In this new series, EPM contributors Christina Shenvi, MD and Nikki Waller, MD offer sage advice on everyday practice dilemmas. Want them to address a particular question? Write in to editor@epmonthly.online.
I am pregnant with my first child and am wondering how I will be able to pump after the baby is born while working a busy ED shift.
First of all, congratulations! And don’t give up on your desire to breastfeed your baby because of the challenges of pumping at work. It is important for all working mothers that we normalize pumping and make it as easy as possible. In fact, did you know there is a federal law that requires employers to provide “reasonable time” and a private, non-bathroom space for employees to pump [1]?I wish I had known that 4 kids ago.
Here are some tips to make it work for you: First, talk with women in your department who have pumped while working in your ED to get advice. Find out what spaces they have used, such as a lactation room (in our dreams), an unused patient care area, or an office near the ED. You need to have a space that is clean, private, and close to the ED so that you don’t waste all your time getting from the ED to the space where you pump. If there is no one who has been through this before at your institution, and you feel comfortable doing so, talk with your medical director or chair. Find out if there is a lactation policy or guideline. I’m guessing there won’t be, but hopefully this may prompt a discussion about how to best accommodate nursing mothers both for you and for women who come after you.
After each of my kids, when pumping on the job, there are several things I would do to make sure I was able to pump while still managing patient care: I tried to find a lull in the busy-ness when I could leave my desk for a short time. I checked with the charge nurse to make sure no sick patients were anticipated imminently. I would tell the other attending (if present) or resident, and charge nurse that I would be pumping for 15 minutes but would be close by and would have the portable phone on me in case of a code or trauma that came in precipitously. I would take a 15-minute break to pump once during an 8 hour shift, or twice during a 12 hour shift. This was the bare minimum that I could manage. In order to minimize pumping at work, I would pump right before work, and right afterwards, even in the car with a car adapter in the parking lot. I used the Medela pump sterilizing wipes to quickly clean the pump components afterwards. If you are lucky enough to have a space where you can pump that has a computer, then you will barely lose any time at all, as you can work on your charts, look up lab results, etc. Otherwise, if you at least have a space where you can eat while you pump, then you can double up your time efficiency that way.
It is not easy. You will get looks of discomfort if not disgust when you tell people you are going to pump. It is something I did very deliberately in an attempt to normalize the activity, and in the hopes that things will be easier and more accepted for the next new mother in my department who has to figure out the same thing.
We’re seeing a lot of synthetic cannabinoid use in my ED. The patients can present with somnolence and/or agitation. What should I use for sedation for treating agitation? Benzos seem to take too long, but the toxicologists caution against Haldol in these cases.
Synthetic cannabinoid (SCB) abuse is a growing concern worldwide. SCBs were originally synthesized in the 60s (surprise, surprise) to study the effects of marijuana (THC) but were commercialized recently under brand names, such as “Spice,” “K2,” and “herbal incense.” They are inexpensive and readily available online and in shops. They are often undetectable in standard drug screens. For these reasons, SCB abuse has reached epidemic proportions. In 2011, 1 in 9 high school students admitting to using K2 [2]. Despite its popularity a 2013 study showed that only 50-66% of the EM providers surveyed had even heard of K2 or Spice [3].
SCBs are a heterogeneous group of drugs that are more potent, toxic, and unpredictable than THC. The most common adverse effects include tachycardia, drowsiness, agitation, nausea, vomiting, hallucinations, confusion, hypertension, chest pain, and dizziness. Agitation and lethargy each occur in about 15-25% of SCB intoxication [4]. SCBs can trigger acute psychosis in predisposed patients as well as trigger psychotic symptoms in those with preexisting psychiatric diagnoses [5]. Case reports have also connected SCB abuse with seizures, catatonia, stroke, and acute kidney injury. SCBs are often laced with other substances (such as opioids, caffeine, and clenbuterol [for more on this, see the Rx Pad on clenbuterol]which can make it even harder to predict effects.
80% of EM providers do not feel prepared to care for SCB intoxication [3], so you are not along in wondering how best to manage it. Treatment mostly consists of observation and supportive care. Reactions are typically short lived, but, rarely, psychotic reactions can persist for weeks [6]. IV fluids are the most commonly given intervention. As you referenced, benzodiazepines are the first-line agent to reduce agitation. Antipsychotics can also treat agitation and acute psychosis. No evidence exists that Haloperidol (Haldol) cannot be used in cases of SCB intoxication. However, toxicologists recommend against Haldol in undifferentiated acute delirium given its anticholinergic properties which could precipitate symptoms in SCB and other intoxications, such as tachycardia, hyperthermia, and seizures. Beta-blockers can be considered for persistent tachycardia. Anti-emetics may also be necessary.
So, keep giving benzos and fluids as needed but you can definitely consider antipsychotics for refractory agitation and psychosis, particularly if the overdose is known to be SCB. If you are looking for something with a faster onset, you could try Midazolam (Versed) instead of Diazepam (Ativan). You could also consider an atypical antipsychotic, such as Ziprasidone (Geodon) or Olanzapine (Zyprexa) which generally have fewer side effects compared to Haldol.
I suspect I’m getting screwed on my schedule – too many weekend shifts and too many holidays. But we’ve lost a few colleagues recently and everyone is supposed to be sharing the burden. How should I confront the leadership?
This is a very common concern given the nature of our job. It’s also a difficult one to take to leadership without being called “the shift counter.” We all know those people. The colleague with a spreadsheet calculating everyone’s shift breakdown for the past two years: nights, weekends, holidays, etc.
There are a few ways to approach this. First, if the extra shifts are because your group is short-staffed, offer to serve on your group’s recruitment committee to help hire new colleagues to fill the gaps in coverage. Second, take a look at your shift pattern requests. If you have requested a number of day shifts off for other professional activities, you may be stuck working weekends because there aren’t enough shifts on the weekdays for you. So make sure you are not boxing yourself in to weekends by requesting weekdays off. If neither of the above is the case, and you value your weekend time, then one solution would be to offer to work extra overnights instead of weekends or holidays. Finally, if you truly think the schedule is unfair, I recommend scheduling a time to meet with your medical director to sit down and, in a professional manner, explain your concerns. It is much better to approach it in this way than whining to colleagues during sign-out. At your meeting, ask about plans to hire more help: find out if an end is in sight. Explain your concerns and listen to their response. There may be good reasons to explain the shift pattern. Be sure to remain professional and understanding.
If these efforts don’t seem to shed any light or improve your schedule, you may be in the wrong job. Some groups do have seniority rules but they should be clear and transparent. If you believe you are being treated unfairly when you expected equity in shifts, then you could either bump your concern up the chain of command, or you might want to start looking for employment elsewhere that better fits your expectations.
REFERENCES
- United States Breastfeeding Committee. Workplace support in federal law. http://www.usbreastfeeding.org/workplace-law. Updated 2016. Accessed 09/29, 2016.
- Vandrey R, Dunn KE, Fry JA, Girling ER. A survey study to characterize use of spice products (synthetic cannabinoids). Drug Alcohol Depend. 2012;120(1-3):238-241.
- Lank PM, Pines E, Mycyk MB. Emergency physicians’ knowledge of cannabinoid designer drugs. West J Emerg Med. 2013;14(5):467-470.
- Forrester MB. Adolescent synthetic cannabinoid exposures reported to texas poison centers. Pediatr Emerg Care. 2012;28(10):985-989.
- Mills B, Yepes A, Nugent K. Synthetic cannabinoids. Am J Med Sci. 2015;350(1):59-62.
- Kersten BP, McLaughlin ME. Toxicology and management of novel psychoactive drugs. J Pharm Pract. 2015;28(1):50-65.
1 Comment
“if the overdose is known to be SCB. If you are looking for something with a faster onset, you could try Midazolam (Versed) instead of Diazepam (Ativan).”
Diazepam is Valium and lorazepam is Ativan. I’m sure it was a simple editing error, but it is important to keep our medical therapies straight.