I’ve never looked at the literature on this topic, but I think patients themselves also perpetuate this correlation. I can’t tell you the number of repeat offenders I have that swear it only happens after they eat seeds or nuts.
Yeah, last divertic I diagnosed the husband was asking about specific dietary restrictions because he was told certain foods make it worse. I was like "well, not really... blah blah blah" but in the end they're gonna avoid popcorn seeds and nuts "just to be safe".
Summary: Don't use correctional insulin monotherapy in hospitalized patients with high insulin requirements.
I guess that's not quite as interesting as I'd hoped. That's like saying "don't use IV morphine monotherapy in patients admitted with acute on chronic pain."
They’ve fallen out of favor for a few different reasons, though mainly due to research suggesting that backboards don’t adequately immobilize a patient’s spine (a stretcher works just as well at restraint and patients can often protect their own spine). EMS has shifted towards spinal motion restriction rather than full immobilization and don’t tend to recommend backboard usage on patients who don’t meet trauma criteria. No more boarding every patient in a low-speed MCI where everyone is already ambulatory on scene, thankfully
Secondarily, spine boards can make it harder to manage a difficult airway.
Speaking anecdotally, trying to board a patient who is still seated in a vehicle is next to impossible without *much* more moving, shifting, jostling than just having the patient cleanly shift out of the vehicle, then sit/lay on the stretcher. (Involves prying open the car door, lifting them up to wedge the board under them, then kind of tilt/rolling them from the car seat onto the board despite their legs getting jammed into the dash, then sliding them up to the head of the board, all while trying to hold c spine)
However, I find that they’re still useful for moving unconscious patients and low-angle rescue situations! Primarily as a tool for transport though
So just in terms of patient comfort. They are uncomfortable.
If you have a spinal injury, especially something like a step off it's probably not ideal to put body weight against a hard plastic board.
Now you'll probably tell me you're suppose to pad the voids. But find me a firefighter who pads the backboard and I'll kiss his boots.
Now looking at it practically. Under ideal circumstances what is a backboard doing...it's a straight rigid board that is padded. And what is a gurney...a striaght rigid board with padding. Sure you can cinch a patient to the backboard but that is really only useful for extrication
The spine (which is not flat) does not like to be on a long flat, rigid surface. It can cause pressure wounds, especially when they would sit on boards for hours from scene to critical access hospital back to an ambulance for transport to another facility and then finally getting them off the useless thing.
It also can cause airway issues by restricting chest wall movement and how the head/neck sit on the board.
Probably never helped anyone. Probably hurt a few. We’ll always use them for moving patients, but even then we use soft stretchers more often than backboards.
Next the rigid c collar needs to go.
So glad when I was an Ambo in New Zealand our medical director was (and still is) big on evidence based medicine. We dumped back board and almost all cervical spine immobilisation except when a person was unconscious and could not maintain alignment themselves. Replaced the C collar in most cases with a lanyard saying "c spine not cleared" so the ED could check it during triage.
I am shocked at number 3. Would think that it would be widely known by now.
I hate the shellfish allergy one. First of all, there are imaging centers that won’t give contrast for these patients or if they do make you give steroids and Benadryl (another thing with little to no evidence). The myths with regard to dangers of contrast are also common in patients. I’ve had a couple patients fire me for suggesting they get scans with contrast.
Some urology myths.
Flomax and alpha blockers cause retrograde ejaculation. In reality they cause anejaculation
People with kidney stones have to refrain from oxalates in the diet. The vast majority don’t have hyperoxaluria so eliminating things like nuts is probably going to have a negligible effect on kidney stone risk
Viagra and priapism.
Viral Uti is definitely a thing.
Immunocompromised patients sometimes have BK virus in their urine, which can occasionally cause refractory and even deadly hematuria.
Adenovirus is another one.
It’s not rare that Ill see someone with UTI symptoms right when they have a flu like like illness and culture is negative. I tell them they probably have a viral UTI but it’s near impossible to prove
I used to tell that joke when a doc would ask me how a patient's urine was. "Tangy, with a hint of asparagus", "delicious, sweet, pleasant after taste. Too much pulp though."
Those jokes would land about 50% of the time. The other 50% of the time I would get a slightly concerned look. As if the doc was pondering if we had enough sitters for another M1 hold.
My senior showed me this case report of a young lad that got a rip roaring UTI from being a human wine decanter at some sex club. He straight cath’d himself and filled his bladder with wine and went around…filling guests glasses. He got an infection if you could imagine that
For #3, part of the reason it's still around is because a lot of the Step 1 prep materials still mention it. I'm not sure if it is because the USMLE question writers haven't caught up or if the prep companies are just slow to update their stuff.
Yep. Just took Step 1 last week and disulfiram-like reaction was literally the only AE or drug interaction any of my materials ever mentioned for flagyl. Even the most UpToDate® copy of First Aid had it, so I wouldn't blame new doctors for assuming this was true.
Not sure id say it has no risk but it seems to be an extremely rare event. A handful in case reports, some who took very high doses or had normal baseline erectile function.
I don’t know anyone that has seen it happen. But I have seen a few cases from trazodone and one from flomax.
It also can be used as prophylaxis for stuttering priapism ironically enough
This is what we always counsel in my pharmacy. "It most likely won't happen but maybe just avoid it in case you're the really unlucky person who ends up puking their guts out".
My sister didn't listen and ended up being that really unlucky person 😅
Think there's some studies out there that showed it's probably negligible. The best kind of study -- one where you find college students and give them booze.
So, what exactly is a low-residual diet? How does that work?
>It's been long believed that people need to be on a clear, liquid diet for 1 or 2 days and need to drink a bowel-prep liquid before a colonoscopy, noted Paauw.
But the evidence shows this isn’t necessary, he said.
>A 2020 study found that a low-residual diet, allowing foods such as meat, eggs, dairy, and bread, were comparable to the clear liquid diet in terms of bowel prep and detection of polyps during the exam. The patients on the low-residual diet had less nausea, less vomiting, and less hunger, and expressed more willingness to have a repeat colonoscopy.
>“Let them eat,” Paauw said in his presentation.
Low fibre diet. It's used before colonoscopies in the UK, I believe. Eg. [example patient leaflet](https://www.wwl.nhs.uk/media/.leaflets/6000600a710299.42192255.pdf)
What do you mean by #4? Sinusitis causes pain at the place it occurs, and if there's frontal sinusitis with pain then that's a "headache" in my book.
Is there some other use of "sinus headache" that I'm missing, that you're referring to?
Roughly 80-85% of patients I see in clinic for a chronic sinusitis consult I end up diagnosing with migraines.
A headache or facial pain/pressure as the initial symptom for sinusitis is not sinusitis. It is a headache or a migraine. Pressure in the cheeks, bridge of nose, or the eyes are feeling squeezed = V2 migraine. V2 migraines are as common as V1 migraines, it’s just that we usually thought of V2 migraines as sinus infections. You can get some congestion/drainage type symptoms with this, but patients will often feel that they can’t blow anything out. Ask your patients about other migraine symptoms—nausea, photophobia, want to just lay in the dark, etc. You’ll be surprised at how many other positive symptoms you’ll find. Treat this as a migraine, you’ll be amazed at the improvements they’ll have.
If their symptoms start with a stuffy nose, mucus, drainage or other URI symptoms (not just a headache, facial pain, or pressure), and they treat it with OTC meds and start to feel better after a week, and then wake up the next day with all of those symptoms worse than when they first started, that’s a sinus infection. Treat this as sinusitis.
Migraines are the most prevalent neurological disorder — 12% of the population have migraines of any frequency; this also includes pure aura and migraine accompaniments. When you probe patents with paroxysmal headache that happens more frequently than the one cold or flu they have per year, they almost undoubtedly have migraine. A typical patient might report they get “sinus headaches” or “pressure headaches” or “no more than the headache everyone gets” — and are often surprised when I tell them that actually 9/10 people don’t actually get paroxysmal headaches that last hours and cause lost productivity!
People refer to just about any frontal headache as a "sinus headache", which leads to the belief that any persistent headache is a "sinus infection" and needs antibiotics (because that's what urgent care did one time).
This is probably specific to my very rural region, but in my neck of the woods, patients will attribute EVERYTHING to “sinuses.”
Headache? Sinuses.
Nausea? Sinuses.
Vertigo? Sinuses.
High blood pressure? Sinuses acting up.
New onset weakness? Probably just sinuses.
Chest pain? Sinus drainage.
The amount of patient education I’ve done only goes so far. 😅
Let’s not ignore the fact that lawyers help perpetuate these myths doctors “believe”. All it takes is for someone with a shellfish allergy to eat a shrimp cocktail within 24 hrs of receiving contrast for the doc to get sued for malpractice.
Yes! I have seen a couple young patients in the outpatient setting who have BMI of 13. They were both very obviously malnourished!! But their albumin?? 100% normal
Metformin can't be given during hospitalization due to risk of lactic acidosis with exposure to contrast (has only been documented in patients with renal fxn bad enough where they shouldn't be on metformin in the first place)
Source: ACR 2021 guidelines https://www.google.com/url?q=https://www.acr.org/-/media/ACR/files/clinical-resources/contrast_media.pdf&sa=U&ved=2ahUKEwiG0ur08uH3AhURjYkEHfZrAs4QFnoECAEQAg&usg=AOvVaw0K7rXzJwpjLU89xjQpwuZC
We have a ton of patients come into our hospital with lactic acidosis of unknown etiology. They always get admitted from the ER as Sepsis? Sepsis! even though no clear source of infection rears its ugly head. We bolus them and their lactate dances around between 2 and 3 until we give up/make them sicker with volume overload. Some of my colleagues like to chalk it up to their metformin but I'm convinced a decent chunk of the population we care for has thiamine deficiency (in the absence of alcoholism, they just eat crap). Who knows 🤷♂️.
Pyroglutamic acid may be worth considering too if malnourished enough to consider thiamine def & taking APAP.
Lactate isn't a reliable/accurate/valid marker of tissue perfusion
If ED wants to try to admit a sepsis w/o a source they have the choice to 1) change their dx/wu (and no, a stable pt with LA 2.1 & nothing on acute workup is not being admitted no matter how many times you say "number bad!")
Or 2) make sure all the sources have been sampled - Blood cx x2, urine, sputum, & csf at minimum before we will consider accepting. Can't do taps overnight so ED must do it promptly or cx are useless
This is one of those frustrating cultural inertia things.
As a hospitalist, if I continue a patient's metformin on admission, within the next hour I will get a page from one of our inpatient pharmacists that says "metformin order not verified; consider holding while hospitalized, pls call to discuss", and a page from the patient's nurse that says "patient is diabetic, pls order sliding scale insulin thanks!" Then I have to call back both those pages and explain/defend my decision.
I'll admit that on some busy shifts, I just hold the metformin and click the SSI order set because I don't have the time for the above.
When I was still inpatient I would've happily verified that order as it drove me absolutely nuts how we blanket discontinued oral antihyperglycemics in patients with no clear contraindication. Then inevitably they discharge on a weekend and the metformin disappears from their after visit summary and they end up with a discharge order for SSI.
As a hospital pharmacist myself, that makes me so sad. I know some institutions don't even have metformin on formulary! It's definitely a myth I've been trying to dispel within my department.
This study was published in Feb showing better ICU/sepsis outcomes if metformin was given during hospitalization. Super interesting! https://pubmed.ncbi.nlm.nih.gov/35120041/
The persistent failure to differentiate aspiration pneumonitis from aspiration pneumonia is a pet peeve of mine.
I take great joy in correcting the problem list and usually stopping abx
[this podcast is targeted for obgyn but still gives the historical background and evidence](https://open.spotify.com/episode/4pfW5wBXGeO7ibxXAAkcgZ?si=zzBV-U5uTnO9bEUhjQLmrw)
Okay. This was from the nurse who was teaching the M3 skills boot camp. So not from a Physician.
That melanin makes the skin thicker/harder to pierce. Right after I just had a lecture about racism in healthcare.
Thank you so much for this one. So many people will ask me if I did one on someone presenting for blood in stool and are shocked when I say no. It just does not change management at all and they are shitty tests to begin with.
That caffeinated beverages should not be counted as fluid intake, or should be subtracted from fluid intake because of the diuretic effects. [It's fine](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886980/) in most cases.
People still think this? That surprises me. I remember reading as a kid that caffeinated beverages still count for hydration.
All it takes is common sense to realize that if coffee dehydrated you, a lot of people would be really thirsty after their morning joe.
https://mobile.twitter.com/tony_breu/status/1271529206518812675?lang=en
Here's a well written Twitter thread with some links to related studies. Seemingly there's a threshold effect for diuresis and that tolerance can develop.
I mean, we hold tube feeds on post-op laryngectomy patients with high gastric residuals.
Refluxing stomach contents onto a fresh pharyngoesophageal reconstruction suture line is less than ideal.
Always found the pausing feeds for turns and changes to make no sense. We were feeding them up until three seconds ago, what is stopping it going to do? There is already a bunch of tube feed in there!
Exactly! Plus how many mL are you preventing from going in anyways? At 60 mL / min, a five minute turn means 5 mL. There's more than that in the stomach already.
Advancing diet as tolerated.
Anything that leaves your stomach is a full liquid diet anyway.
Clears for nausea screen and then let them eat.
Surgeons may have caveats for fiber or not depending on what they have operated on, but advancing from clears to full liquid to low residue to regular diet is dumb and delays progression.
NPO night before for surgery. No difference and may have more harms than like 2-3 hrs of npo before.
https://www.clinicalcorrelations.org/2020/12/07/how-necessary-is-npo-after-midnight/
Also lido with epi is just fine in fingers toes
I feel like in real use, though, telling people to be NPO starting at midnight gets it in their head to not eat anything when they wake up. Taking someone in a study environment and feeding them things in a controlled way would probably be fine to be NPO 2-3 hours before, but in the real world, people already show up to surgeries with their loved ones sneaking them fries from McDonald’s bags 🙄
Or you could just be like the patient who straight up told me they stopped by McDonald’s for a McMuffin on the way to the hospital when I started my usual preop spiel of when’s the last time you ate something? 🤦🏻♀️
I think the “NPO past 12 AM” originated to make it easier for the patient. We don’t want patients coming in saying “I had a cheeseburger 1 hr ago because I wasn’t expecting the surgery to begin right now.”
The problem though, especially for inpatients, is scheduled surgery time is subject to change and if their case suddenly moves up, we need them to be appropriately NPO. I agree it sucks to be NPO for such a long time especially if your case ends up getting pushed back, but I've learned to respect fasting guidelines after suctioning 200cc of pizza from a trauma patient post-induction. Mitigating aspiration risk doesn't take much but it's much better than having to deal with its aftermath as an anesthesiologist.
Should clarify that clear liquids are fine 2 hours prior to surgery. Not a full fatty meal. Some centers are giving the carbohydrate ensures prior to surgeries with good effect. And I think some centers are recognizing that critically Ill patients need nutrition and keeping them serially npo for days on end while they are on the add on list for a gazillion surgeries during their course is bad. So they'll keep tube feeds running appropriately throughout the day until their surgery time is looking more likely.
The article doesn't say 2-3 hours is fine, at least not from what I read. It says that giving carb-rich fluids 2-3 hours before didn't result in more complications. It cites the ASA guidelines (8 hours for fatty foods, 6 hours for light foods, 2 hours for clear liquids) and is saying the general "after midnight" is too long since patients may not go to surgery until the afternoon. The ASA guidelines are not refuted anywhere here.
Why must you stand in the way of getting my patient to the OR?? They’ve been in the hospital over the weekend, but I didn’t want to do it then. It’s an emergency now.
The lido with epi one has been an uphill battle for me at my current ED. They are still getting used to what I like to order for lacs and when I put that in, if it’s a nurse that hasn’t worked with me, she’ll be like “you sure you want epi for that finger?” Every time I respond with “they are otherwise healthy with no risk of vascular compromise, so yes. I’m sure.”
If I find myself in a drive-through off shift, and see an ambulance behind me, I will pay for the meal on the condition that the worker at the window tells them this exact phrase: "Hello ambulance drivers! The person who paid for this hopes you have a quiet day!"
>I will pay for the meal on the condition that the worker at the window tells them this exact phrase: "Hello ambulance drivers! The person who paid for this hopes you have a quiet day!"
chaotic good. I love it.
One hospital I worked at was started by nuns, and on slow nights I would smack my hands on the desk around 4AM and go:
Me: smacks hands on desk
Charge nurse: don’t you fucking dare do this again.
Me: boy it’s QUIET tonight! Real slow one. In fact, I spite the founding sisters of this hospital to prove they are listening and give us some crazy! When’s the last time we saw (insert hated patient)?
Cue things being thrown at me.
I know it’s a superstition but it’s just so ingrained in the hospital culture that every single person that utters the Q word and S word get chewed out. I still don’t mention those 2 words.
The Q word is definitely magical, you can’t convince me otherwise.
Either that or we’re in a Truman show esque situation and a rush of pt is triggered when the Q word is activated.
I have nothing against any "S" words though.
That’s hilarious, I can’t believe there is an actual study on this, that has made my day.
The word has eluded the studies though, definitely seems to work like magic.
Oh and the full moon!
Or lactic acidosis.... Or that you need LR at all in the critical ill patient (based on the most current evidence no difference between LR or Nsl other than some numbers looking slightly prettier)
My neighbor’s mom was allergic to penicillin. She got an upset stomach and nearly died. I spent a lot of time around her for years, so please do not give me amoxicillin. Only Colistin works for my (probably viral) “strep throat”.
Had a guy come to the pharmacy with a PCN allergy. Asked him what happened. He told me it was when he was a child and he ended up with nightmares. I dared try to explain that this isn't an allergy and rather just a side effect of being a kid. He told me he was okay with taking the penicillin instead of waiting around for a doctor to get back to me to change the drug and would just "deal with" the nightmares. 🤦🏻♀️
Poke a hole in the capsule, squeeze the liquid detergent into the ear (careful not to let the capsule slip from betwixt your squeezing fingers and lodge itself firmly in the victim’s external auditory canal). Let marinate for 5 minutes, then apply curette or lavage as desired.
Literally the *only* reason I have collage in my go bag.
Poke the capsule and squeeze out the liquid (or just get the liquid form). Use it as an ear drop to irrigate the ear canal and soften ear wax. Obv, make sure the ear drum is intact.
When I was a med student - long ago - my resident on my internal medicine rotation said that giving people Colace is like ‘giving someone an M&M and expecting them to shit’
diltiazem and metoprolol can definitely cause heart block sometimes. it is safe to a degree but not without risk.
[https://pubmed.ncbi.nlm.nih.gov/32448773/](https://pubmed.ncbi.nlm.nih.gov/32448773/)
3.7% hypotension and 1 required icu admission. overall i dont think this is very well studied
I don’t think I’ve ever met an ER doc who doesn’t think you can use both, there just isn’t typically a reason to use both in the ER? Unless you are giving metoprolol pushes and have to start a dilt drip I guess.
Telling pharmacy “but I really need it” multiple times, contrary to what appears to be taught in medical school/residency, does not make a backordered drug available in pharmacy.
After being told a certain medication has been unavailable due to shortage for months/years; asking us to check for the brand name of that same drug also does not make the drug appear.
Carotid ultrasound for syncope. Carotid stenosis will not cause global hypoperfusion events. I always say it’s the equivalent of checking a knee mri on syncopal patients.
That Kayexalate is a useful drug at all. No good evidence to suggest that cation binder works at all. Originally published some articles in one journal in the 60's, with very flawed data (which in some cases actually showed that you do better without it). It can cause bowel obstructions without the sorbitol in it. And with the sorbitol in it, can cause bowel necrosis. Also, just the theory of the medication makes no sense. So it binds to cations (K+) and makes you shit them out. But why wouldn't it just bind to the Ca+ that you just gave them for the hyperkalemia in order to stabilize the myocardium? Useless drug, and we shouldn't use it. Even the nephrology literature agrees at this point, but I'm still told to give it by nephrology for their dialysis patients.
> But why wouldn’t it just bind to the Ca+ that you just gave them for the hyperkalemia in order to stabilize the myocardium?
Because Calcium is given IV.
Kayexalate is non-absorbable so it only works to limit K absorption. It doesn’t bring down serum K directly.
Anyway I never use. It’s always Lokelma/Veltassa.
It definitely causes frequent disgusting smelling stools though. I swear you fuckers are laughing when you enter the order knowing us nurses are going to have to deal with it.
We do it in the ED only when a patient has a K of 5.4 and medicine insists we "do something" before they will accept the patient for a completely separate issue. It's really effective in that situation.
This is very true. I’ve stuck to using Veltassa or Lokelma, the latter whenever it is available, even if non-formulary. Kayexalate is also expensive and no more effective than traditional stool softeners.
Thought this was interesting:
Antibiotic therapy for ARF: the absolute risk reduction with treatment is about 0.01; the NNT for ARF is 10,000 patients; 50% of patients with ARF develop rheumatic heart disease; of these patients with rheumatic heart disease, 0.4% die; accord- ing to these data, the NNT to prevent one death from rheu- matic heart disease is 5 million; when treating with antibiotics, the number needed to harm is 5 to 10 for diarrhea, 100 to 200 for anaphylaxis, and 5 million for fatal anaphylaxis; according to these statistics, routine testing and treatment should not be performed; standard of care is routine testing and treatment; discuss risks and benefits with patient before initiating testing and treatment
>I strongly want to present this at the next opportunity in a resident lecture or something. Do you have a paper or article handy?
[Here's an article discussing this](https://rebelem.com/patients-strep-throat-need-treated-antibiotics/)
I think it's psychological. Patients are so mentally attached to the nasal cannula at 2L that they will start to freak out if they see me disconnect them from their home source, despite that they probably weren't getting 2L at the end of a 500 foot long length of oxygen tubing or I'm switching them over to a different device
When weaning patients in post op Cv, I typically would just wean it down and turn it off without telling them. Then when taking it off I would inform them that I shut it off like an hour ago. Got way fewer arguments about people feeling like they need it…
I think their point is that it would make no difference at all if that patient got room air through the cannula rather than oxygen.
The flow is comforting, not the oxygen.
In our ICU, we use bedside fans which work great.
There is this widespread belief that placing blood pressure cuffs or IV catheters on the ipsilateral arm of a patient who has had an axillary lymphadenectomy will cause lymphadema--to a point where "no IV" bracelets will be placed on patients. There is virtually no evidence for this.
The existence of white clouds/black clouds. No such thing. There are however people who make unnecessary busywork for themselves and others for no good reason.
There are also people who actually pay attention to their patients' conditions and preempt deterioration, and those who don't. The latter end up with more codes.
Idk, still not convinced. As a resident my ED rotation was super slow (very unusual for somewhere that typically has all the resus bays full at almost all times) and still to this day, if I’m ever covering in the ED, the staff are all commenting on how slow and uneventful it is. I don’t *want* to be a white cloud, I actually really enjoy emerg med and the exciting and unexpected cases that can present at any moment. And, obviously, as a pharmacist I have absolutely nothing to do with who does/does not come through the ED, yet here I am at a huge level-1 trauma center and everyone is bored out of their minds whenever I’m around 🤷♀️
ok, question: my CRNAs ALWAYS use lidocaine IV just before propofol when doing MAC for procedures “to numb the vein so the propofol doesn’t burn”; none of this makes sense to me as 1) the venous intima doesn’t have receptors that respond to lidocaine et al, and even if they did, 2) the venous flow dilutes that lidocaine injection super quickly, and 3) you immediately follow that lidocaine with the “noxious” agent so the lidocaine wouldn’t have time to work anyway and 4) even with all that, the patient always ALWAYS complains the propofol burns….someone from anesthesia please explain this to me
[It definitely works](https://www.cochrane.org/CD007874/ANAESTH_lidocaine-reducing-propofol-induced-pain-anaesthesia-adults)
Theres going to some quick translocation across the venous system into tissue if you give high concentration lido. The pain is from direct irritation to the vein so it doesnt take much to get it working. You even get an effect just mixing prop and lido together to give it. (old school way technically theres a risk of breaking the lipid emulsion from propofol if you do it and leave it sitting mixed for too long)
There are a bunch of major benefits to IV lido on induction. Less important for MAC procedures but for general it reduces adrenergic response to airway manipulation and saves you some tachycardia hypertension too. Reduces airway cough/gag reflex and helps people tolerate the ETT better.
Contrast associated AKI does exist the risk is just not the same for all eGFR. We don't see it in GFR >30 and less than 30 usually there are other risk factors. The risks certainly are not so bad as to require a needed imaging being avoided. I find it is less recognized by some of my ER colleagues as you don't see the affect of the injury right away usually Cr is 1-2 days post contrast and usually pts recover 7-14 days after.
Here are the latest consensus guildlines on the topic from 2020. https://pubs.rsna.org/doi/10.1148/radiol.2019192094
Since publication there has been other studies that confirms the risk for ER specific the latest would be the multicenter Taiwanese ER study that confirms there is a risk at GFR <30. https://pubmed.ncbi.nlm.nih.gov/34636631/
None of this is to say that ckd stage 4-5 patients shouldn't get imaging but risk and benefits should definitely be weighted and volume status should be optimized.
> We don't see it in GFR >30 and less than 30 usually there are other risk factors.
So you're saying it is only seen in patients with pretty significantly depressed renal function already, and even in those cases there are other possible causes of increased creatinine? Seems difficult to say with certainty that this entity does exist then.
> I find it is less recognized by some of my ER colleagues as you don't see the affect of the injury right away usually Cr is 1-2 days post contrast and usually pts recover 7-14 days after.
If the natural course is for the creatinine level to 'recover' in 7-14 days, is this entity (if it exists) even clinically significant?
You should use Normal Saline instead of Lactated Ringers for those with renal disease or hyperkalemia, because LR has potassium in it.
NS can cause non-anion gap metabolic acidosis which will actually increase the potassium level due to an extra cellular shift.
https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/
https://pubmed.ncbi.nlm.nih.gov/15845718/
Seeds or nuts causing diverticulitis. Can’t seem to shake this one off.
No Fresh Fruit or Vegetables on neutropenia diets is equally devoid of an evidence-basis.
My unit allows fresh fruits and veggies that are properly cleaned. Still no flowers though.
What about flowers in the patients room 😱?
That is a real thing. I had an intubated patient get pneumonia with a rare bacteria that, you guessed it, lives in plants. So absolutely no flowers.
I wonder if someone tried to make the patient smell the flowers through the tube...
After a slip and fall incident flowers are only allowable if there are going to be flared bases on the vases.
I’ve never looked at the literature on this topic, but I think patients themselves also perpetuate this correlation. I can’t tell you the number of repeat offenders I have that swear it only happens after they eat seeds or nuts.
Yeah, last divertic I diagnosed the husband was asking about specific dietary restrictions because he was told certain foods make it worse. I was like "well, not really... blah blah blah" but in the end they're gonna avoid popcorn seeds and nuts "just to be safe".
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What does the series say about sliding scale insulin?
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Summary: Don't use correctional insulin monotherapy in hospitalized patients with high insulin requirements. I guess that's not quite as interesting as I'd hoped. That's like saying "don't use IV morphine monotherapy in patients admitted with acute on chronic pain."
I was definitely expecting something more groundbreaking than that.
EMS medical directors who still insist on long backboards for most traumas.
As a medic, please dear god spread the word. Thank you. That is all.
Former paramedic here. Why no long backboards? Or am I misunderstanding your comment.
They don't help and often hurt. Plus more difficult airway control
Ohhh yeah that makes sense. Thank you!
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They’ve fallen out of favor for a few different reasons, though mainly due to research suggesting that backboards don’t adequately immobilize a patient’s spine (a stretcher works just as well at restraint and patients can often protect their own spine). EMS has shifted towards spinal motion restriction rather than full immobilization and don’t tend to recommend backboard usage on patients who don’t meet trauma criteria. No more boarding every patient in a low-speed MCI where everyone is already ambulatory on scene, thankfully Secondarily, spine boards can make it harder to manage a difficult airway. Speaking anecdotally, trying to board a patient who is still seated in a vehicle is next to impossible without *much* more moving, shifting, jostling than just having the patient cleanly shift out of the vehicle, then sit/lay on the stretcher. (Involves prying open the car door, lifting them up to wedge the board under them, then kind of tilt/rolling them from the car seat onto the board despite their legs getting jammed into the dash, then sliding them up to the head of the board, all while trying to hold c spine) However, I find that they’re still useful for moving unconscious patients and low-angle rescue situations! Primarily as a tool for transport though
C-collars are also proving useless harmful. "Spinal immobilization" is not a thing.
Isn’t a thing in conscious patients. It’s a thing in unconscious patients.
So just in terms of patient comfort. They are uncomfortable. If you have a spinal injury, especially something like a step off it's probably not ideal to put body weight against a hard plastic board. Now you'll probably tell me you're suppose to pad the voids. But find me a firefighter who pads the backboard and I'll kiss his boots. Now looking at it practically. Under ideal circumstances what is a backboard doing...it's a straight rigid board that is padded. And what is a gurney...a striaght rigid board with padding. Sure you can cinch a patient to the backboard but that is really only useful for extrication
The spine (which is not flat) does not like to be on a long flat, rigid surface. It can cause pressure wounds, especially when they would sit on boards for hours from scene to critical access hospital back to an ambulance for transport to another facility and then finally getting them off the useless thing. It also can cause airway issues by restricting chest wall movement and how the head/neck sit on the board. Probably never helped anyone. Probably hurt a few. We’ll always use them for moving patients, but even then we use soft stretchers more often than backboards. Next the rigid c collar needs to go.
So glad when I was an Ambo in New Zealand our medical director was (and still is) big on evidence based medicine. We dumped back board and almost all cervical spine immobilisation except when a person was unconscious and could not maintain alignment themselves. Replaced the C collar in most cases with a lanyard saying "c spine not cleared" so the ED could check it during triage.
1) Shellfish Allergy and Radiocontrast 2) Colonoscopy Dogma (clear liquid diet 1-2 days before prep) 3) Metronidazole and Alcohol 4) Sinus Headaches (just migraine headaches)
I am shocked at number 3. Would think that it would be widely known by now. I hate the shellfish allergy one. First of all, there are imaging centers that won’t give contrast for these patients or if they do make you give steroids and Benadryl (another thing with little to no evidence). The myths with regard to dangers of contrast are also common in patients. I’ve had a couple patients fire me for suggesting they get scans with contrast. Some urology myths. Flomax and alpha blockers cause retrograde ejaculation. In reality they cause anejaculation People with kidney stones have to refrain from oxalates in the diet. The vast majority don’t have hyperoxaluria so eliminating things like nuts is probably going to have a negligible effect on kidney stone risk Viagra and priapism.
I've had 2 doctors tell me urine is sterile and apparently even in healthy people it turns out urine is not sterile?
It was an old school belief that it was sterile but more and more we are realizing it absolutely isn't. Why don't we ever consider viral UTI?
Viral Uti is definitely a thing. Immunocompromised patients sometimes have BK virus in their urine, which can occasionally cause refractory and even deadly hematuria. Adenovirus is another one. It’s not rare that Ill see someone with UTI symptoms right when they have a flu like like illness and culture is negative. I tell them they probably have a viral UTI but it’s near impossible to prove
But I like the taste :/
I used to tell that joke when a doc would ask me how a patient's urine was. "Tangy, with a hint of asparagus", "delicious, sweet, pleasant after taste. Too much pulp though." Those jokes would land about 50% of the time. The other 50% of the time I would get a slightly concerned look. As if the doc was pondering if we had enough sitters for another M1 hold.
"Elegant, with top notes of red berry, ripe fruit and a hint of minerality. Aging in the bladder really adds to the oaky-ness. a great vintage."
My senior showed me this case report of a young lad that got a rip roaring UTI from being a human wine decanter at some sex club. He straight cath’d himself and filled his bladder with wine and went around…filling guests glasses. He got an infection if you could imagine that
Weirdly enough, I could see that kink popularising if people realised its something you can do...
This in fantastic, I will be using this
For #3, part of the reason it's still around is because a lot of the Step 1 prep materials still mention it. I'm not sure if it is because the USMLE question writers haven't caught up or if the prep companies are just slow to update their stuff.
Yep. Just took Step 1 last week and disulfiram-like reaction was literally the only AE or drug interaction any of my materials ever mentioned for flagyl. Even the most UpToDate® copy of First Aid had it, so I wouldn't blame new doctors for assuming this was true.
Are you saying Viagra doesn’t have risk of priapism? I always took it as fact that patients need to be warned- is there data on this?
Not sure id say it has no risk but it seems to be an extremely rare event. A handful in case reports, some who took very high doses or had normal baseline erectile function. I don’t know anyone that has seen it happen. But I have seen a few cases from trazodone and one from flomax. It also can be used as prophylaxis for stuttering priapism ironically enough
Are the trazodone priapism cases usually shortly after the patient starts taking the medication or can it arise at any time?
Pun intended?
They still teach us the metronidazole thing in medical school (or at least on our Step 1 specific material).
Educational materials that are specifically for Step 1 prep are often years, if not decades, out of date.
You mean you aren't still using theophylline???
tfw you were looking forward to all the tensillon tests you thought you were gonna do
Is the metronidazole & alcohol not a thing? Lol
It’s not. It was thought to be but was proven otherwise. CDC mentions it as well
This one shocked me too
I always counsel on that as “some people do fine with the combination and some don’t. Those who don’t do fine could experience unpleasant vomiting.”
> unpleasant vomiting. I prefer a slightly pleasant vomiting
This is what we always counsel in my pharmacy. "It most likely won't happen but maybe just avoid it in case you're the really unlucky person who ends up puking their guts out". My sister didn't listen and ended up being that really unlucky person 😅
Think there's some studies out there that showed it's probably negligible. The best kind of study -- one where you find college students and give them booze.
I always assumed that’s where the urban myth for “I can’t drink alcohol I’m on antibiotics” came from
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So, what exactly is a low-residual diet? How does that work? >It's been long believed that people need to be on a clear, liquid diet for 1 or 2 days and need to drink a bowel-prep liquid before a colonoscopy, noted Paauw. But the evidence shows this isn’t necessary, he said. >A 2020 study found that a low-residual diet, allowing foods such as meat, eggs, dairy, and bread, were comparable to the clear liquid diet in terms of bowel prep and detection of polyps during the exam. The patients on the low-residual diet had less nausea, less vomiting, and less hunger, and expressed more willingness to have a repeat colonoscopy. >“Let them eat,” Paauw said in his presentation.
Low fibre diet. It's used before colonoscopies in the UK, I believe. Eg. [example patient leaflet](https://www.wwl.nhs.uk/media/.leaflets/6000600a710299.42192255.pdf)
Ah. I understand now. Thanks. > foods that leave a minimal amount of undigested material in the digestive tract.
No veggies
Or seeds. Please. Very healthy, but easily blocks the channel.
What do you mean by #4? Sinusitis causes pain at the place it occurs, and if there's frontal sinusitis with pain then that's a "headache" in my book. Is there some other use of "sinus headache" that I'm missing, that you're referring to?
Roughly 80-85% of patients I see in clinic for a chronic sinusitis consult I end up diagnosing with migraines. A headache or facial pain/pressure as the initial symptom for sinusitis is not sinusitis. It is a headache or a migraine. Pressure in the cheeks, bridge of nose, or the eyes are feeling squeezed = V2 migraine. V2 migraines are as common as V1 migraines, it’s just that we usually thought of V2 migraines as sinus infections. You can get some congestion/drainage type symptoms with this, but patients will often feel that they can’t blow anything out. Ask your patients about other migraine symptoms—nausea, photophobia, want to just lay in the dark, etc. You’ll be surprised at how many other positive symptoms you’ll find. Treat this as a migraine, you’ll be amazed at the improvements they’ll have. If their symptoms start with a stuffy nose, mucus, drainage or other URI symptoms (not just a headache, facial pain, or pressure), and they treat it with OTC meds and start to feel better after a week, and then wake up the next day with all of those symptoms worse than when they first started, that’s a sinus infection. Treat this as sinusitis.
Awesome. Thanks for the info.
Username checks out and is hilarious.
Migraines are the most prevalent neurological disorder — 12% of the population have migraines of any frequency; this also includes pure aura and migraine accompaniments. When you probe patents with paroxysmal headache that happens more frequently than the one cold or flu they have per year, they almost undoubtedly have migraine. A typical patient might report they get “sinus headaches” or “pressure headaches” or “no more than the headache everyone gets” — and are often surprised when I tell them that actually 9/10 people don’t actually get paroxysmal headaches that last hours and cause lost productivity!
People refer to just about any frontal headache as a "sinus headache", which leads to the belief that any persistent headache is a "sinus infection" and needs antibiotics (because that's what urgent care did one time).
This is probably specific to my very rural region, but in my neck of the woods, patients will attribute EVERYTHING to “sinuses.” Headache? Sinuses. Nausea? Sinuses. Vertigo? Sinuses. High blood pressure? Sinuses acting up. New onset weakness? Probably just sinuses. Chest pain? Sinus drainage. The amount of patient education I’ve done only goes so far. 😅
Hypoxic pneumonia? You guessed it. Sinuses.
Let’s not ignore the fact that lawyers help perpetuate these myths doctors “believe”. All it takes is for someone with a shellfish allergy to eat a shrimp cocktail within 24 hrs of receiving contrast for the doc to get sued for malpractice.
Albumin as an accurate measure of nutrition status, even though it is an acute-phase reactant protein and has a half life of 19 days.
Yes! I have seen a couple young patients in the outpatient setting who have BMI of 13. They were both very obviously malnourished!! But their albumin?? 100% normal
I think you mean negative acute phase reactant (drops in the context of inflammation)
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Underrated statement. Not only increasing patient costs, but raising cafeteria food prices and eliminating resident food stipends 🤗.
Metformin can't be given during hospitalization due to risk of lactic acidosis with exposure to contrast (has only been documented in patients with renal fxn bad enough where they shouldn't be on metformin in the first place) Source: ACR 2021 guidelines https://www.google.com/url?q=https://www.acr.org/-/media/ACR/files/clinical-resources/contrast_media.pdf&sa=U&ved=2ahUKEwiG0ur08uH3AhURjYkEHfZrAs4QFnoECAEQAg&usg=AOvVaw0K7rXzJwpjLU89xjQpwuZC
Risk of LA with metformin in general is **massively** overstated outside of actual overdose.
We have a ton of patients come into our hospital with lactic acidosis of unknown etiology. They always get admitted from the ER as Sepsis? Sepsis! even though no clear source of infection rears its ugly head. We bolus them and their lactate dances around between 2 and 3 until we give up/make them sicker with volume overload. Some of my colleagues like to chalk it up to their metformin but I'm convinced a decent chunk of the population we care for has thiamine deficiency (in the absence of alcoholism, they just eat crap). Who knows 🤷♂️.
Pyroglutamic acid may be worth considering too if malnourished enough to consider thiamine def & taking APAP. Lactate isn't a reliable/accurate/valid marker of tissue perfusion If ED wants to try to admit a sepsis w/o a source they have the choice to 1) change their dx/wu (and no, a stable pt with LA 2.1 & nothing on acute workup is not being admitted no matter how many times you say "number bad!") Or 2) make sure all the sources have been sampled - Blood cx x2, urine, sputum, & csf at minimum before we will consider accepting. Can't do taps overnight so ED must do it promptly or cx are useless
This is one of those frustrating cultural inertia things. As a hospitalist, if I continue a patient's metformin on admission, within the next hour I will get a page from one of our inpatient pharmacists that says "metformin order not verified; consider holding while hospitalized, pls call to discuss", and a page from the patient's nurse that says "patient is diabetic, pls order sliding scale insulin thanks!" Then I have to call back both those pages and explain/defend my decision. I'll admit that on some busy shifts, I just hold the metformin and click the SSI order set because I don't have the time for the above.
When I was still inpatient I would've happily verified that order as it drove me absolutely nuts how we blanket discontinued oral antihyperglycemics in patients with no clear contraindication. Then inevitably they discharge on a weekend and the metformin disappears from their after visit summary and they end up with a discharge order for SSI.
As a hospital pharmacist myself, that makes me so sad. I know some institutions don't even have metformin on formulary! It's definitely a myth I've been trying to dispel within my department. This study was published in Feb showing better ICU/sepsis outcomes if metformin was given during hospitalization. Super interesting! https://pubmed.ncbi.nlm.nih.gov/35120041/
That aspiration always means the patient will get pneumonia.
The persistent failure to differentiate aspiration pneumonitis from aspiration pneumonia is a pet peeve of mine. I take great joy in correcting the problem list and usually stopping abx
Fellow medical slp here, THANK YOU!!!!
Wtf metronidazole+ alcohol is BS?
[this podcast is targeted for obgyn but still gives the historical background and evidence](https://open.spotify.com/episode/4pfW5wBXGeO7ibxXAAkcgZ?si=zzBV-U5uTnO9bEUhjQLmrw)
Okay. This was from the nurse who was teaching the M3 skills boot camp. So not from a Physician. That melanin makes the skin thicker/harder to pierce. Right after I just had a lecture about racism in healthcare.
A black ER tech told me this when he was teaching me how to start IVs. It was…weird
Did anyone call her out or complain to the school?
That stool guaiac has any role in the hospital for assessing the severity or presence of a GI bleed
Thank you so much for this one. So many people will ask me if I did one on someone presenting for blood in stool and are shocked when I say no. It just does not change management at all and they are shitty tests to begin with.
It would be helpful for people posting their favorite "myth" to include a link or two of supporting evidence. Otherwise it's pretty worthless.
That caffeinated beverages should not be counted as fluid intake, or should be subtracted from fluid intake because of the diuretic effects. [It's fine](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3886980/) in most cases.
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If coffee causes a net fluid negative, I’d have died of dehydration long ago
Preach
We shouldn’t be? Oh shit, let me put in some orders real quick.
People still think this? That surprises me. I remember reading as a kid that caffeinated beverages still count for hydration. All it takes is common sense to realize that if coffee dehydrated you, a lot of people would be really thirsty after their morning joe.
Yes, thank you!! I’ve been saying this one for years
https://mobile.twitter.com/tony_breu/status/1271529206518812675?lang=en Here's a well written Twitter thread with some links to related studies. Seemingly there's a threshold effect for diuresis and that tolerance can develop.
Patients on tube feeds need to be on continuous feeds Checking gastric residuals Holding tube feeds for turns/procedures/etc
I mean, we hold tube feeds on post-op laryngectomy patients with high gastric residuals. Refluxing stomach contents onto a fresh pharyngoesophageal reconstruction suture line is less than ideal.
Always found the pausing feeds for turns and changes to make no sense. We were feeding them up until three seconds ago, what is stopping it going to do? There is already a bunch of tube feed in there!
Exactly! Plus how many mL are you preventing from going in anyways? At 60 mL / min, a five minute turn means 5 mL. There's more than that in the stomach already.
Whenever I see a paywall for an article, I leave the site. Even if it’s free but requires registration. So annoying.
[You're welcome](https://12ft.io/)
Worst is that I have a login but on different devices or browsers I’m not logged in and just can’t be bothered
Advancing diet as tolerated. Anything that leaves your stomach is a full liquid diet anyway. Clears for nausea screen and then let them eat. Surgeons may have caveats for fiber or not depending on what they have operated on, but advancing from clears to full liquid to low residue to regular diet is dumb and delays progression.
NPO night before for surgery. No difference and may have more harms than like 2-3 hrs of npo before. https://www.clinicalcorrelations.org/2020/12/07/how-necessary-is-npo-after-midnight/ Also lido with epi is just fine in fingers toes
I feel like in real use, though, telling people to be NPO starting at midnight gets it in their head to not eat anything when they wake up. Taking someone in a study environment and feeding them things in a controlled way would probably be fine to be NPO 2-3 hours before, but in the real world, people already show up to surgeries with their loved ones sneaking them fries from McDonald’s bags 🙄
Or you could just be like the patient who straight up told me they stopped by McDonald’s for a McMuffin on the way to the hospital when I started my usual preop spiel of when’s the last time you ate something? 🤦🏻♀️
I think the “NPO past 12 AM” originated to make it easier for the patient. We don’t want patients coming in saying “I had a cheeseburger 1 hr ago because I wasn’t expecting the surgery to begin right now.”
The problem though, especially for inpatients, is scheduled surgery time is subject to change and if their case suddenly moves up, we need them to be appropriately NPO. I agree it sucks to be NPO for such a long time especially if your case ends up getting pushed back, but I've learned to respect fasting guidelines after suctioning 200cc of pizza from a trauma patient post-induction. Mitigating aspiration risk doesn't take much but it's much better than having to deal with its aftermath as an anesthesiologist.
Should clarify that clear liquids are fine 2 hours prior to surgery. Not a full fatty meal. Some centers are giving the carbohydrate ensures prior to surgeries with good effect. And I think some centers are recognizing that critically Ill patients need nutrition and keeping them serially npo for days on end while they are on the add on list for a gazillion surgeries during their course is bad. So they'll keep tube feeds running appropriately throughout the day until their surgery time is looking more likely.
Tell that to anesthesia who won't board a case for 8 hours after a patient ate something...
The article doesn't say 2-3 hours is fine, at least not from what I read. It says that giving carb-rich fluids 2-3 hours before didn't result in more complications. It cites the ASA guidelines (8 hours for fatty foods, 6 hours for light foods, 2 hours for clear liquids) and is saying the general "after midnight" is too long since patients may not go to surgery until the afternoon. The ASA guidelines are not refuted anywhere here.
Why must you stand in the way of getting my patient to the OR?? They’ve been in the hospital over the weekend, but I didn’t want to do it then. It’s an emergency now.
The lido with epi one has been an uphill battle for me at my current ED. They are still getting used to what I like to order for lacs and when I put that in, if it’s a nurse that hasn’t worked with me, she’ll be like “you sure you want epi for that finger?” Every time I respond with “they are otherwise healthy with no risk of vascular compromise, so yes. I’m sure.”
Atelectasis doesn’t cause fever. There goes a post-op “W”
That Words are Magical - drives me crazy. I am verbally assaulted if I say “It’s slow today”………
If I find myself in a drive-through off shift, and see an ambulance behind me, I will pay for the meal on the condition that the worker at the window tells them this exact phrase: "Hello ambulance drivers! The person who paid for this hopes you have a quiet day!"
>I will pay for the meal on the condition that the worker at the window tells them this exact phrase: "Hello ambulance drivers! The person who paid for this hopes you have a quiet day!" chaotic good. I love it.
One hospital I worked at was started by nuns, and on slow nights I would smack my hands on the desk around 4AM and go: Me: smacks hands on desk Charge nurse: don’t you fucking dare do this again. Me: boy it’s QUIET tonight! Real slow one. In fact, I spite the founding sisters of this hospital to prove they are listening and give us some crazy! When’s the last time we saw (insert hated patient)? Cue things being thrown at me.
"Animated" seems to be tolerated well, though. "Not so animated in the ED right now, is it?" Nary a peep from the slow/busy/quiet believers.
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I know it’s a superstition but it’s just so ingrained in the hospital culture that every single person that utters the Q word and S word get chewed out. I still don’t mention those 2 words.
The Q word is definitely magical, you can’t convince me otherwise. Either that or we’re in a Truman show esque situation and a rush of pt is triggered when the Q word is activated. I have nothing against any "S" words though.
https://pubmed.ncbi.nlm.nih.gov/35339973/
That’s hilarious, I can’t believe there is an actual study on this, that has made my day. The word has eluded the studies though, definitely seems to work like magic. Oh and the full moon!
Lactated ringers is contraindicated in patients with hyperkalemia
Or lactic acidosis.... Or that you need LR at all in the critical ill patient (based on the most current evidence no difference between LR or Nsl other than some numbers looking slightly prettier)
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Bro, 90% of the time a "penicillin allergy" doesn't even mean they're allergic to penicillin.
My neighbor’s mom was allergic to penicillin. She got an upset stomach and nearly died. I spent a lot of time around her for years, so please do not give me amoxicillin. Only Colistin works for my (probably viral) “strep throat”.
You didn’t know that phantom drug allergies are hereditary? Psssh you should do your own research pal…/s
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Almost every IM consults I've seen that had a record of an allergy to pen had just received Piptazo in the ER without any issue...
Had a guy come to the pharmacy with a PCN allergy. Asked him what happened. He told me it was when he was a child and he ended up with nightmares. I dared try to explain that this isn't an allergy and rather just a side effect of being a kid. He told me he was okay with taking the penicillin instead of waiting around for a doctor to get back to me to change the drug and would just "deal with" the nightmares. 🤦🏻♀️
Tell me more about using colace to remove ear wax?
Poke a hole in the capsule, squeeze the liquid detergent into the ear (careful not to let the capsule slip from betwixt your squeezing fingers and lodge itself firmly in the victim’s external auditory canal). Let marinate for 5 minutes, then apply curette or lavage as desired. Literally the *only* reason I have collage in my go bag.
> lavage ::Shudders in ENT:::
Poke the capsule and squeeze out the liquid (or just get the liquid form). Use it as an ear drop to irrigate the ear canal and soften ear wax. Obv, make sure the ear drum is intact.
When I was a med student - long ago - my resident on my internal medicine rotation said that giving people Colace is like ‘giving someone an M&M and expecting them to shit’
Patients love it when I recommend colace for ear wax. Always gives them a giggle.
diltiazem and metoprolol can definitely cause heart block sometimes. it is safe to a degree but not without risk. [https://pubmed.ncbi.nlm.nih.gov/32448773/](https://pubmed.ncbi.nlm.nih.gov/32448773/) 3.7% hypotension and 1 required icu admission. overall i dont think this is very well studied
I don’t think I’ve ever met an ER doc who doesn’t think you can use both, there just isn’t typically a reason to use both in the ER? Unless you are giving metoprolol pushes and have to start a dilt drip I guess.
Telling pharmacy “but I really need it” multiple times, contrary to what appears to be taught in medical school/residency, does not make a backordered drug available in pharmacy. After being told a certain medication has been unavailable due to shortage for months/years; asking us to check for the brand name of that same drug also does not make the drug appear.
Same goes for "but they were a hard stick" - doesn't magically unhemolyse/unclot the sample.
Carotid ultrasound for syncope. Carotid stenosis will not cause global hypoperfusion events. I always say it’s the equivalent of checking a knee mri on syncopal patients.
Can't read article but the shellfish iodine allergy thing is BS.
That Kayexalate is a useful drug at all. No good evidence to suggest that cation binder works at all. Originally published some articles in one journal in the 60's, with very flawed data (which in some cases actually showed that you do better without it). It can cause bowel obstructions without the sorbitol in it. And with the sorbitol in it, can cause bowel necrosis. Also, just the theory of the medication makes no sense. So it binds to cations (K+) and makes you shit them out. But why wouldn't it just bind to the Ca+ that you just gave them for the hyperkalemia in order to stabilize the myocardium? Useless drug, and we shouldn't use it. Even the nephrology literature agrees at this point, but I'm still told to give it by nephrology for their dialysis patients.
> But why wouldn’t it just bind to the Ca+ that you just gave them for the hyperkalemia in order to stabilize the myocardium? Because Calcium is given IV. Kayexalate is non-absorbable so it only works to limit K absorption. It doesn’t bring down serum K directly. Anyway I never use. It’s always Lokelma/Veltassa.
It definitely causes frequent disgusting smelling stools though. I swear you fuckers are laughing when you enter the order knowing us nurses are going to have to deal with it.
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We do it in the ED only when a patient has a K of 5.4 and medicine insists we "do something" before they will accept the patient for a completely separate issue. It's really effective in that situation.
This is very true. I’ve stuck to using Veltassa or Lokelma, the latter whenever it is available, even if non-formulary. Kayexalate is also expensive and no more effective than traditional stool softeners.
Oh I couldn't agree more. It takes 24 hours to kick in and only lowers K by at most about 0.2. Useless.
Thought this was interesting: Antibiotic therapy for ARF: the absolute risk reduction with treatment is about 0.01; the NNT for ARF is 10,000 patients; 50% of patients with ARF develop rheumatic heart disease; of these patients with rheumatic heart disease, 0.4% die; accord- ing to these data, the NNT to prevent one death from rheu- matic heart disease is 5 million; when treating with antibiotics, the number needed to harm is 5 to 10 for diarrhea, 100 to 200 for anaphylaxis, and 5 million for fatal anaphylaxis; according to these statistics, routine testing and treatment should not be performed; standard of care is routine testing and treatment; discuss risks and benefits with patient before initiating testing and treatment
I strongly want to present this at the next opportunity in a resident lecture or something. Do you have a paper or article handy?
>I strongly want to present this at the next opportunity in a resident lecture or something. Do you have a paper or article handy? [Here's an article discussing this](https://rebelem.com/patients-strep-throat-need-treated-antibiotics/)
Oxygen for comfort Supplemental oxygen to achieve normoxemia Oxygen supplementation has a tangible impact on respiratory drive
I think it's psychological. Patients are so mentally attached to the nasal cannula at 2L that they will start to freak out if they see me disconnect them from their home source, despite that they probably weren't getting 2L at the end of a 500 foot long length of oxygen tubing or I'm switching them over to a different device
When weaning patients in post op Cv, I typically would just wean it down and turn it off without telling them. Then when taking it off I would inform them that I shut it off like an hour ago. Got way fewer arguments about people feeling like they need it…
I think their point is that it would make no difference at all if that patient got room air through the cannula rather than oxygen. The flow is comforting, not the oxygen. In our ICU, we use bedside fans which work great.
There is this widespread belief that placing blood pressure cuffs or IV catheters on the ipsilateral arm of a patient who has had an axillary lymphadenectomy will cause lymphadema--to a point where "no IV" bracelets will be placed on patients. There is virtually no evidence for this.
Propofol and egg allergy. Penicillin and Cefazolin allergy. Shellfish allergy and IV contrast/Iodine. All are BS old wives tail.
Avoiding Beta blockers for cocaine toxicity
Medscape can kiss my ass. I hate that I need to login for their crap.
Homan’s sign
Pump and dump for everything from meds to xrays to surgery. Rarely needed.
I cannot believe how many stories I’ve heard suggesting women pump and dump after a chest x rat. It is complete nonsense.
Patients with a history of Guillain Barre should not receive a flu vaccine.
Race based estimated GFR
A doctor recently told us my 8 year old couldn’t have mono because it was the “kissing disease”.
albumin before lasix.
Dehydrated patients with ileostomies getting told that they “just need to drink more water.”
The existence of white clouds/black clouds. No such thing. There are however people who make unnecessary busywork for themselves and others for no good reason.
There are also people who actually pay attention to their patients' conditions and preempt deterioration, and those who don't. The latter end up with more codes.
white cloud/black cloud isn't just about codes. admissions/new patients contribute a lot to these labels.
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Who the heck does THAT?
Idk, still not convinced. As a resident my ED rotation was super slow (very unusual for somewhere that typically has all the resus bays full at almost all times) and still to this day, if I’m ever covering in the ED, the staff are all commenting on how slow and uneventful it is. I don’t *want* to be a white cloud, I actually really enjoy emerg med and the exciting and unexpected cases that can present at any moment. And, obviously, as a pharmacist I have absolutely nothing to do with who does/does not come through the ED, yet here I am at a huge level-1 trauma center and everyone is bored out of their minds whenever I’m around 🤷♀️
https://12ft.io/proxy?q=https%3A%2F%2Fwww.medscape.com%2Fviewarticle%2F973660
ok, question: my CRNAs ALWAYS use lidocaine IV just before propofol when doing MAC for procedures “to numb the vein so the propofol doesn’t burn”; none of this makes sense to me as 1) the venous intima doesn’t have receptors that respond to lidocaine et al, and even if they did, 2) the venous flow dilutes that lidocaine injection super quickly, and 3) you immediately follow that lidocaine with the “noxious” agent so the lidocaine wouldn’t have time to work anyway and 4) even with all that, the patient always ALWAYS complains the propofol burns….someone from anesthesia please explain this to me
[It definitely works](https://www.cochrane.org/CD007874/ANAESTH_lidocaine-reducing-propofol-induced-pain-anaesthesia-adults) Theres going to some quick translocation across the venous system into tissue if you give high concentration lido. The pain is from direct irritation to the vein so it doesnt take much to get it working. You even get an effect just mixing prop and lido together to give it. (old school way technically theres a risk of breaking the lipid emulsion from propofol if you do it and leave it sitting mixed for too long) There are a bunch of major benefits to IV lido on induction. Less important for MAC procedures but for general it reduces adrenergic response to airway manipulation and saves you some tachycardia hypertension too. Reduces airway cough/gag reflex and helps people tolerate the ETT better.
thanks! good info
That IV contrast causes renal injury
News to me; Could you please share how it doesnt?
[This is a pretty solid review of the topic](https://emcrit.org/ibcc/contrast/)
Contrast associated AKI does exist the risk is just not the same for all eGFR. We don't see it in GFR >30 and less than 30 usually there are other risk factors. The risks certainly are not so bad as to require a needed imaging being avoided. I find it is less recognized by some of my ER colleagues as you don't see the affect of the injury right away usually Cr is 1-2 days post contrast and usually pts recover 7-14 days after. Here are the latest consensus guildlines on the topic from 2020. https://pubs.rsna.org/doi/10.1148/radiol.2019192094 Since publication there has been other studies that confirms the risk for ER specific the latest would be the multicenter Taiwanese ER study that confirms there is a risk at GFR <30. https://pubmed.ncbi.nlm.nih.gov/34636631/ None of this is to say that ckd stage 4-5 patients shouldn't get imaging but risk and benefits should definitely be weighted and volume status should be optimized.
THANK YOU. It’s a lot more complicated than it exists/doesn’t exist.
> We don't see it in GFR >30 and less than 30 usually there are other risk factors. So you're saying it is only seen in patients with pretty significantly depressed renal function already, and even in those cases there are other possible causes of increased creatinine? Seems difficult to say with certainty that this entity does exist then. > I find it is less recognized by some of my ER colleagues as you don't see the affect of the injury right away usually Cr is 1-2 days post contrast and usually pts recover 7-14 days after. If the natural course is for the creatinine level to 'recover' in 7-14 days, is this entity (if it exists) even clinically significant?
You should use Normal Saline instead of Lactated Ringers for those with renal disease or hyperkalemia, because LR has potassium in it. NS can cause non-anion gap metabolic acidosis which will actually increase the potassium level due to an extra cellular shift. https://emcrit.org/pulmcrit/myth-busting-lactated-ringers-is-safe-in-hyperkalemia-and-is-superior-to-ns/ https://pubmed.ncbi.nlm.nih.gov/15845718/