Masquerade

I'm still getting over Peter Shaft. But along the lines of costumes, someone should tell Kerry that most people don't find Halloween costumes that scary, and most of them actually think it's pretty funny. And comforting, because it kinda distracts from the rather un-fun environment of the emergency department; shows we're not humorless and too serious about ourselves. To borrow a phrase from Homer Simpson: "Mellow out, man."

Mark took a lot of flak on alt.tv.er this week over his decision to not do a pregnancy test on Coco before giving her Haldol. Yeah, it's glaringly obvious that he should have done a pregnancy test -- now. But that's a damned easy thing to miss, and you're really playing the odds here: a woman comes in faking labour pains. You go to examine her, and don't find a fetal heartbeat or uterine changes; later, you find she's retaining over two litres of urine. And then she later turns out to be pregnant. If I had the benefit of hindsight in advance, I wouldn't have to pay my malpractice premiums, but I don't, so my insurance company is still in business. And so you have to make decisions -- guesses, really -- and hoping you won't be too wrong when you guess incorrectly. (It will happen.) Like with what happened in "Tribes," people are going to have their own take on the situation, and I can argue with them until I'm blue in the face, but it won't solve anything. I sympathize with Mark, and the last I'm going to say on this is that there's no easy way around this one.

That said, there are few antipsychotics and neuroleptics that don't have an adverse effect on the fetus, which is why picking a good one is so hard. Haldol LA is good if you're aiming for long-term management, but it isn't useful for acute cases. (I guess the LA stands for "Long Acting.") But, as was pointed out on the newsgroup, most antipsychotics are considered to be of questionable safety in pregnancy, with the benefit to the mother having to be weighed against the potential harm to the fetus. Haldol is generally one of the safest drugs available to a physician, only just not here.

I'm with Romano on the sternal saw issue. To avoid the inevitable "but there hasn't been any research done on it!" complaint I usually get after making such comments around my peers, I'm going to say I'm well aware that there haven't been many studies involving midline emergency department thoracotomies. (I can think of only two off the top of my head, and that's because I went and looked it up.) But there is plenty of compelling research that has been done into lateral thoracotomies (ones done on the side of the chest rather than straight down the middle, which is what Kerry was advocating), and the survival rates she quoted to Romano were from lateral thoracotomies -- 10% survival if the patient arrests before their arrival in the ED; 30% survival rate if the patient arrests in the department. Most of these studies didn't take long-term outcomes into effect and don't consider neurologic impairment after the procedure either.

Kerry basically wants to take what is still an operating room procedure, move it down to the emergency department, and start cracking the chests of all traumatic arrest patients arriving, on the theory that the established standard (crack only when there are signs of life post-arrest but pre-thoracotomy in penetrating traumatic arrest OR the patient is massively shocked due to cardiac tamponade OR there is massive chest or abdominal bleeding OR when the patient has suffered chest or abdominal trauma and is profoundly shocked, unresponsive to fluid resuscitation, and isn't likely to survive until he reaches the surgeons) provides for a miserably survival rate. Well, it does, and there's a reason for that: traumatic cardiac arrest usually involves not only the heart stopping but massive damage to multiple organ systems. These patients die because they're hurt bad enough to die -- that might not make a lot of sense, but it's a pretty good summary of the problem. I think Kerry's theory runs something along these lines: they're going to die anyway, so we might as well crack them and see who doesn't.

There's nothing wrong with that thinking, except that it ignores two fundamental truths about medicine today.
First, it ignores the fact that this all costs money. A lot of it. And people get billed for our services whether we're successful or not -- this isn't an "customer satisfaction or your money back" kind of deal. Doing thoracotomies on patients who ultimately don't survive the experience places an additional burden on the family of the deceased who already has quite enough to worry about. Apparently, Kerry only worries about money when its her own, and not someone else's, but she should remember that most government hospitals run a deficit because a significant portion of their patients are not covered by medical insurance. (Which is true even in Canada; some of the biggest users of the health care system are those who cannot pay the low premiums to the government, so when we treat them, we're essentially taking a loss. There's a lawsuit in progress right now in BC that claims $14M in lost funds because of this.)
Secondly, I have a hard time seeing how a procedure that is invasive as hell in a lateral form and has a miserable survival rate is going to, in a form that is way more invasive, produce more survivors. A midline thoracotomy is even messier than a lateral one, and I don't see any real practical advantages to doing it -- only a big pile of practical and theoretical disadvantages. That said, as a general rule, the trauma surgeon is the one that ultimately opens the chest, not the emergency physician, so it would still be a surgical decision in the end. At a real hospital, anyway.

And from the "weird stuff I get in my mailbox" file. . . someone asked me whether doctors and medical students really listen to the kind of music (I call it noise) that was playing at the Halloween party. A friend laughed quite loudly and said, "What're we supposed to listen to? Roy Orbison?" (I should point out that she's a very big Van Halen fan.) The answer, in case it's not evident, is yes, some people do. My current play list includes the Goo Goo Dolls, Paula Cole, Sarah McLachlan, Live, Jennifer Paige, Tori Amos, and Smash Mouth, as well as a few bands you've probably never heard of, unless you live in Victoria. (Carolyn Neapole rocks my world!) And yes, I like jazz too; my favourite composer was Bach, and I'm quite fond of Delibes operas. I and a colleague went to Lilith Fair this year. (And I went the year before too.)
Any more questions on the musical habits of medical people? That was an easy one. :)