GI, Mythbusting

Haloperidol- one anti-emetic to rule them all.

When all else has failed, and the patient does not meet admission criteria, where do patients go?  Obs, of course!  I view it as a valuable tool to augment my ED armamentarium.  Specifically, for instances like, say, gastroparesis or cyclic vomiting.

This randomized, double-blind, placebo-controlled trial was performed at two urban hospitals looking at patients with a previous diagnosis of gastroparesis comparing conventional therapy + placeo to conventional therapy + 5mg of IV haloperidol.  They looked at pain severity and nausea every 15 minutes for 1 hour.  Secondary outcomes were disposition status (hospital admission or discharge), ED length of stay, and nausea resolution at 1 hour.  Sadly, they only looked at 33 patients total over a two year study period.

While the two groups were similar in terms of the conventional therapy received, in the haloperidol group, disposition was made sooner and more patients were discharged home, with a significant reduction in pain at one hour (on a scale of 0-10, a mean improvement of 5.37 vs 1.11 in favor haloperidol), as well a reduction in nausea at one hour (scale of 0-5, improvement of 2.7 vs 0.72 in favor of haloperidol).  Fewer patients were admitted (26.7% vs 72.2%) who received haloperidol, with median length of stay shorter for haloperidol (4.8 hrs vs 9 hrs).  Surprisingly, patients in the haloperidol group experienced no adverse events, including QT prolongation and dystonic reactions.  This is probably due to small sample size.

This does not address haloperidol as sole treatment,  and at only a few dozen patients in this study, certainly does not solidify haloperidol’s use as first line.  However, it does add to the pile of data showing haloperidol as safe and efficacious in these patients.  As an aside, if your hospital is anything like mine, you can not give haloperidol IV, so I’ve trialed 5-10mg IM.  Over the last 4-5 years, I’ve become fond of IM haloperidol for refractory vomiting, and (anecdotally) I’ve used it dozens of times with high rates of success.

So yes, better analgesia, decreased nausea, fewer admissions, and decreased LoS with haloperidol.  Pretty much everything you want.  I just wish a broader study in non-specific abdominal pain with vomiting would compare haloperidol as singular treatment and compare it to standard care.

Look, there are some patients who are vomiting so profusely that they seemingly require an exorcism.  For those patients, I think adding a bit of haloperidol for symptomatic relief does not have much downside, I just wouldnt go mixing multiple QT prolonging agents at once.

So, I ask, whats downside?

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"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?

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