EM LEGAL PEARLS

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13 Comments

1. TOOLS Vs. RULES

   Enough with all these “Rules” already. Now we have the PERC Rules too. We need to use different terminology or the trial lawyers are going to have a field day with us when we don’t follow the rules. Rules are rules, not meant to be broken. Tools are implements you use when they will help you with the task at hand. Other terms such as “Criteria” or “Decision Instrument” are fine too, but can we (especially the researchers) please abolish the word “Rule” from our vocabulary. We all know that we need to be careful and double-check our work, but we also need care for each patient individually and we definitely don’t need to do anything that is going to worsen the current malpractice climate.

2. Toradol should not be used for anything, including kidney stones. Ibuprofen works just as fast, is a fraction of the cost and has a much better safety profile. Narcotics are even better. Toradol has 27 times the risk of GI bleeding as does ibuprofen and there are cases of acute renal failure after one time injections. Why would you give it to someone with kidney problems? It has been taken off the market in several European countries due to safety concerns.
   Let’s all save our patient’s and our country money and nephrons. Stop using Toradol. Ibuprofen and morphine should be the go to drugs for acute renal colic in the ED.

3. Prophylactic anti-emetics are not recommended routinely when using narcotic analgesics. They add to cost and potential side effects. Less than 1 in 10 patient’s will need them, so save them for those that do, those that are already nauseated or those who know they always vomit with narcotics. For the other 90% of patients just give the morphine or dilaudid “a-la-carte”.

4. In PIOPED-2, the sensitivity of multidetector CT was only 83% compared to 98% for VQ in PIOPED-1. In properly chosen patients with a normal chest xray. VQ will be conclusive in 90% of patients, so it is often the test of choice when available. VQ is a better test in the young healthy patient with a normal chest xray and no concern for conditions other than PE because VQ is more sensitive than CT, and has about 1/8th of the radiation dose of CT. VQ is also preferred in renal insufficiency because there is no IV contrast. CT is a better test if the chest x-ray is abnormal or if other conditions such as aortic dissection or occult pneumonia are considerations. In older patients the higher radiation dose from CT is less of a concern, but IV contrast may require more caution. In pregnancy, CT is preferred only because the fetal dose of radiation is lower than VQ. The fetus can be screened by a lead apron for CT, but not in VQ as the radiotracer accumulates in the bladder. Though VQ is better for ruling out PE, CT may be better for ruling it in and, when there is uncertainty clinically, can be used to confirm an indeterminant VQ.

5. Why can’t we use droperidol anymore? Ask Ortho-McNeil-Janssen, makers of Risperdal. They bought the company that made droperidol and then reported a bunch of cases of Long QT related problems to the FDA so they would place the black box and make it easier for them to sell their new expensive drug. Most of these cases were all reported on the same day and almost all are pretty much bogus. Sound familiar? Compazine and Zofran? It’s definitely a conspiracy. Don’t trust those drug companies – not a one. And don’t forget ZOFRAN PROLONGS THE QT INTERVAL ALSO.

6. The emergency radiology book I recommend, at least for starters is

   Accident and Emergency Radiology, by Raby, Berman, & de Lacey

7. I usually go with CT KUB for most patients, especially if I want to avoid delays (sick patient, end of shift nearing) or if they have risks for an adverse effect of contrast (bowel obstruction, dehydrated, etc.)

   I use IV contrast in trauma or for patients with risks for vascular conditions (but not necessarily when looking for a AAA)

   When my suspicion is on the lower side or I think the disease process is in its early stages or the patient is young and/or thin, but I”m not comfortable without a CT, I will often go for full contrast, so that when it’s negative, I’m a bit more confident that subtle findings won’t be missed and no one will recommend I repeat the scan.

8. SHOULDER DISLOCATION REDUCED:

   I know it’s the opposite of what Dr. Cunningham recommends, but some colleagues and I have had great success using this method without any sedation at all.

   1 – explain to patient pain is mostly from muscles pulling bones together and bone on bone contact. (Periosteum is very sensitive)
   2 – get them to try to relax muscles, may do gentle massage a la Dr. C before and during relocation
   3 – starting in position of preference of patient apply gentle traction in line with one hand while providing counter traction with your other hand in the armpit
   4 – continue to hold traction patiently, shoulder should go in within 3 minutes

9. My 2 cents on the chronic pain patient:

   I think NO opiate prescriptions for these patients if they keep coming back. They need to get prescriptions from a single doctor or clinic otherwise there is little control of the controlled substance.

   Also no IV push opiates. They should get IM/SQ/IVPB or even better oral opiates while they are in the ED.

   Finally for conditions where specialists recommend against opiates, we should give other meds:
   – Dental pain: NSAIDs and a local block.
   – Migraines: triptans, Reglan, Mg, valproic acid, ice pack.
   – Chest pain: nitraites or GI cocktail.
   – Recurrent abdominal pain: antispasmotics, H2 blockers.

   Of course we can always make exceptions when indicated. I’m all for treating pain expertly!

10. We all know that the “taint” is the perineal area that “taint” anus and “taint” scrotum or vagina.

    What should we call the area between McBurney’s point and Murphy’s point? “Right middle quadrant” just doesn’t do it. How about “the abdominal taint” or “McMurphy’s point”?

11. I don’t because >50% end up sloughing or having chronic deformity, cold intolerance or skin fissuring if they do take.

12. Best Practice Advice 1: Don’t like that they don’t include gestalt. They mention in the body of the paper that it is as good as decision rules for experienced EP’s, but it should be part of their conclusion too. Don’t want the standard of care to include calculating a score

    Best Practice Advice 2: like it. Supports PERC

    Best Practice Advice 3: like it. Supports D-dimer in low-med risk

    Best Practice Advice 4: like it. Supports use of age adjusted D-dimer. Wish they would discuss trimester adjusted D-dimer

    Best Practice Advice 5: like it. Don’t image if D-dimer negative

    Best Practice Advice 6: Don’t like that they make CTPA the test of choice and VQ the backup. From what I have read VQ has less radiation and is more sensitive when it is read as normal. You just have to know who to use it in: people with no lung disease and a normal CXR, esp if they are young.

13. Q: What’s the first 3 things you should think of in patients with chest pain?
    A: Aortic dissection, PE and ACS. Why not MI? Because by the time you see the patient, any good nurse will have drawn the troponin and handed you the EKG and prevent you from missing an acute MI. Not thinking first of the other 3 major killers leads to disaster.