 30 minutes left to order abx and cultures or else everyone’s getting an email.
Click to expand...

If I recall correctly, there's something like that where a student asks: "why we have to do stuff like this."
 
RustedFox said:
If I recall correctly, there's something like that where a student asks: "why we have to do stuff like this."
Click to expand...
There's definitely the whole "door to balloon" thing in Ep 2, which is all anyone seems to care about with that guy. Meet the metric so nobody gets in trouble.
 
FAST scans for everyone… seems realistic thus far
 
RustedFox said:
Yeah, and he's pissed that he's had orders from triage and hasn't seen a doc properly yet.
They just drew his 2 hour trop and sent him back to the WR.
Click to expand...
That's funny.

We do that all the time.

Usually pts are grateful that they are in a hospital where it's warm and there are other people they can talk to, as opposed to the streets where they are homeless and get beat up every day.
 
The real conversation on the show should go like this:

What the F*&K do you want us to do?

You have said "Anyone, at any time, for any reason, came come for any medical complaint no matter how trivial or serious."
You advertise this on your hospital building, community magazines, and on social media.
And it will be FREE for the majority of you. For the suckers that have health insurance, we will charge you $$$.

Let's listen to the community:
Hey honey! Let's go to the emergency department so they can look in my ear.
Hey Honey! We need advice on how to manage a runny nose.
Hey Honey! I had one diarrhea. What should I do? GO TO THE HOSPITAL"

And they come
They come individually, they come in groups. They come as "family plans."

So what the F*&K do you want us to do?
 
Watched the first 4 episodes. Episode 1 starts off with a bang we can all relate to with the aforementioned press ganey comment by admin with some attending/resident/student power dynamics in the next 2 episodes which was cool. Episode 4 spends most of the time on palliative extubation. I think I'll just go to work and get paid rather than relive this at home. They really built up something that ended up being meh. would not recommend.
 
valianteffort said:
Watched the first 4 episodes. Episode 1 starts off with a bang we can all relate to with the aforementioned press ganey comment by admin with some attending/resident/student power dynamics in the next 2 episodes which was cool. Episode 4 spends most of the time on palliative extubation. I think I'll just go to work and get paid rather than relive this at home. They really built up something that ended up being meh. would not recommend.
Click to expand...

I'm gonna watch all the episodes because I hate myself and my life choices.
 
A patient with a nail in the heart and pericardial blood decompensated immediately after intubation and the team failed to high-5 and say, “Yes! We did this!” Intubating such a patient “to get them ready for the OR” is a great way to pad those ED thoracotomy numbers.

On the bright side, I do think the hyper-aggressive, overly tattooed, female resident with no self-awareness is an accurate representation of today’s top medical school recruit. It’s as if admissions committees are trying to test the faculty by recruiting the most annoying trainees.
 
ShockIndex said:
A patient with a nail in the heart and pericardial blood decompensated immediately after intubation and the team failed to high-5 and say, “Yes! We did this!” Intubating such a patient “to get them ready for the OR” is a great way to pad those ED thoracotomy numbers.

On the bright side, I do think the hyper-aggressive, overly tattooed, female resident with no self-awareness is an accurate representation of today’s top medical school recruit. It’s as if admissions committees are trying to test the faculty by recruiting the most annoying trainees.
Click to expand...

The really bitchy one who keeps needling the students? I thought she was a MS4.

Not the gal with the ankle bracelet. She's a PGY2.
 
RustedFox said:
The really bitchy one who keeps needling the students? I thought she was a MS4.

Not the gal with the ankle bracelet. She's a PGY2.
Click to expand...
I've never seen an ankle bracelet live in person. Someone prob had one, but it wasn't on my radar.

But, if the drama had a doc wearing the bracelet (I don't know, haven't seen it), it reminds me of a thread I started over 20 years ago in the Lounge, where I asked "Ever known anyone that was a criminal on COPS?", after I saw a guy I worked with on the ambulance "pulled over" by the Sheriff's Department boat, while the guy was on a jet ski.
 
Apollyon said:
I've never seen an ankle bracelet live in person. Someone prob had one, but it wasn't on my radar.

But, if the drama had a doc wearing the bracelet (I don't know, haven't seen it), it reminds me of a thread I started over 20 years ago in the Lounge, where I asked "Ever known anyone that was a criminal on COPS?", after I saw a guy I worked with on the ambulance "pulled over" by the Sheriff's Department boat, while the guy was on a jet ski.
Click to expand...
You've never had the "skin irritation from ankle monitor" patient? Dr. Apollyon over here only treating the fancies... /s.

In regards to the PITT, the idea of an attending physician that has a hypercompetent charge RN that follows him around and carries out all his verbal orders while keeping track of what labs and tests are back on everyone in the department is as close to paradise as I think we'll get in this life. Can you imagine how hard you could go if you never had to interact with EMR/CPOE?
 
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