Zofran

I have a touch of cognitive dissonance. Bear with me as I work through this.

I see new medics giving a ton of Zofran (ondansetron). It seems like whenever a patient mentions in passing, “I have a little nausea…” BAM Zofran. “I have a tendency to get car sick sometimes…” BAM Zofran. I’ve even seen medics give prophylactic Zofran after narcotic administration, because Fentanyl and Morphine can cause nausea. I think we give anti-emetics too generously. I have always reserved it for cases when I can’t get my job done, like a patient who can’t be immobilized without making a little vertical fountain of beer-soaked burrito (it is always alcohol-soaked Mexican food, for some reason), or when I can’t take a history due to the shouting pukes.

It caused me a little embarrassment, once. For years, the indication for anti-emetic administration was “intractable vomiting.” That may be because the only anti-emetic we used was droperidol – a medication with a more dangerous profile than Zofran. One day a trainee and I were discussing my opinions regarding her being way too generous with the Zofran. I made her pull out her protocols and read the indications out loud. I expected her to say the phrase “intractable vomiting” and I could scold her for giving Zofran to vomitless nausea. Instead, she read the indication: “Nausea and vomiting.” Wait. What? When did that change?

I hate seeing medics give Zofran at the first report of the slightest amount of nausea. Screw subjective nausea.

But on the other hand, I am pretty generous with Fentanyl when people complain of pain. If a patient is hurting, I give the good stuff. I find myself starting with higher Fentanyl doses than my peers, and I find myself giving higher total doses of narcotics than the average medic. Nausea can be just as uncomfortable and debilitating as pain. So, why the difference between being lavish with administering narcotics, but getting irritated when other medics are generous with anti-emetics?

See? Cognitive dissonance. I don’t like feeling like a hypocrite. I also don’t like not being able to rationally explain my actions. So I had to think through my feelings about anti-emetics.

I decided that the difference is the setting.  When a patient claims to be nauseated, but is distracted from my history taking efforts due to posting ambulance selfies on Facebook, I don’t think Zofran is indicated. Nor would Fentanyl be normally indicated in that setting. Show me something. Even something subtle, but show me something. The equivalent requirement before I administer analgesia would be an expression of discomfort on one’s face, a little alteration in vital signs, or otherwise acting in a manner consistent with being in pain. Another sign of pain that isn’t necessarily so subtle is to show me a broken bone. Show me a burn. Show me a little something, and I am free with the narcs.

Concerning nausea, don’t just tell me you’re nauseated; show me something. Give me one little shout for your friend Ralph. Show me the puke you sprayed everywhere before I arrived. Even a little uncomfortable-looking lip smacking or wet-sounding burps. Nystagmus. Anything. Show me something and I can be generous with Zofran, too.

Even when I am aggressively treating subjective complaints, I think there should be a minimal level of objective support for the complaint. So that is why I can find it irritating when medics give ondansetron for a reported tendency towards car sickness before we even get into the ambulance. But in fairness, I do need to slide a little bit away from my hard-ass point of view and be a bit more free with the Zofran. (But only a little bit.)

Next, I need to explain my irritation about starting an IV just to give Zofran. Intramuscular Zofran works just fine. But that is another post…