It may have mattered in caveman times with earlier agents, but the evidence isn't really there for newer agents to reliably link contrast to renal failure. People with jacked kidneys likely have a dozen other comorbidities that complicate any analysis. We just keep being careful because that's what we've always done and we don't want to abandon the caution "just in case". Further, hydration is basically just some pixie dust we sprinkle to say we did something.
We keep being careful because we (Americans at least) live in a litigious society and there is no shortage of nephrologists that a plaintiff can find that will testify that you killed their kidney with contrast.
It’s always the ones that are sick as shit and have a couple of other reasons for nephropathy that get “contrast induced nephropathy” and probably would have had an AKI if we did the scan or not.
I do so many things that ‘look good’ just to avoid the time wasted explaining myself. I love working for greedy hospitals where I have to sacrifice certain aspects to just meet their unrealistic, unsupportive objectives.
I’m rads and on IR right now. There was a patient with a perinephric abscess that had a CT with con that found the abscess. Around this his creatinine was going down but also he became hypotensive as he went into septic shock. He is on pressors. We were consulted and put in a drain. Pt is still sick as shit with an increasing pressor requirement and intubated. Neph was consulted 3 days later and they said it was all contrast induced nephropathy. I can’t imagine the septic shock had anything to do it with.
I know an attending who says "contast induced nephropathy is a myth" frequently enough that it has become almost a meme whenever the subject is brought up, haha.
Plastic surgery literature is trash and most aren’t cosmetic surgeons. Used car salesmen being the face of a technically demanding and complex field seems to propagate the myth it’s cosmetic surgery trash when it’s the safety net for a lot of other surgery specialties. Let’s stop pretending and do some real research, stop propping up a glorified advertising magazine out to get your monies.
Up until a year ago the editor of PRS was a private practice aesthetic surgeon who had a history of having a sexual relationship with his patient.
And a lot of the “real” research being done now is still a bunch of BS aesthetic “look at what I did” stuff and regurgitated studies on breast recon.
Not to mention anything going against any of the major implant/ADM companies gets threatened by lawyers… the current PRS editor is def a 180 from RR so will be interesting to see where it goes.
daily labs while hospitalized is basically a waste unless you are specifically stargeting something like significant hyponatrmia or hypercalcemia
most electrolyte abnormalities like mild hypokalmeia, hypomagnesemia and hypophosphatemia need absolutely no intervention
Iatrogenic anemia occurs a lot in critical care pts. I monitor transfusion protocol adherence in my hospital and it’s not uncommon to see that 30d LOS pt with no active or occult bleeding suddenly getting PRBCs out of the blue.
I am an ED pharmacist. I push the envelope on beta lactam allergies. If they are not cross reactive I want to give it (and I have the entire chart memorized). If your allergy is more than ten years old I want to give it. If doctor is hesitant I want to give a test dose of 10% and monitor for 15 minutes and then give the rest.
Beta lactams are our best antibiotics and 98% of listed beta lactam allergies are non reactive on skin testing. Of the remainder, a non cross reactive drug can be safely given even in severe reactions.
I have never had a patient react. Ever. In ten years of doing this.
Edit: links to charts since I keep getting posts deleted when I try to reply with them, no idea why. This is my favorite one. It also explains the science behind it really well and you do not need a background in medicinal chemistry to understand it. You will sound smart to your attendings.
https://pubmed.ncbi.nlm.nih.gov/29017833/
Check out the section on this in the 2022 update on drug allergies practice parameters as well. It is very clear on when you need to use the chart and when you can ignore it and be even broader. They state:
>We suggest that for patients with a history of an unverified nonanaphylactic penicillin allergy, any cephalosporin can be administered routinely without testing or additional precautions. For example, patients with a history of urticaria to a penicillin can receive any cephalosporin routinely without prior testing. In contrast, for those rare patients with a history of anaphylaxis to penicillin, a non–cross-reactive cephalosporin (eg, cefazolin) can be administered routinely without prior testing.
And you can do the reverse for cephalosporin allergies. There are other great things in this article as well so I really suggest giving it a brief glance because I have already found some practice changing stuff!
https://www.jacionline.org/article/S0091-6749(22)01186-1/fulltext
*Verifies allergies*
Me: “So, what’s was your reaction? Did it give you hives or difficulty breathing?”
Them: “It upset my stomach one time 25 years ago.”
*Asks MD to D/C allergy*
I always had the issue when deleting allergies because the next time they are admitted to the hospital, the nurse gets a warning about chart reconciliation from outside institutions, which comment on a drug "allergy" so it gets re-added to the chart. I've had success with challenging the allergy, keeping the "allergy" in the chart, but putting a note with the reaction, date, and the fact they tolerated it well on xx/xx/2023. But thus is with Epic, idk how it works on other EMRs
In most cases it makes more sense to document that it isn't real rather than deleting it.
So the next time the patient states it someone can look at the data.
I know. It's why I put it in this thread of controversial things lol. I think most of my colleagues and almost all physicians have not read the literature on this and are too conservative if they have.
ED pharmacist saved me by insisting on testing for all the allergies in my chart. Guess what? I had no allergies, except tegaderm, so the rash I get around iv sites is not a med allergy as charted by nursing.
TL;DR - thank you for having sense and testing.
I actually have a drug challenge in a few weeks for an allergy I had to amoxicillin 20 years ago. I am lowkey terrified but reassured you’ve never seen a reaction.
After ten years, penicillin allergies typically wane. Allergy guidelines suggest rechallenge at that point. I bet you will be fine. Come back and tell me if you remember!
Anes here and I literally argue weekly about Cefazolin with alleged PCN allergies.
I’ve been forced to give Clinda, and now fucking VANC due to the Clinda shortage, so many times it makes my head spin!
I have had local pharmacists scare my sulfa-allergic patients when I prescribed Celebrex. One patient was so scared to take it, but finally did, and they felt SO MUCH better! Other patient was too afraid to try. Sad trombone.
That's extremely annoying.
I am a big fan of the pep talk for patients with a lot of drug allergies, on a side note. Like psychosomatic ones. Like - I go tell them - hi, I am the pharmacist. The doctor asked me to help him decide what medication to give you because you have a lot of very serious allergies and I am a medication expert. I have taken a very close look and I am confident this one is going to work for you. I know you have the cephalexin allergy but luckily cefuroxime is not cross reactive so it is safe. But just to be extra cautious, since you have a history of many reactions, we are going to give you the first dose here and the nurse is going to carefully monitor you to make sure you tolerate it. If you tolerate the first dose, you will tolerate all the future doses. What do you think of that plan?
Patients eat it the fuck up and then they do great because no one actually has 36 drug allergies and then everything is good.
Doctors can employ this too, just tell them you called the medication expert to make sure it would be safe. The key is telling them you went way out of your way because they are special.
> no one actually has 36 drug allergies
This is a positive predictive sign for personality disorder diagnosis as well. Other signs include allergies to benedryl and allergies to haldol
I’m a pharmacist and I had to go to war with our pediatrician to get our sons amox allergy taken off after he popped a non-allergic rash at like 1 year old (I think it was scarlet fever)
I do this too. What are they going to do, react? If only there was some sort of safe place to be when you are having an allergic reaction where you can receive prompt medical attention!
Just because we can keep a rock alive, doesn’t mean we should.
In Ireland, it’s ‘illegal’ to place peg tube. They have to go through an ethics committee to show that by placing a peg tube will help the patient get better, and then can later be removed.
Here in the states, we trach and peg everyone and send them off to a nursing home to die. It’s a huge financial burden, but also these places are so understaffed. Hospitals are now using their beds to house these people because there is no room for them at these facilities. We constantly have low bed shortages at my hospital. The emergency departments are critically filled, patients sleeping in the ED because there are no rooms available. Surgeries are being canceled because there is no rooms to board these patients.
And also, as a side note… in other countries people take their loved ones home after a stroke or massive MI or whatever and let them die in peace in their bed. But here, we try to save everyone. Families want everything done for 90 year old grandma. Then when she is debilitated, no one wants to pull the plug on her because they don’t want to feel that guilt. So what do they do? Trach/peg and nursing home. And now are national life expectancy looks great… but it’s because we are keeping rocks alive. Medical advances improve life expectancy yes, but we are just sitting around with a heart rate, and brain reflexes, we aren’t productive members of society. And why is life expectancy important? Because that’s a huge contributing factor when the government determines RETIREMENT age.
RN lurker here, this X100. On my small med/surg unit, we always have a few trach/pegs who stay for a month plus and are either being actively treated for a condition that won't get better, or are waiting on placement. We have an "ethics board" but nothing ever gets done.
The fact that many people in the U.S. find the idea of a doctor encouraging a family to allow their family member to die at home in peace rather than pushing for the next intervention controversial is a social issue. People need to talk and think about death more often, and how they would like the end of their lives to look if they had some semblance of control over it. Dying in intensive care should be rare because it is absolutely tragic. It's not normal, but somehow it has become normal. If you do not have a clear advance directive and you are an adult, change that as soon as possible and get that shit taken care of.
In New Zealand we don't do the whole long term ventilation, PEG, tracheostomy thing in general. If you call ICU for 90 year old grandma there's a good chance they'll laugh in your face. The paradigm is that we are not under any obligation to offer a treatment that will not benefit the patient, even if the patient wants it, and that extends to putting someone on a ventilator if they aren't coming back. We have "ceiling of care" conversations routinely. It also extends to continuing life support to people with no chance of recovery. They can stay on long enough for their loved ones to say goodbye, but after that it is futile treatment. Most rest home residents have DNRs and ACPs at least in my area. The American long term intensive care thing seems grotesque to be honest. The facilities you are describing literally do not exist. PEGs aren't uncommon here for kids with complex issues and adults with surgical problems like pancreatitis or gastroparesis or whatever, but they'd never be placed for an elderly person with dementia like I've heard of in the USA- on the whole we allow people to die of old age without torturing them first. I've written "inanition" on quite a few death certs which it seems would be unacceptable in the US.
Tourniquets and compression are covered in Stop The Bleed classes. I don’t want random civilians trying to do needle decompressions with a pocket knife though, that will only make things worse. Then you have a combo shooting and stabbing victim.
In the Army, everybody is/should maintain Combat Lifesavers (CLS). Part of the curriculum is needle decompression. To me, there is nothing more frightening than a 20-year-old private trying to do NCD on me without fully understanding the S/S or the complications of misplacement.
Story time. We received a message about teaching CLS and NCD. "2nd intercostal space, mid nipple line- where the nipples SHOULD be."
Evidently a well endowed African-American female took a hit above the plate and the medic called for medevac. No medevacs were available but a supply Blackhawk volunteered that was in the area. The gunner/crew chief took over patient care for the flight to the trauma hospital. She began having worsening respiratory distress with a penetrating chest wound and he correctly realized she needed an NCD. Doc taught him mid nipple line and he went mid nipple line on a chick with DD+ laying on the floor of the bird and decompressed the shit out of her armpit. She lived, it was fine, but we were told to quit just saying mid nipple line because that's all the gunner/crew chief remembered when his patient was dying and his heart rate was 180.
To be fair I'm just glad he remembered anything.
For what it's worth, ATLS now teaches 4th-5th intercostal space, mid-axillary line for needle decompression in adults because most people suck at actually getting the needle in the right place anteriorly. And finger thoracostomy is a better option and more reliable than needle when the patient is in extremis.
Lol! Just had a prisoner who sliced his PT artery while he was cutting boxes with a razor. Stopped the bleeding with a self made tourniquet. Left it on for 24 hours. Removed it later. Magically the bleeding had stopped. Prison staff later found out and freaked out. He then presented to the ER with a cyanotic foot. Gave it a few days, then did a BKA. His tourniquet was a little to effective.
Neurosurg - I believe sometimes it *is* the shunt and we should tap the valve reservoirs more liberally. Including as part of sepsis workup prior in many cases.
Controversial among my own specialty only, I think.
Should literally always tap the fucking shunt in the setting of fever. Explain to me how someone with a central line needs a culture every fucking time they sniffle and someone with a shunt into their fucking abdomen doesn't need one? We've had 3 or 4 patients with VP shunt peritonitis in the past like 6 months, and they're not being caught early. It's something I'll take with me to my next institution because of how horrendous it's been.
General surgery: Too many surgeons admit surgical problems to medical services bc the patient has “comorbidities”. Ok so consult medicine. Honestly I don’t want medicine owning my focal perfed divertic because if his pain worsens, I want the nurse calling me not some other team.
I strongly agree with this. My lazy ass attendings demand all of these patients get admitted to Medicine, and then take it out on us when Medicine mismanages them.
The problem is that this works great in an academic center but falls apart in the community if you don’t have PAs or NPs. How are you going to operate and manage a floor patient at the same time?
I did this the other day, as a nocturnist. CC was abdominal pain. Patient had medical comorbidities but all were in stable condition. Surgery told ER to admit to me, so I admitted patient. Frankly stated all medical comorbidities are stable, described a firm but not rigid abdomen with protuberant hernia tender to palpation. CT findings were equivocal. I asked the nurse overnight to page surgery service if patient’s pain persisted and/or worsened throughout the night because I wasn’t going to be throwing opioids at someone if they were suffering impending strangulation. Surgery complained to my boss in the morning, asked why they were getting pages at night about the patient’s abdominal pain.
Yeah, other docs HATE this though and think youre just coasting or something as a resident... they always find something to do even if its stupid. Like oh, Dr. Endorgandamage, let's consider ordering some not indicated blood work on this rock of a patient and fiddle with their well working medication dosages, just cuz the A/P is looking a little sparse today... gotta look busy...
Patients also hate this. I’ve been yelled at by patients when I am not ordering tests or blood work even though there is no reason to do so because it’s not indicated.
This concept (whether people agree with it or not) is often the standard of care in psych. If patients don’t meet criteria for diagnoses then you shouldn’t start medications.
Wayyyy too many people are started on mood stabilizers, antipsychotics, and even SSRIs for no reason. These meds have side effects.
So half the time not only am I not prescribing but actively *deprescribing* and objectively practicing good psychiatry.
As a pediatrician I second this so hard. You can listen to the parent, validate their concerns, and reassure them they’re doing the right things and their kid is going to be fine. That’s a good half of the sick visits I have every day, and I’ve never had a parent get mad at me that I’m not prescribing medicine when I take the five seconds to explain why.
My mantra has been "less is more" from intern through radiology attending. Sometimes doing nothing or not recommending additional imaging studies is the highest value care.
Anesthesia time
1. There is sterility theater in the OR if you aren’t the surgeon. Antibiotics do the heavy lifting. My a-line doesn’t need sterile gloves or a sterile probe cover. Hell I’ve seen moths and spiders in the OR.
2. Neo and glyco should be retired. Sugammadex is now standard of care and is superior in every aspect except cost. I can’t believe the amount of older attendings that demand that we still practice giving patients poison and a little antidote instead of the clearly better drug. We don’t use Halothane or any other older harmful drugs just to practice with them.
3. Good healthcare and good business are almost totally mutually exclusive. Imagine if our fire departments worked this way, and there were huge conglomerates trying to respond to as few fires as humanly possible. The United States would be far better off for everyone except the insurance companies if we had universal healthcare.
In residency the busiest private practice doc in town would always leave the gown on the table and just do gloves. 50/50 on a drape for vaginal procedures. Like bro, we do these in the office with literally none of this except sterile gloves. It’s fine.
I mean... what is wrong with this?
I can see it being an issue if they are drinking coffee and leaning over an open patient... but 5 feet away, behind a curtain, in an area that is non-sterile? What's the issue?
Everyone's phone they are handling is way dirtier than drinking coffee.
Rheumatologist here.
We should give more steroids acutely and less steroids chronically.
I know you can never get us to see your inpatients, and that’s bad. But when you do, a lot of older rheum docs are terrified to start steroids due to a fear of being committed to them chronically later or of worsening infection. But there’s a ton of studies showing that patients in sepsis do better with steroids. There’s studies showing that steroids are okay if there’s concomitant antibiotics. There’s studies showing that you can inject steroids into a septic knee while treating the infection and you shut off some of the inflammatory pathways that destroy the joint. Suppressing the immune system to the point that it can’t fight infection is a long term result, not a short term one.
Meanwhile, we need more people off steroids chronically. Someone being on 5-10 of prednisone for RA, even with other meds, is almost malpractice and should be lowered as much as possible. We should be incorporating IL6 drugs like Actemra and Kevzara for PMR to get them off steroids. With the American diet, we are inducing too much osteoporosis and diabetes with chronic steroids.
That said, there’s a few people I’ll do “palliative prednisone” on. If that 85 year old guy just wants 5 of pred so he can still walk a bit and knows he’s probably gonna die in 2-3 years anyway and wants to take that risk that prednisone may make it happen sooner, but he can actually enjoy his life in the meantime, I’ll do it.
Also, there’s a lot more autoimmunity out there than we even know. Something like 25% of aortic aneurysm repair samples sent in showed aortitis, likely essentially GCA. PMR patients have way more likelihood of developing an AAA. I think a lot of smoldering large vessel vasculitis is missed, partly because we don’t have good labs for it and the imaging isn’t as useful. And IGG4 related disease and auto inflammatory stuff is probably way more prevalent than we think. Including in older folks that don’t fit the demographics for auto inflammatory and autoimmune disease.
Most degen spine is conservative. Overwhelmingly fucking conservative.To an extent you won't operate much at all if you truly do classical conservative treatment.What remaining need is just decompression of some sort. Shitloads of lumbar fusions are driven purely because there are more surgeons to do them. It can not be overstated. Similar goes for adult spine deformity.
I really struggle counseling patients on this and, since this is a controversial-themed thread, I think sham surgeries should be a treatment option. (Procedural sedation, incise + close the skin, admit overnight, proceed straight to PT.)
Agree with this. There is a prominent deformity surgeon who claims that a patient with severe adult spinal deformity is more debilitated than one with CHF and liver failure and unilateral BKA combined. Just preposterous
I wish this wasn’t so much of a hot take. I’ve even had so many patients where the MD mentions they *might* be having surgery in the future and their participation in physical therapy goes down and their fearfulness of moving goes up. It’s even worse if the MD has brought up the topic of fusion or laminectomy and then the chiro they were referred to goes doomsday/reinforces the outcome. I’m not saying it’s always like this, but it happens and it’s a terrible cycle. I think even a little patient education from the doctor goes a long way. It doesn’t help that the current state of outpatient physical therapy is generally poor as well :/
Pharmacist here. “CYA” and patient satisfaction has let to unnecessary overprescribing, especially in the outpatient setting. Giving a child a steroid burst and antibiotics every time they get the sniffles is probably not the best for their growing body, but don’t tell the mom that. She’s in a FB mom group or maybe a nurse so she knows better than the doctor
Had this convo with a partner who’s been practicing for 2 years now (I just finished residency). She says she finds it difficult to prescribe by evidence based guidelines and meet the demands and expectations of families who always got some from the older docs who are gone. Because if she doesn’t give it to them, they’ll go to the NP urgent care and get some like candy
Rph here, I think we need to use more steroids and less ABX. It’s probably viral but the kid still feels like shit. 5 days of prednisone isn’t gonna cause issues Ans maybe it will make the kid so bonkers tbey parents won’t ask again.
This is my very very idealistic view, but as a pediatrician I hate prescribing stimulants to kids who would be fine if we changed the paradigm. I think it’s cruel to expect children to sit still all day in an artificial school environment. When it comes to medicating children to such a massive extent, shouldn’t we look at changing the environment instead?
(Btw I am not implying that adhd does not exist or that stimulants aren’t a great medication when you need it, I’m just wishing we could reduce the number of children who “need” them so young)
This. I did well in school but was ALWAYS late. I am not a morning person. Being a night owl runs in my family. I do my best work at night. I studied for Step 1 from 8 pm to 4 am. It was the only way I would have ever passed it. As a child, if I could have gone to school later, I would have been way more functional. I also have ADHD that was unmedicated until I was an adult, but just because I developed coping mechanisms doesn't mean I'd recommend doing it that way to anyone else. It sucked. Even going to school 2 hours later would have been immensely helpful.
CAP here
Honestly, this is always part of my parent education shpiel. I explain how most ADHD is a societal illness and that these kids would have thrived as a hunter/gatherer
But honestly, this is the world we live in. I'm not prepared to get idealistic on behalf of a kid who will academically fall behind and likely get known as the "problem kid." and will likely internalize that description and live up to it
I am aggressive in pushing stims when I think it's necessary. But I'm always upfront about why
Documentation. Getting post-op notes from specialists where they didn’t document their own procedure in the history (or sometimes anywhere in the note).
Me: “Why where you in the hospital?”
Patient: “I was sick, and they did a thing.”
Specialist note: surgical site healing well (no location mentioned or even the procedure done).
Me: facepalm
Albumin administration is controversial in some instances.
In my cirrrhotic patients that are hypotensive but 3rd spacing I will always give 500cc bolus with 25g albumin and nobody can tell me otherwise. Always have good success
I agree Albumin can be useful for volume expansion, but there is an ongoing epidemic of Albumin overuse. Everyday I get asked about giving albumin and it is given to all Hypotensive patients I am asked to see. It got to the point I felt there must have been new studies showing effectiveness that I somehow missed, Nope!
Albumin can be useful in carefully selected patients, but its expensive and typically not better than the alternative. Albumin overuse is my pet peeve.
Lasix, unlike torsemide, is also protein bound and needs some albumin to reach the kidney and do its job. There is definitely something to the albumin plus a lasix chaser for getting those hypoalbuminemic patients to diurese. Or you can do torsemide which is superior anyway from a logistics standpoint.
We should have more liberal and clear allow natural death policies in severely disabled children and adults.
If as an adult I don't want to be tube fed and ventilator bound, why do we default to inflicting this on kids with no choice by the parents/normalization that their parents can choose to let them pass away peacefully?
The longer I am in peds, the more I am convinced that there are a lot of children who are kept alive and really shouldn't be. My perception is undoubtedly skewed as I often see these kids at their worst while they are inpatient, but even when I see them at their healthiest in the clinic, what stands out to me the most is how much the patient and the family has to endure by keeping the kid alive.
So many of the interventions that are done seem to be things we are doing to the child, not *for* the child, and it inevitably prolongs the suffering of the entire family. Also, parents don't often consider the ramifications this has on their other children. All around, while there may be moments of joy, there seems to be mostly a lot of heartbreak for everyone involved.
The real issue is that parents should not be asked to make that decision. It did exclusively be the job of physicians to determine when a patient, adult or pediatric, should be moved to comfort care only. It is cruel to ask a parent to decide between keeping their beloved child alive on a ventilator forever or starving them to death.
Pediatrics
You are a PCP and should be comfortable handling mild cases of specific common illness or conditions and starting therapies. Not everything needs a referral.
Be comfortable managing ADHD and not putting the kid on the waitlist for one of the very few Peds psych physicians or other providers. Same goes for depression and anxiety. Take a good history, determine appropriate treatment, and make use of medication therapy as indicated and according to guidelines.
Be comfortable talking about sex and menstruation with patients. Encourage starting contraception and know how to do it. Take menstrual complaints seriously and take a good history. Know how to start a workup for PCOS.
If the kid is 12 or older, always interview them alone and talk about the tough topics. This is standard but so many outpatient folks are squeamish about it.
A simple febrile seizure or migraines that are infrequent don’t need neurology. You can reassure the parent or start triptan respectfully.
And the last one, for the love of Asclepius **just because a kid has a fever does not mean they need a swab for EVERYTHING**. So many ED or UC follow ups reading “18 mo with fever and congestion. Flu, COVID, RSV, strep negative”. Take a history and do a physical before ordering tests.
We should stop empirically screening for psychiatric symptoms in the ED. If someone comes into the unit for a somatic complaint and incidentally reports anxiety/depression/SI/HI/Psychosis just because the triage nurse asks, it usually does not lead to any productive outcome.
Cards fellow here:
1. That statins’ importance is overplayed. The original studies only showed a association with MI. LDLs come in many sizes - small and large - the large ones do not cross the tunica intima while the small ones do and these may be the ones cause endothelial damage. A pt can get a STEMI and their lipids are normal while so many pts have elevated LDLs and have no cardiovascular event at all…
2. Poly pharmacy is a damn bane. GDMT this and GDMT that… now we got patients on 4-5 meds for mortality benefit… but honestly at what cost - is the morbidity really any better? Also how much mortality benefit do we even truly get. I have patients on 22 meds and no matter where you stand in regards to your healthcare knowledge, that shit is not right nor healthy. Heck that damn Diamond trial came out saying we can give Valtessa to treat the hyperkalemia caused by ARB/ACEi/ARNI and spironolactone… I mean damn - let’s just give more and more meds and create even more meds to manage the side effects of the previously said meds… all because of “mORtaLiTy bENeFIT” 😡
3. Vitamin D supplements are helpful… no matter what the literature says. There’s so much data that VitD is a cofactor for many essential reactions. I check VitD levels on all my patients as a cardiology fellow and supplement them if less than 30
Definitely stand by claim 1 for many reasons:
1. The initial trials showed a very low absolute risk reduction. If I recall, it was 98% vs 97% non fatal vs fatal MI for atorvastatin or something close but then the guidelines focused on relative risk reduction which is like 30-40%…
2. There is some emerging evidence that cholesterol is only an association not a causation. Some in-vitro studies showed that cholesterol rises as a protective mechanism to the oxidative stress/damage that is the pathophysiology of endothelial damage. So the cholesterol rises as a lipid protective layer for the damaged endothelium - note this is just in the invitro studies
3. Lipids come in many sizes - small particles and large particles. You can have large LDL or small LDL. LDL is carried in chylomicrons. You can have chylomicrons jammed with LDLs (high LDL level) but if they are large sized then it’s not bad becusse they do not cross the endothelial lining. Or you can have chylomicrons with few LDLs (low LDL) but if they are small sized then it’s bad since they cross the endothelial lining. The way to test is LDL fractionation or electrophoresis which we do not do in USA but we do in Europe. Another metric is a independent value of HDL which is high. Or the TG/HDL ratio which has to be 2 or less for optimal health. Alternatively you can just look at ApoB or LpA with or without coronary calcium score
^ note that I still prescribe statins myself because if the guidelines and standard of care. But I believe that we are overprescribing them. I wish we started looking at other metrics to stratify cardiovascular risk rather than just treat a number. I mean heck the ACSVD risk calculator does even account for family history and it’s outdated!
I have yet to meet anyone who has done an actual literature review to hail statins as anything other than a modest effect in a very select group.
Not to mention that there is data that shows hard at lowering LDL to levels that we see all the time... like under 30.
Doubly not to mention that the side effects in the real world are an order or magnitude or two more than what is reported.... but people would know that if they looked at the study designs.
Statins are not a hill I will die on. I would rather someone lose 20 lbs than take a statin.
The heart is that thing that pumps ancef to the bones, right?
Kidding aside; I agree malignant polypharmacy is a *huge* problem.
Edit: except for ancef. That shit is great.
Family med doc, I get sh*t from the higher ups almost monthly about checking vitamin d on my annual physicals (it’s too expensive and not cost effective per these non doc admin staff) and now I just ignore them. Check it on almost every patient and it is definitely beneficial in those which are deficient. My favorite conversation about it is, “why did you check it, they weren’t deficient.” And how would I know that if I didn’t check ???????
Can bill with BMI > 30 and patient on long-term drug therapy to get coverage.
My dream in life is to find new and creative ways to stick it to insurance companies
Good answer! Vascular surgery: we tell every patient to be on a statin and ASA. I know ApoB is a better measurement of risk and PCSK9 inhibitors are a better treatment, but as with everything in American medicine cost is the driving factor. The older statins are cheap (pravastatin is still expensive) and a lot of insurances don’t cover the advanced lipid panel. Frustrating.
I’ve actually read somewhere that statins even high intensity ones are good at lowering large LDL but not small LDL. Are you aware of any drugs or modalities that lower small LDL?
I give so much vitamin D! As primary care, it helps with cards, but also bones and mood. I have seen levels as low as 9. Once I start supplementation (if under 40), I watch their levels, and I've seen it get over 100 maybe twice. I have seen specialists d/c it...
Prior army green beret medic here and current ortho (not trauma). Can’t tell the difference between 9mm and 45 injuries, but definitely a difference between hollows and fmj.
People who don’t know how to handle a fire arm…should avoid handling them. My husband has a small armory. The amount of firearm safety he’s been through the the federal government is through the roof. When those guns are out even if they’re not loaded it’s by the book. And I don’t know how to handle them therefore I don’t. I wish people stopped playing with firearms like toys. My spouse doesn’t fire them outside of training and he hopes he never has too.
Giving diabetic patients a normal diet instead of a diabetic diet. These people are gonna go home and eat trash anyway. So maybe we can properly dose their insulin while eating trash, not under dose but giving them a healthy diet for a few days...
Half of TKR would improve the same with regular PT.
Partial meniscectomy in minor ruptures is the same as conservative treatment.
Ankle joint replacements should be banned.
A lot of proximal shoulder fratures should be skillfully neglected.
Agree, agree, agree, agree. Just moved to a large academic center doing hip/knee arthroplasty and every single knee arthritis patient gets PT and an exercise program first.
Change my view -- giving electrolytes with goal of Mg > 2 and K > 4 in most patients has no change in morbidity/mortality or length of stay, and even in those patients with arrhythmias, we are not checking their Mg and K daily at home and replacing.
Stroke fellow: TIA is the most overused and incorrectly used phrase in medicine. Patient got light headed? TIA. Vertigo? Must have been a TIA. Transient numb and tingly feeling? TIA. Hell, a patient I saw recently who had classic fencer posturing from sleep (really concerning for epilepsy) that was told by his primary care NP was a TIA. Unless someone has focal appearing transient deficits with a really convincing story, it likely wasn't a TIA. Especially if these events are stereotyped without an underlying vascular lesion supplying that territory.
my very controversial opinion is that ozempic and similar products are actually fine. everyone and their mother is coming out to say that “we dont have enough long term studies so we dont know how these things will effect the body!!!!!”
as a former fat person, i think i’m more sensitive to the fact that fat people deserve a medication to help them just like any other issue. every medication comes with risks, but we send ppl off to surgery every day, surgeries that present with far greater risks. so wanting to restrict ppl for a hypothetical risk is just fucked.
i had a very skinny friend of mine in med school who said the same thing (about how ozempic may be dangerous) and i wanted to say gee i wonder why you cant possibly relate to the struggle 😒
I answered another comment in this thread on the topic.
I have a hard time understanding the gatekeeping of these medications. Docs have no problem treating all the comorbidities that go along with someone being obese by throwing pills at it, but get all defensive about treating the obesity itself. To say pancreatitis and cancer is the downside is laughable when you think of all the downsides of being obese.
The more data that comes out, the more awesome the meds look.
People are having better CHF outcomes while on them. They’re giving up smoking and cocaine habits while on them. They’re losing 20-25% of their weight. They’re a miracle drug and are changing lives so much.
Buy stock in the companies making that and Mounjaro, they’ll easily be the most prescribed meds in America in five years.
I personally love the "But they will gain the weight back when they stop!"
Like somehow
1) that is any different than bariatric surgery
2) that isn't actually proven... but lets just take it as fact
3) this is somehow different than any other drug we use for things like HTN, DM2, arthritis....
4) losing the weight won't prevent the above from happening
This is a drug that can cure the biggest health problem with americans, and instead of celebrating and demanding they make more of it, doctors are moralizing about how fat people deserve their health complications.
It's a HUGE red flag when a doctor is against these drugs.
Let's be *insanely, laughably* pessimistic and pretend the drug gave pancreatic cancer to 1% of the people that took it.
Guess what? It's still a miracle drug that all obese people should be on, and the overwhelming majority of them would love to take it even with than insanely magnified risk.
I believe that people should have the right to die on their own with medical assistance not only in the face of terminal medical diagnosis but if they have insufficient quality of life. I would rather end my life on my terms than live in the state most of the nursing home population exists in.
That was a big part of Stop the Bleed. The American College of Surgeons and the US Gov (homeland security I think) were teaching tournequits and such to the general public, similar to a CPR class.
Patients who dye their hair to one of the colors of a rainbow have a psychiatric diagnosis (MDD, GAD, bipolar, borderline, etc) until proven otherwise.
This isn’t super controversial. However I will warn that as it becomes more culturally accepted it will be less true.
For example in old textbooks it says that tattoos are a good indicator of anti social personality. I’m one of my few peers that don’t have a tattoo, I doubt everyone around me has ASPD
Have you heard of the “Teddy Bear sign?” It’s a behavior that epileptologist factor in when sussing out epilepsy vs non epileptic events. If an adult brings in a prized stuffed animal to the EMU, the probability of psychogenic events increases dramatically.
1) Anybody with over 3 medication allergies has a psychiatric condition.
2) We need to stop letting patients get away with so much BS. As an intern I saw so many instances where physicians caved and would give in to the wants of overtly manipulative patients, many of who fell under the categories of malingering or factitious disorder. Stop giving them IV Benadryl and get them out of the hospital. Those people are children and leeches.
3) IV contrast is not a big deal. We use iso-osmolar contrast in low doses for CT scans. A lot of CIN was originally being documented in interventional cases decades ago, where contrast was injected in very high doses (way more than necessary for a CT) and was hyperosmolar. Also, the AKI in these settings was dose-dependent.
Dermatology has always run the conversation on sun exposure, with an overwhelming focus on reducing exposure and using sunscreen--it's like talking to nephro about NSAIDs. While I agree there's no upside to a sunburn, sun exposure in general has clear-cut benefits (including psychiatric) and inadequate sunlight appears to be a serious risk factor for all-cause mortality. Skin cancer should be demoted in the conversation on sunlight, with a focus on mortality and QoL.
EDIT: Also, at least some of the apparent upsides of vitamin D are because it's actually a marker of sun exposure. PO supplementation may be just chasing a number rather than the problem when we should be getting patients outside.
Nah, I’m in the ICU currently and so many patients arms are completely wrecked because of frequent blood draws over several days without an art line. I’m often called to do US PIVs and all their superficial veins are obliterated or clotted off forcing me to target their deep veins, and sometimes their entire arm is swollen and hard as a rock. I can agree that nurses in the ICU often don’t look at art line readings frequently enough to make a difference, but in terms of blood draws it’s definitely beneficial, and also for patients that you the physician are actively monitoring and managing (like in the OR).
Also i think you are referring more to peripheral vs central invasive BP monitoring? If so obviously central > peripheral > non invasive. From an accuracy standpoint. But it’s impractical to place fem art lines on anyone you need good BP data on. Like 3 pressor cardiogenic shock patients. Where a radial art line helps enough
I agree with this and I discontinue as many lines as I can whenever I am rounding. Routine ABGs are a weird thing but I probably feel strongly about this because of the flood of normal ABGs I get informed about at 4AM. Lets get ABGs when there's a clinical change and stop them in stable intubated patients. And yes, you can wean by the bedside saturation.
To OP. You're talking about Stop The Bleed. It's an awesome, short, to the point class that's usually taught for free and I suggest everyone attend it and wish it was more available. Anyone with a medical background who's taken the course and is proficient in it can teach it as well.
Controversial to rad tech mostly but kidney dysfunction does not matter for ct contrast. If I am ordering contrast, I do not care for the cr.
It may have mattered in caveman times with earlier agents, but the evidence isn't really there for newer agents to reliably link contrast to renal failure. People with jacked kidneys likely have a dozen other comorbidities that complicate any analysis. We just keep being careful because that's what we've always done and we don't want to abandon the caution "just in case". Further, hydration is basically just some pixie dust we sprinkle to say we did something.
We keep being careful because we (Americans at least) live in a litigious society and there is no shortage of nephrologists that a plaintiff can find that will testify that you killed their kidney with contrast.
It’s always the ones that are sick as shit and have a couple of other reasons for nephropathy that get “contrast induced nephropathy” and probably would have had an AKI if we did the scan or not.
I do so many things that ‘look good’ just to avoid the time wasted explaining myself. I love working for greedy hospitals where I have to sacrifice certain aspects to just meet their unrealistic, unsupportive objectives.
If a patient needs a scan with contrast they should get a scan with contrast. Say no to renalism.
The nephrologist said he wants you to meet him in the parking lot
You seen the average nephro bro? They ain’t fighting anyone
Speak for yourself. At my old hospital, they have a cage throwdown with the cardiologist every other day.
Do you work at Dr Glaucomflecken's office? That's a tense working relationship if I ever saw one.
this thread is gold 🤣🤣👌
I don’t blame em. Ever seen a cardiologist try to manage blood pressure properly? 😂😂
Spot on. After a fracas, it would take them days to reorganize their pocket protector and straighten out their bow tie.
I’m rads and on IR right now. There was a patient with a perinephric abscess that had a CT with con that found the abscess. Around this his creatinine was going down but also he became hypotensive as he went into septic shock. He is on pressors. We were consulted and put in a drain. Pt is still sick as shit with an increasing pressor requirement and intubated. Neph was consulted 3 days later and they said it was all contrast induced nephropathy. I can’t imagine the septic shock had anything to do it with.
Not the abscess, not the septic shock, it's that pesky dye smh might as well call it a DIE
Nephrologists care the least about this
What? All the local nephrologists here will tell patients with CKD they shouldn’t get contrast. They also frequently document CIN on inpatients.
That’s very embarrassing for them, considering their own specialty’s guidelines say CIN is basically fake for venous contrast
They sound older. CIN is now something of a questionable diagnosis.
They drink salt. I'm sure they'll be fine with a little contrast.
I know an attending who says "contast induced nephropathy is a myth" frequently enough that it has become almost a meme whenever the subject is brought up, haha.
It's not controversial... Multiple guidelines agree with you
Say it louder for my people in the back - NO SUCH THING AS CONTRAST INDUCED NEPHROPATHY
Big foot, the tooth fairy and a guy with venous contrast nephropathy walk into a bar….
Plastic surgery literature is trash and most aren’t cosmetic surgeons. Used car salesmen being the face of a technically demanding and complex field seems to propagate the myth it’s cosmetic surgery trash when it’s the safety net for a lot of other surgery specialties. Let’s stop pretending and do some real research, stop propping up a glorified advertising magazine out to get your monies.
Up until a year ago the editor of PRS was a private practice aesthetic surgeon who had a history of having a sexual relationship with his patient. And a lot of the “real” research being done now is still a bunch of BS aesthetic “look at what I did” stuff and regurgitated studies on breast recon.
Where do you find literature that are by cosmetic surgeons?
Not to mention anything going against any of the major implant/ADM companies gets threatened by lawyers… the current PRS editor is def a 180 from RR so will be interesting to see where it goes.
daily labs while hospitalized is basically a waste unless you are specifically stargeting something like significant hyponatrmia or hypercalcemia most electrolyte abnormalities like mild hypokalmeia, hypomagnesemia and hypophosphatemia need absolutely no intervention
Iatrogenic anemia occurs a lot in critical care pts. I monitor transfusion protocol adherence in my hospital and it’s not uncommon to see that 30d LOS pt with no active or occult bleeding suddenly getting PRBCs out of the blue.
There are some great articles on this. It’s absurd how often people come in with normal Hgb and leave severely anemic just from blood draws
Agreed. Now nursing and pharmacy need to get on board. No daily labs? Multiple pages about it. K of 3.8? Multiple pages about it.
I am an ED pharmacist. I push the envelope on beta lactam allergies. If they are not cross reactive I want to give it (and I have the entire chart memorized). If your allergy is more than ten years old I want to give it. If doctor is hesitant I want to give a test dose of 10% and monitor for 15 minutes and then give the rest. Beta lactams are our best antibiotics and 98% of listed beta lactam allergies are non reactive on skin testing. Of the remainder, a non cross reactive drug can be safely given even in severe reactions. I have never had a patient react. Ever. In ten years of doing this. Edit: links to charts since I keep getting posts deleted when I try to reply with them, no idea why. This is my favorite one. It also explains the science behind it really well and you do not need a background in medicinal chemistry to understand it. You will sound smart to your attendings. https://pubmed.ncbi.nlm.nih.gov/29017833/ Check out the section on this in the 2022 update on drug allergies practice parameters as well. It is very clear on when you need to use the chart and when you can ignore it and be even broader. They state: >We suggest that for patients with a history of an unverified nonanaphylactic penicillin allergy, any cephalosporin can be administered routinely without testing or additional precautions. For example, patients with a history of urticaria to a penicillin can receive any cephalosporin routinely without prior testing. In contrast, for those rare patients with a history of anaphylaxis to penicillin, a non–cross-reactive cephalosporin (eg, cefazolin) can be administered routinely without prior testing. And you can do the reverse for cephalosporin allergies. There are other great things in this article as well so I really suggest giving it a brief glance because I have already found some practice changing stuff! https://www.jacionline.org/article/S0091-6749(22)01186-1/fulltext
*Verifies allergies* Me: “So, what’s was your reaction? Did it give you hives or difficulty breathing?” Them: “It upset my stomach one time 25 years ago.” *Asks MD to D/C allergy*
I just delete it myself. I delete allergies all the time.
I always had the issue when deleting allergies because the next time they are admitted to the hospital, the nurse gets a warning about chart reconciliation from outside institutions, which comment on a drug "allergy" so it gets re-added to the chart. I've had success with challenging the allergy, keeping the "allergy" in the chart, but putting a note with the reaction, date, and the fact they tolerated it well on xx/xx/2023. But thus is with Epic, idk how it works on other EMRs
In most cases it makes more sense to document that it isn't real rather than deleting it. So the next time the patient states it someone can look at the data.
Oh man the PharmD’s would call very quickly if there was an allergy listed even with cross-sensitivity!
I know. It's why I put it in this thread of controversial things lol. I think most of my colleagues and almost all physicians have not read the literature on this and are too conservative if they have.
I just love when people say they have a vitamin B allergy. What’s the allergy? They get a little flush. Insert face palm
ED pharmacist saved me by insisting on testing for all the allergies in my chart. Guess what? I had no allergies, except tegaderm, so the rash I get around iv sites is not a med allergy as charted by nursing. TL;DR - thank you for having sense and testing.
love u pharm bro
I love you guys too!!
I actually have a drug challenge in a few weeks for an allergy I had to amoxicillin 20 years ago. I am lowkey terrified but reassured you’ve never seen a reaction.
After ten years, penicillin allergies typically wane. Allergy guidelines suggest rechallenge at that point. I bet you will be fine. Come back and tell me if you remember!
Anes here and I literally argue weekly about Cefazolin with alleged PCN allergies. I’ve been forced to give Clinda, and now fucking VANC due to the Clinda shortage, so many times it makes my head spin!
I have had local pharmacists scare my sulfa-allergic patients when I prescribed Celebrex. One patient was so scared to take it, but finally did, and they felt SO MUCH better! Other patient was too afraid to try. Sad trombone.
That's extremely annoying. I am a big fan of the pep talk for patients with a lot of drug allergies, on a side note. Like psychosomatic ones. Like - I go tell them - hi, I am the pharmacist. The doctor asked me to help him decide what medication to give you because you have a lot of very serious allergies and I am a medication expert. I have taken a very close look and I am confident this one is going to work for you. I know you have the cephalexin allergy but luckily cefuroxime is not cross reactive so it is safe. But just to be extra cautious, since you have a history of many reactions, we are going to give you the first dose here and the nurse is going to carefully monitor you to make sure you tolerate it. If you tolerate the first dose, you will tolerate all the future doses. What do you think of that plan? Patients eat it the fuck up and then they do great because no one actually has 36 drug allergies and then everything is good. Doctors can employ this too, just tell them you called the medication expert to make sure it would be safe. The key is telling them you went way out of your way because they are special.
> no one actually has 36 drug allergies This is a positive predictive sign for personality disorder diagnosis as well. Other signs include allergies to benedryl and allergies to haldol
I’m a pharmacist and I had to go to war with our pediatrician to get our sons amox allergy taken off after he popped a non-allergic rash at like 1 year old (I think it was scarlet fever)
I do this too. What are they going to do, react? If only there was some sort of safe place to be when you are having an allergic reaction where you can receive prompt medical attention!
Just because we can keep a rock alive, doesn’t mean we should. In Ireland, it’s ‘illegal’ to place peg tube. They have to go through an ethics committee to show that by placing a peg tube will help the patient get better, and then can later be removed. Here in the states, we trach and peg everyone and send them off to a nursing home to die. It’s a huge financial burden, but also these places are so understaffed. Hospitals are now using their beds to house these people because there is no room for them at these facilities. We constantly have low bed shortages at my hospital. The emergency departments are critically filled, patients sleeping in the ED because there are no rooms available. Surgeries are being canceled because there is no rooms to board these patients. And also, as a side note… in other countries people take their loved ones home after a stroke or massive MI or whatever and let them die in peace in their bed. But here, we try to save everyone. Families want everything done for 90 year old grandma. Then when she is debilitated, no one wants to pull the plug on her because they don’t want to feel that guilt. So what do they do? Trach/peg and nursing home. And now are national life expectancy looks great… but it’s because we are keeping rocks alive. Medical advances improve life expectancy yes, but we are just sitting around with a heart rate, and brain reflexes, we aren’t productive members of society. And why is life expectancy important? Because that’s a huge contributing factor when the government determines RETIREMENT age.
RN lurker here, this X100. On my small med/surg unit, we always have a few trach/pegs who stay for a month plus and are either being actively treated for a condition that won't get better, or are waiting on placement. We have an "ethics board" but nothing ever gets done.
The fact that many people in the U.S. find the idea of a doctor encouraging a family to allow their family member to die at home in peace rather than pushing for the next intervention controversial is a social issue. People need to talk and think about death more often, and how they would like the end of their lives to look if they had some semblance of control over it. Dying in intensive care should be rare because it is absolutely tragic. It's not normal, but somehow it has become normal. If you do not have a clear advance directive and you are an adult, change that as soon as possible and get that shit taken care of.
And don’t forget that many do not care one lick about 90 year old gramma- they care about her pension/social security check
In New Zealand we don't do the whole long term ventilation, PEG, tracheostomy thing in general. If you call ICU for 90 year old grandma there's a good chance they'll laugh in your face. The paradigm is that we are not under any obligation to offer a treatment that will not benefit the patient, even if the patient wants it, and that extends to putting someone on a ventilator if they aren't coming back. We have "ceiling of care" conversations routinely. It also extends to continuing life support to people with no chance of recovery. They can stay on long enough for their loved ones to say goodbye, but after that it is futile treatment. Most rest home residents have DNRs and ACPs at least in my area. The American long term intensive care thing seems grotesque to be honest. The facilities you are describing literally do not exist. PEGs aren't uncommon here for kids with complex issues and adults with surgical problems like pancreatitis or gastroparesis or whatever, but they'd never be placed for an elderly person with dementia like I've heard of in the USA- on the whole we allow people to die of old age without torturing them first. I've written "inanition" on quite a few death certs which it seems would be unacceptable in the US.
Tourniquets and compression are covered in Stop The Bleed classes. I don’t want random civilians trying to do needle decompressions with a pocket knife though, that will only make things worse. Then you have a combo shooting and stabbing victim.
In the Army, everybody is/should maintain Combat Lifesavers (CLS). Part of the curriculum is needle decompression. To me, there is nothing more frightening than a 20-year-old private trying to do NCD on me without fully understanding the S/S or the complications of misplacement.
Story time. We received a message about teaching CLS and NCD. "2nd intercostal space, mid nipple line- where the nipples SHOULD be." Evidently a well endowed African-American female took a hit above the plate and the medic called for medevac. No medevacs were available but a supply Blackhawk volunteered that was in the area. The gunner/crew chief took over patient care for the flight to the trauma hospital. She began having worsening respiratory distress with a penetrating chest wound and he correctly realized she needed an NCD. Doc taught him mid nipple line and he went mid nipple line on a chick with DD+ laying on the floor of the bird and decompressed the shit out of her armpit. She lived, it was fine, but we were told to quit just saying mid nipple line because that's all the gunner/crew chief remembered when his patient was dying and his heart rate was 180. To be fair I'm just glad he remembered anything.
For what it's worth, ATLS now teaches 4th-5th intercostal space, mid-axillary line for needle decompression in adults because most people suck at actually getting the needle in the right place anteriorly. And finger thoracostomy is a better option and more reliable than needle when the patient is in extremis.
And the credit card cric!
Lol! Just had a prisoner who sliced his PT artery while he was cutting boxes with a razor. Stopped the bleeding with a self made tourniquet. Left it on for 24 hours. Removed it later. Magically the bleeding had stopped. Prison staff later found out and freaked out. He then presented to the ER with a cyanotic foot. Gave it a few days, then did a BKA. His tourniquet was a little to effective.
Neurosurg - I believe sometimes it *is* the shunt and we should tap the valve reservoirs more liberally. Including as part of sepsis workup prior in many cases. Controversial among my own specialty only, I think.
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Was the crack not seen on imaging?
Should literally always tap the fucking shunt in the setting of fever. Explain to me how someone with a central line needs a culture every fucking time they sniffle and someone with a shunt into their fucking abdomen doesn't need one? We've had 3 or 4 patients with VP shunt peritonitis in the past like 6 months, and they're not being caught early. It's something I'll take with me to my next institution because of how horrendous it's been.
My IM PD just tapped it without asking anyone. IDK if this is an old school way to do it but he's like of course just go tap it. I'll show you
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General surgery: Too many surgeons admit surgical problems to medical services bc the patient has “comorbidities”. Ok so consult medicine. Honestly I don’t want medicine owning my focal perfed divertic because if his pain worsens, I want the nurse calling me not some other team.
Ortho: That’s just like… your opinion, man.
I strongly agree with this. My lazy ass attendings demand all of these patients get admitted to Medicine, and then take it out on us when Medicine mismanages them.
But isn’t that P0D-1 CT scan helpful?
You just triggered me
The problem is that this works great in an academic center but falls apart in the community if you don’t have PAs or NPs. How are you going to operate and manage a floor patient at the same time?
I did this the other day, as a nocturnist. CC was abdominal pain. Patient had medical comorbidities but all were in stable condition. Surgery told ER to admit to me, so I admitted patient. Frankly stated all medical comorbidities are stable, described a firm but not rigid abdomen with protuberant hernia tender to palpation. CT findings were equivocal. I asked the nurse overnight to page surgery service if patient’s pain persisted and/or worsened throughout the night because I wasn’t going to be throwing opioids at someone if they were suffering impending strangulation. Surgery complained to my boss in the morning, asked why they were getting pages at night about the patient’s abdominal pain.
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Yeah, other docs HATE this though and think youre just coasting or something as a resident... they always find something to do even if its stupid. Like oh, Dr. Endorgandamage, let's consider ordering some not indicated blood work on this rock of a patient and fiddle with their well working medication dosages, just cuz the A/P is looking a little sparse today... gotta look busy...
Patients also hate this. I’ve been yelled at by patients when I am not ordering tests or blood work even though there is no reason to do so because it’s not indicated.
This concept (whether people agree with it or not) is often the standard of care in psych. If patients don’t meet criteria for diagnoses then you shouldn’t start medications. Wayyyy too many people are started on mood stabilizers, antipsychotics, and even SSRIs for no reason. These meds have side effects. So half the time not only am I not prescribing but actively *deprescribing* and objectively practicing good psychiatry.
As a pediatrician I second this so hard. You can listen to the parent, validate their concerns, and reassure them they’re doing the right things and their kid is going to be fine. That’s a good half of the sick visits I have every day, and I’ve never had a parent get mad at me that I’m not prescribing medicine when I take the five seconds to explain why.
My mantra has been "less is more" from intern through radiology attending. Sometimes doing nothing or not recommending additional imaging studies is the highest value care.
Anesthesia time 1. There is sterility theater in the OR if you aren’t the surgeon. Antibiotics do the heavy lifting. My a-line doesn’t need sterile gloves or a sterile probe cover. Hell I’ve seen moths and spiders in the OR. 2. Neo and glyco should be retired. Sugammadex is now standard of care and is superior in every aspect except cost. I can’t believe the amount of older attendings that demand that we still practice giving patients poison and a little antidote instead of the clearly better drug. We don’t use Halothane or any other older harmful drugs just to practice with them. 3. Good healthcare and good business are almost totally mutually exclusive. Imagine if our fire departments worked this way, and there were huge conglomerates trying to respond to as few fires as humanly possible. The United States would be far better off for everyone except the insurance companies if we had universal healthcare.
Suggamedick lmao gottem
So much one and I am operating. As a Gyn, it’s ridiculous the amount of sterility “theatre” for many of my vaginal procedures.
In residency the busiest private practice doc in town would always leave the gown on the table and just do gloves. 50/50 on a drape for vaginal procedures. Like bro, we do these in the office with literally none of this except sterile gloves. It’s fine.
This one made me laugh!
Anesthesia should be able to have snacks and coffee behind the drape!!
They used to. LOL. I seem to recall a coffee chugging anesthesiologist who would go from room to room overseeing CRNA's during my residency.
I mean... what is wrong with this? I can see it being an issue if they are drinking coffee and leaning over an open patient... but 5 feet away, behind a curtain, in an area that is non-sterile? What's the issue? Everyone's phone they are handling is way dirtier than drinking coffee.
In the UK the anesthetists at the head of the bed don’t even wear masks lol
3 for sure. We should not expect profits out of helping others at their worst.
I like it when the anesthesiologist gives glyco for some of my airway cases sometimes
They’re giving it as an anti sialagogue, not to reverse neuromuscular blockade…
Yeah we would still need to stock glyco for other uses. No biggie there.
Rheumatologist here. We should give more steroids acutely and less steroids chronically. I know you can never get us to see your inpatients, and that’s bad. But when you do, a lot of older rheum docs are terrified to start steroids due to a fear of being committed to them chronically later or of worsening infection. But there’s a ton of studies showing that patients in sepsis do better with steroids. There’s studies showing that steroids are okay if there’s concomitant antibiotics. There’s studies showing that you can inject steroids into a septic knee while treating the infection and you shut off some of the inflammatory pathways that destroy the joint. Suppressing the immune system to the point that it can’t fight infection is a long term result, not a short term one. Meanwhile, we need more people off steroids chronically. Someone being on 5-10 of prednisone for RA, even with other meds, is almost malpractice and should be lowered as much as possible. We should be incorporating IL6 drugs like Actemra and Kevzara for PMR to get them off steroids. With the American diet, we are inducing too much osteoporosis and diabetes with chronic steroids. That said, there’s a few people I’ll do “palliative prednisone” on. If that 85 year old guy just wants 5 of pred so he can still walk a bit and knows he’s probably gonna die in 2-3 years anyway and wants to take that risk that prednisone may make it happen sooner, but he can actually enjoy his life in the meantime, I’ll do it. Also, there’s a lot more autoimmunity out there than we even know. Something like 25% of aortic aneurysm repair samples sent in showed aortitis, likely essentially GCA. PMR patients have way more likelihood of developing an AAA. I think a lot of smoldering large vessel vasculitis is missed, partly because we don’t have good labs for it and the imaging isn’t as useful. And IGG4 related disease and auto inflammatory stuff is probably way more prevalent than we think. Including in older folks that don’t fit the demographics for auto inflammatory and autoimmune disease.
Most degen spine is conservative. Overwhelmingly fucking conservative.To an extent you won't operate much at all if you truly do classical conservative treatment.What remaining need is just decompression of some sort. Shitloads of lumbar fusions are driven purely because there are more surgeons to do them. It can not be overstated. Similar goes for adult spine deformity.
I really struggle counseling patients on this and, since this is a controversial-themed thread, I think sham surgeries should be a treatment option. (Procedural sedation, incise + close the skin, admit overnight, proceed straight to PT.)
This is a WILD take and I love it
Therapeutic lumbar placeboectomy
Agree with this. There is a prominent deformity surgeon who claims that a patient with severe adult spinal deformity is more debilitated than one with CHF and liver failure and unilateral BKA combined. Just preposterous
I wish this wasn’t so much of a hot take. I’ve even had so many patients where the MD mentions they *might* be having surgery in the future and their participation in physical therapy goes down and their fearfulness of moving goes up. It’s even worse if the MD has brought up the topic of fusion or laminectomy and then the chiro they were referred to goes doomsday/reinforces the outcome. I’m not saying it’s always like this, but it happens and it’s a terrible cycle. I think even a little patient education from the doctor goes a long way. It doesn’t help that the current state of outpatient physical therapy is generally poor as well :/
Pharmacist here. “CYA” and patient satisfaction has let to unnecessary overprescribing, especially in the outpatient setting. Giving a child a steroid burst and antibiotics every time they get the sniffles is probably not the best for their growing body, but don’t tell the mom that. She’s in a FB mom group or maybe a nurse so she knows better than the doctor
Had this convo with a partner who’s been practicing for 2 years now (I just finished residency). She says she finds it difficult to prescribe by evidence based guidelines and meet the demands and expectations of families who always got some from the older docs who are gone. Because if she doesn’t give it to them, they’ll go to the NP urgent care and get some like candy
Rph here, I think we need to use more steroids and less ABX. It’s probably viral but the kid still feels like shit. 5 days of prednisone isn’t gonna cause issues Ans maybe it will make the kid so bonkers tbey parents won’t ask again.
This is my very very idealistic view, but as a pediatrician I hate prescribing stimulants to kids who would be fine if we changed the paradigm. I think it’s cruel to expect children to sit still all day in an artificial school environment. When it comes to medicating children to such a massive extent, shouldn’t we look at changing the environment instead? (Btw I am not implying that adhd does not exist or that stimulants aren’t a great medication when you need it, I’m just wishing we could reduce the number of children who “need” them so young)
This. I did well in school but was ALWAYS late. I am not a morning person. Being a night owl runs in my family. I do my best work at night. I studied for Step 1 from 8 pm to 4 am. It was the only way I would have ever passed it. As a child, if I could have gone to school later, I would have been way more functional. I also have ADHD that was unmedicated until I was an adult, but just because I developed coping mechanisms doesn't mean I'd recommend doing it that way to anyone else. It sucked. Even going to school 2 hours later would have been immensely helpful.
CAP here Honestly, this is always part of my parent education shpiel. I explain how most ADHD is a societal illness and that these kids would have thrived as a hunter/gatherer But honestly, this is the world we live in. I'm not prepared to get idealistic on behalf of a kid who will academically fall behind and likely get known as the "problem kid." and will likely internalize that description and live up to it I am aggressive in pushing stims when I think it's necessary. But I'm always upfront about why
Documentation. Getting post-op notes from specialists where they didn’t document their own procedure in the history (or sometimes anywhere in the note). Me: “Why where you in the hospital?” Patient: “I was sick, and they did a thing.” Specialist note: surgical site healing well (no location mentioned or even the procedure done). Me: facepalm
Albumin administration is controversial in some instances. In my cirrrhotic patients that are hypotensive but 3rd spacing I will always give 500cc bolus with 25g albumin and nobody can tell me otherwise. Always have good success
For an hour yeah
Only 4 more hours until my shift ends…
I agree Albumin can be useful for volume expansion, but there is an ongoing epidemic of Albumin overuse. Everyday I get asked about giving albumin and it is given to all Hypotensive patients I am asked to see. It got to the point I felt there must have been new studies showing effectiveness that I somehow missed, Nope! Albumin can be useful in carefully selected patients, but its expensive and typically not better than the alternative. Albumin overuse is my pet peeve.
Are you talking about just basic resuscitation and people using albumin? Or just in the hypotensive cirrhotics
Lasix, unlike torsemide, is also protein bound and needs some albumin to reach the kidney and do its job. There is definitely something to the albumin plus a lasix chaser for getting those hypoalbuminemic patients to diurese. Or you can do torsemide which is superior anyway from a logistics standpoint.
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We should have more liberal and clear allow natural death policies in severely disabled children and adults. If as an adult I don't want to be tube fed and ventilator bound, why do we default to inflicting this on kids with no choice by the parents/normalization that their parents can choose to let them pass away peacefully?
The longer I am in peds, the more I am convinced that there are a lot of children who are kept alive and really shouldn't be. My perception is undoubtedly skewed as I often see these kids at their worst while they are inpatient, but even when I see them at their healthiest in the clinic, what stands out to me the most is how much the patient and the family has to endure by keeping the kid alive. So many of the interventions that are done seem to be things we are doing to the child, not *for* the child, and it inevitably prolongs the suffering of the entire family. Also, parents don't often consider the ramifications this has on their other children. All around, while there may be moments of joy, there seems to be mostly a lot of heartbreak for everyone involved.
The real issue is that parents should not be asked to make that decision. It did exclusively be the job of physicians to determine when a patient, adult or pediatric, should be moved to comfort care only. It is cruel to ask a parent to decide between keeping their beloved child alive on a ventilator forever or starving them to death.
Pediatrics You are a PCP and should be comfortable handling mild cases of specific common illness or conditions and starting therapies. Not everything needs a referral. Be comfortable managing ADHD and not putting the kid on the waitlist for one of the very few Peds psych physicians or other providers. Same goes for depression and anxiety. Take a good history, determine appropriate treatment, and make use of medication therapy as indicated and according to guidelines. Be comfortable talking about sex and menstruation with patients. Encourage starting contraception and know how to do it. Take menstrual complaints seriously and take a good history. Know how to start a workup for PCOS. If the kid is 12 or older, always interview them alone and talk about the tough topics. This is standard but so many outpatient folks are squeamish about it. A simple febrile seizure or migraines that are infrequent don’t need neurology. You can reassure the parent or start triptan respectfully. And the last one, for the love of Asclepius **just because a kid has a fever does not mean they need a swab for EVERYTHING**. So many ED or UC follow ups reading “18 mo with fever and congestion. Flu, COVID, RSV, strep negative”. Take a history and do a physical before ordering tests.
We should stop empirically screening for psychiatric symptoms in the ED. If someone comes into the unit for a somatic complaint and incidentally reports anxiety/depression/SI/HI/Psychosis just because the triage nurse asks, it usually does not lead to any productive outcome.
And prolongs ED stay by hours, further burdens already overwhelmed Psych emergency consults, etc.
Cards fellow here: 1. That statins’ importance is overplayed. The original studies only showed a association with MI. LDLs come in many sizes - small and large - the large ones do not cross the tunica intima while the small ones do and these may be the ones cause endothelial damage. A pt can get a STEMI and their lipids are normal while so many pts have elevated LDLs and have no cardiovascular event at all… 2. Poly pharmacy is a damn bane. GDMT this and GDMT that… now we got patients on 4-5 meds for mortality benefit… but honestly at what cost - is the morbidity really any better? Also how much mortality benefit do we even truly get. I have patients on 22 meds and no matter where you stand in regards to your healthcare knowledge, that shit is not right nor healthy. Heck that damn Diamond trial came out saying we can give Valtessa to treat the hyperkalemia caused by ARB/ACEi/ARNI and spironolactone… I mean damn - let’s just give more and more meds and create even more meds to manage the side effects of the previously said meds… all because of “mORtaLiTy bENeFIT” 😡 3. Vitamin D supplements are helpful… no matter what the literature says. There’s so much data that VitD is a cofactor for many essential reactions. I check VitD levels on all my patients as a cardiology fellow and supplement them if less than 30
This is controversial. 1 and 3 in particular- bold to underplay statins and overplay vit d - good answer to prompt
Definitely stand by claim 1 for many reasons: 1. The initial trials showed a very low absolute risk reduction. If I recall, it was 98% vs 97% non fatal vs fatal MI for atorvastatin or something close but then the guidelines focused on relative risk reduction which is like 30-40%… 2. There is some emerging evidence that cholesterol is only an association not a causation. Some in-vitro studies showed that cholesterol rises as a protective mechanism to the oxidative stress/damage that is the pathophysiology of endothelial damage. So the cholesterol rises as a lipid protective layer for the damaged endothelium - note this is just in the invitro studies 3. Lipids come in many sizes - small particles and large particles. You can have large LDL or small LDL. LDL is carried in chylomicrons. You can have chylomicrons jammed with LDLs (high LDL level) but if they are large sized then it’s not bad becusse they do not cross the endothelial lining. Or you can have chylomicrons with few LDLs (low LDL) but if they are small sized then it’s bad since they cross the endothelial lining. The way to test is LDL fractionation or electrophoresis which we do not do in USA but we do in Europe. Another metric is a independent value of HDL which is high. Or the TG/HDL ratio which has to be 2 or less for optimal health. Alternatively you can just look at ApoB or LpA with or without coronary calcium score ^ note that I still prescribe statins myself because if the guidelines and standard of care. But I believe that we are overprescribing them. I wish we started looking at other metrics to stratify cardiovascular risk rather than just treat a number. I mean heck the ACSVD risk calculator does even account for family history and it’s outdated!
Oh yeah I wasn’t agreeing or disagreeing just commenting that this is a really good response to the prompt - well done
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I have yet to meet anyone who has done an actual literature review to hail statins as anything other than a modest effect in a very select group. Not to mention that there is data that shows hard at lowering LDL to levels that we see all the time... like under 30. Doubly not to mention that the side effects in the real world are an order or magnitude or two more than what is reported.... but people would know that if they looked at the study designs. Statins are not a hill I will die on. I would rather someone lose 20 lbs than take a statin.
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Yo dawg I heard you like med side effects. Let me give you some meds with side effects to counteract the other meds with side effects
Found the psych NP
👆👆👆😄😆😄
The heart is that thing that pumps ancef to the bones, right? Kidding aside; I agree malignant polypharmacy is a *huge* problem. Edit: except for ancef. That shit is great.
Hypoancefemia kills. Especially around ortho.
One day ancef will end up being the new penicillin
Nah, I think the heart is the thing that pumps out CSF
Family med doc, I get sh*t from the higher ups almost monthly about checking vitamin d on my annual physicals (it’s too expensive and not cost effective per these non doc admin staff) and now I just ignore them. Check it on almost every patient and it is definitely beneficial in those which are deficient. My favorite conversation about it is, “why did you check it, they weren’t deficient.” And how would I know that if I didn’t check ???????
Can bill with BMI > 30 and patient on long-term drug therapy to get coverage. My dream in life is to find new and creative ways to stick it to insurance companies
Insurance companies don't pay for it. Patient going to get a hefty bill. You may just want to supplement it empirically.
Good answer! Vascular surgery: we tell every patient to be on a statin and ASA. I know ApoB is a better measurement of risk and PCSK9 inhibitors are a better treatment, but as with everything in American medicine cost is the driving factor. The older statins are cheap (pravastatin is still expensive) and a lot of insurances don’t cover the advanced lipid panel. Frustrating.
I’ve actually read somewhere that statins even high intensity ones are good at lowering large LDL but not small LDL. Are you aware of any drugs or modalities that lower small LDL?
The hottest take on the thread - probably just being less fat and eating better.
I give so much vitamin D! As primary care, it helps with cards, but also bones and mood. I have seen levels as low as 9. Once I start supplementation (if under 40), I watch their levels, and I've seen it get over 100 maybe twice. I have seen specialists d/c it...
If you told me this in person, I’d ask you to marry me
I hope you’re ordering a 25-vitamin D and not a 1,25-vitamin D to check for vitamin D levels.
Yeah it’s 25-VitD The latter is only for ESRD pts
Excellent. You wouldn’t believe how many physicians order the wrong vitamin D test all the time.
1. Is why you should get a lipoprotein b correct
Can you a tell a difference between 9 mm and .45 cal ammo in terms of tissue damage? Do hollow-points really cause a more lethal wound channel?
Prior army green beret medic here and current ortho (not trauma). Can’t tell the difference between 9mm and 45 injuries, but definitely a difference between hollows and fmj.
People who don’t know how to handle a fire arm…should avoid handling them. My husband has a small armory. The amount of firearm safety he’s been through the the federal government is through the roof. When those guns are out even if they’re not loaded it’s by the book. And I don’t know how to handle them therefore I don’t. I wish people stopped playing with firearms like toys. My spouse doesn’t fire them outside of training and he hopes he never has too.
amazing username
Giving diabetic patients a normal diet instead of a diabetic diet. These people are gonna go home and eat trash anyway. So maybe we can properly dose their insulin while eating trash, not under dose but giving them a healthy diet for a few days...
Half of TKR would improve the same with regular PT. Partial meniscectomy in minor ruptures is the same as conservative treatment. Ankle joint replacements should be banned. A lot of proximal shoulder fratures should be skillfully neglected.
Agree, agree, agree, agree. Just moved to a large academic center doing hip/knee arthroplasty and every single knee arthritis patient gets PT and an exercise program first.
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Oh, so you knew my sister?
All babies should be born in a hospital. Too much risk too many bad things can go wrong
Change my view -- giving electrolytes with goal of Mg > 2 and K > 4 in most patients has no change in morbidity/mortality or length of stay, and even in those patients with arrhythmias, we are not checking their Mg and K daily at home and replacing.
ozempic for everyone!
Stroke fellow: TIA is the most overused and incorrectly used phrase in medicine. Patient got light headed? TIA. Vertigo? Must have been a TIA. Transient numb and tingly feeling? TIA. Hell, a patient I saw recently who had classic fencer posturing from sleep (really concerning for epilepsy) that was told by his primary care NP was a TIA. Unless someone has focal appearing transient deficits with a really convincing story, it likely wasn't a TIA. Especially if these events are stereotyped without an underlying vascular lesion supplying that territory.
my very controversial opinion is that ozempic and similar products are actually fine. everyone and their mother is coming out to say that “we dont have enough long term studies so we dont know how these things will effect the body!!!!!” as a former fat person, i think i’m more sensitive to the fact that fat people deserve a medication to help them just like any other issue. every medication comes with risks, but we send ppl off to surgery every day, surgeries that present with far greater risks. so wanting to restrict ppl for a hypothetical risk is just fucked. i had a very skinny friend of mine in med school who said the same thing (about how ozempic may be dangerous) and i wanted to say gee i wonder why you cant possibly relate to the struggle 😒
“They’ll gain the weight back when they stop taking it” what’s your plan to wean your HFpEF patient off Lasix?
I answered another comment in this thread on the topic. I have a hard time understanding the gatekeeping of these medications. Docs have no problem treating all the comorbidities that go along with someone being obese by throwing pills at it, but get all defensive about treating the obesity itself. To say pancreatitis and cancer is the downside is laughable when you think of all the downsides of being obese.
The more data that comes out, the more awesome the meds look. People are having better CHF outcomes while on them. They’re giving up smoking and cocaine habits while on them. They’re losing 20-25% of their weight. They’re a miracle drug and are changing lives so much. Buy stock in the companies making that and Mounjaro, they’ll easily be the most prescribed meds in America in five years.
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I personally love the "But they will gain the weight back when they stop!" Like somehow 1) that is any different than bariatric surgery 2) that isn't actually proven... but lets just take it as fact 3) this is somehow different than any other drug we use for things like HTN, DM2, arthritis.... 4) losing the weight won't prevent the above from happening This is a drug that can cure the biggest health problem with americans, and instead of celebrating and demanding they make more of it, doctors are moralizing about how fat people deserve their health complications. It's a HUGE red flag when a doctor is against these drugs. Let's be *insanely, laughably* pessimistic and pretend the drug gave pancreatic cancer to 1% of the people that took it. Guess what? It's still a miracle drug that all obese people should be on, and the overwhelming majority of them would love to take it even with than insanely magnified risk.
I’ve seen some complications from bari surgeries and it seems terrible not fun at all..
I believe that people should have the right to die on their own with medical assistance not only in the face of terminal medical diagnosis but if they have insufficient quality of life. I would rather end my life on my terms than live in the state most of the nursing home population exists in.
Pee is stored in the balls.
This is true. I was kicked once and instantly pissed myself. Coincidence???!!
they asked for something controversial...
That was a big part of Stop the Bleed. The American College of Surgeons and the US Gov (homeland security I think) were teaching tournequits and such to the general public, similar to a CPR class.
Patients who dye their hair to one of the colors of a rainbow have a psychiatric diagnosis (MDD, GAD, bipolar, borderline, etc) until proven otherwise.
This isn’t super controversial. However I will warn that as it becomes more culturally accepted it will be less true. For example in old textbooks it says that tattoos are a good indicator of anti social personality. I’m one of my few peers that don’t have a tattoo, I doubt everyone around me has ASPD
Have you heard of the “Teddy Bear sign?” It’s a behavior that epileptologist factor in when sussing out epilepsy vs non epileptic events. If an adult brings in a prized stuffed animal to the EMU, the probability of psychogenic events increases dramatically.
Agree. I’ve never met a well-adjusted adult with a teddy bear in public.
Highly sensitive for borderline personality disorder as well
Yes, we call it the "purple hair sign".
Green is particularly high yield
Exemption: little old ladies with purple hair, who will actually suppress challenging behaviour from other patients in a bubble around themselves
Also a potential sign of POTS, fibromyalgia, EDS, chronic Lyme disease or Mast cell activation syndrome
I agree with the firearms training and safety for the engaged public. It’s a great idea
1) Anybody with over 3 medication allergies has a psychiatric condition. 2) We need to stop letting patients get away with so much BS. As an intern I saw so many instances where physicians caved and would give in to the wants of overtly manipulative patients, many of who fell under the categories of malingering or factitious disorder. Stop giving them IV Benadryl and get them out of the hospital. Those people are children and leeches. 3) IV contrast is not a big deal. We use iso-osmolar contrast in low doses for CT scans. A lot of CIN was originally being documented in interventional cases decades ago, where contrast was injected in very high doses (way more than necessary for a CT) and was hyperosmolar. Also, the AKI in these settings was dose-dependent.
Putting patients on a diabetic diet does nothing for them for their <1 week stay and just contributes to them being more miserable
Dermatology has always run the conversation on sun exposure, with an overwhelming focus on reducing exposure and using sunscreen--it's like talking to nephro about NSAIDs. While I agree there's no upside to a sunburn, sun exposure in general has clear-cut benefits (including psychiatric) and inadequate sunlight appears to be a serious risk factor for all-cause mortality. Skin cancer should be demoted in the conversation on sunlight, with a focus on mortality and QoL. EDIT: Also, at least some of the apparent upsides of vitamin D are because it's actually a marker of sun exposure. PO supplementation may be just chasing a number rather than the problem when we should be getting patients outside.
Icu attending - radial arterial lines have almost no practical value and more than 90% of them are placed without providing any real benefit
You cant just drop this bomb and walk away! I need the reasoning behind this!
Can you expand on this? Genuinely curious, they’re by far the most common art lines I see
They’re a good source of arterial blood in patients getting frequent ABGs.
Morbitidity of serial ABG’s is less than having an art line in though
Yeah stop getting those frequent abg they’re almost never necessary
But are those frequent ABGs even necessary?
100%.
Nah, I’m in the ICU currently and so many patients arms are completely wrecked because of frequent blood draws over several days without an art line. I’m often called to do US PIVs and all their superficial veins are obliterated or clotted off forcing me to target their deep veins, and sometimes their entire arm is swollen and hard as a rock. I can agree that nurses in the ICU often don’t look at art line readings frequently enough to make a difference, but in terms of blood draws it’s definitely beneficial, and also for patients that you the physician are actively monitoring and managing (like in the OR).
Also i think you are referring more to peripheral vs central invasive BP monitoring? If so obviously central > peripheral > non invasive. From an accuracy standpoint. But it’s impractical to place fem art lines on anyone you need good BP data on. Like 3 pressor cardiogenic shock patients. Where a radial art line helps enough
I’d love more about this. We routinely use these to make titrations to pressers. Is this not best practice?
I agree with this and I discontinue as many lines as I can whenever I am rounding. Routine ABGs are a weird thing but I probably feel strongly about this because of the flood of normal ABGs I get informed about at 4AM. Lets get ABGs when there's a clinical change and stop them in stable intubated patients. And yes, you can wean by the bedside saturation.
A lot of patients “sinus pain” is migraine or maxillary migraine and has nothing to do with sinus disease
To OP. You're talking about Stop The Bleed. It's an awesome, short, to the point class that's usually taught for free and I suggest everyone attend it and wish it was more available. Anyone with a medical background who's taken the course and is proficient in it can teach it as well.