"Palliative" is not a dirty word, GI, Improving Outcomes, Improving Throughput, Mythbusting, Radiology

Versed, Pavlov, & the NGT

I admire & strive for efficiency, empathy, and efficacy.  Thus, if a certain painful procedure extends lengths of stay without significant benefit to the patient, I’m hesitant to order it. However, sometimes it is frowned upon to not play nice in the sandbox with our Pavlov consultants who request NG tubes for small bowel obstructions.



Thus, if you must place an NG tube for an obstruction, keep today’s study in mind.

Up at The U (of Vermont), patients that were ordered an NG tube and were between 18 and 60 years of age were given 1 ml of intranasal atomized co-phenylcaine (lidocaine 5% with 0.5% phenylephrine to each nostril, followed by either placebo or 2 mg of IV midazolam with NG tube placement within 5 minutes of placebo or midazolam. Using a 100 mm VAS for pain and discomfort, as the primary endpoint, the patients were interviewed 15 or 45 minutes after the procedure.

After 51 total cases (23 of which qualified for the study), the trial was stopped early as several ED clinicians felt that midazolam prior to insertion was superior to topical anesthetics alone and did not want their patients randomized in the study.

Hence, the numbers are a good bit low. Only 13 patients in the control arm, and 10 in the treatment arm. The mean difference in pain scores was 31mm and 36mm for discomfort. None of the midazolam placements were rated difficult by nursing who placed the NG tube, whereas 3/13 in the control group were rated as difficult or very difficult to place.

So yes. The numbers are small, and the authors shed some light on questions we would have. They spoke about anecdotally about 1mg of midazolam for those over 60 years old or with known pulmonary disease – which they felt did not alleviate pain or discomfort. Here, I think a 1mg bolus followed by 0.5mg boluses as needed is reasonable.

They cite a paper stating that 91% of providers would change their practice if new literature showed a convenient way to reduce patient discomfort. Well, here it is. So, if Pavlov’s dog barks and you HAVE to place an NG tube, hopefully your institutional policy allows IV midazolam without considering it procedural sedation (or, potentially using intranasal midazolam for anxiolysis).

"Palliative" is not a dirty word, Improving Outcomes

The Missing Link Between Provider & Patient Satisfaction

Over the last few years at the annual EM conferences, there’s been a lot of discussion on provider burnout and patient satisfaction.  While running, yoga, Starbucks, and your family are all important and contribute to your well being as a provider, you are not treating the underlying problem of the daily grind of working in an Emergency Department.

Shhhhh.  I’ve got a secret.  There’s a missing link between provider and patient happiness, a way to satiate these two demands that at times, are seemingly at odds with one another – until these two publications.  A simple way to increase physician satisfaction by 25% and patient satisfaction by up to 14%.

Sound too good to be true?  It isn’t.  Its called empathy.

In this study, 85 physicians with at least 1 year experience with oncology patients, and put them through a series of a simulated patient encounter over 3 weeks.  They first reviewed the patients medical, psychological, and social history, followed by a video viewing of the simulated patient with her oncologist discussing goals of care, and the third phase was a video of the same oncologist with “the team” reviewing treatment possibilities.  These 85 test physicians were then involved in a discussion with the simulated patient who was coached to choose a treatment plan that was not first or second line therapy.  Afterwards, the 85 test subjects were asked about their satisfaction with the encounter.  Multiple variables were tested to determine what caused an increase or decrease in satisfaction with the simulated encounter.

The two most important variables for physician satisfaction – which were responsible for a 25% increase in satisfaction in this simulation – were the physician’s level of anxiety due to uncertainty, and perceived physician empathy (based off the Jefferson Scale of Physician Empathy).

Think about this: these are modifiable factors.  Anxiety due to uncertainty?  That’s stress inoculation – SIM training, mental modeling of success.  Empathy?  We can easily modify this.  It’s displaying emotion and not minimizing the patient (“You sound really congested and unhappy. Let’s talk about what we can do to get you feeling better.”).  Its developing a toolbox to expand the options we can offer to patients – like offering dental blocks over oxycodone for toothaches.  FOAM in general expands your toolbox to offer patients.

So, while we can talk about burnout and the need to go on vacation and the use of casino shifts, ultimately, partnering with our patients makes for a happier patient, which in turn, makes for a happier physician.  I mean, who doesn’t like to hear “thank you” while on shift?

"Palliative" is not a dirty word, Improving Outcomes

“The Treatment of Pain is Very Important.”

Back to pain being the 5th vital sign, or so this study may have us believe. This study included an independent investigator essentially sneaking into the patient room to tell half the patients that “the treatment of pain is very important and be sure to tell the staff when you have pain.”

77.6% of the control vs 88.8% of the intervention group reported being provided with the above “pain advice” and the intervention group had an absolute and relative increase in satisfaction of 6.3% vs 14.2%, respectively. 91.3% of patients who were “very satisfied” had received this advice vs 76.3% of patients who were not “very satisfied” having received “pain advice.”

I think that ultimately, the aforementioned increase in patient satisfaction goes with giving clear instructions, and being clear with your projected management and expectations. I imagine that having a third party (such as Dr McDreamy) come over and say, “the treatment of pain is very important and be sure to tell the staff when you have pain,” will undoubtedly boost patient satisfaction. Likewise, I also question if it buys a bit (too much?) into “pain is the 5th vital sign” that got us into our current opiate frenzy in the first place. Regardless, there is potential for this to be a useful word choice in the quest for improved Press Ganey scores.

"Palliative" is not a dirty word, Improving Outcomes

Remember Palliative Care for Dementia!

A 78 year old patient is brought to the ED for the 4th time in 3 months for “not acting quite right.” Previously, the patient has been admitted for a urinary tract infection twice, and once for altered mental status. The patient seems friendly, answers many questions smiling, chuckling, and downplaying their symptoms. In fact, the patient seemingly can not explain why they are in the ED, and seem oblivious to there being anything wrong. The family reports that the patient is not eating as much as they used to, and that the patient had wandered out of the house and gotten lost twice last week. One family member admits that things seem to not be getting better despite their previous admissions, while another eagerly requests to “check the urine.”

An Australian study looked at 5261 patients who died with dementia over a 2 year period, with 2685 comparative patients without dementia who died with conditions amenable to palliative care. More than 70% of both groups visited an ED in the last year of life. Only 6% of the dementia cohort vs 26% of the non-dementia cohort were involved in palliative care. In the last year of life, those that did not receive palliative care were 1.4 times more likely to have a repeat visit to the ED within the next 3 months, and 6.7 times more likely to visit the ED in the weeks preceding death.

Here is an intervention that makes patients and family happier, has been proven to extend life, die with dignity, and save hospital visits & admissions. Why are we not doing this more?

So what can palliative care provide? Good question. So I asked a palliative care doc (@palliativedocto) what they thought. Their take:

I would make sure the family, and patient if it’s early dementia, understand the symptoms and progression of dementia, environmental adaptions for a demented family member, the medications that can be used to help with symptom management, the use of feeding tubes, and the importance of completing an advance directive if that has not been done. I would, as you suggest, eliminate any unnecessary medications, being cognizant of the stage of the dementia. Hospice should be brought up, if not for now, for the future. And finally, have social work see the family for help with everything they need, including any financial benefits they’re eligible for, as well as the expected crises that will surely ensure.”

Doesn’t that sound awful? Provider’s educating patients & family on a chronic, irreversible disease. Such a terrible thing! This makes for a great situation to place the patient in the observation unit, set the wheels in monitor for palliative care to see the family & patient, and save a visit to the ED.

Palliative is not a dirty word.

"Palliative" is not a dirty word, GI, Improving Outcomes, Mythbusting

Adding Haldol to the Emesis Toolkit

For emesis, when zofran fails, where else do you turn? Reglan? compazine? Ativan?  What about for the cyclic vomiters / cannabinoid abusers?

I don’t disagree with zofran as first line, I think most, if not all, of us can agree on that. And if you want to say Reglan or compazine as second line, that’s ok.  I think many of us have seen either an SBO or cyclic vomiter that does not respond well to the above.

Enter Haldol.
It certainly raises an eyebrow.  It’s efficacy, however, is quite impressive.  For those of you using Ativan, as far as pubmed tells me using lorazepam and vomiting as a query, it has only been studied as an adjuvant, and only as recently as the late 90s – with an increased amount of side effects vs Reglan or Zofran.  A 2007 & 2012 study found haldol to be as effective as zofran for post operative nausea and vomiting with pain scores, sedation scores, and recovery times were similar in the two groups, and no prolongation of the QTc interval was observed in either group.  In a separate study, the combination of haldol and zofran vs zofran alone for post op nausea & vomiting had more complete responders,  less nausea, and required less rescue medication. Sedation and QTc prolongation were not different, with no increased side effects in the Haldol + Zofran group.   For malignant bowel obstruction, it’s considered first line for various protocols, and has been in the palliative care toolbox for years.  For an obstruction, if Zofran fails, reconsider giving Reglan, as it may increase colic, and therefore, abdominal pain.

So go ahead. Give haldol a whirl.

PMID: 7900711
PMID: 17470885
PMID: 18420853
PMID: 22297625
PMID: 18359221
PMID: 23137588

"Palliative" is not a dirty word, Mythbusting

Peacefully Passing in the ED.

I’ve often half-jokingly stated that I believe we treat our pets better than our family at the end of life.  Our beloved Fido dies after a run on the beach, a steak dinner, and with a slug of morphine.  Grandma?  She gets intubated without pain medication, gags a bit, and likely dies in significant distress.

We can make this process more peaceful.  There is a significant movement for emergency medicine to OWN palliative care.  We need to recognize when heroic efforts will go for naught (1 year mortality for a patient >85 years old admitted to the ICU is 97%).  We can be soothing.  We can start Fentanyl drips.  We can add on anti-secretory agents.  We can add on a bit of anxiolytics.

As per a recent study, according to the family of the deceased, what factors were associated with the perception of peaceful death?  Adequate personal attention.  Adequate personal care.  Family finds enough nurses available.  And a you can make a phone call.

Religious affiliation reflected in end-of-life decision making has been associated with the perception of a peaceful passing.  Simply offering a chaplain to come in often times is soothing to the family and provides a sense of closure.  There is something about the end of a loved ones life that brings out an inner spirituality to both atheists and believers.  This is so simple to do!  If the RN asked me if they could page the chaplain for my dying patient, I would be embarrassed I had yet to do it myself.  It is one of few things that we all could do that has been shown to influence a family members opinion that their loved one passed peacefully.

Next time it appears futile, and the end of life discussion has been had, offer a chaplain.  The discussion and reality is never going to be easy for the family.  Let’s make an honest attempt to make it less difficult.  Let’s turn off the monitor, turn on the Fentanyl drip, load the patient with hyoscine, and get the chaplain on board.




When do people with dementia die peacefully? An analysis of data collected prospectively in long-term care settings PMID:24292158

Outcome of elderly patients with circulatory failure. PMID: 24132383