The PITT

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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.
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OK, that makes sense that she is a MS4 doing an AI. At first I thought she was an intern.

Mel Herbert from EMRAP was touting the show since several of the EMRAP contributors and USC/LAC faculty serve as advisors for the show. I was not surprised given the progressive vibes from the first couple of episodes.
 
ShockIndex said:
OK, that makes sense that she is a MS4 doing an AI. At first I thought she was an intern.

Mel Herbert from EMRAP was touting the show since several of the EMRAP contributors and USC/LAC faculty serve as advisors for the show. I was not surprised given the progressive vibes from the first couple of episodes.
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Mel Herbert has about as much insight into real world EM as I do into neurosurgery
 
I had a similar thought about Mel. He seems like a great guy and escaped the grind and I’m sure he’s happier but he’s like the physician who becomes an administrator. Their credibility as a physician goes down the further away from clinical work they get.
 
Apollyon said:
I'm not a left coaster. What I know of Mel is a smart guy. If that has changed, well, it's possible.
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You're confusing me saying he has no practical credibility as a pit doc with me saying he's not smart.

I'd rather them use the doc that's 10 notes behind, hasn't eaten all shift, and is missing his kids dance recital to work, rather than an EM celebrity.
 
I have no personal knowledge of Herbert’s ability to handle a busy department. Don’t really care to know.

I was more speaking to a paradigm shift in emergency medicine away from resuscitation and towards social determinants of health and health equity. It’s palpable in the EM faculty and trainees at my shop, on EMRAP, and reflected in this show. Some would say this is needed; others would say the pendulum has swung too far and we are graduating EM residents who can correct misgendering in the EMR but struggle to resuscitate sick patients.
 
ShockIndex said:
I have no personal knowledge of Herbert’s ability to handle a busy department. Don’t really care to know.

I was more speaking to a paradigm shift in emergency medicine away from resuscitation and towards social determinants of health and health equity. It’s palpable in the EM faculty and trainees at my shop, on EMRAP, and reflected in this show. Some would say this is needed; others would say the pendulum has swung too far and we are graduating EM residents who can correct misgendering in the EMR but struggle to resuscitate sick patients.
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I was just thinking of my days as a firefighter. What if I had said to the fire, "But, fire, why do you feel like burning?" Instead, I just put the wet stuff on the red stuff.
 
Watching episode 5 now.
This time, our hero tells off both admin and the CMG d!ckbreath that "wants to buy the department".
 
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I was skeptical to watch as I definitely ascribe to the "I don't wanna watch work at home" mentality. I watched the 1st ep. and that's where I'll leave it. The waiting room medicine was spot on. The two ER docs on the roof contemplating life..who has that kinda time on shift?? The admin/doc squabble hit close to home except I've never seen admin approach a pit doc with these demands...usually they pressure the medical director who in turns pressures us. Not sure why the senior resident thought her attending was gonna kill a crashing presumed hyperK+ pt by pushing calcium gluconate. And as an old doc, I'm definitely jealous of residents and their ultrasound skills, but every patient in the Pitt was getting timely bedside FAST exams. It takes me 20 min-> 10 to find the machine, five to watch it boot up, and another 5 to find some gel.
Also wondered where all the nurses are at. The docs were doing everything from compressions, grabbing the crash cart, pushing meds, etc.
 
I made it to episode 3. I just got exhausted. It's way too similar to real work and I just want to check my brain out when I get home and not have to think about anything ER related. My wife likes it but I told her she's going to have to watch it by herself. Back to SILO.
 
Groove said:
I made it to episode 3. I just got exhausted. It's way too similar to real work and I just want to check my brain out when I get home and not have to think about anything ER related. My wife likes it but I told her she's going to have to watch it by herself. Back to SILO.
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The fact that multiple EM docs get tired watching this show is probably the most ringing endorsement.

Another thing that I find interesting is how the frenetic pacing makes it difficult for people to keep up. My wife’s a non-EM physician and she’s constantly asking “who are they talking about? Which character is that? Wait where did this guy come from?”, while my brain has automatically slotted all the patient characters into rooms, assignments, dispos, holds, etc.

There are certain touches that are just so spot-on like the one resident who has to change into scrubs of shame nearly every shift or the whiney chest painer that you know is going to get discharged from the WR after a 15 hr wait.

I hope they do a bit on a patient getting weird during ketamine sedation. And the way the show is going they just might!
 
Ceez said:
I was skeptical to watch as I definitely ascribe to the "I don't wanna watch work at home" mentality. I watched the 1st ep. and that's where I'll leave it. The waiting room medicine was spot on. The two ER docs on the roof contemplating life..who has that kinda time on shift?? The admin/doc squabble hit close to home except I've never seen admin approach a pit doc with these demands...usually they pressure the medical director who in turns pressures us. Not sure why the senior resident thought her attending was gonna kill a crashing presumed hyperK+ pt by pushing calcium gluconate. And as an old doc, I'm definitely jealous of residents and their ultrasound skills, but every patient in the Pitt was getting timely bedside FAST exams. It takes me 20 min-> 10 to find the machine, five to watch it boot up, and another 5 to find some gel.
Also wondered where all the nurses are at. The docs were doing everything from compressions, grabbing the crash cart, pushing meds, etc.
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Maybe it's a dumb senior resident. Calcium gluconate is a very benign medicine in the grand scheme of things.
 
Jabbed said:
The fact that multiple EM docs get tired watching this show is probably the most ringing endorsement.

Another thing that I find interesting is how the frenetic pacing makes it difficult for people to keep up. My wife’s a non-EM physician and she’s constantly asking “who are they talking about? Which character is that? Wait where did this guy come from?”, while my brain has automatically slotted all the patient characters into rooms, assignments, dispos, holds, etc.

There are certain touches that are just so spot-on like the one resident who has to change into scrubs of shame nearly every shift or the whiney chest painer that you know is going to get discharged from the WR after a 15 hr wait.

I hope they do a bit on a patient getting weird during ketamine sedation. And the way the show is going they just might!
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that's funny. You know the dispo for all the pts on the TV show faster than the TV docs do.
 
hoot504 said:
Say what? If anything I load with higher and higher doses these days.
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There's a scene where senior resident half-scolds the intern for not giving more Ativan to a seizing patient (she wanted to avoid respiratory depression) and suggesting switching strategies to keppra.

So senior resident gives more Ativan, aborts the seizure, then says to her: "There. Now we can SAFELY load keppra the RIGHT way."

Me: "Excuse me, WTF? How is keppra loading unsafe??"
 
RustedFox said:
There's a scene where senior resident half-scolds the intern for not giving more Ativan to a seizing patient (she wanted to avoid respiratory depression) and suggesting switching strategies to keppra.

So senior resident gives more Ativan, aborts the seizure, then says to her: "There. Now we can SAFELY load keppra the RIGHT way."

Me: "Excuse me, WTF? How is keppra loading unsafe??"
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Almost as dangerous as pushing calcium gluconate in suspected hyperkalemia.

“If his calcium is high, you’ll kill him!!”

/s
 
RustedFox said:
There's a scene where senior resident half-scolds the intern for not giving more Ativan to a seizing patient (she wanted to avoid respiratory depression) and suggesting switching strategies to keppra.

So senior resident gives more Ativan, aborts the seizure, then says to her: "There. Now we can SAFELY load keppra the RIGHT way."

Me: "Excuse me, WTF? How is keppra loading unsafe??"
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Maybe the writers had a brain fart and confused it with Dilantin? Although that and even Cerebyx has fallen out of favor for quite some time now.
 
RustedFox said:
There's a scene where senior resident half-scolds the intern for not giving more Ativan to a seizing patient (she wanted to avoid respiratory depression) and suggesting switching strategies to keppra.

So senior resident gives more Ativan, aborts the seizure, then says to her: "There. Now we can SAFELY load keppra the RIGHT way."

Me: "Excuse me, WTF? How is keppra loading unsafe??"
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ativan is underdosed in seizures. if status, give 4 mg IV straight up
 
To play devil's advocate, I think we emergently over treat a lot of seizures. Or maybe I just encounter a lot of psychogenic non-epileptiform seizure patients 😉 Many seizures resolve on their own within 5 minutes. A large percentage of the time the seizure has stopped by the time the nurse calls me, Ativan is ordered and the nurse finally pulls it from he pyxis. I observe other colleagues then still proceed with administering the Ativan once the seizure has stopped. Now you have a postictal patient that is further sedated. One you can't dispo them home quickly, two you can't admit them to the floor lethargic or unresponsive without the floor nurse calling a rapid response, and three if you admit them to the ICU invariably someone decides to intubate them uneccessarily rather than let them metabolize off the Ativan over a few hours. Instead, load with Keppra and avoid the benzos. We have one Neurologist (Epileptologist) who often puts in his consult notes not to treat a seizure until absence of self-abortion within 5 minutes. Sure, in true status epilepticus proceed with lots of benzos plus other AEDs. My two cents though that you don't have to panic and treat every seizure like the entire room wants to do. Don't just stand there! Stand there and do nothing. Provide supportive positioning and respiratory care while giving it just a little time.
 
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100%. As soon as someone seizures then the rush is to completely snow them with ativan when the seizure will likely stop on its own rather quickly. Turns out people with seizure disorders have seizures.
 
JacobMcCandles said:
100%. As soon as someone seizures then the rush is to completely snow them with ativan when the seizure will likely stop on its own rather quickly. Turns out people with seizure disorders have seizures.
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My clientele is different than yours. 2 mg rarely snows any of my patients. LOL

If it's an undifferentiated seizure, then yes, they get 2 mg of lorazepam even if it stops (1 mg if older). New onset, possible alcohol withdrawal, etc. If it's a known seizure that's a breakthrough seizure and they're on something I need a level for, then yes, they also get lorazepam until their level comes back.

I also give Keppra if it's new onset or they're not on it (and I'm waiting on a level for something). Keep in mind that Keppra takes 30-60 minutes to work. Peak plasma concentration occurs in about 60-90 mins. My decision to give lorazepam while loading with Keppra is to prevent another seizure in that hour of waiting for Keppra to take effect, which will thus eliminate another interruption in my workflow by another call from a nurse insisting that I come see the patient that is seizing again.

Not sure where you are, but none of my patients make it to a med/surg floor in <4 hours where the lorazepam has not worn off. Most are staying in the ER for 24 hours before getting a bed.
 
southerndoc said:
My clientele is different than yours. 2 mg rarely snows any of my patients. LOL

If it's an undifferentiated seizure, then yes, they get 2 mg of lorazepam even if it stops (1 mg if older). New onset, possible alcohol withdrawal, etc. If it's a known seizure that's a breakthrough seizure and they're on something I need a level for, then yes, they also get lorazepam until their level comes back.

I also give Keppra if it's new onset or they're not on it (and I'm waiting on a level for something). Keep in mind that Keppra takes 30-60 minutes to work. Peak plasma concentration occurs in about 60-90 mins. My decision to give lorazepam while loading with Keppra is to prevent another seizure in that hour of waiting for Keppra to take effect, which will thus eliminate another interruption in my workflow by another call from a nurse insisting that I come see the patient that is seizing again.

Not sure where you are, but none of my patients make it to a med/surg floor in <4 hours where the lorazepam has not worn off. Most are staying in the ER for 24 hours before getting a bed.
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Practice environments are variable. You work in a setting that is not typical of most. Getting antiepileptic medication levels back in any timely manner is not common at many places. Places that prioritize efficiency, and have the luxury, are not keeping a patient in the ED for 24 hours. Certainly boarding is another story, but you still have to have a hospitalist accept the patient for admission to the floor in their current state.

Regarding the bolded font, many patients that have a seizure do not go on to have a second seizure. At least in my location, the vast majority of patients that present with a seizure are discharged.
 
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I haven't watched the PITT yet, but would check it out if I didn't have to pay for yet another streaming service. I went on a relaxing 7 mile run in the mountains today though and it was probably a better break from work than watching quasi-work on TV. I watched the first season of The Agency recently though and like it. Seemed maybe more realist than many spy thrillers.
 
Mount Asclepius said:
To play devil's advocate, I think we emergently over treat a lot of seizures. Or maybe I just encounter a lot of psychogenic non-epileptiform seizure patients 😉 Many seizures resolve on their own within 5 minutes. A large percentage of the time the seizure has stopped by the time the nurse calls me, Ativan is ordered and the nurse finally pulls it from he pyxis. I observe other colleagues then still proceed with administering the Ativan once the seizure has stopped. Now you have a postictal patient that is further sedated. One you can't dispo them home quickly, two you can't admit them to the floor lethargic or unresponsive without the floor nurse calling a rapid response, and three if you admit them to the ICU invariably someone decides to intubate them uneccessarily rather than let them metabolize off the Ativan over a few hours. Instead, load with Keppra and avoid the benzos. We have one Neurologist (Epileptologist) who often puts in his consult notes not to treat a seizure until absence of self-abortion within 5 minutes. Sure, in true status epilepticus proceed with lots of benzos plus other AEDs. My two cents though that you don't have to panic and treat every seizure like the entire room wants to do. Don't just stand there! Stand there and do nothing. Provide supportive positioning and respiratory care while giving it just a little time.
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I agree with much of this.
 
Mount Asclepius said:
To play devil's advocate, I think we emergently over treat a lot of seizures. Or maybe I just encounter a lot of psychogenic non-epileptiform seizure patients 😉 Many seizures resolve on their own within 5 minutes. A large percentage of the time the seizure has stopped by the time the nurse calls me, Ativan is ordered and the nurse finally pulls it from he pyxis. I observe other colleagues then still proceed with administering the Ativan once the seizure has stopped. Now you have a postictal patient that is further sedated. One you can't dispo them home quickly, two you can't admit them to the floor lethargic or unresponsive without the floor nurse calling a rapid response, and three if you admit them to the ICU invariably someone decides to intubate them uneccessarily rather than let them metabolize off the Ativan over a few hours. Instead, load with Keppra and avoid the benzos. We have one Neurologist (Epileptologist) who often puts in his consult notes not to treat a seizure until absence of self-abortion within 5 minutes. Sure, in true status epilepticus proceed with lots of benzos plus other AEDs. My two cents though that you don't have to panic and treat every seizure like the entire room wants to do. Don't just stand there! Stand there and do nothing. Provide supportive positioning and respiratory care while giving it just a little time.
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Actively seizing, I will wait to see if it stops. Usually it does. I rarely give 2mg of Ativan. That said, I will routinely give 1mg Ativan after they stop seizing to prevent further seizures while I'm keppra loading.


1mg Ativan rarely causes any significant sedation beyond their existing post-ictal appearance. I also frequently will send these patients home after a couple of hours if it's a known and fairly common occurrence for them.

PNES? I tell them to stop it, and if they don't I insert a nasal trumpet. No Ativan under any circumstances. The last thing any of us need is feeding into a reward pathway that incentivizes more of that garbage.
 
BoardingDoc said:
PNES? I tell them to stop it, and if they don't I insert a nasal trumpet. No Ativan under any circumstances. The last thing any of us need is feeding into a reward pathway that incentivizes more of that garbage.
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I used to do rectal exams until a patient insinuated to her mother I assaulted her

thankfully the mother watched me do it and was actually relieved she wasn't seizing and apparently will do all kinds of **** for attention

never went anywhere but did serve as a wake up call that aborting seizures with rectal exams, while effective, probably not a good idea. So I stopped.
 
AlmostAnMD said:
I used to do rectal exams until a patient insinuated to her mother I assaulted her

thankfully the mother watched me do it and was actually relieved she wasn't seizing and apparently will do all kinds of **** for attention

never went anywhere but did serve as a wake up call that aborting seizures with rectal exams, while effective, probably not a good idea. So I stopped.
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At what point did you ever think doing a rectal exam on a seizing (whether real or fake) patient was appropriate? Call me crazy but that seems like sexual assault. Before someone mentions rectal exams on trauma patients I think that’s ridiculous, too (are they even doing them anymore?). There’s certainly a spectrum of gray but that seems well beyond.
 
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Mount Asclepius said:
To play devil's advocate, I think we emergently over treat a lot of seizures. Or maybe I just encounter a lot of psychogenic non-epileptiform seizure patients 😉 Many seizures resolve on their own within 5 minutes. A large percentage of the time the seizure has stopped by the time the nurse calls me, Ativan is ordered and the nurse finally pulls it from he pyxis. I observe other colleagues then still proceed with administering the Ativan once the seizure has stopped. Now you have a postictal patient that is further sedated. One you can't dispo them home quickly, two you can't admit them to the floor lethargic or unresponsive without the floor nurse calling a rapid response, and three if you admit them to the ICU invariably someone decides to intubate them uneccessarily rather than let them metabolize off the Ativan over a few hours. Instead, load with Keppra and avoid the benzos. We have one Neurologist (Epileptologist) who often puts in his consult notes not to treat a seizure until absence of self-abortion within 5 minutes. Sure, in true status epilepticus proceed with lots of benzos plus other AEDs. My two cents though that you don't have to panic and treat every seizure like the entire room wants to do. Don't just stand there! Stand there and do nothing. Provide supportive positioning and respiratory care while giving it just a little time.
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Reminds me of a postop patient I had who had a history of pseudoseizures in pacu who had another pseudoseizure that looked nothing like a real seizure. But the pacu nurse freaked out, another physician gave ativan unnecessarily then they called a stroke code, took the patient to ct scan where the patient had a code blue called in the scanner because of suspected aspiration. CT scan and eeg were totally normal btw.
 
JacobMcCandles said:
At what point did you ever think doing a rectal exam on a seizing (whether real or fake) patient was appropriate? Call me crazy but that seems like sexual assault. Before someone mentions rectal exams on trauma patients I think that’s ridiculous, too (are they even doing them anymore?). There’s certainly a spectrum of gray but that seems well beyond.
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High volume shop

Didn't gaf

Just wanted them to stop seizing asap and get them out of my department without using benzos (they took our ammonia tabs away)

In retrospect not a good idea but I could basically wash my hands and hand them discharge papers. Worked well

Had a lot of prisoners come in pretending to seize or be dead or whatever and this fixed that 100% of the time too
 
JacobMcCandles said:
At what point did you ever think doing a rectal exam on a seizing (whether real or fake) patient was appropriate? Call me crazy but that seems like sexual assault. Before someone mentions rectal exams on trauma patients I think that’s ridiculous, too (are they even doing them anymore?). There’s certainly a spectrum of gray but that seems well beyond.
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This is pretty damn weird, not gonna lie.

Never heard of anyone doing this.
 
AlmostAnMD said:
High volume shop

Didn't gaf

Just wanted them to stop seizing asap and get them out of my department without using benzos (they took our ammonia tabs away)

In retrospect not a good idea but I could basically wash my hands and hand them discharge papers. Worked well

Had a lot of prisoners come in pretending to seize or be dead or whatever and this fixed that 100% of the time too
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This is absolutely so strange to me. I mean, if I were the parent you were talking about earlier I would have likely fought you.
 
AlmostAnMD said:
Oh man! you're taking this personally I see

2 kids

If they act like buffoons they deserve whatever fate awaits too
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I haven't taken it personally but I was just curious to see if you should understand that even the best of parents can have wayward children for a variety of reasons.
 
BoardingDoc said:
PNES? I tell them to stop it, and if they don't I insert a nasal trumpet. No Ativan under any circumstances. The last thing any of us need is feeding into a reward pathway that incentivizes more of that garbage.
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I give droperidol for pseudoseizures. 2.5 mg IM. Works like a charm everytime.
 
Completely agree with most people overtreating these self limited seizures.

At the same time nearly everyone I've ever worked with is undertreating patients in status with little 2-4mg doses in patients.

Nearly all the neurologists I've spoken with say it should be at least 0.1mg/kg which is often 8-12mg doses in american patients.
 
southerndoc said:
I give droperidol for pseudoseizures. 2.5 mg IM. Works like a charm everytime.
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I agree droperidol is amazing here. Or Zyprexa if out of droperidol.

Last 2-3 years I think almost all my non-epileptic seizure patients know it's a seizure but not a seizure seizure. A little medication to ease out of the symptoms and they're ready to go home.
 
BoardingDoc said:
PNES? I tell them to stop it, and if they don't I insert a nasal trumpet. No Ativan under any circumstances. The last thing any of us need is feeding into a reward pathway that incentivizes more of that garbage.
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My approach as well. It's a lot easier to defend trying to protect their airway. I certainly wouldn't perform a sensitive exam on these patients. Agree that it's detrimental to treat PNES with Ativan.
 
southerndoc said:
I give droperidol for pseudoseizures. 2.5 mg IM. Works like a charm everytime.
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I agree that anti-psychotics are better for this patient population than more addictive benzodiazepines, but it requires absolute certainty in the diagnosis otherwise if wrong and a bad outcome occurs it appears that you were dismissive from the beginning. I prefer an initial BLS approach in knowing that most seizures self-abort and delayed AED administration might be more defensible than errant Droperidol administration. I also don't like to contribute to the medication seeking behavior of PNES patients.
 
Mount Asclepius said:
My approach as well. It's a lot easier to defend trying to protect their airway. I certainly wouldn't perform a sensitive exam on these patients. Agree that it's detrimental to treat PNES with Ativan.
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You realize it's conversion disorder i.e. a mental health issue i.e. they're not intentionally doing it even if they can stop it? You treat anxiety attacks with medicine?
 
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