Drug shortages are an all-too-common problem in the United States. Emergency physicians are more aware of the severity of the issue than most, as we use such a wide variety of medications. While the causes of drug shortages are multi-faceted, there is one contributing factor that’s been flying under the radar: “pay for delay.”

Those concerned about the use of etomidate in septic patients seem to focus on two primary issues. First, that etomidate results in adrenocortical suppression. Second, that suppression is associated with increased mortality.

In January, it was reported that 29 children had died from influenza nationwide1. More recently, the CDC reported that through February 2 pediatric deaths had increased to 59. Such numbers cause the public to cry out that the medical community do more to prevent these catastrophes. But can these cases be prevented? As awful as it sounds, I have to say that I doubt it.

It may take 700 LPs to find a subarachnoid hemorrhage, but it’s a needle-in-a-haystack worth finding.  Dr. Klauer challenges Dr. David Newman’s cost-effective approach in the SAH workup.

Big pharma is paying the price for pushing off-label applications and putting inappropriate pressure on medical education, but is it too little too late? Industry influence runs deeper than you might imagine.

A walk down memory lane reminds us that we have yet to see a stroke study of sufficient size to end the tPA debate. And even when we had such data, it was largely ignored. Let’s study our history to avoid repeating mistakes.

Although the technology is fascinating, caution must be exercised when applying coronary computed tomography angiography (CCTA) to emergency department chest pain patients. The only way this diagnostic modality will help us, and our patients, is if it guides us with risk stratification, showing a clear path to discharge for patients we currently don’t know what to do with.

Two years ago I called into question the use of the sepsis bundle of therapies defined by the “Surviving Sepsis” campaign (EPM, March 2010) Although aggressively managing sepsis is a good thing, and the mere focus on the rapid identification and application of appropriate management strategies for sepsis is essential to good patient outcomes, it appears that EGDT and the research it was based on may have promised more than it could deliver.

Although we used to have any drug we needed at our fingertips (regulatory interference notwithstanding) today we don’t. So, what has changed? Have they run out of the rare “zine” compound that is needed to make Compazine, or the “tron” in ondansetron? Hardly! We can only order what the pharmaceutical companies are willing and able to produce.

The FDA-approved drug dabigatran is being marketed as a safe alternative to Coumadin. But without a proven reversal agent available, it has the potential to create a new set of complications, and send unsuspecting patients right back to the ED.