Saturday, September 10, 2011

The Theme of the Shift

"The theme of the week is: the heart as a pump."
-Dr. Joseph Parambil

I don't know why this is, but it seems like every shift has a theme.  Yesterday's theme was GI bleeds.  I literally had three patients in a row with a chief complaint of melena, and I went room to room doing rectal exams and fecal occult analyses.  All three times, the stool samples on the card turned bright blue, which means a positive result for blood.  So I paged the GI fellow to tell him that I had three patients to admit for workup of GI bleeding. Unsurprisingly, he was not thrilled about getting so many patients all at one time, but I think it's probably better than paging him to come down to the ED three separate times.  At least this way, he only had to come down once.

On another shift, all of my patients were coming in with headaches.  It gave me the chance to develop my "migraine cocktail," which consists of metoclopramide, ketorolac, and diphenhydramine.  The metoclopromide helps with the patient's nausea; the ketorolac helps with the pain; and the diphenhydramine makes them drowsy so they can sleep for a while and recover from the headache.  I have to admit that I was a little skeptical when the attending suggested that I try metoclopramide with ketorolac, but it worked beautifully.  One of the nurses suggested adding the diphenhydramine, which was the perfect touch.  There are other combinations that can be used to treat migraines, but I'm pretty happy with this one.

I had a shift of all panic attacks, too.  Those patients often come to the ED thinking that they are having a myocardial infarction (MI), especially if it's their first panic attack. Typically, it's a young woman in her late teens or twenties with no medical history except maybe some anxiety.  My job is to rule out anything bad going on with the patient's heart, which entails putting him or her on a heart monitor, getting serial EKGs, and measuring two sets of troponin enzymes.  Odds are good that, unless the patient is a cocaine user, he or she is probably not having an MI.  But cocaine use is a risk factor for MI in young people, so I always specifically ask about it.  Every once in a while, someone admits to using cocaine, and that is an opportunity for patient education as well as ruling out a potential MI.

Of course, just about every shift is an abdominal pain shift.  It seems like abdominal pain is the most common complaints in the ED, and also one of the hardest to diagnose.  There are just so many organs in the abdomen, particularly for women, and any of them can cause pain.  Plus, sometimes organs in the abdomen can cause chest pain, and organs in the chest can cause abdominal pain.  For example, I've seen several patients with MIs who came in complaining of acid reflux.  That's what the MI feels like to them, and sometimes they even feel better when they take antacids.  So if someone complains of upper abdominal pain, I still have to keep MI in the differential.

It's impossible to know ahead of time what the theme of the shift will be, and that can be frustrating sometimes.  But the constant daily surprise is also part of what makes EM fun.


  1. Love your blog! It was my understanding that diphenhydramine is given with Metoclopramide as part of the migraine cocktail to prevent Metoclopramide's extrapyramidal side effects, not do make the patient drowsy. But I guess that's a nice added benefit!

    Keep up the great work!

  2. Yeah, I've heard that too. It makes theoretical sense since diphenhydramine has anticholinergic effects, and inhibiting dopamine receptors with metoclopramide could knock the dopamine/acetylcholine balance in the brain out of whack, leading to EPS. An anticholinergic should improve the neurotransmitter balance again. But as far as I know, there hasn't ever been a randomized trial looking at rates of akathisia for patients given metoclopramide with and without diphenhydramine, let alone studies of the mechanism of action. There is plenty of anecdotal evidence that it works though. (Here's a case report, for example: So like so many things in medicine, this is something we do because we think it works and it makes sense that it should work.

    As for why it works, assuming the effect is real, who knows? Your proposed mechanism makes perfect sense, and maybe we're both right. I mean, making you super drowsy is bound to decrease your sense of restlessness too, right? :-)


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