The Myth of Islands

An Island is a lie.

On my way to work, I drive along Willapa Bay and pass by the two Islands that can be seen from the mainland. Long Island crowds just feet from the highway that hugs the shore. Heavily forested it stretches away to the horizon, appearing as solid shoreline. Long Island holds a grove of ancient forest and in days past was inhabited with settlements. There is a ferry landing just off the road that used to bring trucks back and forth across the narrow thread of water that separates it from the rest of Washington state.

A little farther on is a defiant little islet several hundred yards from where the tourist pass by on their way to the beach.. The US Geographic survey named it Round Island back in 1858. Locals call it Baby Island. Its shoulders’ hunched and spiked with snags and cedar that burl in the winter storms. Only a few acres of brush and trees, it appears a picturesque myth centered in the waters of the bay. Steep rocks rising from the silver gray waters and lonely alone.

We like to think of ourselves as islands, as individuals, as ecosystems wholly within ourselves. We like to believe that our actions affect no one beyond our ragged shore. We like to believe ourselves surrounded by waters isolated from the world outside. We like to think ourselves individuals, the center of our own solar systems -- centered yet separated by time and space from mothers, wives, children and friends who dip into our orbit for time only to swing away again.

It is easy to feel alone.

It is easy to think that our actions do not shatter the mirrored water that flows around us, yet the decisions we make ripple out into the world.

We see it in politics, where the temptation is to live and let live, assuming no responsibility for the community, the state, the nation or the world.

I hear it all the time. I’ll take care of myself, do what I want, and it won’t affect anyone else. If other people make bad choices, can’t access health care or mental health services or run out of money when they are too old to work, that’s their problem. It won’t affect me.

Yet it does.

I work as a nurse in an emergency room. It is the front line of the consequences of bad choices.

I meet a lot of people who until that moment thought that they were islands. Many thought their decisions affected no one but them and them alone.  Some have long suffering loved ones at bedside, others have long since burned those bridges to the mainland. Perhaps they justified this as a way to limit that damage they caused, or perhaps the connection was never very good in the first place.

If not family and friends, there are always the professionals -- the police officers, EMTs, nurses, doctors and socials workers -- who crash in waves trying to make a difference until the last breath.

Every wave recedes taking a little away from the beach and leaving a little of itself behind. Yet, the ocean itself is not unchanged.

I have watched as addiction destroys families and devastates public resources. I have seen suicide shatter communities. I have seen health care professionals struggle to make a difference in the face of increasing needs and decreasing resources.

I have seen doctors and law enforcement officers that I worked with take their own life.

Studies have shown that nurses experience depression at twice the rate of the general population. Doctors have a suicide rate that is at least twice that of the general population and that rate is even greater for female physicians. The stresses come from long hours, increasing work loads and the crushing expectations of health care systems that are always demanding more and paying less. Unfortunately, few seek professional help.

So too some of the stress comes from our own expectations. Physician Pranay Sinha, in a 2014 essay entitled “Why Do Doctors Commit Suicide?”  in the New York Times explained it this way:

“There is a strange machismo that pervades medicine. Doctors, especially fledgling doctors like me, feel the need to project intellectually, emotional and physical prowess beyond what we truly possess. We masquerade as strong and untroubled professionals even in our darkest and most self doubting moments. How, then, are we supposed to identify colleagues in trouble -- or admit that we need help ourselves?”

Individual strength, resilience  and freedom are cultural virtues in our nation.Yet we achieve most when we come together and recognize our connections and that through those connections our individual decisions have repercussions on the world around us.

This far north the tides are impressive - a dozen feet in sea level change can drastically alter your perspective in a few hours time. When the tide is low, the water drains out of old Shoalwater bay and Round Island is exposed as connected to mainland by mudflats that the unwary may be tempted to walk across.

Drain away the oceans that appear to separate us, and you will find underneath the connections that tie us all together. 

What we do and say and how we act affects those near and far.

How we treat each other and how we take care of ourselves matters.

If you think you are an island, just wait until low tide.

-30-

This essay was originally written for the The Daily Astorian and published on 4/29/2016.

Droperidol Rides Again!

Droperidol / Inapsine is back in the Emergency Room. Is it safe?

When I was a new nurse in the Emergency Room of a little coastal hospital, I learned to use a medication called  Droperidol - a powerful antipsychotic and antiemetic medication.

One shot was often enough to bring clarity and calm to an out of control behavioral health patient in just a few minutes. The paramedics carried it and often would dose in the field prior to patient arrival. It was a wonderful drug.

Switch to a bigger hospital a few years ago.  Mention of the name Droperidol instantly elicited the response of "black box." Indeed, the new hospital had had a sentinel event with the medication and many of the nurses that remembered the medication were still spooked by it. The patient coded - and the code did not got well.

This week however, droperidol was back in the pyxsis and back on the jump kits of our local paramedics -- and quickly was back in use in the ED.

The nursing staff was divided by the drugs reintroduction. Some remembering it fondly while others insisted that every pysch patient MUST be on a cardiac monitor and get 12 lead EKGs before adminstration -- of course, if you can get a psych patient to sit still for a EKG, you don't need droperidol.

This medication was also widely known as an effective antiemetic and was widely used post-op before it received it's black box. With an ongoing nationwide shortage of compazine, droperidol is being offered as an alternative to compazine in the treatment of migraine headaches and intractable vomiting. The doses are much lower for these applications than for acute psychosis.

What is the history of this medication? What are the risks?

Droperidol was discovered back in 1961. A powerful D2 anatagonist, with some seritonin  and histamine effect, small doses ( < 1 mg IV ) effective prevented post-op nausea and vomiting. Larger IM doses (5 - 10 MG) were used for acute psychotic patients. (details here)

In 2001, the FDA issued a an expanded black box warning and it was controversial. While, the medication already carried a warning for the potential of sudden cardiac death in doses greater than 25 mg in psychotic patients, the new warning expanded to include even small doses. The medication was essentialy pulled by the manufacturer soon after.

According to the Wikipedia entry:

"In 2001, the FDA changed the labeling requirements for droperidol injection, to include a so-called "Black Box Warning", citing concerns ofQT prolongation and torsades de pointes. The evidence for this is disputed, with 9 reported cases of torsades in 30 years and all of those having received doses in excess of 5 mg. QT prolongation is a dose-related effect,^[4] and it appears that droperidol is not a significant risk in low doses.

Writing in the July 2004 edition of the journal Anethesia and Analgesia, Duke University's  Tong Gan wrote about his experience on an FDA review panel for the medication. (full text)

I represented the Society of Ambulatory Anesthesia (SAMBA) membership and presented during the open public hearing session, to express the view that FDA’s “black box” warning is unwarranted for the antiemetic doses of droperidol, and that the warning has effectively removed one of the most efficacious drugs for the management of PONV for our patients. I presented evidence that droperidol is a cost-effective antiemetic and its safety profile when used in antiemetic doses is excellent. We have previously reported the 10 cases in the FDA database in which serious cardiovascular events were possibly related to the administration of droperidol at doses of 1.25 mg or less. Review of these case reports shows that there are many confounding factors that make it impossible to establish the precise cause of the adverse cardiac events. Many concomitant drugs with the potential of causing QTc prolongation were administered around the time of droperidol (3). Of note, since droperidol was approved in 1970, there has not been a single case report in a peer-reviewed journal where droperidol in doses used for the management of PONV has been associated with QTc prolongation, arrhythmias, or cardiac arrest (1).

Gan goes on to explain that there were millions of this medication in use, yet only a handful of clearly documented events supporting the black box warning. Yet the black box effectively wiped out the medication's use.

Close to 10 million vials of droperidol were sold in 2001 before the “black box” warning, and it was estimated that its use was reduced by 90% following the warning. It was recognized that there is a significant lack of data for the small doses of droperidol causing QT prolongation.

The problem is, lot's of widely used medications also cause QT prolongation -- many of which were often used in the same environment as droperidol. (Here is a full list and here is a good discussion )

For example propofol and Reglan are often used in surgery. How do you sort out which drug is causing the change in repolarization?

Indeed, when our ED nurses received our fact sheet on the reintroduction of droperidol this week, we were surprised at some of the commonly used medications that are also associated with long QT. Tons of medications that we used all the time without cardiac monitoring have a QT association. You don't automatically reach for the cardiac monitor every time give a patient Avelox, Azithromycin or Albuterol do you?

Moreover, the medication that replaced droperidol as the IM choice for "rapid tranquillisation" psychotic patients is Haldol. Haldol is the same class of medication, and in 2007 it too got the same warning from the FDA about QT.  Until droperidol reappeared this week, we used Haldol combined with Ativan.

Yet, even without these confounding medications, it is not all that easy to precisely measure QT changes in a way that allows researchers to determine a cause and effect with certainty  Moreover, Gan wrote: "QT interval is only a surrogate measure for Torsade de Pointe, which is what concerns clinicians." 

If you aren't familiar with Torsade's -- consult your ACLS manual - it will be under lethal ventricular tachycardia.