July 20131)A bit of a groaner, but could be helpful if you practice in someforsaken place like Alice Springs Australia, or YpsilantiMichigan. Those little bottles of bacteriostatic normal salinehave a preservative called benzyl alcohol which has mildanesthetic properties (ethyl alcohol probably has more) If youinject this before the IV, you will get some anesthesia,although less than by lidocaine. It is of course cheaper( JPerianesth Nurs 27(6)399) Here are my comments. Firstly,kudos to the authors who have shown a good double blindedstudy done by nurses. Secondly, many nurses are not allowedto inject lidocaine but are allowed to inject this agent. Thirdly,we need to remember that IVs do sting and it is a humanething to do to take away the pain. On the other side, it wouldbe hard to say that this stuff works as IV are not that painfuland it was not that beneficial. In addition lidocaine is prettycheap. TAKE HOME MESSAGE: In a pinch- you can usebacteriostatic water as a local anesthetic before IV insertion.2)Really, I am not just looking for pain and palliative carearticles since MD Anderson took us aboard- this is just what
happened. In some hospitals you can call for a palliative careconsult- this does happen not infrequently in the ED wherethey do have this service and usually is used for young peoplewho meet with trauma or sudden death. ( J Palliatve Care15(6)633)However- and Knox is free to disagree with me-these consults were for bereavement counseling. True that isuncomfortable for us, but I would like to see more instructionin palliative and comfort care- like making that end stage lungcancer who is gasping for breath (what a night mare) morecomfortable with out killing him. I should mention here thatpalliative care is a recognized subspecialty of EM and is anincreasingly popular career track for emergency physicians-https://www.abem.org/public/_Rainbow/Documents/Eligibility%20Criteria%20for%20Web.pdf TAKE HOME MESSAGE:Palliative care consults are appropriate in the ED. On a relatedsubject; here is an article that you should all not only read buttune in to what it means. Patients have fears- what they call"existential suffering." These are fears that add on thephysical suffering of being sick. They include death, anxiety,loss and change in their lives, loss of control of their lives, loss
of dignity, fundamental aloneness, altered quality of relationships, the innate search for meaning in our lives, andmystery as to the unknowable. Be sensitive to this and Ipromise you will be the best physician you could be. (Arch IntMed 172(19)1501) TAKE HOME MESSAGE: Feel for youpatients- it isn't easy being ill.
One size fits all is a dangerous way to ventilate. Obesepatients have different mechanics and diminished endexpiratory lung volumes. This paper recommends step wiserecruitment maneuvers before PEEP applications –which Ireally do not what that is, and tidal volume titration accordingto inspiratory capacity (Minerva Anest 78(12) 1136) Basically Ithink this is another call to not use formulas for tidal volume-go by plateau pressure. Remember the magic number is lessthan 30. TAKE HOME MESSAGE: Obese patients have differentventilator needs and should be titrated to cause the least lungstrain. China had a dilemma. Chinese is a very differentlanguage than English, yet the British had a colony calledHong Kong and insisted that all movies that were producedthere had to have English subtitles. The Chinese complied and