Someone please start an academic discussion.

[RustedFox]

So, I keep trying to encourage posters to give mini lectures on a common topic, a topic of interest, some common management pitfall/nuance, or whatever... but I've yet to see anyone accept this small challenge.

Come on guys. Don't be EMussies.

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[Crabbygas]

OK. I'll jump in because I am dying of boredom. You don't need to use the needle that comes in the kit to do an LP. Please do not use that needle. You will just end up consulting me for the blood patch. A 22ga works just fine. I have even done a tap with a 25ga in a young woman. Yeah you have to sit around for a while if you want 4 tubes but it's less time than a rebound the next day.
Feel free to share opposing opinions.

 

[RustedFox]

OK. I'll jump in because I am dying of boredom. You don't need to use the needle that comes in the kit to do an LP. Please do not use that needle. You will just end up consulting me for the blood patch. A 22ga works just fine. I have even done a tap with a 25ga in a young woman. Yeah you have to sit around for a while if you want 4 tubes but it's less time than a rebound the next day.
Feel free to share opposing opinions.

Where are you getting these long 22 gauge needles from?

Politely; you do realize that most people that we have to do LPs on require a harpoon. "Hubbing the needle" and not yet reaching the target space happens more often than you think.

[Honestly, I can't stand the obese. God Forbid you tell them to NOT eat the whole buffet. Sure, this is America - and you can do whatever you want as long as it's legal... but that doesn't mean that you should.]

 

[Brigade4Radiant]

LP's are not an emergent procedure just call IR if you suspect meningitis call ID admit and have IR do it in the morning. If you can't do it in three tries move on you have other patients to see.

 

[RustedFox]

LP's are not an emergent procedure just call IR if you suspect meningitis call ID admit and have IR do it in the morning. If you can't do it in three tries move on you have other patients to see.

I mean, you should really tap before abx, and fast. Come on now. I don't like doing them either because people in general are such giant sissies, but it's not a hard procedure as long as they're not a whale or a terrifically arthritic 80+ year old (which is most of my people here in FL).

 

[Crabbygas]

Where are you getting these long 22 gauge needles from?

Politely; you do realize that most people that we have to do LPs on require a harpoon. "Hubbing the needle" and not yet reaching the target space happens more often than you think.

[Honestly, I can't stand the obese. God Forbid you tell them to NOT eat the whole buffet. Sure, this is America - and you can do whatever you want as long as it's legal... but that doesn't mean that you should.]

Your OR has a collection of needles I'm sure. And thank you for the politeness. I truly don't get to see all the folks you do. I will say it is not at all unusual for me to be putting the standard length 25ga spinal needle into a 5'2" 300 pound woman. Never needed the longer one if I had the right space. Non cutting needles are great for avoiding the headache too. Probably not available in 22ga but even that's better than the usual 18ga. Old and arthritic less likely to have a headache so you have that going for you.

 

[RustedFox]

Your OR has a collection of needles I'm sure. And thank you for the politeness. I truly don't get to see all the folks you do. I will say it is not at all unusual for me to be putting the standard length 25ga spinal needle into a 5'2" 300 pound woman. Never needed the longer one if I had the right space. Non cutting needles are great for avoiding the headache too. Probably not available in 22ga but even that's better than the usual 18ga. Old and arthritic less likely to have a headache so you have that going for you.

Hey, no problem; I genuinely like it when other docs come in here to comment. We tend to be a lively crowd.

One thing that I'll never understand is how we don't have immediate access to these things. For me to get access to a 22/25ga spinal needle from the OR would require getting the charge nurse to bother someone else (generally house supervisor), who is then going to consider their next snack for awhile before coming to the ER and asking me "if I really need it" before then walking around and taking generally :60-:90 minutes before finding the item in question; if they find it at all.

 

[CoolDoc1729]

getting the charge nurse to bother someone else (generally house supervisor), who is then going to consider their next snack for awhile before coming to the ER and asking me "if I really need it" before then walking around and taking generally :60-:90 minutes

I love when I click through 4 menus to order something I don’t usually order and then they ask if I really want it. Unusual meds or labs. Like yeah I put a lot of effort to ask for it. Yes I really want it. Then the finding it came can commence .. what tube does it go in? 🤷🏻‍♀️ is it in the Pyxis ? 🤷🏻‍♀️

 

[lucid_leprechaun]

Where are you getting these long 22 gauge needles from?

Politely; you do realize that most people that we have to do LPs on require a harpoon. "Hubbing the needle" and not yet reaching the target space happens more often than you think.

[Honestly, I can't stand the obese. God Forbid you tell them to NOT eat the whole buffet. Sure, this is America - and you can do whatever you want as long as it's legal... but that doesn't mean that you should.]

Didn’t realize this wasn’t standard, I don’t think I’ve ever used the 18 g needle in the kit. We use the 22 quinke. Would like a non cutting but that we would have to find from OR.

 

[turkeyjerky]

Call me a sadist, but part of me wants the patient to suffer if they so histrionic that they're getting an LP. Other than than the critically ill and neonates, seems that 90% of the patients I tap are whiny migraineurs, who claim to not be "headachy" people (then why have you been here for headaches 12 times in the past 2 years?) who come to triage saying "the last time I had a HeaDaCHe LikE ThiS iT wAs MeniGiTiS!" And when you look back, it was inevitably either a negative tap but they got admitted anyway, a traumatic tap, or viral.

 

[Tiger26]

Didn’t realize this wasn’t standard, I don’t think I’ve ever used the 18 g needle in the kit. We use the 22 quinke. Would like a non cutting but that we would have to find from OR.

I agree--I've never used anything larger that a 22g. I wish we had 25g but the idea of routinely doing an 18g seems so old school (in a bad way).

Also, I specifically don't want them to suffer because it maximizes my chance of a successful procedure. I feel this way about every invasive thing I do, but the more pain relief I can provide, the more likely the outcome will be good. I usually numb up LPs enough that I'm just pulling out the needle when they ask when I'm going to get started after the initial poke from the lido.

 

[RustedFox]

Call me a sadist, but part of me wants the patient to suffer if they so histrionic that they're getting an LP. Other than than the critically ill and neonates, seems that 90% of the patients I tap are whiny migraineurs, who claim to not be "headachy" people (then why have you been here for headaches 12 times in the past 2 years?) who come to triage saying "the last time I had a HeaDaCHe LikE ThiS iT wAs MeniGiTiS!" And when you look back, it was inevitably either a negative tap but they got admitted anyway, a traumatic tap, or viral.

We have a significant number of obese whiners with ventriculoperitoneal shunts, or lumbar-peritoneal shunts, or mouth-to-ass shunts or whatever that love to say stupid things in the ER like "my neurosurgeon told me to come here because he's here and he told me to tell you to w...h...a...t...e...v...e...r... I ... s...t...o...p...p...e...d l...i...s...t...e...n...i...n...g."

They're uniformly obese and addicted.

 

[RustedFox]

I agree--I've never used anything larger that a 22g. I wish we had 25g but the idea of routinely doing an 18g seems so old school (in a bad way).

Also, I specifically don't want them to suffer because it maximizes my chance of a successful procedure. I feel this way about every invasive thing I do, but the more pain relief I can provide, the more likely the outcome will be good. I usually numb up LPs enough that I'm just pulling out the needle when they ask when I'm going to get started after the initial poke from the lido.

Yeah, I go aggro with the lido on my taps. No reason not to.

 

[turkeyjerky]

Yeah, I go aggro with the lido on my taps. No reason not to.

My SOP is to to use a bunch of lido w/ epi and then come back in 5 min or so to actually do the tap.

 

[RustedFox]

My SOP is to to use a bunch of lido w/ epi and then come back in 5 min or so to actually do the tap.

A fellow man of taste, I see.
Also, a fellow lidocaine hoarder, I see.

 

[thegenius]

Didn’t realize this wasn’t standard, I don’t think I’ve ever used the 18 g needle in the kit. We use the 22 quinke. Would like a non cutting but that we would have to find from OR.

Our kits are 20g cutting. Usually sufficient unless > two fiddy.

 

[thegenius]

I agree--I've never used anything larger that a 22g. I wish we had 25g but the idea of routinely doing an 18g seems so old school (in a bad way).

Also, I specifically don't want them to suffer because it maximizes my chance of a successful procedure. I feel this way about every invasive thing I do, but the more pain relief I can provide, the more likely the outcome will be good. I usually numb up LPs enough that I'm just pulling out the needle when they ask when I'm going to get started after the initial poke from the lido.

I give all those needing an LP versed 2 mg IV priory. Love it.

How can you effectively guide a flimsy 25 gauge to exactly where you want it? Seems like it would bend and shiiit while going in.

 

[Janders]

Honestly we have issues stocking… well… all sorts of stuff in our ED. But it wasn’t hard to stock 18 / 22 / 25g standard LP needles and the true 22g harpoons. They sit on a shelf next to the LP trays. Easy peasy, they rarely go out of stock and have other uses too.

Agree w/ OP, the needle in our kit is a rigid 20g and is not a good first choice. As well our kit comes with like 0.75mL of 1% lido. Screw that, use a whole bottle of 2% w/ epi.

That said, my bar to LP people is high, but if they need it I’m happy to do it. Sitting up. Full of lido. So. Much lido I obliterate the landmarks and find the space using the Force.

 

[Janders]

I give all those needing an LP versed 2 mg IV priory. Love it.

How can you effectively guide a flimsy 25 gauge to exactly where you want it? Seems like it would bend and shiiit while going in.

I mean, I don’t know I like the slightly flimsy 25g? I put them in about 2cm, take the stylet out and leave it out, and actually can feel them passing ligament and into the space like 75% of the time before getting CSF. I find the firm needles take my touch out of the equation.

 

[Radetzky]

I promised you one on PE, so here goes.

Mechanisms of hypoxemia

Hypoxemia is not simply due to vascular obstruction. Blockage of the pulmonary circulation to a capillary results in increase blood flow via the bronchial circulation. But the high pressures from the systemic circuit result in oedema and capillary damage leading to RBC extravasation. If not resorbed sufficiently necrosis and infarction result. This is why central PEs are less hypoxemic- the high pressure is distributed over a larger area.

Hemodynamics

The concept of the RV as preload dependent arises from studies of RV infarction. Against a normal afterload the RV maintains its high compliance and stroke volume can be recruited without raising the CVP too much. However the story is completely different in situations with high afterload- the CVP rises rapidly and the constraint of the pericardium means that most of this pressure is transmitted to the LV through the septum where it limits the diastolic filling of the LV (so called D shaping of the LV). It has been shown in dog models that while a little fluid helps, too much results in cardiovascular collapse- basically the more septal shift the worse the hemodynamics- this is the main mechanism that kills people- when the dogs had their chests open (pericardial constraint removed)- fluid only ever improved hemodynamics.

So one should transition pretty quickly to inotropic support. There is a fear that vasoconstrictors increase PVR- but in fact in most studies the PVR drops upon initiation of norepinephrine- probably due to better RV perfusion pressure, underappreciated inotropic effects and the fact that PVR is more complicated than constriction/dilation.

There is no echo finding specific to PE. Additionally If one measures a systolic pulmonary pressure > 50 or a RV wall thickness > 5mm you should be suspicious the RV failure is chronic (or at least subacute). Healthy RVs cannot generate a pressure greater than 50 acutely and still be beating.

PE can also result in bronchospasms due to acute release of various inflammatory mediators.

 

[Rekt]

LP's are not an emergent procedure just call IR if you suspect meningitis call ID admit and have IR do it in the morning. If you can't do it in three tries move on you have other patients to see.

This **** pisses me off. Stop being lazy. Why bother resuscitating anyone sick? Just call the NPP from the ICU to put the line in or intubate them for you. Chest pain? Just call cards to figure it out. Belly pain? Why bother thinking. Just call both GS and GI to see them.

Stop having people do work for you or you're just a triage tech. You should not be calling any consultant until you've maxed out your personal knowledge or effort or have a real question you can't answer.

 

[Apollyon]

Our kits are 20g cutting. Usually sufficient unless > two fiddy.

So, like, erryone??

 

[thegenius]

So, like, erryone??

Haha yea its most.

Don’t you hate looking at the board and you read “fever, ha, vomiting” and you be like dammit I don’t even want to go in there….and they are probably fat too. Then you go in and it’s a skinny young person and are like “YES dodged a bullet there”

 

[RustedFox]

I promised you one on PE, so here goes.

Mechanisms of hypoxemia

Hypoxemia is not simply due to vascular obstruction. Blockage of the pulmonary circulation to a capillary results in increase blood flow via the bronchial circulation. But the high pressures from the systemic circuit result in oedema and capillary damage leading to RBC extravasation. If not resorbed sufficiently necrosis and infarction result. This is why central PEs are less hypoxemic- the high pressure is distributed over a larger area.

Hemodynamics

The concept of the RV as preload dependent arises from studies of RV infarction. Against a normal afterload the RV maintains its high compliance and stroke volume can be recruited without raising the CVP too much. However the story is completely different in situations with high afterload- the CVP rises rapidly and the constraint of the pericardium means that most of this pressure is transmitted to the LV through the septum where it limits the diastolic filling of the LV (so called D shaping of the LV). It has been shown in dog models that while a little fluid helps, too much results in cardiovascular collapse- basically the more septal shift the worse the hemodynamics- this is the main mechanism that kills people- when the dogs had their chests open (pericardial constraint removed)- fluid only ever improved hemodynamics.

So one should transition pretty quickly to inotropic support. There is a fear that vasoconstrictors increase PVR- but in fact in most studies the PVR drops upon initiation of norepinephrine- probably due to better RV perfusion pressure, underappreciated inotropic effects and the fact that PVR is more complicated than constriction/dilation.

There is no echo finding specific to PE. Additionally If one measures a systolic pulmonary pressure > 50 or a RV wall thickness > 5mm you should be suspicious the RV failure is chronic (or at least subacute). Healthy RVs cannot generate a pressure greater than 50 acutely and still be beating.

PE can also result in bronchospasms due to acute release of various inflammatory mediators.

This is exactly what I have been trying to encourage.

Quick question for clarity: When you say "D-shaping of the LV", do you mean that the LV volume is reduced due to the septum being pushed from R to L and into the space inside the ventricle?

Because when I draw the picture in my head, that seems like a D-shaped RV, not a LV.

 

[Radetzky]

This is exactly what I have been trying to encourage.

Quick question for clarity: When you say "D-shaping of the LV", do you mean that the LV volume is reduced due to the septum being pushed from R to L and into the space inside the ventricle?

Because when I draw the picture in my head, that seems like a D-shaped RV, not a LV.

Yes septum pushed over to the left, reducing the space inside the LV.

See the pic for clarity- top is RV, bottom is LV.

 

[lucid_leprechaun]

I mean, I don’t know I like the slightly flimsy 25g? I put them in about 2cm, take the stylet out and leave it out, and actually can feel them passing ligament and into the space like 75% of the time before getting CSF. I find the firm needles take my touch out of the equation.

Yeah the 25 g feels good to use but I once sat in a room for 45 minutes collecting CSF so never again.

 

[guytakingboards]

I'm a neurorad and I can't stand driving a 25g needle. 22g or bust. Only time i use a 25g is if they're young and <150lb, am just doing a myelo/IT chemo but not collecting fluid, or they have bleeding concerns.

Yeah the 25 g feels good to use but I once sat in a room for 45 minutes collecting CSF so never again.

In my experience, that's not crazy uncommon on the IP side even with a 22g. I've had LP's where I've sent the rad tech to lunch or do other cases. Some patients are just that dehydrated. I had two dripper LP's on Monday that were probably 25-30min of collection time each.

 

[Brigade4Radiant]

This **** pisses me off. Stop being lazy. Why bother resuscitating anyone sick? Just call the NPP from the ICU to put the line in or intubate them for you. Chest pain? Just call cards to figure it out. Belly pain? Why bother thinking. Just call both GS and GI to see them.

Stop having people do work for you or you're just a triage tech. You should not be calling any consultant until you've maxed out your personal knowledge or effort or have a real question you can't answer.

Cool but your examples don’t make sense You need to intubate someone because if you don’t they will die. You need a central line as well because they are critical.

I always attempt to do a lumbar puncture’s but if I can’t do it in three sticks it’s unfair to the patient to keep sticking them I have done many but I see docs spend an hour in the room which is just harmful.

Also your example of not being called until maxing out every resource doesn’t really make sense. You’re also bound by EMTLA also it’s your job. Please don’t think too highly of yourself. I’m not your resident if a patient needs a consult I will do it unapologetically

Cards and GI are also often called if the dispo is in question like most EM docs we make decisions on most of our patients alone

 

[RustedFox]

Yes septum pushed over to the left, reducing the space inside the LV.

See the pic for clarity- top is RV, bottom is LV.

Crystal. Clear. Perfect.

 

[BoardingDoc]

OK. I'll jump in because I am dying of boredom. You don't need to use the needle that comes in the kit to do an LP. Please do not use that needle. You will just end up consulting me for the blood patch. A 22ga works just fine. I have even done a tap with a 25ga in a young woman. Yeah you have to sit around for a while if you want 4 tubes but it's less time than a rebound the next day.
Feel free to share opposing opinions.

We have 20g needles in stock that I routinely use over the 22g because I am impatient. That said, I agree there isn't a reason I can think of to use an 18g. CSF collection start --> finish takes 1 minute with a 20g instead of 10 with a 22g. I honestly would not even consider using a 25g on anyone unless I had a PA available to sit and collect the CSF for me. Opting to wait 45 minutes to collect CSF when you're solo coverage in a busy ED is simply inappropriate.

 

[guytakingboards]

We have 20g needles in stock that I routinely use over the 22g because I am impatient. That said, I agree there isn't a reason I can think of to use an 18g. CSF collection start --> finish takes 1 minute with a 20g instead of 10 with a 22g. I honestly would not even consider using a 25g on anyone unless I had a PA available to sit and collect the CSF for me. Opting to wait 45 minutes to collect CSF when you're solo coverage in a busy ED is simply inappropriate.

The literature rates for post-dural puncture headaches are about 33% for a 20g cutting needle and 8-25% for a 22g cutting needle.

IMHO, it's disservice to the patient to increase their rates of PDPH and need for subsequent blood patch because you can't wait 10min. There's literally no one available, MA or nurse, to hold a tube for 10min?

 

[BoardingDoc]

The literature rates for post-dural puncture headaches are about 33% for a 20g cutting needle and 8-25% for a 22g cutting needle.

IMHO, it's disservice to the patient to increase their rates of PDPH and need for subsequent blood patch because you can't wait 10min. There's literally no one available, MA or nurse, to hold a tube for 10min?

I'm assuming from this comment that you're not an emergency medicine doc. Apologies if I'm wrong, and you simply have better resources available to you than literally any ED I've ever worked in. We don't have MA's in the ED, we have techs. Tech's can't get sterile to hold the needle for the procedure. Nursing would blow a gasket if I asked them to hold onto a spinal needle to collect fluid. As I mentioned above, unless you have a PA available to take care of it, that isn't really an option.

All of these explanations also completely ignore the elephant in the room, which is the need of the emergency doc to be available instantaneously in the event of an issue. Unlike in a clinic or other controlled setting, it is not an uncommon occurrence to be pulled immediately out of a room to deal with an urgent issue. Leaving a spinal needle in a patient's back to go do that isn't an option, so that means the patient risks getting poked a second time.

In any event, you're certainly right that in a controlled setting, using a 22g is preferable. The ED is not a controlled setting, and is almost never as resource rich (even in very basic ways) as some of our colleagues in other professions assume it is. I'm not suggesting what you propose is impossible as I'm sure other ED docs will sometimes use a 22. Just figured I'd elaborate a bit more about why I care about speed so much.

 

[RustedFox]

I'm assuming from this comment that you're not an emergency medicine doc. Apologies if I'm wrong, and you simply have better resources available to you than literally any ED I've ever worked in. We don't have MA's in the ED, we have techs. Tech's can't get sterile to hold the needle for the procedure. Nursing would blow a gasket if I asked them to hold onto a spinal needle to collect fluid. As I mentioned above, unless you have a PA available to take care of it, that isn't really an option.

All of these explanations also completely ignore the elephant in the room, which is the need of the emergency doc to be available instantaneously in the event of an issue. Unlike in a clinic or other controlled setting, it is not an uncommon occurrence to be pulled immediately out of a room to deal with an urgent issue. Leaving a spinal needle in a patient's back to go do that isn't an option, so that means the patient risks getting poked a second time.

In any event, you're certainly right that in a controlled setting, using a 22g is preferable. The ED is not a controlled setting, and is almost never as resource rich (even in very basic ways) as some of our colleagues in other professions assume it is. I'm not suggesting what you propose is impossible as I'm sure other ED docs will sometimes use a 22. Just figured I'd elaborate a bit more about why I care about speed so much.

You said it before I did.

EDIT: We have so many rules as to why "this person can't do that" and they really hamstring us.

Sounds like a great thing for a useless admin to do... come down and be OddJob in the ER.

Maybe then they'll understand.

 

[xaelia]

Unlike in a clinic or other controlled setting, it is not an uncommon occurrence to be pulled immediately out of a room to deal with an urgent issue.

Sadly, most of these "urgent issues" are nonsense, but when Code Back Pain gets activated, you gotta go rule out an epidural abscess AND make sure there's door-to-Dilaudid within 10 minutes or CMS will revoke your Medicare reimbursement.

The capacity to accomodate ED scavenger hunt is low; both ED techs are sitting watch for psych patients, after all. Unless it's something required for life- or limb-saving investigation or treatment, we're just gonna make do with what we've got on hand.

 

[turkeyjerky]

Sadly, most of these "urgent issues" are nonsense, but when Code Back Pain gets activated, you gotta go rule out an epidural abscess AND make sure there's door-to-Dilaudid within 10 minutes or CMS will revoke your Medicare reimbursement.

This is so true that it hurts. However, so many other docs, inpatient and outpatient, don't understand our workflow or environment at all. Took a call from a PCP once, they were sending in a guy w/ a positive RPR who had a mentioned a headache as well, she wanted an LP to check for tertiary syphilis. I said to her,somewhat sarcastically, "ok, so you want him admitted for an ID consult and IV pen G?" She gets all huffy and asks me, "what you don't think it's an emergency?" No I don't.

 

[RustedFox]

This is so true that it hurts. However, so many other docs, inpatient and outpatient, don't understand our workflow or environment at all. Took a call from a PCP once, they were sending in a guy w/ a positive RPR who had a mentioned a headache as well, she wanted an LP to check for tertiary syphilis. I said to her,somewhat sarcastically, "ok, so you want him admitted for an ID consult and IV pen G?" She gets all huffy and asks me, "what you don't think it's an emergency?" No I don't.

Sounds like a direct admission to me.

 

[thegenius]

I'm assuming from this comment that you're not an emergency medicine doc. Apologies if I'm wrong, and you simply have better resources available to you than literally any ED I've ever worked in. We don't have MA's in the ED, we have techs. Tech's can't get sterile to hold the needle for the procedure. Nursing would blow a gasket if I asked them to hold onto a spinal needle to collect fluid. As I mentioned above, unless you have a PA available to take care of it, that isn't really an option.

All of these explanations also completely ignore the elephant in the room, which is the need of the emergency doc to be available instantaneously in the event of an issue. Unlike in a clinic or other controlled setting, it is not an uncommon occurrence to be pulled immediately out of a room to deal with an urgent issue. Leaving a spinal needle in a patient's back to go do that isn't an option, so that means the patient risks getting poked a second time.

In any event, you're certainly right that in a controlled setting, using a 22g is preferable. The ED is not a controlled setting, and is almost never as resource rich (even in very basic ways) as some of our colleagues in other professions assume it is. I'm not suggesting what you propose is impossible as I'm sure other ED docs will sometimes use a 22. Just figured I'd elaborate a bit more about why I care about speed so much.

It's for these reasons that I just stick to the 20g cutting that's in the kit. Sometimes I bring an extra needle in with me because occasionlly the first one gets clotted with blood or bent or whatever and need another. But the spares we have are cutting too IIRC.

Our ER is so dysfunctional and lack of LP needles is on the list...around #52 of things that need to be fixed.

 

[thegenius]

You said it before I did.

EDIT: We have so many rules as to why "this person can't do that" and they really hamstring us.

Sounds like a great thing for a useless admin to do... come down and be OddJob in the ER.

Maybe then they'll understand.

Nurses say they are "not credentialed" to do a disimpaction. I'm not credentialed either.

 

[johnny_bananas]

Call me a sadist, but part of me wants the patient to suffer if they so histrionic that they're getting an LP. Other than than the critically ill and neonates, seems that 90% of the patients I tap are whiny migraineurs, who claim to not be "headachy" people (then why have you been here for headaches 12 times in the past 2 years?) who come to triage saying "the last time I had a HeaDaCHe LikE ThiS iT wAs MeniGiTiS!" And when you look back, it was inevitably either a negative tap but they got admitted anyway, a traumatic tap, or viral.

Instead of inflicting unnecessary pain you could consider taking an extra 5 minutes to take a better history to see if an LP is indicated. But sure, tell yourself it's the patients fault you are doing the unnecessary procedure and it's good that they suffer!

 

[RustedFox]

Instead of inflicting unnecessary pain you could consider taking an extra 5 minutes to take a better history to see if an LP is indicated. But sure, tell yourself it's the patients fault you are doing the unnecessary procedure and it's good that they suffer!

You act like the typical histrionic headache patients are going to give any useful or even reliable data by opening their mouths.

 

[thegenius]

Sounds like a direct admission to me.

Yea this patient doesn't need emergency services. If they want to be worked up for neurosyphilis then they will probably need a 48 hr stay in a hospital. This isn't the role for the ER doc. If the pt is unconsciousness, yea then I'll be happy to resuscitate and stabilize him.

 

[thegenius]

Instead of inflicting unnecessary pain you could consider taking an extra 5 minutes to take a better history to see if an LP is indicated. But sure, tell yourself it's the patients fault you are doing the unnecessary procedure and it's good that they suffer!

Dear god. I can't believe you wrote this.

 

[RustedFox]

Dear god. I can't believe you wrote this.

Reading his post history, it looks like he's (1) Neurology and (2) Canadian, which means:

1. He's really not familiar with the variety of riffraff that we deal with in the ER, as he is upstairs and we play goalie.
2. All of his patients are bound by law to tell only truths, or they'll lose their Canadian Citizenship.

Yeah, that doesn't work in our world, amigo.

 

[johnny_bananas]

You act like the typical histrionic headache patients are going to give any useful or even reliable data by opening their mouths.

90% of the patients turkeyjerky taps are histrionic and poor historians? Does that sound believable to you? Easier to label a patient histrionic than to take the extra time to obtain a carful history.

I would also respectively disagree with you when it comes to “histrionic” patients, it is always useful to take a careful history, though this may take longer with these patients.

 

[johnny_bananas]

Dear god. I can't believe you wrote this.

You are surprised I wrote this, but not by someone stating that 90% of the LPs they perform are on “whiny migraineurs” and they want the patient to suffer. Only on this forum is that considered normal.

 

[RustedFox]

90% of the patients turkeyjerky taps are histrionic and poor historians? Does that sound believable to you? Easier to label a patient histrionic than to take the extra time to obtain a carful history.

I would also respectively disagree with you when it comes to “histrionic” patients, it is always useful to take a careful history, though this may take longer with these patients.

To address your top sentence: UHH, YEAH BRO. 90% of my patients in total (regardless of whether or not they require a LP) are histrionic and poor historians. You clearly don't work in the ED.

To address your bottom sentence: "Yeah, you're right, taking a careful history is always impor-... BWAHAHAHAHAHAAAAAAA.

Ohh, Christ - thank God you don't do EM. You'd never make it a shift.

@turkeyjerky and I cross swords on occasion on here, but he's dead-nuts-on-point here. What 90% of my patients really need is a good healthy dose of "shut the eff up and quit whining", but you can't say that - because this is America, where everything is a "disability", including failure to act like an adult. Someones, pain - or the threat thereof, is a very effective truth serum.

Guys, guys... the fact that he asked "Does that sound believable to you?".... AHHAAAAHAAAAAAAHAAHAAAAA! ! !

I'm laughing so hard I scared the cat and woke up the wife. Now, she's mad and it's his fault. LOL.

 

[lucid_leprechaun]

We have 20g needles in stock that I routinely use over the 22g because I am impatient. That said, I agree there isn't a reason I can think of to use an 18g. CSF collection start --> finish takes 1 minute with a 20g instead of 10 with a 22g. I honestly would not even consider using a 25g on anyone unless I had a PA available to sit and collect the CSF for me. Opting to wait 45 minutes to collect CSF when you're solo coverage in a busy ED is simply inappropriate.

Hah you caught me I asked one of our NPs to put on some gloves and come collect some CSF so I could pop out and do some other work

 

[RustedFox]

Hah you caught me I asked one of our NPs to put on some gloves and come collect some CSF so I could pop out and do some other work

Smart use of an NP.
That's a genuine compliment.

 

[aafisahar]

Sounds like a direct admission to me.

direct admit will happen sometime before 2024 if they're lucky

 

[RustedFox]

Hah you caught me I asked one of our NPs to put on some gloves and come collect some CSF so I could pop out and do some other work

Begs the question: do you really need sterile gloves to collect the CSF?
I mean, you're holding a tube, that's not touching anything. Don't touch the drape, don't touch the back...

???