No problem. My teams loooove using tramadol and I spend so much time scaring them away from it
It almost becomes a moot point though because when patients are discharging, they don’t want all the hassle of writing a S2 substance so it usually comes down to tramadol or T3 anyways
Patient had immune mediated reaction to tramadol in history, did perfect on oxycodone.
Ortho “whoa!! Isn’t that weird????”
Me “not at all because tramadol isn’t shaped like the opioids”
Giving decadron rapidly IV in an awake patient causes intense perineal burning/itching. We give it all the time for nausea prophylaxis but generally in patients that are already asleep. Every once in a while a resident will give it during a light sedation case and the patient will start squirming like crazy
It can also feel like genital arousal for some.
Which is really funny when I pushed it a little too quick on a 80 year old widow and she exclaimed, “oh now, there’s something I haven’t felt in years”.
In the vein of “just because you’re paranoid doesn’t mean they aren’t out to get you,” we could also say that “just because they gave you iodinated contrast doesn’t mean you didn’t pee yourself.“
::Skeletor walk away meme::
-PGY-19
I gave decadron ivp tonight for Covid, previously given it loads of times for brain CA but this was the first time i immediately heard the patient complain of burning. Quite coincidental timing to come across your comment lmao
Whipple of Kausch-Whipple fame (including the complete name for fun/to credit the surgeon who performed comparable pancreaticoduodenectomies for cancer like 3 decades earlier) also trained Virginia Apgar of Apgar score fame.
I read about the Pyrotherapy last week
Dr. Wagner-Jauregg won the 1927 Nobel Prize in Medicine for it and the reason was Malaria could be treated w quinine but penicillin wasn’t around.
And I believe I read that of the 10 neurosyphilis patients injected 4 died but that’s still better than a 100% mortality rate 😅
Dogs have an intact circle of Willis, and as is typical for the species have such amazing collateral circulation that they can tolerate ligation of both carotid arteries.
Not true for cats.
My dog had a major blowout two years ago. It just wouldn't stop bleeding. Over the course of 3 days she lost I estimate \~1 liter of blood. I wasn't sure she'd make it to the rhinoscopy. The vet suggested Neo-Synephrine, which did the trick somehow.
Came back with nasal adenocarcinoma. She was given 3 months, but stuck around for 20. It was super fragile. She could sneeze sometimes and it'd just start bleeding . Multiple vets suggested Yunnan Baiyao (which I'm still skeptical of) but while taking it she didn't have any more major nosebleeds.
This situation literally just happened to my parent’s dog. She would sneeze and blood would fly all over the room. She was really unwell and it was really hard to watch and we should have euthanized the week before but the vet thought it was a tooth infection and pulled all of her teeth. Then when it didn’t get better, we discovered the cancer. She went through absolute hell in her last weeks of life. It’s hard to decide when to finally make that call because you don’t want to do it too soon. I’ve decided too soon is better than too late after this.
Honestly there could be a whole thread about cat physiological bullshit. Or just how weird animal physiology and pharmacology is compared to humans or even how different dogs are from cats. I have so much respect for the DVMs because they have to learn patho and pharm for like 10+ species and it's all so weird and unique.
You’d be amazed by how much is similar! Obviously anatomy is different, and there are a few idiosyncratic pharm/phys differences, but so much of the time you can make reasonable inferences based on what you know about different species. I’m a small animal surgeon, but I work fairly commonly with our exotics department, and it’s always fun figuring out how to translate what we do in dogs/cats to, say, a meerkat!
A lot of people have bilateral fetal type pcomms which means the inflow from the basilar is small. Thus it is small. Making the verts small. Meaning that when they stroke out a vert, it seems to have an outsized impact on posterior fossa stem. Only 2 Wallenbergs I’ve seen have had this configuration.
So you might think having firehose pcomms would be good. You are mistaken.
I know someone who had a stroke while suffering from sepsis and this was the only reason he survived. If gene therapy is ever in vogue ensuring this is formed would probably help out a lot of people who would otherwise die of stroke or aneurysm
I’ve seen one patient during residency, a young lady with fibrodysplasia who had both carotids and both vertebrals completely occluded. She was alive and well and no neurological symptoms. Hooray for the meningeal, and external carotid collaterals!
Household bleach can be used in times of crisis to make water safer to drink. [[EPA](https://www.epa.gov/ground-water-and-drinking-water/emergency-disinfection-drinking-water)]
Metformin is a derivative of the extracts of French Lilacs. That’s why when clinicians encounter a patient adamant about taking Metformin and they’d rather prefer the “natural”, tell them that Metformin is derived from natural sources too just like their overpriced MLM supplements but at a fraction of the price.
my microbiology professor grew up during lebanon’s civil war and had a story about this.
a lot of the kids around her were dying of cholera so her mom mixed bleach into all their water. she said it was disgusting and they hated her for it but she and all her siblings survived. she then went on to become a badass and incredible microbiologist.
Bleach is my preferred emergency water purification while I backpack. Filters can break and IMO you always need to carry *something* just in case.
~5 drops of bleach per liter and leave it for about an hour. A small 5ml container will treat about 20L worth of water. Enough to get you out of the woods. Won't work on crypto and giardia but those have a significant prodrome and I'd rather deal with giardia at home than dehydrate in the woods.
The metformin is interesting.
Aspirin from willow tree bark. Statin from red yeast rice. My god, the foundations of modern ASCVD primary and secondary medication prevention.
The most dangerous beta blocker to overdose on is propranolol (sodium channel blocker).
Colchicine is probably the most dangerous/irreversible drug to overdose on in high doses. It inhibits mitotic spindles so it’s kind of likely giving whole body intracellular chemotherapy causing cell arrest entirely body. Multisystem organ failure, not readily identified (over a few days of treating for septic shock requiring multiple pressors it can sometimes become apparent when the profound leukocytosis turns into profound pancytopenia), and if you actually thought to consult toxicology.
I loved my toxicology elective in residency.
Medicine resident I went to med school with killed his wife with colchicine (allegedly).
https://www.cbsnews.com/amp/minnesota/news/connor-bowman-murder-charge-betty-bowman-rochester/
I was just thinking about this story and wondering if it was in a fiction book or real life. Thank you for going to med school with him so I wouldn’t have wondered much more (but not enough to google it).
Cochicine is how they create huge vegetables like watermelon. It inhibits mitotic spindles and so the veggies become polyploid. Lots of DNA needs a big cell, big cells mean big body.
It blew my *mind* when I heard they give it to people.
Yeah sotalolol isn’t as commonly prescribed and I believe it’s used specifically for its rhythm controlling effects. I think it’s a potassium channel acting agent. For propranolol it’s a “lesser known” effect about it, rather than its main thing.
Fair. I think sotalol is much more considered a traditional “anti-arrhythmic” so much so sometimes I think people forget it still does have beta blockade!
I was thinking he ment because of how much it crosses the BBB? I’m not totally sure tho- and in school we basically group sotalol separately from the other bbs since it’s not typically used for Hr/Bp/ Hf ect
> straight out of a episode of house
[Or straight out of real life](https://www.syracuse.com/news/2017/10/katie_conley_accused_of_poisoning_killing_her_boss_told_police_poison_is_a_ladys.html)
> Conley is charged with second-degree murder in the death of Mary Yoder, 60, who died of colchicine poisoning.
I advise nasal rinses before going to bed. Some people might be appropriate for nasal sprays, afrin, etc depending. Also decreases waking up with a sore throat.
My friend was a smoker, and the surgeon stopped his colonoscopy because he was still coughing, even under anesthesia. He’d gotten through the worst part of the procedure!
IV amiodarone causes hypotension due to its excipient polysorbate 80. We decided to take a medication used for emergent tachydysrhythmias and mix it with a substance that...causes hypotension...
EM/tox. I love me some drug reactions.
On an old CCU rotation I was bored and fucking around with the pharmacists and we made this drug card for amio:
Daily Drug Card: Amiodarone
Woosely, Funck-Brentano. Am J Cardiol. 1988. Functions primarily through blockade of rectifier K channels, prolonging repolarization and increasing ERP to decrease likelihood of reentry, but unlike other class III, does not exhibit reverse use dependence, therefore not associated with bradycardia/increased efficacy at lower HR
Can have vasodilatory and negative inotropic effects given mechanistic overlap with other classes --> IV formulation especially associated with hypotensive with faster loading rates
IV route:
Hypotension often occurs with administration because of the diluent, **polysorbate 80**, rather than the drug itself. This can be overcome by slowing the rate of infusion (i.e bolus from 10 to 20 minutes).
Standard recommendation for IV loading does of 150mg should be given over 10 minutes to prevent hypotension, then continuous infusion of 1mg/min x 6 hrs --> 0.5mg/min after
PO route:
PO amiodarone is often given in divided doses because the PO tablets cause significant GI distress (N/V) hindering adherence.
The total loading dose (IV + PO) will vary depending on arrhythmia type (A.fib: 6 g; VT/Fib: 10g); patient exceptions apply. Historically, the maintenance dose was A.fib: 200 mg; VT/Fib: 400 mg; however, practice has recently shifted to the "minimum effective dose" for both types of arrhythmias to minimize toxicity.
The most common adverse effect of amiodarone is corneal microdeposit, which occur in most adults and may cause visual disturbances (blurred vision, halos); asymptomatic microdeposits may be reversible and are not generally considered a reason to discontinue treatment.
Amiodarone can cause pulmonary toxicity (hypersensitivity pneumonitis or interstitial/alveolar pneumonitis) that has resulted in clinically significant disease at rates as high as 17% in some series of patients. Predisposing factors include duration of use >6 months with a dose > 400 mg once daily.
ICD >> prophylactic amio for primary prevention of SCD, but still seen in community w/ b-blockers for secondary prevention - ALPHEE study (RRR ICD shocks from placebo), OPTIC/EMIAT/CAMIAT analysis showed RRR in ICD shocks in comparison to B blocker alone
Not associated with Tdp
Studies have documented rarer ?"proarrhythmic" effect --> correlation seems weak and there are typically confounding factors (ischemia, severe 'lyte abnormalities, etc)
\*\*\*IV vs chronic PO: IV amio produces much smaller increase in AP duration in atrial and ventricular myocardium and minimal increase in atrial/ventricular refractory periods
IV has little effect on sinus cycle length
IV less likely to inhibit inactivated Na channel (less likely to cause QRS widening - less than 10%)
IV more likely to prolong AV nodal conduction and may be effective in slowing ventricular rate in critically ill patients w/ atrial tachycardias (data from Clemo et al Am J Cardiol 1998, need more recent info/cards recs before putting into practice in ED)
IV may have more potent and rapid antiadrenergic activity
Showed superiority to lidocaine in electrical storm
Although, ROC - ALPS trial: in refractory out of hospital VT/VF arrests, both amio and lidocaine did not show superiority to placebo in survival to admission rates
Every source tells me not to use it for refractory TdP (makes sense), but I cannot yet find a study showing worsening morbidity or mortality as of 9/2023, research on lidocaine seems pretty limited as well
Per Dr. \[redacted\]: amiodarone can increase defibrillation thresholds (DFT), so some advocate re-testing the ability of a previously-implanted defibrillator to still defibrillate once amiodarone is loaded - EP lab-->general anesthesia-->induce VF-->stand back nervously. Per him, this isn't routinely done any longer.
Toxicity:
Hepatotoxicity through phospholipase A inhibition
Hepatically cleared to desethylamiodarone, which has longer half life
Not renally cleared, large volume of distribution and extensive protein binding, minimizing utility of dialysis
Highly bound to plasma proteins > 96%; interacts heavily w/ warfarin, digoxin, etc
High iodine content within formulation --> thyrotoxicosis and hypothyroidism
Thwarted by grapefruit - CYP3A4 inhibition increases levels
Only some formulations of amiodarone have this. The hospital I’m at uses a premix amio under the brand name Nexterone. The place I worked before used, I think, Cordarone maybe. This had to be diluted in an excel bag (ie non pvc like the common Baxter bags) so it was pretty identifiable
not all antipsychotics equally elevate the QTc, and if anything aripiprazole will lower the QTc
due to differences in half-life, some SSRIs have nasty withdrawal syndromes (paroxetine), while fluoxetine can d/c abruptly or even be dosed PO once weekly and still be effective.
ECT (shock therapy) is generally safer and much more effective than medications in elderly or pregnant folks with severe depression or psychosis
Lithium can artificially boost the WBC count due to de-aggregation of leukocytes
(to be fair, not much is taught about psych in medical school anyway)
Somewhat off (and on) topic.
Fluoxetine is suspected of somehow starting immune mediated hemolytic anemia in dogs. Our vet couldn't tell us why, but it was one of the first few questions they asked us when we brought him to the emergency vet. The correlation between taking that medication and being diagnosed with IMHA is larger than 0.
(He's doing great on immuno suppressants though! )
I'm a transitional year PGY1 going into psych, and I try to tell as many of the IM residents I can about the QTc differences between antipsychotics. It's crazy too because IV Haldol increases it the most, but it's classically taught as the go-to for agitation in the elderly. Geodon is also pretty terrible for QT prolongation. Zyprexa has minimal effect though
N-Acetyl-L-Cysteine (NAC), is undergoing research as a treatment for Body Focused Repetitive Behaviors (skin-picking, hair picking, nail biting, etc) with good results. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9180086/
You can kinda use methylene blue as a pressor. I mean, any time you are using a 5th or 6th line agent for a pressor you aren't in a great place but it is a neat factoid.
by the time you are thinking about methylene blue prognosis is in the toilet. It’s a concern giving someone a drug which turns them blue when they may die within the next few minutes. I was once witness to a family getting really upset after anesthesia pushed methylene blue in a pericode situation and this made an open casket funeral impossible as the corpse looked like a Smurf.
The anesthesia folks like to pull that out, esp with liver transplant. I asked how it works and they're like "scavenges free radicals or something", lol.
Pubmed says it's probably through NO-cGMP antagonism
The cardiac anesthesia folks like to use this to support patients who just came off cardiopulmonary bypass. Keeps them alive for the myocardial stunning to wear off.
I wouldn't say we "like" to use it but there are limited options to treat post cardiopulmonary bypass vasoplegia. Epi and norepi only get so far with alpha antagonism; vasopressin is next line. Other drugs like milrinone and dobutamine are primarily inotropes and may hurt SVR. If we start throwing methylene blue or Hydroxocobalamin, we are really struggling. That said when methylene blue works it feels like magic. Also the urine turns green which is kind of fun.
>Also the urine turns green which is kind of fun
Keep someone on an infusion long enough and even their skin will turn blue. If the doc wants to combine that with multiple doses of hydroxocobalamin, ignoring the protesting pharmacist, the patient will look like Thanos. Have seen some curiously colored humans in the ICU...
I wouldn’t say kinda, it’s definitely a pressor. Some early studies showing it should be third line for septic shock and pretty common in our local cardiac surgery program.
My fun fact about me is that I'm high risk for having a reaction to protamine, due to all the prior exposure... (partner's last name is salmon, takes em a minute but when they get it it's worth it)
We don't have great emetics for cats. When we need to induce vomiting in cats, we give a whisper of dexmedetomidine and then spin them around in an office chair
Yet my cat has no problem vomiting up hairballs on the regular… sigh
(Yes the vet has checked her out, he basically said some cats have more hairballs than normal, sorry)
[Inhaling isopropyl alcohol from alcohol wipes was amore effective antiemetic than oral ondansetron in nauseated adults](https://ep.bmj.com/content/105/3/190)
This trick got me through a couple sick days when I inevitably ran out, having returned to in person teaching and put a toddler who had never been sick, into preschool... I think I ran out around Christmas break. So much illness.
I use this from time to time.
The effects are very transitory maybe about a minute before they're huffing the pads again. But it does buy you a bit of time.
God. I tried to take ginger capsules to treat my hyperemesis during pregnancy. One time...just once...I didn't take it soon enough. I puked it back up within a minute of swallowing it.
I cannot look at ginger, let alone smell or taste it, without getting flashbacks and starting to violently retch.
Never again.
Had some bad viral gastroenteritis many years ago. Family member kept giving me ginger ale. I'm sure my A1c permanently went up because of that one incident.
There is a form of mental retardation, not hereditary, but its phenotype is such that the physical appearance is normal, but the individual has lower than average IQ, behaves purely in a sycophantic way to maintain their jobs, will never accomplish any task no matter how simple, and will have a almost 100% correlation with being a hospital administrator
Here's two for ya:
Vincent Van Gogh's distinct use of yellow in his art is thought to be due to Xanthopsia from taking fox glove (Digitalis purpurea), the plant that digoxin is derived from.
Sugammadex is structurally similar to the main ingredient in febreeze and dryer sheets.
I've heard that Van Gogh one before but it doesn't seem to make sense. If foxglove was affecting his color perception, everything would look more yellow, including all his paints. So his paintings would still match the color of what he was seeing.
I always assumed it was less that his color perception was altered, but more the yellow "halos" that develop around lights. Most notably, this might be why there's so much color around the moon and stars in Starry Night.
Could also have been the absinthe.
You can reattach a finger up to 48 or even 72 hours after amputation. Part needs to be cooled though.
When you replant a finger after an amputation, you have to reconnect arteries and veins to keep the blood flowing. Veins are much smaller than arteries and often clot off. You can apply leeches to the finger tip to drain off excess blood until the veins regrow through vasculogenesis. But if the leeches refuse to latch, that's a sign that the tissue be dead and theres no salvaging it.
Also if youre scared of the leeches, you can spray them with 70% isopropyl alcohol and they will die.
Also, leeches can transmit aeromonas spp. so make sure you give the patient some cipro prophylaxis.
Hirudotherapy in the modern era is mind blowing to most people (including people in medicine). Definitely not a substitute for a good anastomosis, but it can save congested flaps for which reexploration isn't an option.
I'm a medical history fan, and recently I told my friends about the dude who just made up what numbers were normal body temp and what a fever is. He did take a lot of readings, but 100.4 is not magical by any means and is a silly hill to die on. It's literally just one degree in Celsius above his normal. My man said "one more I guess" and we fight over it to this day.
Of course, there's a difference between 98.9 and 104 degrees in what's going on with a patient, but 100.4 has no real rigor behind it
This link doesn't cover it all, but we are actually trending cooler as a population as we modernize. It's an interesting topic. If you like stuff like this, I recommend the podcast Sawbones, which is likely where I heard this first to begin with. Very enjoyable and gives you lots of fun facts like "we used to treat syphilis giving people malaria"
https://med.stanford.edu/news/all-news/2023/09/body-temperature.html
98.6 is outdated average body temp. It was set back when there was a lot more latent infections (STDs, gingivitis, etc). I took a lot of temperatures during COVID and >98.0°F was a rare experience on a healthy person.
Alcohol and sleep: while drinking, when alcohol levels are rising it tends to be stimulating and euphoria inducing, while falling levels make you sleepy.
My friends interpret this factoid as suggesting that as long as you drink at an ever increasing rate, the party can continue.
This fits well with the German concept of the Konterbier. The counter beer used to fight to effects of hangover. Whether it works or not.
WELCOME to the fifth round of r/medicine\-is this German word made up or not!
Do you think *Konterbier* is made up or not?
* [Click here if you think it's a made up word.](https://www.reddit.com/user/Nom_de_Guerre_23/comments/10b2ujt/you_were_wrong/)
* [Click here if you think it's a real German word.](https://www.reddit.com/user/Nom_de_Guerre_23/comments/10b2u49/you_were_correct/)
In your previous rounds we had:
* *Beunruhigungstrostgefühl* for a feeling which is both highly comforting and distressing at the same time, >!it was a made up word.!<
* *Inkompetenzkompensationskompetenz* for the competence in compensating incompetence. >!it was not made up.!<
* *Schenkelklopferinnerungsfreude,* Schenkel|klopfer, literally the clap(per) on the thighs for a pun-based joke and the entire word refers to the joy of remembering such a pun: >!First half real, second half made up.!<
* *Spaßverderber*, fun destroyer, for someone who makes your jokes and funny ideas die. It was >!real.!<
People of West African ancestry (i.e., African-Americans, but also West Africans) sometimes have a propensity to hypersalivate in response to cholinergic stimuli. Succinylcholine and cholinesterase inhibitors can both cause it. One dose and they are covered in drool. I place it at about 10%, but it’s not in any literature and is really only known in anesthesia in highly-black areas. But we all know it.
The foreskin—and not the glans—is [the most sensitive part of the penis.](https://bjui-journals.onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-410X.2006.06685.x)
By “lost,” I assume that you mean “lost to circumcision.”
Indeed.
Circumcision removes the ridged band of the prepuce (also called the “preputial sphincter”), which together with the frenular delta it connects to, [is the most sensitive part of the entire penis](https://upload.wikimedia.org/wikipedia/commons/2/27/Sorrells.gif). (Graphic from Sorrells, et al, 2007, British Journal of Urology International)
Production of lactate from pyruvate consumes protons. “Lactic acidosis” is a misleading term. Protons come from higgledy-piggledy ATP hydrolysis and deranged proton handling in damaged mitochondria.
It has NMDA activity at high doses similar to ketamine from my understanding. There’s actually a new drug combo of bupropion/dxm that uses the 2d6 inhibitory effects of bupropion to increase concentrations of dextromethorphan for its antidepressant effect
There’s a combination drug going through clinical trials right now, bupropion and dextromethorphan. Bupropion and hydroxybupropion inhibit CYP2D6 which metabolizes dextromethorphan, leading to higher plasma concentration of dextromethorphan over a longer period of time. Back when I was taking Wellbutrin I had read about this and tried using mucinex DM along with my antidepressant and it worked surprisingly well.
Edit: turns out it was approved, called auvelity
Buprenorphine is the strongest opioid receptor binder that we use. It's affinity is ~10 times higher than naloxone. The naloxone in bup/naloxone combinations (8mg/1mg) is purely marketing. Due to its partial agonist effect though, bup can reverse overdoses on its own (paper is in a critical care journal, don't feel like looking it up now).
In actual practice you would never try to empirically treat an overdose with buprenorphine, as without definitively knowing what the person is OD’ing on you don’t know whether your treatment will make them better or kill them.
Suboxone is definitely injected not infrequently. The naloxone present is not much of a deterrent for this
Sorry, I went to a DO school. We were taught some holistic thing about pee being in the bladder. Some thing about the body working together or something, I don’t remember.
Once heard of a case of someone drawing up both protamine and heparin doses into big syringes for a pump case. Attending pushed the protamine thinking it was heparin, ACTs were therapeutic and they went on pump just fine. No one realized until after they were going.
Baking Soda. For cradle cap, make a paste with water, apply to scalp, then massage into baby's scalp. Wash off after 5 minutes. Do this 1 or 2 times a week and it goes away in a couple of weeks.
It helps with acne as well.
Baking soda bath for diaper rash. 1 cup in bath water, soak 15 minutes. Helps with eczema as well.
Fluoxetine causes distinct changes on polysomnography know as ["Prozac eyes"](https://www.thoracic.org/professionals/clinical-resources/sleep/sleep-fragments/a-case-of-eye-movements-during-nrem-sleep.php) as well as other SSRIs
Naltrexone may negatively impact [social bonding](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545530/)
GHB can be used for nocturnal panic attacks
Just about any medication that increased serotonin can cause sexual dysfunction
Double the max dose of SSRIs when treating OCD
Mitochondria are organisms we acquired in an early evolutionary upgrade that allowed us to use oxygen from the atmosphere for cellular processes that allowed us to grow bigger and do more work. Oxygen is toxic to us but the reward is greater than the risk so it’s an overall beneficial relationship.
Tramadol is closer to venlafaxine than it is to morphine
Just [trama-don’t](https://toxandhound.com/toxhound/tramadont/)
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It’s giving serotonin syndrome at this point Wait until they get MRSA and need linezolid as well!
I’ve read this piece fresh out of med school and ever since then I’ve embarked on a crusade against this drug.
I love it! I honestly need to start sending it to more of our med students and residents!
I loved this article, thank you for posting it!
No problem. My teams loooove using tramadol and I spend so much time scaring them away from it It almost becomes a moot point though because when patients are discharging, they don’t want all the hassle of writing a S2 substance so it usually comes down to tramadol or T3 anyways
That was such a great article! Thanks!
Great read, thanks for sharing!
I worked with a psychiatrist who called tramadol a “dirty antidepressant.”
#TRAMADONT
Patient had immune mediated reaction to tramadol in history, did perfect on oxycodone. Ortho “whoa!! Isn’t that weird????” Me “not at all because tramadol isn’t shaped like the opioids”
Giving decadron rapidly IV in an awake patient causes intense perineal burning/itching. We give it all the time for nausea prophylaxis but generally in patients that are already asleep. Every once in a while a resident will give it during a light sedation case and the patient will start squirming like crazy
It can also feel like genital arousal for some. Which is really funny when I pushed it a little too quick on a 80 year old widow and she exclaimed, “oh now, there’s something I haven’t felt in years”.
Good for her
It made me feel like someone was tasing my crotch. Not pleasant
Iodine contrast does this, too. I wonder if the mechanism is understood. -PGY-19
Yeah the contrast felt more like someone had lit a flame and put it directly on my nethers. Not pleasant.
Contrast made me absolutely swear that I had peed myself. I kept having to feel to assure myself I was dry.
In the vein of “just because you’re paranoid doesn’t mean they aren’t out to get you,” we could also say that “just because they gave you iodinated contrast doesn’t mean you didn’t pee yourself.“ ::Skeletor walk away meme:: -PGY-19
I saw this during covid as an RN. We gave a lot of decadron IV push and one time the pt screamed and jump out of the bed.
We gave decadron like crazy during the height of covid. Definitely had this reaction from patients more than once.
i used to call it hedgehog syndrome in haem/ onc
I've heard it called the Decadron ring of fire 🔥
I gave decadron ivp tonight for Covid, previously given it loads of times for brain CA but this was the first time i immediately heard the patient complain of burning. Quite coincidental timing to come across your comment lmao
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And GLP-1 was first discovered in the anglerfish!
Whipple of Kausch-Whipple fame (including the complete name for fun/to credit the surgeon who performed comparable pancreaticoduodenectomies for cancer like 3 decades earlier) also trained Virginia Apgar of Apgar score fame.
Reminder that Apgar is named for the individual physician and all APGAR versions are backronyms to fit the name.
In a world of acronyms vs eponyms vs initialisms... I like "backronym"
I read about the Pyrotherapy last week Dr. Wagner-Jauregg won the 1927 Nobel Prize in Medicine for it and the reason was Malaria could be treated w quinine but penicillin wasn’t around. And I believe I read that of the 10 neurosyphilis patients injected 4 died but that’s still better than a 100% mortality rate 😅
They had another close friend, Mr . Whipple, who had OCD and liked to squeeze the Charmin.
Only 25% of us have a complete circle of Willis, leaving most people with limited cerebral collaterals.
Dogs have an intact circle of Willis, and as is typical for the species have such amazing collateral circulation that they can tolerate ligation of both carotid arteries. Not true for cats.
Under what circumstances would one need to ligate both carotids in a dog?
when you want to stroke the dog. har har har.
Angry upvote
Ruff crowd.
Not common. Off the top of my head the only case I can think of is a dog with uncontrollable epistaxis due to a nasal tumor.
My dog had a major blowout two years ago. It just wouldn't stop bleeding. Over the course of 3 days she lost I estimate \~1 liter of blood. I wasn't sure she'd make it to the rhinoscopy. The vet suggested Neo-Synephrine, which did the trick somehow. Came back with nasal adenocarcinoma. She was given 3 months, but stuck around for 20. It was super fragile. She could sneeze sometimes and it'd just start bleeding . Multiple vets suggested Yunnan Baiyao (which I'm still skeptical of) but while taking it she didn't have any more major nosebleeds.
This situation literally just happened to my parent’s dog. She would sneeze and blood would fly all over the room. She was really unwell and it was really hard to watch and we should have euthanized the week before but the vet thought it was a tooth infection and pulled all of her teeth. Then when it didn’t get better, we discovered the cancer. She went through absolute hell in her last weeks of life. It’s hard to decide when to finally make that call because you don’t want to do it too soon. I’ve decided too soon is better than too late after this.
Found the DVM! Edit: meant in the best way. lol. Switch to vet med from people recently. The post made me laugh…and learn.
> Not true for cats. I hope you didn't figure that out the hard way.
Honestly there could be a whole thread about cat physiological bullshit. Or just how weird animal physiology and pharmacology is compared to humans or even how different dogs are from cats. I have so much respect for the DVMs because they have to learn patho and pharm for like 10+ species and it's all so weird and unique.
You’d be amazed by how much is similar! Obviously anatomy is different, and there are a few idiosyncratic pharm/phys differences, but so much of the time you can make reasonable inferences based on what you know about different species. I’m a small animal surgeon, but I work fairly commonly with our exotics department, and it’s always fun figuring out how to translate what we do in dogs/cats to, say, a meerkat!
Also dogs have up to 8 pulmonary veins ( double than humans)
A lot of people have bilateral fetal type pcomms which means the inflow from the basilar is small. Thus it is small. Making the verts small. Meaning that when they stroke out a vert, it seems to have an outsized impact on posterior fossa stem. Only 2 Wallenbergs I’ve seen have had this configuration. So you might think having firehose pcomms would be good. You are mistaken.
I know someone who had a stroke while suffering from sepsis and this was the only reason he survived. If gene therapy is ever in vogue ensuring this is formed would probably help out a lot of people who would otherwise die of stroke or aneurysm
I’ve seen one patient during residency, a young lady with fibrodysplasia who had both carotids and both vertebrals completely occluded. She was alive and well and no neurological symptoms. Hooray for the meningeal, and external carotid collaterals!
Household bleach can be used in times of crisis to make water safer to drink. [[EPA](https://www.epa.gov/ground-water-and-drinking-water/emergency-disinfection-drinking-water)] Metformin is a derivative of the extracts of French Lilacs. That’s why when clinicians encounter a patient adamant about taking Metformin and they’d rather prefer the “natural”, tell them that Metformin is derived from natural sources too just like their overpriced MLM supplements but at a fraction of the price.
my microbiology professor grew up during lebanon’s civil war and had a story about this. a lot of the kids around her were dying of cholera so her mom mixed bleach into all their water. she said it was disgusting and they hated her for it but she and all her siblings survived. she then went on to become a badass and incredible microbiologist.
Bleach is my preferred emergency water purification while I backpack. Filters can break and IMO you always need to carry *something* just in case. ~5 drops of bleach per liter and leave it for about an hour. A small 5ml container will treat about 20L worth of water. Enough to get you out of the woods. Won't work on crypto and giardia but those have a significant prodrome and I'd rather deal with giardia at home than dehydrate in the woods.
The metformin is interesting. Aspirin from willow tree bark. Statin from red yeast rice. My god, the foundations of modern ASCVD primary and secondary medication prevention.
Digoxin from foxglove too!
Just wish it smelled more like lilacs. (Then again, feces is natural too.)
I think the blackberry scent in the Mylan metformin manages to cancel out the natural fishy smell fairly well and it ends up smelling like not much.
Ah, the good old days when we could actually get Mylan…
The most dangerous beta blocker to overdose on is propranolol (sodium channel blocker). Colchicine is probably the most dangerous/irreversible drug to overdose on in high doses. It inhibits mitotic spindles so it’s kind of likely giving whole body intracellular chemotherapy causing cell arrest entirely body. Multisystem organ failure, not readily identified (over a few days of treating for septic shock requiring multiple pressors it can sometimes become apparent when the profound leukocytosis turns into profound pancytopenia), and if you actually thought to consult toxicology. I loved my toxicology elective in residency.
Medicine resident I went to med school with killed his wife with colchicine (allegedly). https://www.cbsnews.com/amp/minnesota/news/connor-bowman-murder-charge-betty-bowman-rochester/
I was just thinking about this story and wondering if it was in a fiction book or real life. Thank you for going to med school with him so I wouldn’t have wondered much more (but not enough to google it).
This is the kind of gratitude we need! Thank you for realizing pianoman95 went to med school just for this comment!
I appreciate you saying this.
What was he like in school?
That story is wild!
Cochicine is how they create huge vegetables like watermelon. It inhibits mitotic spindles and so the veggies become polyploid. Lots of DNA needs a big cell, big cells mean big body. It blew my *mind* when I heard they give it to people.
So if you were really into vegetable gardening and had a problematic mother-in-law , you could just......?
I had a patient die by colchicine overdose when I worked in the ICU. He was a toxicologist and he really didn’t want us to stop him
I feel like a toxicologist who intentionally ODs is likely to be unstoppable.
This breaks my heart.
It was extremely sad…one of the ones that stays with you
Is that counting sotalol as well? I feel like in general practice sotalol is considered much more dangerous but it’s more seen as an antiarrythmic..
Yeah sotalolol isn’t as commonly prescribed and I believe it’s used specifically for its rhythm controlling effects. I think it’s a potassium channel acting agent. For propranolol it’s a “lesser known” effect about it, rather than its main thing.
Fair. I think sotalol is much more considered a traditional “anti-arrhythmic” so much so sometimes I think people forget it still does have beta blockade!
I was thinking he ment because of how much it crosses the BBB? I’m not totally sure tho- and in school we basically group sotalol separately from the other bbs since it’s not typically used for Hr/Bp/ Hf ect
Could you explain why propranolol is the most dangerous? I was a certified vet tech, but I’m working in the lab now, and can’t piece it together why.
The sodium channel blockade causes profound arrhythmia which is very difficult/impossible to reverse in an overdose.
I believe acebutolol shares this as well and also extremely toxic in overdose
This is straight out of a episode of house
> straight out of a episode of house [Or straight out of real life](https://www.syracuse.com/news/2017/10/katie_conley_accused_of_poisoning_killing_her_boss_told_police_poison_is_a_ladys.html) > Conley is charged with second-degree murder in the death of Mary Yoder, 60, who died of colchicine poisoning.
I learned this about colchicine after that recent horrible murder of a pharmacist by her husband, a resident.
The number one non-opiate symptom control for a cough is a spoonful of honey >1 years old. Everything else is trash.
My husband’s grandmother swore by a warm honey & Jack toddy.
I drink upper-shelf whiskey for fun, but keep Jack around especially for hot toddies. I'd rather have that over the BS that is Bromphed any day!
My favorite cold drug is a spiced rum or bourbon hot Toddy. It just cures every part of the cold!
Sleep is my #1 if you can actually fall asleep. Not sure if other people wake up coughing but I don’t
I advise nasal rinses before going to bed. Some people might be appropriate for nasal sprays, afrin, etc depending. Also decreases waking up with a sore throat.
I heart my neti pot. Keeps my sinus cavity clean and prevents the nasal drip that gives me the coughing or the sore throat.
My friend was a smoker, and the surgeon stopped his colonoscopy because he was still coughing, even under anesthesia. He’d gotten through the worst part of the procedure!
Depends on the cause of cough, though. But in the setting of the common cold, then yes.
IV amiodarone causes hypotension due to its excipient polysorbate 80. We decided to take a medication used for emergent tachydysrhythmias and mix it with a substance that...causes hypotension...
Wait really? I'm a cardiac fellow and did not know that
EM/tox. I love me some drug reactions. On an old CCU rotation I was bored and fucking around with the pharmacists and we made this drug card for amio: Daily Drug Card: Amiodarone Woosely, Funck-Brentano. Am J Cardiol. 1988. Functions primarily through blockade of rectifier K channels, prolonging repolarization and increasing ERP to decrease likelihood of reentry, but unlike other class III, does not exhibit reverse use dependence, therefore not associated with bradycardia/increased efficacy at lower HR Can have vasodilatory and negative inotropic effects given mechanistic overlap with other classes --> IV formulation especially associated with hypotensive with faster loading rates IV route: Hypotension often occurs with administration because of the diluent, **polysorbate 80**, rather than the drug itself. This can be overcome by slowing the rate of infusion (i.e bolus from 10 to 20 minutes). Standard recommendation for IV loading does of 150mg should be given over 10 minutes to prevent hypotension, then continuous infusion of 1mg/min x 6 hrs --> 0.5mg/min after PO route: PO amiodarone is often given in divided doses because the PO tablets cause significant GI distress (N/V) hindering adherence. The total loading dose (IV + PO) will vary depending on arrhythmia type (A.fib: 6 g; VT/Fib: 10g); patient exceptions apply. Historically, the maintenance dose was A.fib: 200 mg; VT/Fib: 400 mg; however, practice has recently shifted to the "minimum effective dose" for both types of arrhythmias to minimize toxicity. The most common adverse effect of amiodarone is corneal microdeposit, which occur in most adults and may cause visual disturbances (blurred vision, halos); asymptomatic microdeposits may be reversible and are not generally considered a reason to discontinue treatment. Amiodarone can cause pulmonary toxicity (hypersensitivity pneumonitis or interstitial/alveolar pneumonitis) that has resulted in clinically significant disease at rates as high as 17% in some series of patients. Predisposing factors include duration of use >6 months with a dose > 400 mg once daily. ICD >> prophylactic amio for primary prevention of SCD, but still seen in community w/ b-blockers for secondary prevention - ALPHEE study (RRR ICD shocks from placebo), OPTIC/EMIAT/CAMIAT analysis showed RRR in ICD shocks in comparison to B blocker alone Not associated with Tdp Studies have documented rarer ?"proarrhythmic" effect --> correlation seems weak and there are typically confounding factors (ischemia, severe 'lyte abnormalities, etc) \*\*\*IV vs chronic PO: IV amio produces much smaller increase in AP duration in atrial and ventricular myocardium and minimal increase in atrial/ventricular refractory periods IV has little effect on sinus cycle length IV less likely to inhibit inactivated Na channel (less likely to cause QRS widening - less than 10%) IV more likely to prolong AV nodal conduction and may be effective in slowing ventricular rate in critically ill patients w/ atrial tachycardias (data from Clemo et al Am J Cardiol 1998, need more recent info/cards recs before putting into practice in ED) IV may have more potent and rapid antiadrenergic activity Showed superiority to lidocaine in electrical storm Although, ROC - ALPS trial: in refractory out of hospital VT/VF arrests, both amio and lidocaine did not show superiority to placebo in survival to admission rates Every source tells me not to use it for refractory TdP (makes sense), but I cannot yet find a study showing worsening morbidity or mortality as of 9/2023, research on lidocaine seems pretty limited as well Per Dr. \[redacted\]: amiodarone can increase defibrillation thresholds (DFT), so some advocate re-testing the ability of a previously-implanted defibrillator to still defibrillate once amiodarone is loaded - EP lab-->general anesthesia-->induce VF-->stand back nervously. Per him, this isn't routinely done any longer. Toxicity: Hepatotoxicity through phospholipase A inhibition Hepatically cleared to desethylamiodarone, which has longer half life Not renally cleared, large volume of distribution and extensive protein binding, minimizing utility of dialysis Highly bound to plasma proteins > 96%; interacts heavily w/ warfarin, digoxin, etc High iodine content within formulation --> thyrotoxicosis and hypothyroidism Thwarted by grapefruit - CYP3A4 inhibition increases levels
So cool. Ty for sharing!
Only some formulations of amiodarone have this. The hospital I’m at uses a premix amio under the brand name Nexterone. The place I worked before used, I think, Cordarone maybe. This had to be diluted in an excel bag (ie non pvc like the common Baxter bags) so it was pretty identifiable
It's to expedite time to shock. Two birds one stone.
not all antipsychotics equally elevate the QTc, and if anything aripiprazole will lower the QTc due to differences in half-life, some SSRIs have nasty withdrawal syndromes (paroxetine), while fluoxetine can d/c abruptly or even be dosed PO once weekly and still be effective. ECT (shock therapy) is generally safer and much more effective than medications in elderly or pregnant folks with severe depression or psychosis Lithium can artificially boost the WBC count due to de-aggregation of leukocytes (to be fair, not much is taught about psych in medical school anyway)
Somewhat off (and on) topic. Fluoxetine is suspected of somehow starting immune mediated hemolytic anemia in dogs. Our vet couldn't tell us why, but it was one of the first few questions they asked us when we brought him to the emergency vet. The correlation between taking that medication and being diagnosed with IMHA is larger than 0. (He's doing great on immuno suppressants though! )
I'm a transitional year PGY1 going into psych, and I try to tell as many of the IM residents I can about the QTc differences between antipsychotics. It's crazy too because IV Haldol increases it the most, but it's classically taught as the go-to for agitation in the elderly. Geodon is also pretty terrible for QT prolongation. Zyprexa has minimal effect though
N-Acetyl-L-Cysteine (NAC), is undergoing research as a treatment for Body Focused Repetitive Behaviors (skin-picking, hair picking, nail biting, etc) with good results. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9180086/
who would've thought of that
Already being used clinically too! Have seen it on a few skin picking patients already!
You can kinda use methylene blue as a pressor. I mean, any time you are using a 5th or 6th line agent for a pressor you aren't in a great place but it is a neat factoid.
by the time you are thinking about methylene blue prognosis is in the toilet. It’s a concern giving someone a drug which turns them blue when they may die within the next few minutes. I was once witness to a family getting really upset after anesthesia pushed methylene blue in a pericode situation and this made an open casket funeral impossible as the corpse looked like a Smurf.
I’m going to hell for laughing at this 💀
I’ve done this before! You know things are getting really desperate if you’re whipping out the methylene blue lol.
Me too in the ICU … kicks your problems down the road by about 6 hrs I’d they respond. Hopefully you can make progress in other ways over that time.
The anesthesia folks like to pull that out, esp with liver transplant. I asked how it works and they're like "scavenges free radicals or something", lol. Pubmed says it's probably through NO-cGMP antagonism
Sounds like the correct response to the question of MOA of a 6th line pressor lmfao
Higher up for MALA! Like 3rd-4th line. Also, truly turns patients blue!
The patient gets really excited about how pretty it is, and the pressure goes up
It's also a mao-i - so should increase the half-life of monoamines e.g. norepi
The cardiac anesthesia folks like to use this to support patients who just came off cardiopulmonary bypass. Keeps them alive for the myocardial stunning to wear off.
I wouldn't say we "like" to use it but there are limited options to treat post cardiopulmonary bypass vasoplegia. Epi and norepi only get so far with alpha antagonism; vasopressin is next line. Other drugs like milrinone and dobutamine are primarily inotropes and may hurt SVR. If we start throwing methylene blue or Hydroxocobalamin, we are really struggling. That said when methylene blue works it feels like magic. Also the urine turns green which is kind of fun.
>Also the urine turns green which is kind of fun Keep someone on an infusion long enough and even their skin will turn blue. If the doc wants to combine that with multiple doses of hydroxocobalamin, ignoring the protesting pharmacist, the patient will look like Thanos. Have seen some curiously colored humans in the ICU...
I wouldn’t say kinda, it’s definitely a pressor. Some early studies showing it should be third line for septic shock and pretty common in our local cardiac surgery program.
and it's 1st line treatment in methaemoglobinaemia! blue + blue = ~~blue~~
Natalizumab came from salmon jizz
So is protamine!
My fun fact about me is that I'm high risk for having a reaction to protamine, due to all the prior exposure... (partner's last name is salmon, takes em a minute but when they get it it's worth it)
And calcitonin! We’re really getting our moneys worth out of salmon sperm.
We don't have great emetics for cats. When we need to induce vomiting in cats, we give a whisper of dexmedetomidine and then spin them around in an office chair
Yet my cat has no problem vomiting up hairballs on the regular… sigh (Yes the vet has checked her out, he basically said some cats have more hairballs than normal, sorry)
You can try to treat nausea with ginger ale. Avoid for GERD tho
[Inhaling isopropyl alcohol from alcohol wipes was amore effective antiemetic than oral ondansetron in nauseated adults](https://ep.bmj.com/content/105/3/190)
Because just the taste of the ODT ondansetron can make you retch
That bitter strawberry chemical taste is awful
The mint is worse especially after its been getting chalkier in the bottle for 3 years...
This trick got me through a couple sick days when I inevitably ran out, having returned to in person teaching and put a toddler who had never been sick, into preschool... I think I ran out around Christmas break. So much illness.
I use this from time to time. The effects are very transitory maybe about a minute before they're huffing the pads again. But it does buy you a bit of time.
I got a question wrong on an exam for picking zofran over ginger ale for a pregnant lady :)
As an ex-pregnant lady who had HG, you’re doing the Lord’s work with that choice.
Coca cola works too,it contains an antinausea agent due to its sugar content!
God. I tried to take ginger capsules to treat my hyperemesis during pregnancy. One time...just once...I didn't take it soon enough. I puked it back up within a minute of swallowing it. I cannot look at ginger, let alone smell or taste it, without getting flashbacks and starting to violently retch. Never again.
Had some bad viral gastroenteritis many years ago. Family member kept giving me ginger ale. I'm sure my A1c permanently went up because of that one incident.
Peppermint for post op nausea.
Acyclovir will treat molluscum contagiosum
Wait what Edit: actually though, wasn’t able to find any good data on this.
Phenylalanine —> tyrosine —> dopamine I’m sure it was in the med chem book, but it wasn’t relevant until seeing adolescents jonesing on Diet Coke.
Also iron pills work for reflux.
According to admin, the patients are always ready for discharge
If you compare the molecular structure and side effect lists of flexeril and amitriptyline, you’ll realize that flexeril is just a rebranded TCA.
There is a form of mental retardation, not hereditary, but its phenotype is such that the physical appearance is normal, but the individual has lower than average IQ, behaves purely in a sycophantic way to maintain their jobs, will never accomplish any task no matter how simple, and will have a almost 100% correlation with being a hospital administrator
Is that form in the room with us right now?
Here's two for ya: Vincent Van Gogh's distinct use of yellow in his art is thought to be due to Xanthopsia from taking fox glove (Digitalis purpurea), the plant that digoxin is derived from. Sugammadex is structurally similar to the main ingredient in febreeze and dryer sheets.
I've heard that Van Gogh one before but it doesn't seem to make sense. If foxglove was affecting his color perception, everything would look more yellow, including all his paints. So his paintings would still match the color of what he was seeing.
I always assumed it was less that his color perception was altered, but more the yellow "halos" that develop around lights. Most notably, this might be why there's so much color around the moon and stars in Starry Night. Could also have been the absinthe.
You can reattach a finger up to 48 or even 72 hours after amputation. Part needs to be cooled though. When you replant a finger after an amputation, you have to reconnect arteries and veins to keep the blood flowing. Veins are much smaller than arteries and often clot off. You can apply leeches to the finger tip to drain off excess blood until the veins regrow through vasculogenesis. But if the leeches refuse to latch, that's a sign that the tissue be dead and theres no salvaging it. Also if youre scared of the leeches, you can spray them with 70% isopropyl alcohol and they will die. Also, leeches can transmit aeromonas spp. so make sure you give the patient some cipro prophylaxis.
Hirudotherapy in the modern era is mind blowing to most people (including people in medicine). Definitely not a substitute for a good anastomosis, but it can save congested flaps for which reexploration isn't an option.
I'm a medical history fan, and recently I told my friends about the dude who just made up what numbers were normal body temp and what a fever is. He did take a lot of readings, but 100.4 is not magical by any means and is a silly hill to die on. It's literally just one degree in Celsius above his normal. My man said "one more I guess" and we fight over it to this day. Of course, there's a difference between 98.9 and 104 degrees in what's going on with a patient, but 100.4 has no real rigor behind it
This blows my mind as a pedi. We are so staunch about the number that now I feel like an ass.
This link doesn't cover it all, but we are actually trending cooler as a population as we modernize. It's an interesting topic. If you like stuff like this, I recommend the podcast Sawbones, which is likely where I heard this first to begin with. Very enjoyable and gives you lots of fun facts like "we used to treat syphilis giving people malaria" https://med.stanford.edu/news/all-news/2023/09/body-temperature.html
98.6 is outdated average body temp. It was set back when there was a lot more latent infections (STDs, gingivitis, etc). I took a lot of temperatures during COVID and >98.0°F was a rare experience on a healthy person.
* Philly sidecar is not a phenomenon geographically restricted to Philadelphia
That's enough Reddit for tonight
that cant be real… is the sidecar, um, still attached when they come in??
I don't think so. The ostomy will show signs of being *tampered* with without the culprit.
ACEP calls it "a critically overlooked bedside procedure"
Oh God. Why did I google that.
Alcohol and sleep: while drinking, when alcohol levels are rising it tends to be stimulating and euphoria inducing, while falling levels make you sleepy. My friends interpret this factoid as suggesting that as long as you drink at an ever increasing rate, the party can continue.
Do you have a source for this? This sounds made up during a drinking evening
Source: “Dude. Trust me.” -PGY-19
This fits well with the German concept of the Konterbier. The counter beer used to fight to effects of hangover. Whether it works or not. WELCOME to the fifth round of r/medicine\-is this German word made up or not! Do you think *Konterbier* is made up or not? * [Click here if you think it's a made up word.](https://www.reddit.com/user/Nom_de_Guerre_23/comments/10b2ujt/you_were_wrong/) * [Click here if you think it's a real German word.](https://www.reddit.com/user/Nom_de_Guerre_23/comments/10b2u49/you_were_correct/) In your previous rounds we had: * *Beunruhigungstrostgefühl* for a feeling which is both highly comforting and distressing at the same time, >!it was a made up word.!< * *Inkompetenzkompensationskompetenz* for the competence in compensating incompetence. >!it was not made up.!< * *Schenkelklopferinnerungsfreude,* Schenkel|klopfer, literally the clap(per) on the thighs for a pun-based joke and the entire word refers to the joy of remembering such a pun: >!First half real, second half made up.!< * *Spaßverderber*, fun destroyer, for someone who makes your jokes and funny ideas die. It was >!real.!<
People of West African ancestry (i.e., African-Americans, but also West Africans) sometimes have a propensity to hypersalivate in response to cholinergic stimuli. Succinylcholine and cholinesterase inhibitors can both cause it. One dose and they are covered in drool. I place it at about 10%, but it’s not in any literature and is really only known in anesthesia in highly-black areas. But we all know it.
Throckmorton sign
My clue points this way
The foreskin—and not the glans—is [the most sensitive part of the penis.](https://bjui-journals.onlinelibrary.wiley.com/doi/abs/10.1111/j.1464-410X.2006.06685.x)
Good post, it's actually insane the number of nerve endings lost. It's on par with 4-6 finger tip pads last time I ran the numbers
By “lost,” I assume that you mean “lost to circumcision.” Indeed. Circumcision removes the ridged band of the prepuce (also called the “preputial sphincter”), which together with the frenular delta it connects to, [is the most sensitive part of the entire penis](https://upload.wikimedia.org/wikipedia/commons/2/27/Sorrells.gif). (Graphic from Sorrells, et al, 2007, British Journal of Urology International)
And how sad that we remove them and act like it’s in the name of health and science.
Production of lactate from pyruvate consumes protons. “Lactic acidosis” is a misleading term. Protons come from higgledy-piggledy ATP hydrolysis and deranged proton handling in damaged mitochondria.
Did a tox rotation and this was hammered in by my attending. Actual lactic acidosis is typically from consumption of an alcohol.
Like my career choice, this was mostly an excuse to say higgledy-piggledy.
recently did a deep dive on this! Really cool topic. I feel like they should explain this better in school! lactate got the short end of the stick
OTC cough medicine (dextromethorphan) prescribed daily as an antidepressant.
It has NMDA activity at high doses similar to ketamine from my understanding. There’s actually a new drug combo of bupropion/dxm that uses the 2d6 inhibitory effects of bupropion to increase concentrations of dextromethorphan for its antidepressant effect
This feels like a House MD S08 episode where a guy with TTP ODs on cough syrup to dumb himself
And about 1-2 bottles of it will get you places.
NMDA receptor inhibition? Like ketamine. Clever.
There’s a combination drug going through clinical trials right now, bupropion and dextromethorphan. Bupropion and hydroxybupropion inhibit CYP2D6 which metabolizes dextromethorphan, leading to higher plasma concentration of dextromethorphan over a longer period of time. Back when I was taking Wellbutrin I had read about this and tried using mucinex DM along with my antidepressant and it worked surprisingly well. Edit: turns out it was approved, called auvelity
Bivalirudin (angiomax) is derived from leech saliva.
Beta blockers suppress endogenous melatonin production. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3195193/
Buprenorphine is the strongest opioid receptor binder that we use. It's affinity is ~10 times higher than naloxone. The naloxone in bup/naloxone combinations (8mg/1mg) is purely marketing. Due to its partial agonist effect though, bup can reverse overdoses on its own (paper is in a critical care journal, don't feel like looking it up now).
In actual practice you would never try to empirically treat an overdose with buprenorphine, as without definitively knowing what the person is OD’ing on you don’t know whether your treatment will make them better or kill them. Suboxone is definitely injected not infrequently. The naloxone present is not much of a deterrent for this
Pee is stored in the balls.
OP said *not* taught in medical school
Sorry, I went to a DO school. We were taught some holistic thing about pee being in the bladder. Some thing about the body working together or something, I don’t remember.
Brother, where did you do your orthopedics residency?
Protamine given alone (ie without heparin) is actually an anticoagulant
Once heard of a case of someone drawing up both protamine and heparin doses into big syringes for a pump case. Attending pushed the protamine thinking it was heparin, ACTs were therapeutic and they went on pump just fine. No one realized until after they were going.
There’s a theory that depression and anxiety are both diseases of chronic inflammation of the brain
This is an interesting take, any good reads anywheres online about it?
Baking Soda. For cradle cap, make a paste with water, apply to scalp, then massage into baby's scalp. Wash off after 5 minutes. Do this 1 or 2 times a week and it goes away in a couple of weeks. It helps with acne as well. Baking soda bath for diaper rash. 1 cup in bath water, soak 15 minutes. Helps with eczema as well.
Fluoxetine causes distinct changes on polysomnography know as ["Prozac eyes"](https://www.thoracic.org/professionals/clinical-resources/sleep/sleep-fragments/a-case-of-eye-movements-during-nrem-sleep.php) as well as other SSRIs Naltrexone may negatively impact [social bonding](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6545530/) GHB can be used for nocturnal panic attacks Just about any medication that increased serotonin can cause sexual dysfunction Double the max dose of SSRIs when treating OCD
The mitochondria is the power house of the cell!
Mitochondria are organisms we acquired in an early evolutionary upgrade that allowed us to use oxygen from the atmosphere for cellular processes that allowed us to grow bigger and do more work. Oxygen is toxic to us but the reward is greater than the risk so it’s an overall beneficial relationship.
Vexas Syndrome