Labor day was spent in my particular labor, the ED, doing my thing to save disease and stamp out lives (joke). I was at my part-time gig, which is a very nice ‘community ED’, a departure form the inner city referral-center ED that’s my real job.
At the real job I don’t see kids under 12 much, as we’re in a complex with a huge peds referral center. At the real job I see inner city problems and patients, and a lot of exacerbations of chronic diseases. Oh, and a terrific lot of blunt trauma. It’s good emergency medicine, and I help the team make a difference, but it’s a pretty well defined patient population. A lot of acuity, a lot of sick patients, a very high admission rate. Not bad or good, just different.
The part-time gig, on the other hand, is on the edge of the big metroplex, and as such is much more of a ‘real’ ER: kids with colds, ankle sprains, and the occasional really sick patient. Lots of patients, but as a rule they’re not as sick and not as chronic. Trauma is steered away by EMS, but they get MI’s, etc. And nursing home patients, but not nearly the volume of the Big Joint.
Today I got to talk to my patients a little bit more. I got to get a bead out of the nose of a kid (10 Fr. foley plus a little etomidate worked the charm in a rambunctious and completely uncooperative toddler), I did a diagnostic and therapeutic thoracentesis in a nice little-old-person who felt miserable trying to breathe with one diseased lung rather then the usual two; the change was dramatic. And appreciated, by both of us: the patient for a life made better, and me for a renewal of energy. I used judgement, skills and hands to make a patient comfortable, facilitate a diagnosis, and prove to myself I cold help.
Yes, they’re common procedures for an EM physician, but today it felt different. Good.
I’m like you, I need good days, and love them when I have them. Today was one.
My initial use of Etomidate was in World-Famous-Medical-Center-With-Trauma. I was under the impression that Etomidate was a general anesthetic that lasted about 5 minutes.
When our hospital said we were going to start using it in kids (Yikes!), one of the ER doctors looked it up and it was supposedly not for use in pediatrics, and supposedly neither is Ketamine which I hate! As do some of the ED docs….
My hospital has not started using either one, yet….
Looks like I may need an attitude adjustment where these two drugs are concerned!
Well, first of all, Ketamine and Etomidate are both drugs from the gods. The use of brutane is evil, IMHO.
Second, if you’re not using those agents, what other than brutane are you using? (Hint: want to decrease your patient times in the ED? Use very short-acting sedation agents. Patients awake and ready to go in 15 minutes free up nurses and make the patients and their patients happy). Admittedly, that’s more for the etomidate than the ketamine, but both are very useful tools. And safe, and proven.
Never had a problem with ketamine. Had to bag 2 kids through etomidate. Brutane has the quickest offset (for those who don’t get the joke, brutane means getting big strong people to hold the kid down) and is my preferred method, but to each his own. The problem at our institution with sedation is that there is a sedation packet with about 20 pages that need to be filled out, much of it by the MD. It takes longer to do the paperwork than the procedure. Been a long time since I did a thoracentesis–they say never let the sun set on an effusion, but they just don’t seem to come my way.
If I had to list the number of drugs that have ‘not approved for use under the age of…” on the vial, half of our stock would be off-limits. Mostly drug companies covering themselves. Ketamine is pretty good, we use it in PICU to cover chest drain removals. Using a bit more clonidine of late, and of course the Wonderful White Drug propofol, sparingly with an intubated child.
Had to look up etomidate. Never used it, never even seen it. Guess it’s a US thang, or at least confined to theatres over here.
We used ketamine on a young girl with a need for extensive and frequent dressing changes on her leg, having had fasciitis. It worked well. But I’ll never forget the wail she emitted each time she emerged: starting low, getting higher and higher, as if terrified beyond anything I could know. As if she’d looked through the gates into hell. She didn’t remember. But it was always the same, and somehow it’s hard not to believe that some of it stayed with her, somewhere.
Ketamine has a well-documented ’emergence phenomenon’, usually manifesting in very real hallucinations, usually of the terrifying sort.
The general recommendation is for some benzo addition when the age is over 6 or so, and a lot of places shun it in adults for the reason you describe (which probably freaks the staff out more than the patient).
Is there such a thing as a cooperative toddler?
I think of toddlers as a range, starting with ‘mildly uncooperative’ and ranging to ‘wildebeest on the Serengeti.
It’s when toddlers start getting cooperative that I start moving very quickly.
I saw an odd reaction to a ketamine dose the other day, after I’d left the above comment. Myoclonic twitching is apparently fairly common after giving the drug but I’d never seen it so pronounced and repetitive, particularly in the arms and combined with lip/tongue movements. It looked for all the world like a seizure, so much so that I had one of our fellows stop by to check the patient.
There’s a 2002 article I browsed to on the use of ketamine in an emergency department, available as a PDF.