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Mel Herbert has about as much insight into real world EM as I do into neurosurgery
The PITT
Started by Groove
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Mel Herbert has about as much insight into real world EM as I do into neurosurgery
That's a little harsh, bud. I'm just sayin'.
When's the last time he worked a shift?
When did he last work a shift without residents?
They don't even write notes at LAC lol
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I'm not a left coaster. What I know of Mel is a smart guy. If that has changed, well, it's possible.
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.
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.
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.
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".
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.
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.
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!
This show is probably more fruitful and entertaining for premeds and medical students. Not really residents or attendings. Or they could just read SDN and get more out of the realities of emergency medicine
Maybe it's a dumb senior resident. Calcium gluconate is a very benign medicine in the grand scheme of things.
that's funny. You know the dispo for all the pts on the TV show faster than the TV docs do.
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I'm all caught up.
Some of the stuff is getting more ridiculous, but the veneer on our hero is beginning to crack.
I'm in.
Some of the stuff is getting more ridiculous, but the veneer on our hero is beginning to crack.
I'm in.
I wanna know when keppra became dangerous to "load".
Say what? If anything I load with higher and higher doses these days.
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??"
Almost as dangerous as pushing calcium gluconate in suspected hyperkalemia.
“If his calcium is high, you’ll kill him!!”
/s
Makes sense to me, thanks for the professional advice!
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.
ativan is underdosed in seizures. if status, give 4 mg IV straight up
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.
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.
I agree with much of this.
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.
Am I the only one that pronounces it PENIS?
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.
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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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.
Yes.
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
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.
I'd say you're a terrible parent for raising a child to seize for attention
everyone is a loser here
How many kids you got?
Oh man! you're taking this personally I see
2 kids
If they act like buffoons they deserve whatever fate awaits too
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.
I give droperidol for pseudoseizures. 2.5 mg IM. Works like a charm everytime.
I use ammonia inhalant wipes .
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.
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.
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.
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?
Saw your next post lol
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Yet, still a non-emergent condition.
That can GTFO.
I was told by experienced people both EMS and in residency that "people that fake seizures have real seizures", so, in the acute moment, 1mg Ativan isn't going to break the bank, if no information is available right that second.
I mean, I rode along on a shift with the sheriff's dept about 17 years ago. One guy got "jailitis", and had a "seizure", and I told the deputy to apply painful stimulus, and he did, and guy kept "seizing". I lifted his arm, and it avoided his face. I said right there, "See, didn't pee his pants, and look at this - he's volitional" (and quickly told the deputy what that meant). Just like turning off a light switch, guy stops, and becomes model prisoner, on his way to the graybar hotel.
I mean, I rode along on a shift with the sheriff's dept about 17 years ago. One guy got "jailitis", and had a "seizure", and I told the deputy to apply painful stimulus, and he did, and guy kept "seizing". I lifted his arm, and it avoided his face. I said right there, "See, didn't pee his pants, and look at this - he's volitional" (and quickly told the deputy what that meant). Just like turning off a light switch, guy stops, and becomes model prisoner, on his way to the graybar hotel.
I’d say true PNES is exceptionally rare, at least in my patient population. I can’t remember the last time I had a patient with a non-epileptic episode that wasn’t clearly demonstrating secondary gain from their episode which is typically familial or relationship sympathy. These patients seem to ALWAYS have an aggressively overbearing family member or spouse that refuses to accept that these are not true seizures. I typically advise the nursing staff to not allow any family members back with the non-epileptic episode patients, or kick them out if they become disruptive. Significantly reduces the rate of work disruption from the family member screaming for me to come in the room every time the patient has an “episode”. Usually the patient magically stops having their “nonstop seizure” when they no longer have their intended audience present.
My more controversial opinion, however, is regarding the teaching that “30% of patients with PNES have true epilepsy”. I think that claim is mostly BS. I’ve yet to see a patient with non-epileptic episodes have a documented positive EEG during prior hospitalizations or noted to have had one on outpatient EEGs. Literally not a single one of the hundreds I’ve seen in my career, and I always chart dive on these patients. I know it happens, and I’m not claiming none of them have true epilepsy as my patient population is probably skewed, but it’s certainly not 30%.
More commonly these patients get put on anticonvulsants by an ER doc or a neurologist after one of their “episodes” “just in case”. Then everyone that sees them afterward just keeps documenting “epilepsy” on their history with their script for Keppra as confirmation of the diagnosis, and so anticonvulsant keeps getting refilled and diagnosis keeps getting documented on their chart. Then someone does a retrospective chart review study using ICD coding and finds that “30% of PNES patients also have true epilepsy” and the myth gets propagated more.
