Point of Origin

Busy episode. I missed the first couple minutes because I was busy taping a Homicide re-run on another channel and forgot to switch back. Generally speaking, nice to see Lucy rotating through the services, although true to form, she's spending far too much time in the emergency department for my own tastes. Can't she go on a rural practice rotation, or something? :)

A few specific points this week I wanted to touch on..

Phyl asked, in her review, whether or not there are "levels" of care to a DNR, and what sorts of treatment are permissible under them. It depends on how the order is written - some DNRs are very explicit in what can and cannot be treated; others are quite vague. If I'm recalling the episode correctly, Kerry's "mother" was throwing PVC (premature ventricular contractions). The problem here is that PVCs, while never a good thing, are not in and of themselves harmful, although they are signs that a more serious arrhythmia is on the way (perhaps something like VTach or VFib). Does reversing PVCs count as resuscitation? Probably not - you aren't resuscitating anything, merely preventing deterioriation. Was it the right thing to do? Depends - on you, on the patient, on the context.

Osteogenesis imperfecta is, as the name suggests, and imperfect formation of bones - kind of like a pediatric form of osteoporesis, only in this case the bones aren't degrading, they just didn't form properly. It's a hereditary disease and tends to be dominant, with two distinct forms - osteogenesis imperfecta congenita (with fractures and deformities occuring in utero, becoming apparent at birth) and osteogenesis imperfecta tarda (with fractures and deformities occuring after birth). The diagnosis is pretty simple, with fragile bones being the most obvious marker. The sclera (white part of the eye) can also be more clear than normal or tinted blue; because of the importance of bones in hearing, deafness can also be present. There is no treatment.

Charlotte Proctor sent me e-mail asking about the use of anti-psychotic drugs in pregnancy, and whether or not Haldol is the only drug of this type that is stocked by emergency departments. Since this has come up more than once on the show (twice this season, in connection to the same patient), I figured I'd turn it into a commentary topic.

The first part of the question had to do with whether there were any "safe" anti-psychotic drugs for use in pregnancy, and the answer, unfortunately, is no. There's a long-acting version of Haldol which is probably safe (although birth defects have been noted in combination with other drugs, so no one's really sure), but the vast majority of anti-psychotics are Class C (probably unsafe) or Class D (very unsafe) for use in pregnant patients.

The second part of the question had to do with the use of Haldol in emergency departments as a method of controlling unruly patients. We call Haldol Vitamin H, and I'm of the opinion it is the single most useful drug in emergency medicine. It is a neuroleptic that we use to sedate obnoxious or violent patients. Some folks used to use succinylcholine to accomplish this - paralyze and intubate - but this practice has fallen out of favor. (I have a great story about sux and obnoxious patients involving Peter Rose I'm trying desperately to work into a commentary.)

Why do we use Haldol? In a word, safety. Haldol is a phenomenally safe and dependable drug: I can give someone 25 mg of Haldol as the "how do you do" dose, and be reasonably sure that 90% of the people I give it to are going to go out like a light. It has very little effect on respiratory drive, and has virtually no effect on the CO2 response curve. This, combined with the sheer effectiveness of the drug, makes it an excellent choice for first-line sedation in the emergency department. EDs tend to stock other drugs for emergency sedation - notably midazolam (Versed) - but because of the effects these have on respiratory drive, it's probably better not to use them unless you know you're going to be intubating later anyway.

There's some conventional wisdom in medicine about Haldol and its safety: notably, some people have heard that Haldol lowers the seizure threshold and makes people more prone to convulsions. The only reason I'm mentioning this here is because it's so funny, and it's an excellent example of junk science - the evidence to support the notion that Haldol lowers the seizure threshold comes out of some work done in the 1960's wherein a bunch of rats were given enough Haldol to almost completely replace their blood volume.

And some of those rats seized.

Well, gee, no kidding, bunk. That's the sum total of the evidence surrounding Haldol and seizures.

I had to laugh at Jerry's misadventures with the methylene blue - it's a pretty standard trick played on people who work in medicine, and I've had it done to me more than once. There are two other agents that get used in this context; one of them is phenylpthalene, and the other is pyridium - both of them turn urine bright pink, and both of them have an effect which has to be seen to believe.

Not that I'd ever do something like that, mind you.