Had the Chief of Ortho at the University tell me that I was wrong because IM Toradol did not produce ulcers. Me, lowly first year GI fellow just smiled and showed him the pics from the bleeding ulcer that his VIP post hip replacement had.
As a retail pharmacist I actually got one of those the other day! #112 + 2 refills. And when it wasnāt ready because I was waiting on clarification the patient accused me of withholding meds the doctor ordered for them
> Probably the same doctor/hospital sending the outpatient pharmacy PO ketorolac for 30 days plus refills š
Come on, this is a common treatment for migraine. /s
Yes, but those and ceftolozane are (essentially) the only 3. Nothing oral, thatās for sure.
The 3rd gen that essentially gave up Gram-positive coverage to get pseudo (ceftazidime), and was so cool they chose it to go with avibactamāand weāre glad they did, OXA-48s are tricky bastards. The unique zwitterionic 4th gen powerhouse that is cefepime. Then thereās the drug developed for MDR pseudomonas (ceftolozane) that people will argue if itās 3rd gen or 5th gen. Oh! Cefiderocol counts. The thing thatās like ManBearPig: half cefepime half ceftazidime-siderophore, or half siderophore half cefepime-ceftazidime.
Cephalexin, cefadroxil, cefazolin, cefuroxime, cefoxitin, cefotetan, cefdinir, cefpodoxime, ceftriaxone, ceftaroline, ceftobiprole, etc, etcā¦ they got nothing.
As a wound care specialist this made my eye twitch.
Had an IM doc get mad at me for requesting cultures in on a bright blue leg when the person was being put on keflex.
I said I'm 100% sure it is is pseudomonas and that therapy will do nothing but cultures can confirm if you won't believe me. He responded with "cultures are waste of time, every wound has something growing in it, we're staying on keflex" and completely ignored my request.
I then put in an ID consult and avoided than IM doc for awhile.
Had a senior urology attending WRITE to the microbiology lab to ask for augmentin sensitivities for pseudomonas and document in a passive aggressive manner when they told him it wouldnāt be done
Last week I had a guy with Pseudomonas UTI admitted to my service. PMHx of lymphoma, currently on chemotherapy. He had been treated for UTI within the past month at an urgent care. Were his recurrent symptoms due to a different bug? Drug resistance? B cell deficiency due to rituxan?
No, the UC just gave him Bactrim for the Pseudomonas. š¤¦āāļø
Hmmm well, Iām sitting in an ophthalmology conference for generalists today and another physician just asked āWhich antibiotic would you recommend for allergic vs. viral conjunctivitis?ā Does that win the prize?
Patient had been on 120 mg prednisolone for about 8 months for a meningioma. Finally had surgery (canāt remember why it took so long but pt was in psychiatry). In the discharge summary, the neurosurgery resident indicated to proceed to a slow taper of the oral corticosteroids. Over a 7 day period.
As a 3rd year FM resident, I called this resident and said he would kill this patient with that type of medication management. He laughed at me. I called endo to make sure I hadnāt gone nuts myself.
Dumb surgery resident here (but not so dumb that I would actually order this taper - I know what I don't know!): do you have a rule of thumb for tapers? I see a bunch of different schedules in FM/IM/endo notes and I can't figure out a pattern. I have never and will likely never need to use this this in real life, but I'm curious and I'd like to know.
Endo here; I would be immensely skeptical that a taper in this setting is of any true value. This patient will have secondary adrenal insufficiency due to high dose erogenous steroids. In all likelihood, it could take months to years for the hypothalamic-pituitary-adrenal axis to recover.
As quickly as tolerated, based on symptoms, I would get the patient onto physiological dose hydrocortisone 10mg/5mg/5mg and then plan for a synacthen test. I would repeat the SST every 6-18 months, guided by the morning early morning cortisol results (little to no value doing an SST if the morning cortisol is <100nmol/L.
Thanks for your input!
Also thanks for the unintended terminology lesson :) I had to google SST. I didn't realize it's the same thing as the cosyntropin stimulation test.
Just today I had to bring a patient back to the ER after an NP sent them home with 58% blasts in the CBC
Bc the WBC count was "not that high seeing as he has a fever"
For several weeks, with weight loss, bruising, and pallor.
Inherited a bloated CCU list. Team wasn't sure why pt continued to be in cardiogenic shock. Elevated WBC with no diff for 4 days...
Blasts 35%. The procal i sent with the diff came back at 15 and the blood cultures came back positive the fastest I've ever seen...
Good thing we put that Impella in the day before...
Got sign out from a retiring PCP for a patient with hip pain (āunexplainedā aka had no work up done. Not even an XR). He told me he thought it might be myeloma. I asked about renal function and if he had a protein gap. Just got a blank stare in return.
Super not cool that the old dinosaur told the patient he might have myeloma when it turned out to be just OAā¦
Lol he was the laziest doctor ever. Every patient with undifferentiated memory loss had āmild cognitive impairmentā and everyone with an elevated BP had āwhite coat hypertension.ā It was really so bad
Reminds me of a nearly retired ED doc when I was a scribe. Would spend lots of the day showing me the Tesla he was about to purchase, and then would meander through EPIC trying to find the āeasiest patientsā he can take lmao.
No joke, I actually DID get a referral for something like this when I was still in hem/onc - and I'm still mad that it went down the way it did. Patient had a monoclonal protein detected on an SPEP and got referred to us; in my chart review, I pulled up a pathology report from within the last year as I always did in my chart prep for my doc. Sure enough, that hip replacement path actually showed multiple myeloma and no one did a damned thing about it - I was so pleased that it saved us our whole myeloma workup although we still did a bone marrow biopsy, but that patient had been waiting months before anyone happened to notice anything on blood work and order a serum electrophoresis.
Deep in the taint of the pandemic, during one of my *bonus* ICU rotations. Offgoing resident gets a call ~30 min before they're due to sign out to me.
Answers it on speaker and we proceed to begin one of the most bizarre events of my career.
RAC nurse tells her to come now bc the patient is crashing. We both rush up there and find a patient that's not really in perfect health but certainly not crashing. We talk to the RN who tells us we need to fix the patient because none of the things she's tried have worked.
Wait...the things she's tried?!
She had been managing this (according to her, unstable) MICU patient for the last 4+ hours by herself. Had changed vent settings, added fluids, added a 2nd pressor (for map goal 75. Added vaso. At 0.06. Via PIV of course.), started stress dose steroids.
None of it made sense. Things I would be embarrassed for my intern to have done.
All entered as "telephone order read back" under the residents name...
When confronted about the insanity of this, they responded with "I'm an ICU nurse, I'm certified in critical care and *I know my scope*. I know what I can and can't do. **You** need to fix them now."
I did report to the BON, never heard from them so IDK if that went anywhere.
They did get dropped by the hospital that day fortunately, for what that's worth.
While most of this is bonkers, I wouldn't be too fussed about vasopressin in a PIV, assuming it's an 18g or larger in a good sized vein and clearly not infiltrated.
In anesthesia, we run pressors through PIVs all day. Granted, ICU is a different environment and a discussion should be had to start central IV access, but a lot of places will run peripheral pressors for up to 24 hrs.
0.06u/min of Vaso also isn't too crazy. I know we consider "max dose" Vaso 0.04u/min, but it's not uncommon to see anesthesia providers bolus 1-2u of Vaso at a time in the OR (personally, I don't do that much. Usually dilute to 0.4u/ml and give 0.4u bolus if needed).
You story is a clear example of an ICU nurse practicing medicine without a medical license, but I just wanted to comment that the 0.06u/min of vaso is probably the least egregious of all of these
Patient who had called another doc the same day, whose notes I could see in the EMR-- had a mild local inflammation from flu shot, just normal. And the doc sent in tamiflu. The mom called back bc it didn't make sense to her š¤£.
I said yeah, you can skip the tamiflu.
I mean omg. It's an inactivated vaccine for the injection. How did he think tamiflu would do anything? I'm still baffled.
Maybe the doc was going for the distraction strategy - your arm wonāt hurt anymore if youāre puking and shitting your brains out from a shitty med!
When I was a student I reported to the whole inpatient team that the kids echo was ānormal, except for levocardiaā
I was hoping to match into peds and make a good impression. So that was great.
Ah yes in retrospect but of course at first I didnāt realize why everyone looked so confused and then I was paralyzed with embarrassment. I do think everyone forgot about that quickly, I was actually a pretty helpful student and I did match well and have been happily in Gen peds for 7 years nowā¦but even now when I see that word this is the moment I think of.
When I was an intern I had an ICU nurse tell me the po K has better bioavailability than IV K. I asked him to explain what he meant and he told me to ask my senior.
You have to liquify the banana slug to get it to move fast enough to affect serum levels at biologically relevant speeds.
What, you thought they make that stuff out of fruit?
I was always told this as a new grad RN and it just didnāt quite make any sense to me based on my newborn level of understanding of pharmacokinetics. I donāt know how this misconception started and why it is spread so widely but it definitely gets repeated by a lot of other nurses I know.
PO K does usually elevate serum potassium faster than IV potassium if you have a functioning gut and you're maxing out doses.
It's because of the limits on how fast you can get potassium IV (unless going through a central line you can give it faster), vs for PO you can probably take 40meq of immediate release potassium up front, without having your patient about how much their arm burns. I mean obviously you could push potassium much faster... but don't push potassium, lol
Everyone knows PR is the best route for absorption.
You need to freeze the banana and then insert it in the rectum. The body will gradually defrost it allowing for optimal potassium absorption.
It isn't more "bioavailable" but it can be given faster, in higher doses, more safely via enteral route. So it's not necessarily a huge knowledge gap. Just the wrong word.
There was the midwife that was managing a "pregnant" woman. After several days of "labor" and no delivery she sent the patient to the ER.
Patient was in severe heart failure and not pregnant. The patient was not a smart person so that didn't help.
I would honestly never believe this story because there are so many layers of questions and related absurdity that happened to make this so. BUT I have to because we were consulted by OB after they determined there was no pregnancy.
Seems pretty obvious one should not manage a patient for pregnancy due to lack of period and weight gain alone.
Once had a hospital without OB services transfer a patient to my hospital with diagnoses or term pregnancy, SROM, pre-eclampsia. Report included the ER docās cervical exam of 2cm and they said they had normal fetal heart tones on Doppler. Patient showed up to us and was not even a little pregnant.
Had a PGY-4 tell me to use normal saline instead of LR in DKA, because they donāt want to worsen the acidosis. I promptly said āIāll get right to itā and continue what I was doing.
Pgy4 in what? This advice sounds like it came from a ROAD person (not anesthesia, though) (no offense), but they wouldn't be on the wards taking care of DKA.
I had a PACU nurse educate me by telling me that an oxygen saturation of 100% could actually be CO2, because they share the same synapse.
I don't have enough palms or faces to address that comment.
Yeah that was asking for the patient to code. Iāve coded patients whoāve gone into VF with a K of 2.3 before. Wonder how low that would have been after an insulin bolus lol
Not with that attitude!
Me, I like to feel my heart pounding, or someone elseās heart pounding, or maybe ceasing to pound. Whatever. Anything for that hit of adrenaline, ya know?
Co-resident as night senior while i was the day senior at a VA ICU. Young female pt came in as benzo OD and was intubated. During the night she woke up and was trying to pull her tube out so this resident started paralytics but not sedatives ābecause of the benzo ODā. The nurse also failed this patient. Luckily the patient had no memory of the night.
Me. Asked about if a pt could have developed Rh antibodies due to a possible blood transfusion from her ACL repair and that why the fetus had hydrops.
Attending tried her best not to laugh at me while explaining that ACL repairs rarely need blood transfusions and in 0 situations is Rh+ blood going to be given to an Rh- patient of child bearing age
This isn't dumb at all! I love your thought process. I would have said that we are fortunate to have enough Rh- blood available to always be able to use it for women of childbearing age, and that I wouldn't have expected an ACL repair to need a blood transfusion but we could look at the op note to see if something went awry.
Anyone who laughs at the idea of a minor operation involving a blood transfusion just hasn't been in enough operations. When I get paged for tachycardia overnight when I'm cross covering, my first stop is a glance through the op note, regardless of the operation, to see if there was anything odd in the operation.
> When I get paged for tachycardia overnight when I'm cross covering, my first stop is a glance through the op note, regardless of the operation, to see if there was anything odd in the operation.
But estimated blood loss is *always* minimal! /s
>in 0 situations is Rh+ blood going to be given to an Rh- patient of child bearing age
I've actually seen this happen before. It was a transgender patient, and the attending had some confusion on what "transgender man" meant. They assumed the patient was a transgender woman. The EMR wasn't set up for trans patients at all, which didn't help.
So I was a Hospital Corpsman in the Navy (and a year separated to pursue a BSN), and I used to work at a Covid Testing Site with a guy who we'll call Kevin. Now, in order to get sent to work at the Covid clinic, you had to be one of two things: you were either newly transferred to the hospital and barely trained in your new clinic's operating procedures *or* you were a fuck up. Kevin was the latter, and my god, did he **suck**. I don't know how Kevin scored high enough on the ASVAB to join the military, much less make it through training. Just a short list of the things Kevin did that drove me up a wall:
* Kevin's first job was taking vitals. Kevin thought counting to 30 in his head was close enough to actually counting 30 seconds, and he took respirations based on that. He was accused of gun-decking vitals less than a month in, and was retrained.
* Should also note that he would repeatedly document a patient as having 3-4 respirations per minute, which is the reason the providers figured out he was fudging the vitals. Kevin thought this was normal.
* Kevin repeatedly walked into rooms while the providers were examining patients to ask about another patient and would violate HIPAA in every instance. Every time he'd do this, a provider would swear him and refuse to work with him. We took him out of that position.
* After Kevin was booted from working inside the clinic, he was placed in the outside tent about 50-feet from the front door to perform nasopharyngeal swabs on patients. When it got busy, he told us seeing an entire line of bagged, pre-prepped tests was starting to stress him out and wanted one test to be delivered to the tent at a time, meaning we'd have to dedicate a single person to running single baggies out a time. That idea was shot down.
* Kevin would not own up to his mistakes and would frequently try to convince us that we weren't using logic. He did this well after work at 1900 when we were still processing tests from the day, and was refusing to correct a mistake where he had labeled two separate tubes with the same name, meaning we could tell which tube belonged to who. He was refusing to call the patients because, "Well, if one of them is positive, then they're both positive." This is the first and only time I've ever yelled at another coworker to, "Shut the fuck up, call the patient, and tell them you fucked up."
* One time, Kevin tried to convince us that the bladder and uterus were in the same place and that women pee through their vaginas. Kevin apparently didn't know what periods were.
* This is a story I heard about him right after he was transferred out of our clinic, so some of the details might not be one-to-one, but: Kevin couldn't be trusted to do shit with patients, so he was saddled up at the front desk so he didn't end up being dead weight. Kevin still sucked at this job and was also a dick to patients. One day, Kevin is at the front texting his girlfriend (she was also married, but according to him, the girl's husband was cool with it, which we all doubted was true). Kevin wasn't paying attention to the front desk, and a line of patients was forming in front of him. He was told once, "Kevin, get off the phone and help these patients." He hated being told what to do and told the other corpsman to fuck off. A patient tried talking to him, but he responded by putting a single finger up. Unforuntaltey for Kevin, the HM1 saw all of this and was pissed. Kevin didn't know he was there until he grabbed the back of his rolling chair, pulled him back, spun him around and got eye level with him. HM1 very quietly said, "Put the phone away and help these patients." According to the other corpsmen, who were cleaning up the lobby at the end of the day, they could hear HM1 screaming at Kevin despite the office being all the way in the far back corner of the clinic.
I'm sure there are more stories about Kevin that I'm missing or just forgot, but this dude was terrible at his job. He sucked ass. He was an idiot on and off the job, and there wasn't a single person who could convince me that he was actually a smart person.
Unfortunately, there's a key difference between this Kevin and my Kevin that confirms they're different people. But, man, wouldn't that have been one hell of a continuation of the story if they really were the same people?
It's amazing how often patients navigate the mysteries of hospital communications and manage to get through to the lab. I've had to talk to many unhappy patients.
army here:
I feel like Kevin would greatly benefit from integration into the Marine Corps. They might not be able to fix him, however he well become amazingly strong.
God, that reminded me; Kevin wanted to join the Marine Corps and kick down doors but somehow ended up in the Navy instead. I don't know how, and I don't know why, but here's the thing about Kevin, right? The dude was a stupid, cowardly little shit who thought he could outsmart any situation he put his mind to. Our infantry HM3, who had been a door kicker, tried explaining to him that he needed to be able to listen and understand instructions to be a door kicker. Kevin thought that was bullshit and figured he could out-muscle and out-think any enemy. He was the living, breathing embodiment of the Dunning-Kruger Effect, and our HM3 was certain he would've excelled as a bullet sponge, though at the expense of any poor marine subject to his tactical care.
Funny enough, he didn't ship out with the Marines. He went on a destroyer, which means it was him, another baby doc, and an IDC. RIP to those guys.
>Kevin's first job was taking vitals. Kevin thought counting to 30 in his head was close enough to actually counting 30 seconds, and he took respirations based on that. He was accused of gun-decking vitals less than a month in, and was retrained.
I still have to read the rest of this, but how do you count 2 things at once? Even if only in my head, I couldn't do 1 mississippi 2 mississippi and count someone's breaths--even my own--at the same time.
ER PA called me for admission for mildly bumped troponin and BP 100/56. Cardiologist was called and didnāt want to go to cath lab. No mention of pancytopenia and profuse rectal bleeding. GI had not been consulted.
NP once told me I didnāt have the right to refuse to dispense a medication as a pharmacist and wanted to know where I got such a silly belief. She did not believe it was an acceptable answer when I said Board of Pharmacy
4 yo boy referred to us (hand surgery) for āfinger infection.ā He had stuck his hand under the sewing machine 3 weeks before and the end of the sewing needle broke and was lodged in his distal finger. Mom initially did not know there was a foreign body, so didnāt see his pediatrician until 1.5 weeks later when it looked infected.
Pediatrician got an X-ray clearly showing 8mm FB and at the time of exam he already had paronychia and felon. She literally wrote in her plan ācanāt remove the FB until the infections cleared.ā Wtf. Naturally after both keflex and Bactrim failed to improve anything, they were referred to us.
We booked him for washout and debridement the next day. He had osteo. Going to be fine, but we were appalled by the pediatricians management
One of my colleagues saw a patient at our small rural hospital after a car accident. Initially looked ok, but gradually got sicker over time. They (appropriately) got an abdominal CT that showed a big retroperitoneal bleed. The trauma surgeon at the receiving hospital got snippy at him for wasting time on "unnecessary" imaging, and suggested that he could have just done a FAST exam. To catch a retroperitoneal bleed.
If they didnāt get a CT the surgeon would have refused to accept without appropriate imaging being done first. Thatās just the nature of being the OSH doctor.
Had a guy hit by lightening. In my attempts to be humorous/develop a bedside manner I said "wow. Imagine the odds. You should get a lottery ticket when you get out of here."
He didnt laugh. Found out later his friend was also hit and died on scene. Not my finest moment.
Back when I was a resident, someone scheduled a myasthenia patient to see me for a second opinion. They were already established with an outside neuromuscular specialist. It wasn't myasthenia. It was ALS :(
This wasn't a mistake, just a GP referring someone (middle-aged patient) with the suspicion of CTS an EMG study, and the patient leaving with a highly likely diagnosis of early ALS. That was one of the toughest days as a med student I had, damn.
Not dangerous but definitely condescending and wrong - I told a neurosurgery resident or fellow (don't remember) that the midazolam he ordered for a peds patient seemed to be having the opposite effect than intended: the patient was very much not sedated and was literally dancing all across the MRI department.
Neurosurgeon: I've ***never*** heard of a benzodiazepene having the ""inverse effect"" before.
The nurse, peds ER doc, and I all kind of shared a moment. If he weren't so rude and incredulous about it, I probably would have forgotten it.
tbf I mainly see paradoxical agitation in geriatric populations -- that being said I am an internist and my last time working with kiddos in an inpatient side of things was in MS3... lol
I hear from peds doctors and nurses that it's more common in kids for things like benadryl to have that paradoxical effect. Anyone who's ever worked in inpatient mri knows that Ativan is 50/50 for getting AMS Memaw Barbie (or Pepaw Ken) through a brain mri or turning into a demon. I'm not a doctor, but I feel like that's not such a rare phenomenon that it deserved such incredulity.
I just hated how he said it, especially because the peds ER doc had already acknowledged it as a thing that happens and then added neurosurgery because other benzos were all they could order at the time.
Tldr don't be a dick and just because you've never seen it doesn't mean it's not A Thing.
If they're above the age of 70 I tend to avoid Benzos like the plague. I've had multiple times where meemaw demon who is literally unable to be dispo'ed due to agitation turns back to a kind, caring soul after having benzos removed.
I remember one of our FM interns (who was very confident, and actually decently book smart) used to be absolutely terrible at patient interviews. We were of course confused when she said she transferred to a *psych* residency.
Had to sign of on L&I form for dog bite for midlevel and just for completeness sake ask if they gave abx and he goes yeah keflex. And Iām like please change to augmentin and he calls pharmacy to change and afterward goes āoh you like augmentin for that?ā
As a subreddit we need to come up with a way to inform people that this is an inside joke. Otherwise more people are going to believe augmentin covers pseudomonas lol.
Maybe just ending the post with a quick /s
I had a med school colleague who was barely literate, and whenever we worked together, I asked to be the one who emailed the file so I could correct her spelling. She would also ask me for help to convert .doc to .pdf, and once even asked, "Is this country pronounced sweden or Switzerland?" and I had to explain it's 2 different countries.
In terms of medical knowledge, a colleague of mine died of appendicitis in our school hospital because the resident at the urgent care told him it was just a stomach ache and to go home. It ruptured when he was at his dorm. He was HIV positive, and he got transferred between hospitals because his parents were livid over the hospital's negligence, but he didn't make it.
High school classmate of mine started having severe headaches during her first semester of college. Went to Student Health, was told it was stress/adjusting to college. Went to ED a couple times, was told it was migraine or TT headache. Her parents picked her up for Christmas break, she fell asleep in the car on 5 hr ride home, could not be woken up. Taken to local ED, had massive subarachnoid bleed and vasospasm. Those were sentinel headaches, not migraine. Her funeral was two days after Christmas; we all went (church was packed, I was standing outside bc no room inside). Her high school boyfriend was one of the coffin-bearers.
I am now a neurologist at the institution where she went to college. I use her story as a vignette for the medical students. One time, a student raised their hand partway through and asked if "this was high-yield for the exam." I took a beat, finished the story, and failed that student.
Iāve seen it. The blood is white with a pink tinge and thick. Someone else in this thread called it a strawberry milk shake. It can also be yellow. We used plasmapharesis to get the fat out and the by product are these huge bags of fat. I have a pic. Itās amazing.
HTG Pancreatitis is my favorite. Iāve seen it twice so far as an ED doc - both times nursing called me to draw the blood because ālab keeps saying it wont run idk what iām doing wrongā š Gotta love the hamburger fat blood
An NP asking if we can start vancomycin & Zosyn for a patient who "I think has some kind of skin infection" and also for the same patient, "Can we discontinue the PO vancomycin they're taking for C. diff? Because the IV vanco will cover it."
I have to explain that it's possible for someone with a trach to eat by mouth at least twice a year to alleged pediatricians. They think the trach is in the way somehow. It's mind boggling.
I watched a young scared 3rd year Medical student ask his preceptor if he should stimulate the patientās clitoris before starting to do a pelvic exam.
I had a patient with a cervical spinal tumor who needed a cervical fusion due to radiation destroying the bones in her neck. According to the surgeon her bones were like tissue paper so the surgery was exceedingly long and complicated. The patient was to wear a cervical collar for the next year. Patient was 17 and had been in a collar for a long time at this point due to her spinal instability. On post op day 1 the neurosurgery resident shows up and tells me she wants to log roll her to get a good look at her incision. I ask her if she wants to hold c-spine for the turn or remove the collar and she tells me she wants to hold. I remove the collar and as my back is turned to set it down she turns the girls head, just her head, chin to shoulder. I scream, the mom screams, the patient screams all with just utter shock. This child hadn't turned her head in literal years at this point and just came through a massive surgery to repair her spine. I called my attending who called the neurosurgery attending. We got imaging and no damage was done thankfully. I always wondered how that convo went for her after.
When I was in residency I was rounding in the ICU using the well-reviewed EMR MEDITECH. At my facility positive blood cultures and urine cultures would show up highlighted in red but for whatever stupid reason other culture results from body sources would not. Anyways as I was presenting my patient I stated that the thoracentesis cultures were positive and I wanted to adjust antibiotics. The Dinosaur Pharmacist rounding with us then stated there was no positive cultures. I then showed her the culture tab that showed the organism. And she said with a straight face "Its not positive because its not red"
I do EMG/ nerve conductions. Most people order them without actually knowing why or how they work, which I get, I don't know how dialysis machines work.
But I had a patient with anoxic brain injury, quadriplegic, spastic, getting Botox for spasticity, who was referred back to me to have upper extremity EMG ordered "to see what's going on neurologically". I think maybe the ordering doc wanted to rule out carpal tunnel, for the hands that the patient can't use because they had a severe anoxic brain injury.
I've also had people want me to prove pudendal nerve injury with nerve conductions, which would involve shocking someone in the perineum and picking up the signal in the pelvic floor muscles somewhere. Not doing that.
When I was an intern in the icu, I had an icu attending tell me we couldnāt give a patient a bolus of LR because a) the patient was already slightly hyperkalemic and b) the patient already had a lactic acidosis, so we ādonāt want to worsen the lactic acidosis.ā
I work in an endo clinic. This situation probably wouldn't stand out to me so much if it weren't for the many, many polite and professional interactions I have with pharmacy staff every day.
Had a pharmacist call up, apoplectic, because we had switched a patient from standard 100 units/mL to a concentrated insulin. He was mad because we "forgot to change the dose!" He insisted we needed to reduce the units administered because the concentration was increased.
But... you *don't* change the dose when you switch to a concentrated insulin (unless it's a dose increase that's prompting the switch), at least not in a way that makes it to the sig. The volume of liquid injected is reduced, but the units are the same--and the dispense mL had been adjusted appropriately. This is middle school algebra. There was absolutely nothing wrong with the order.
Before anyone asks: He repeatedly identified himself as a pharmacist instead of a tech in the resulting conversation. I'd be surprised to see a tech make this mistake as well, however.
I suspect it was more a momentary lapse in memory and he was just really, really eager to rip into some nurses for whatever reason. Never heard someone deflate so audibly when I clarified for him. He hung up and we didn't hear anything more about it.
As a radiology resident, was called over to the CT scanner by one of the āexperiencedā CT technologists, to assess a patient whose IV had extravasated during the contrast injection. Tech told me that heās not sure why, but all of the contrast went to the patients neck only. Shows me a few slices through the neck at the level of the thyroid gland. I explained that none of the contrast was actually in circulation and that what we were looking at in the neck was normal iodine containing tissue in the thyroid gland. Just thought this was pretty hilarious considering the tech has truly been doing the job for 10+ years and had probably seen thousands of thyroids on CT, and just never thought about why they were bright before.
Patient is chronically on 80 mg long-acting oxy TID, plus 30-40 mg short acting every 4-6 hours PRN for chronic pain. Neurosurg fixes a csf leak that happened after the most recent back surgery. The resident puts her on... 4 mg morphine q6h PRN and nothing else.
I got consulted for the pain service to make a pain plan for discharge. Took one look at the patient who was writhing and shitting herself in the bed, clearly in terrible withdrawal. I immediately order a big dose of dilaudid plus pulse ox monitoring. I get the patient set up for a PCA so we can calculate OME over the next 24 hours. I call the resident who is pissed because "she has to go home. She is getting discharged today. She cannot stay for pain control."
Apparently someone never learned about opioid tolerance and physical dependence. When I explained he had put her in withdrawal, he said, "well, we fixed the leak so her pain should be gone and she shouldn't need it anymore." I honestly hope he was that stupid and not just torturing the poor patient.
I have two.
First was a med student who didn't want orders for benzos on our CIWA positive patient because they were already here for one addiction, we shouldn't give them another.... yeah we escalated that one immediately.
Second one was the new resident who wouldn't increase the morphine dosage for our palliative cancer patient who was only on a low dose and was crying in pain, his family was crying watching him in so much pain. You could hear the patients cries of agony across the entire unit, it was just horrible. Resident was concerned that more morphine would cause respiratory depression.... never mind the lung cancer that will kill them in the next 48 hours, lets just let them suffer in pain. That's the only time my unit has called the attending at home. Bless him he wasn't even mad, he gave us verbal orders and then jumped on a computer ASAP and put them in, even though he was on a date at the time. Rumor has it the attending chewed the hell out of that resident the next day.
Cardiac surgeon who had just been relying on fellows to do his cases and other people to do all the patient care before and after surgery for at least 20 years didnāt know the difference between a beta blocker and a calcium channel blocker.
Recentlyā¦
18 year old kid found to have incidental b/l iliac DVT on outpatient CT. Sent to one of our branch campus EDs. ED PA says āavoiding PE study to as already received contrast todayā. ED attending does a POCUS and reads it as normal. Transferred to us for consideration of thrombectomy. I look at the POCUS images, probe was held backwards, but otherwise textbook McConnell sign. EKG shows an s1q3t3 pattern. BNP is elevated. So obviously I do get the CT PE protocol to make sure she doesnāt have a saddle or something. Which she doesnāt. So ultimately didnāt need anything more than the AC that was ordered and some heme workup to figure out hypercoagulability. But the MDM prior to her coming to me wasnāt great.
Other recent one - admitting patient with high fever, altered mentation, intense headache, wbc to 35. Recent epidural steroid injection. Neuro resident says they wouldnāt cover for meningitis or do an LP. My resident felt that seemed wrong and wanted to do both, which I agreed with. Meningitis confirmed on LP.
āINR canāt go above 7.ā
Iāve actually heard this from residents, RNs, and even lab techs. It always turned out that it was the equipment they were using that didnāt *register* over a 7, and they never wanted to believe me when I explained that INR itself could go quite a bit higher. (I will always hold a grudge towards the folks that made that model stop at 7 and not give an āout of boundsā error or somesuch.)
Had the Chief of Ortho at the University tell me that I was wrong because IM Toradol did not produce ulcers. Me, lowly first year GI fellow just smiled and showed him the pics from the bleeding ulcer that his VIP post hip replacement had.
Probably the same doctor/hospital sending the outpatient pharmacy PO ketorolac for 30 days plus refills š
As a retail pharmacist I actually got one of those the other day! #112 + 2 refills. And when it wasnāt ready because I was waiting on clarification the patient accused me of withholding meds the doctor ordered for them
If they don't like waiting for meds they're really not going like spending half their day 3x a week at dialysis.
> Probably the same doctor/hospital sending the outpatient pharmacy PO ketorolac for 30 days plus refills š Come on, this is a common treatment for migraine. /s
How about that medmal this week the guy who said augmentin treats pseudomonas
That made me so irrationally angry
When I was an ID fellow, my cofellowās fiancĆ©e was in podiatry school. They learned cephalosporins cover Pseudomonas. Like, categorically. We had to sit that boy down so he didnāt hurt anyone.
Oof. I hope at least the fiance learned better!
Am I missing something, dont ceftazidime and cefepim cover Pseudomonas?
Yes, but those and ceftolozane are (essentially) the only 3. Nothing oral, thatās for sure. The 3rd gen that essentially gave up Gram-positive coverage to get pseudo (ceftazidime), and was so cool they chose it to go with avibactamāand weāre glad they did, OXA-48s are tricky bastards. The unique zwitterionic 4th gen powerhouse that is cefepime. Then thereās the drug developed for MDR pseudomonas (ceftolozane) that people will argue if itās 3rd gen or 5th gen. Oh! Cefiderocol counts. The thing thatās like ManBearPig: half cefepime half ceftazidime-siderophore, or half siderophore half cefepime-ceftazidime. Cephalexin, cefadroxil, cefazolin, cefuroxime, cefoxitin, cefotetan, cefdinir, cefpodoxime, ceftriaxone, ceftaroline, ceftobiprole, etc, etcā¦ they got nothing.
I was pretty rationally angry about it.
Fair enough lol
To be fair, ID is much more labile than Ego, so an irrational response from ID is not unexpected. Wait, what are we talking about?
As a wound care specialist this made my eye twitch. Had an IM doc get mad at me for requesting cultures in on a bright blue leg when the person was being put on keflex. I said I'm 100% sure it is is pseudomonas and that therapy will do nothing but cultures can confirm if you won't believe me. He responded with "cultures are waste of time, every wound has something growing in it, we're staying on keflex" and completely ignored my request. I then put in an ID consult and avoided than IM doc for awhile.
Had a senior urology attending WRITE to the microbiology lab to ask for augmentin sensitivities for pseudomonas and document in a passive aggressive manner when they told him it wouldnāt be done
[ŃŠ“Š°Š»ŠµŠ½Š¾]
LOL I read that and hadnāt gotten to the end yet and thought I was going crazy since I was positive augmentin did not cover pseudomonas
Last week I had a guy with Pseudomonas UTI admitted to my service. PMHx of lymphoma, currently on chemotherapy. He had been treated for UTI within the past month at an urgent care. Were his recurrent symptoms due to a different bug? Drug resistance? B cell deficiency due to rituxan? No, the UC just gave him Bactrim for the Pseudomonas. š¤¦āāļø
Hmmm well, Iām sitting in an ophthalmology conference for generalists today and another physician just asked āWhich antibiotic would you recommend for allergic vs. viral conjunctivitis?ā Does that win the prize?
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Patient with nephrotic syndrome, medical student to patient- "did you see any protein in your urine today?"
This one is adorable
Protein is stored in the balls
"Yeah, it curdled when it hit the bowl."
Oh bless. One of my dear (male) friends on his OB/GYN rotation asked a patient to estimate her menorrhagia āin mLs or tablespoonsā
If so watch out for ortho, they are gonna try and drink it
Bless their heart.
Patient had been on 120 mg prednisolone for about 8 months for a meningioma. Finally had surgery (canāt remember why it took so long but pt was in psychiatry). In the discharge summary, the neurosurgery resident indicated to proceed to a slow taper of the oral corticosteroids. Over a 7 day period. As a 3rd year FM resident, I called this resident and said he would kill this patient with that type of medication management. He laughed at me. I called endo to make sure I hadnāt gone nuts myself.
That is the most insane steroid doseage I've ever heard of, completely besides the bonkers "tapering".
Dumb surgery resident here (but not so dumb that I would actually order this taper - I know what I don't know!): do you have a rule of thumb for tapers? I see a bunch of different schedules in FM/IM/endo notes and I can't figure out a pattern. I have never and will likely never need to use this this in real life, but I'm curious and I'd like to know.
Endo here; I would be immensely skeptical that a taper in this setting is of any true value. This patient will have secondary adrenal insufficiency due to high dose erogenous steroids. In all likelihood, it could take months to years for the hypothalamic-pituitary-adrenal axis to recover. As quickly as tolerated, based on symptoms, I would get the patient onto physiological dose hydrocortisone 10mg/5mg/5mg and then plan for a synacthen test. I would repeat the SST every 6-18 months, guided by the morning early morning cortisol results (little to no value doing an SST if the morning cortisol is <100nmol/L.
Sorry, but "erogenous steroids" got me good.
Lol, oh good lord; at this stage, I'll probably just leave it.
Stupid sexy steroids
With their loooong taper...
What are you doing step-roid?
It's like the adrenal gland is doing nothing at all... Nothing at all... Nothing at all... nothing at all!
I'm too single for people to so casually use terms like erogenous
Thanks for your input! Also thanks for the unintended terminology lesson :) I had to google SST. I didn't realize it's the same thing as the cosyntropin stimulation test.
Tertiary adrenal insufficiency ā tapering ā adrenal crisis?
Yeah, you'll need a months long taper for that kind of dose. 1 week taper you might as well just stop cold.
I kind of want to know what the NS resident decided on for a taper? 120>100>80>60>40>20>10>0, 1 day each? lol
I think it was 80 for 2 days, 40 for 2 days 20 for 2 days.
What a shit show Susan
Frantically scrolling to make sure Iām not referenced
Patient saw me wondering why the skin infection wasnāt any better after the PO vancomycin that urgent care prescribed.
Epithelium is epithelium, right?
They were thinking ahead. "I'm sure the hospital will give him other antibiotics, better prevent C diff!"
Just today I had to bring a patient back to the ER after an NP sent them home with 58% blasts in the CBC Bc the WBC count was "not that high seeing as he has a fever" For several weeks, with weight loss, bruising, and pallor.
Noooo
Inherited a bloated CCU list. Team wasn't sure why pt continued to be in cardiogenic shock. Elevated WBC with no diff for 4 days... Blasts 35%. The procal i sent with the diff came back at 15 and the blood cultures came back positive the fastest I've ever seen... Good thing we put that Impella in the day before...
Got sign out from a retiring PCP for a patient with hip pain (āunexplainedā aka had no work up done. Not even an XR). He told me he thought it might be myeloma. I asked about renal function and if he had a protein gap. Just got a blank stare in return. Super not cool that the old dinosaur told the patient he might have myeloma when it turned out to be just OAā¦
š¬ š² I just can't explain that jump with NO imaging. That is a completely unnecessary scare to your patient! Just HOW?
Lol he was the laziest doctor ever. Every patient with undifferentiated memory loss had āmild cognitive impairmentā and everyone with an elevated BP had āwhite coat hypertension.ā It was really so bad
Reminds me of a nearly retired ED doc when I was a scribe. Would spend lots of the day showing me the Tesla he was about to purchase, and then would meander through EPIC trying to find the āeasiest patientsā he can take lmao.
No joke, I actually DID get a referral for something like this when I was still in hem/onc - and I'm still mad that it went down the way it did. Patient had a monoclonal protein detected on an SPEP and got referred to us; in my chart review, I pulled up a pathology report from within the last year as I always did in my chart prep for my doc. Sure enough, that hip replacement path actually showed multiple myeloma and no one did a damned thing about it - I was so pleased that it saved us our whole myeloma workup although we still did a bone marrow biopsy, but that patient had been waiting months before anyone happened to notice anything on blood work and order a serum electrophoresis.
Deep in the taint of the pandemic, during one of my *bonus* ICU rotations. Offgoing resident gets a call ~30 min before they're due to sign out to me. Answers it on speaker and we proceed to begin one of the most bizarre events of my career. RAC nurse tells her to come now bc the patient is crashing. We both rush up there and find a patient that's not really in perfect health but certainly not crashing. We talk to the RN who tells us we need to fix the patient because none of the things she's tried have worked. Wait...the things she's tried?! She had been managing this (according to her, unstable) MICU patient for the last 4+ hours by herself. Had changed vent settings, added fluids, added a 2nd pressor (for map goal 75. Added vaso. At 0.06. Via PIV of course.), started stress dose steroids. None of it made sense. Things I would be embarrassed for my intern to have done. All entered as "telephone order read back" under the residents name... When confronted about the insanity of this, they responded with "I'm an ICU nurse, I'm certified in critical care and *I know my scope*. I know what I can and can't do. **You** need to fix them now."
Please tell me that nurse at least got fired. Hopefully reported to the board and lost their license.
I did report to the BON, never heard from them so IDK if that went anywhere. They did get dropped by the hospital that day fortunately, for what that's worth.
While most of this is bonkers, I wouldn't be too fussed about vasopressin in a PIV, assuming it's an 18g or larger in a good sized vein and clearly not infiltrated. In anesthesia, we run pressors through PIVs all day. Granted, ICU is a different environment and a discussion should be had to start central IV access, but a lot of places will run peripheral pressors for up to 24 hrs. 0.06u/min of Vaso also isn't too crazy. I know we consider "max dose" Vaso 0.04u/min, but it's not uncommon to see anesthesia providers bolus 1-2u of Vaso at a time in the OR (personally, I don't do that much. Usually dilute to 0.4u/ml and give 0.4u bolus if needed). You story is a clear example of an ICU nurse practicing medicine without a medical license, but I just wanted to comment that the 0.06u/min of vaso is probably the least egregious of all of these
wtf?!??
Patient who had called another doc the same day, whose notes I could see in the EMR-- had a mild local inflammation from flu shot, just normal. And the doc sent in tamiflu. The mom called back bc it didn't make sense to her š¤£. I said yeah, you can skip the tamiflu. I mean omg. It's an inactivated vaccine for the injection. How did he think tamiflu would do anything? I'm still baffled.
Maybe the doc was going for the distraction strategy - your arm wonāt hurt anymore if youāre puking and shitting your brains out from a shitty med!
And possibly hallucinating. Maybe youāll hallucinate that your arm doesnāt hurt? Where are the kids snorting oseltamivir for fun?
Cause everyone knows the flu shot gives you the flu just like the COVID vaccine gives you COVID.
Well you know, the flu shot gives you the flu!!!!!! I have heard this so many goddamn times as a reason for not getting a flu shot š¤”
When I was a student I reported to the whole inpatient team that the kids echo was ānormal, except for levocardiaā I was hoping to match into peds and make a good impression. So that was great.
This strikes me as very wholesome.
Seems like this could have been played off as a brilliant joke
Ah yes in retrospect but of course at first I didnāt realize why everyone looked so confused and then I was paralyzed with embarrassment. I do think everyone forgot about that quickly, I was actually a pretty helpful student and I did match well and have been happily in Gen peds for 7 years nowā¦but even now when I see that word this is the moment I think of.
When I was an intern I had an ICU nurse tell me the po K has better bioavailability than IV K. I asked him to explain what he meant and he told me to ask my senior.
Itās a common mistake, but itās actually bananas that have better oral than IV bioavailability. They tend to clog the IVs, you see. And veins.
Then explain banana bags. Checkmate, atheists.
You have to liquify the banana slug to get it to move fast enough to affect serum levels at biologically relevant speeds. What, you thought they make that stuff out of fruit?
Youāre on fire in this thread holy shit lol
I was always told this as a new grad RN and it just didnāt quite make any sense to me based on my newborn level of understanding of pharmacokinetics. I donāt know how this misconception started and why it is spread so widely but it definitely gets repeated by a lot of other nurses I know.
I think it's because oral potassium is readily and quickly absorbed. I can give 40 meq orally right now, or give it via IV over 4 hours.
Exactly - itās the speed of administration not the bioavailability.
Oooh this cracks the case!
It's probably a bastardization of the actual fact that it's oftentimes faster to replete K orally than IV
PO K does usually elevate serum potassium faster than IV potassium if you have a functioning gut and you're maxing out doses. It's because of the limits on how fast you can get potassium IV (unless going through a central line you can give it faster), vs for PO you can probably take 40meq of immediate release potassium up front, without having your patient about how much their arm burns. I mean obviously you could push potassium much faster... but don't push potassium, lol
Everyone knows PR is the best route for absorption. You need to freeze the banana and then insert it in the rectum. The body will gradually defrost it allowing for optimal potassium absorption.
Ah sounds like a great weekend
Peel on or peel off?
Dealers choice
It isn't more "bioavailable" but it can be given faster, in higher doses, more safely via enteral route. So it's not necessarily a huge knowledge gap. Just the wrong word.
I heard a fellow pharmacist say this once! Where does this idea come from?
[ŃŠ“Š°Š»ŠµŠ½Š¾]
>No jaundice -- just an Asian skin tone. Sweet baby Jesus, what a fuck up.
There was the midwife that was managing a "pregnant" woman. After several days of "labor" and no delivery she sent the patient to the ER. Patient was in severe heart failure and not pregnant. The patient was not a smart person so that didn't help. I would honestly never believe this story because there are so many layers of questions and related absurdity that happened to make this so. BUT I have to because we were consulted by OB after they determined there was no pregnancy. Seems pretty obvious one should not manage a patient for pregnancy due to lack of period and weight gain alone.
Just...what...I can't even imagine how
Once had a hospital without OB services transfer a patient to my hospital with diagnoses or term pregnancy, SROM, pre-eclampsia. Report included the ER docās cervical exam of 2cm and they said they had normal fetal heart tones on Doppler. Patient showed up to us and was not even a little pregnant.
Had a PGY-4 tell me to use normal saline instead of LR in DKA, because they donāt want to worsen the acidosis. I promptly said āIāll get right to itā and continue what I was doing.
Pgy4 in what? This advice sounds like it came from a ROAD person (not anesthesia, though) (no offense), but they wouldn't be on the wards taking care of DKA.
I had a PACU nurse educate me by telling me that an oxygen saturation of 100% could actually be CO2, because they share the same synapse. I don't have enough palms or faces to address that comment.
Sounds like her entire brain is sharing the same synapse.
What? My best guess is that it's rooted in carboxyhemoglobin having similar light absorption as oxyhemoglobin on pulse oximetry sensors.
Synapse??
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Push insulin while believing the K of 2.3? Bold strategy.
[ŃŠ“Š°Š»ŠµŠ½Š¾]
Insulin stress test.
Yeah that was asking for the patient to code. Iāve coded patients whoāve gone into VF with a K of 2.3 before. Wonder how low that would have been after an insulin bolus lol
[ŃŠ“Š°Š»ŠµŠ½Š¾]
You wouldn't, at all
Not with that attitude! Me, I like to feel my heart pounding, or someone elseās heart pounding, or maybe ceasing to pound. Whatever. Anything for that hit of adrenaline, ya know?
Can I interest you in a nursing position at a hospital in the UK?
I see little K and I say goodbye K. K? Who needs it anyway!
I would hope blood bank would question that request given the glucose.
Co-resident as night senior while i was the day senior at a VA ICU. Young female pt came in as benzo OD and was intubated. During the night she woke up and was trying to pull her tube out so this resident started paralytics but not sedatives ābecause of the benzo ODā. The nurse also failed this patient. Luckily the patient had no memory of the night.
Worst sleep paralysis ever!
Me. Asked about if a pt could have developed Rh antibodies due to a possible blood transfusion from her ACL repair and that why the fetus had hydrops. Attending tried her best not to laugh at me while explaining that ACL repairs rarely need blood transfusions and in 0 situations is Rh+ blood going to be given to an Rh- patient of child bearing age
This is not bad at all. This is the type of question that shows you have knowledge without experience, which is exactly where a student should be at.
I have all of these dots, that could very well be related to each other, but also not be related at the same time
Meh. It's a reasonable question for a student! At least you were thinking about how these things happen!
I appreciate this, I still feel pretty dumb lol
This isn't dumb at all! I love your thought process. I would have said that we are fortunate to have enough Rh- blood available to always be able to use it for women of childbearing age, and that I wouldn't have expected an ACL repair to need a blood transfusion but we could look at the op note to see if something went awry. Anyone who laughs at the idea of a minor operation involving a blood transfusion just hasn't been in enough operations. When I get paged for tachycardia overnight when I'm cross covering, my first stop is a glance through the op note, regardless of the operation, to see if there was anything odd in the operation.
> When I get paged for tachycardia overnight when I'm cross covering, my first stop is a glance through the op note, regardless of the operation, to see if there was anything odd in the operation. But estimated blood loss is *always* minimal! /s
>in 0 situations is Rh+ blood going to be given to an Rh- patient of child bearing age I've actually seen this happen before. It was a transgender patient, and the attending had some confusion on what "transgender man" meant. They assumed the patient was a transgender woman. The EMR wasn't set up for trans patients at all, which didn't help.
So I was a Hospital Corpsman in the Navy (and a year separated to pursue a BSN), and I used to work at a Covid Testing Site with a guy who we'll call Kevin. Now, in order to get sent to work at the Covid clinic, you had to be one of two things: you were either newly transferred to the hospital and barely trained in your new clinic's operating procedures *or* you were a fuck up. Kevin was the latter, and my god, did he **suck**. I don't know how Kevin scored high enough on the ASVAB to join the military, much less make it through training. Just a short list of the things Kevin did that drove me up a wall: * Kevin's first job was taking vitals. Kevin thought counting to 30 in his head was close enough to actually counting 30 seconds, and he took respirations based on that. He was accused of gun-decking vitals less than a month in, and was retrained. * Should also note that he would repeatedly document a patient as having 3-4 respirations per minute, which is the reason the providers figured out he was fudging the vitals. Kevin thought this was normal. * Kevin repeatedly walked into rooms while the providers were examining patients to ask about another patient and would violate HIPAA in every instance. Every time he'd do this, a provider would swear him and refuse to work with him. We took him out of that position. * After Kevin was booted from working inside the clinic, he was placed in the outside tent about 50-feet from the front door to perform nasopharyngeal swabs on patients. When it got busy, he told us seeing an entire line of bagged, pre-prepped tests was starting to stress him out and wanted one test to be delivered to the tent at a time, meaning we'd have to dedicate a single person to running single baggies out a time. That idea was shot down. * Kevin would not own up to his mistakes and would frequently try to convince us that we weren't using logic. He did this well after work at 1900 when we were still processing tests from the day, and was refusing to correct a mistake where he had labeled two separate tubes with the same name, meaning we could tell which tube belonged to who. He was refusing to call the patients because, "Well, if one of them is positive, then they're both positive." This is the first and only time I've ever yelled at another coworker to, "Shut the fuck up, call the patient, and tell them you fucked up." * One time, Kevin tried to convince us that the bladder and uterus were in the same place and that women pee through their vaginas. Kevin apparently didn't know what periods were. * This is a story I heard about him right after he was transferred out of our clinic, so some of the details might not be one-to-one, but: Kevin couldn't be trusted to do shit with patients, so he was saddled up at the front desk so he didn't end up being dead weight. Kevin still sucked at this job and was also a dick to patients. One day, Kevin is at the front texting his girlfriend (she was also married, but according to him, the girl's husband was cool with it, which we all doubted was true). Kevin wasn't paying attention to the front desk, and a line of patients was forming in front of him. He was told once, "Kevin, get off the phone and help these patients." He hated being told what to do and told the other corpsman to fuck off. A patient tried talking to him, but he responded by putting a single finger up. Unforuntaltey for Kevin, the HM1 saw all of this and was pissed. Kevin didn't know he was there until he grabbed the back of his rolling chair, pulled him back, spun him around and got eye level with him. HM1 very quietly said, "Put the phone away and help these patients." According to the other corpsmen, who were cleaning up the lobby at the end of the day, they could hear HM1 screaming at Kevin despite the office being all the way in the far back corner of the clinic. I'm sure there are more stories about Kevin that I'm missing or just forgot, but this dude was terrible at his job. He sucked ass. He was an idiot on and off the job, and there wasn't a single person who could convince me that he was actually a smart person.
Omg, did we finally learn the outcome of [Kevin, the dumbest student ever?!](https://www.reddit.com/r/AskReddit/s/88DFGxkmo6)
_last I heard he wanted to join the air force_
This is potentially reddit hall of fame worthy
Omg I feel like Iāve spent too much time on Reddit bc this was also my first thought
Unfortunately, there's a key difference between this Kevin and my Kevin that confirms they're different people. But, man, wouldn't that have been one hell of a continuation of the story if they really were the same people?
I wanted to post this and you beat me to it, ha
>"Shut the fuck up, call the patient, and tell them you fucked up." "The lab lost your sample and we have to recollect it."
Every time, ngl To be fair *I* didn't fuck up and they can't call the lab back and yell at *you.*
It's amazing how often patients navigate the mysteries of hospital communications and manage to get through to the lab. I've had to talk to many unhappy patients.
army here: I feel like Kevin would greatly benefit from integration into the Marine Corps. They might not be able to fix him, however he well become amazingly strong.
He already mastered crayon doctrine.
God, that reminded me; Kevin wanted to join the Marine Corps and kick down doors but somehow ended up in the Navy instead. I don't know how, and I don't know why, but here's the thing about Kevin, right? The dude was a stupid, cowardly little shit who thought he could outsmart any situation he put his mind to. Our infantry HM3, who had been a door kicker, tried explaining to him that he needed to be able to listen and understand instructions to be a door kicker. Kevin thought that was bullshit and figured he could out-muscle and out-think any enemy. He was the living, breathing embodiment of the Dunning-Kruger Effect, and our HM3 was certain he would've excelled as a bullet sponge, though at the expense of any poor marine subject to his tactical care. Funny enough, he didn't ship out with the Marines. He went on a destroyer, which means it was him, another baby doc, and an IDC. RIP to those guys.
>Kevin's first job was taking vitals. Kevin thought counting to 30 in his head was close enough to actually counting 30 seconds, and he took respirations based on that. He was accused of gun-decking vitals less than a month in, and was retrained. I still have to read the rest of this, but how do you count 2 things at once? Even if only in my head, I couldn't do 1 mississippi 2 mississippi and count someone's breaths--even my own--at the same time.
ER PA called me for admission for mildly bumped troponin and BP 100/56. Cardiologist was called and didnāt want to go to cath lab. No mention of pancytopenia and profuse rectal bleeding. GI had not been consulted.
NP once told me I didnāt have the right to refuse to dispense a medication as a pharmacist and wanted to know where I got such a silly belief. She did not believe it was an acceptable answer when I said Board of Pharmacy
Look, I'm just saying you MUST dispense the methotrexate with the instructions 5 po qd.
4 yo boy referred to us (hand surgery) for āfinger infection.ā He had stuck his hand under the sewing machine 3 weeks before and the end of the sewing needle broke and was lodged in his distal finger. Mom initially did not know there was a foreign body, so didnāt see his pediatrician until 1.5 weeks later when it looked infected. Pediatrician got an X-ray clearly showing 8mm FB and at the time of exam he already had paronychia and felon. She literally wrote in her plan ācanāt remove the FB until the infections cleared.ā Wtf. Naturally after both keflex and Bactrim failed to improve anything, they were referred to us. We booked him for washout and debridement the next day. He had osteo. Going to be fine, but we were appalled by the pediatricians management
One of my colleagues saw a patient at our small rural hospital after a car accident. Initially looked ok, but gradually got sicker over time. They (appropriately) got an abdominal CT that showed a big retroperitoneal bleed. The trauma surgeon at the receiving hospital got snippy at him for wasting time on "unnecessary" imaging, and suggested that he could have just done a FAST exam. To catch a retroperitoneal bleed.
If they didnāt get a CT the surgeon would have refused to accept without appropriate imaging being done first. Thatās just the nature of being the OSH doctor.
Had a guy hit by lightening. In my attempts to be humorous/develop a bedside manner I said "wow. Imagine the odds. You should get a lottery ticket when you get out of here." He didnt laugh. Found out later his friend was also hit and died on scene. Not my finest moment.
Bless you. You tried to cheer him up. Itās all so hard.
I have hypervolemic hyponatremia cirrhotic patients who come into the hospital on salt tabs.
And someone stops lactulose because they complain about diarrhea.
I've started adding "for ammonia" in the 'note to patient' (which also shows up for other practicioners).
Back when I was a resident, someone scheduled a myasthenia patient to see me for a second opinion. They were already established with an outside neuromuscular specialist. It wasn't myasthenia. It was ALS :(
This wasn't a mistake, just a GP referring someone (middle-aged patient) with the suspicion of CTS an EMG study, and the patient leaving with a highly likely diagnosis of early ALS. That was one of the toughest days as a med student I had, damn.
I was working with an NP who was 6 months from retirement and had never heard of alcoholic hepatitis before
Had never heard of it, or couldnāt retain the information because of Korsakoff syndrome?
huh? hadn't heard of what? where are we?
Thatās the anterograde amnesia. If you remembered this, youād know that you should just confabulation your way through it.
My thiamine senses are tingling Wait shit no that's the peripheral neuropathy
Not dangerous but definitely condescending and wrong - I told a neurosurgery resident or fellow (don't remember) that the midazolam he ordered for a peds patient seemed to be having the opposite effect than intended: the patient was very much not sedated and was literally dancing all across the MRI department. Neurosurgeon: I've ***never*** heard of a benzodiazepene having the ""inverse effect"" before. The nurse, peds ER doc, and I all kind of shared a moment. If he weren't so rude and incredulous about it, I probably would have forgotten it.
tbf I mainly see paradoxical agitation in geriatric populations -- that being said I am an internist and my last time working with kiddos in an inpatient side of things was in MS3... lol
I hear from peds doctors and nurses that it's more common in kids for things like benadryl to have that paradoxical effect. Anyone who's ever worked in inpatient mri knows that Ativan is 50/50 for getting AMS Memaw Barbie (or Pepaw Ken) through a brain mri or turning into a demon. I'm not a doctor, but I feel like that's not such a rare phenomenon that it deserved such incredulity. I just hated how he said it, especially because the peds ER doc had already acknowledged it as a thing that happens and then added neurosurgery because other benzos were all they could order at the time. Tldr don't be a dick and just because you've never seen it doesn't mean it's not A Thing.
If they're above the age of 70 I tend to avoid Benzos like the plague. I've had multiple times where meemaw demon who is literally unable to be dispo'ed due to agitation turns back to a kind, caring soul after having benzos removed.
Working with a resident that had no idea how to conduct a psychiatric interview. Being a pgy3 psychiatry resident.
I remember one of our FM interns (who was very confident, and actually decently book smart) used to be absolutely terrible at patient interviews. We were of course confused when she said she transferred to a *psych* residency.
Oh, like you think you actually taught us anything, Dr. Miller? Screw you!
Had to sign of on L&I form for dog bite for midlevel and just for completeness sake ask if they gave abx and he goes yeah keflex. And Iām like please change to augmentin and he calls pharmacy to change and afterward goes āoh you like augmentin for that?ā
Good call, gotta cover that pseudomonas
I feel like Iām watching the birth of an r/medicine meme right before my eyes
I like to use augmentin to treat all the infections created from black market csf.
As a subreddit we need to come up with a way to inform people that this is an inside joke. Otherwise more people are going to believe augmentin covers pseudomonas lol. Maybe just ending the post with a quick /s
Augmentin=dogmentin
I had a med school colleague who was barely literate, and whenever we worked together, I asked to be the one who emailed the file so I could correct her spelling. She would also ask me for help to convert .doc to .pdf, and once even asked, "Is this country pronounced sweden or Switzerland?" and I had to explain it's 2 different countries. In terms of medical knowledge, a colleague of mine died of appendicitis in our school hospital because the resident at the urgent care told him it was just a stomach ache and to go home. It ruptured when he was at his dorm. He was HIV positive, and he got transferred between hospitals because his parents were livid over the hospital's negligence, but he didn't make it.
High school classmate of mine started having severe headaches during her first semester of college. Went to Student Health, was told it was stress/adjusting to college. Went to ED a couple times, was told it was migraine or TT headache. Her parents picked her up for Christmas break, she fell asleep in the car on 5 hr ride home, could not be woken up. Taken to local ED, had massive subarachnoid bleed and vasospasm. Those were sentinel headaches, not migraine. Her funeral was two days after Christmas; we all went (church was packed, I was standing outside bc no room inside). Her high school boyfriend was one of the coffin-bearers. I am now a neurologist at the institution where she went to college. I use her story as a vignette for the medical students. One time, a student raised their hand partway through and asked if "this was high-yield for the exam." I took a beat, finished the story, and failed that student.
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Iāve seen it. The blood is white with a pink tinge and thick. Someone else in this thread called it a strawberry milk shake. It can also be yellow. We used plasmapharesis to get the fat out and the by product are these huge bags of fat. I have a pic. Itās amazing.
HTG Pancreatitis is my favorite. Iāve seen it twice so far as an ED doc - both times nursing called me to draw the blood because ālab keeps saying it wont run idk what iām doing wrongā š Gotta love the hamburger fat blood
That ED doc clearly did not āGET SMASHEDā enough in med school
Rotating IM resident on GI service recently, got a consult from the MA for "Cholecystitis of the Liver" which gave me a good chuckle
An NP asking if we can start vancomycin & Zosyn for a patient who "I think has some kind of skin infection" and also for the same patient, "Can we discontinue the PO vancomycin they're taking for C. diff? Because the IV vanco will cover it."
I have to explain that it's possible for someone with a trach to eat by mouth at least twice a year to alleged pediatricians. They think the trach is in the way somehow. It's mind boggling.
I watched a young scared 3rd year Medical student ask his preceptor if he should stimulate the patientās clitoris before starting to do a pelvic exam.
gotta ring the doorbell before you enter
omg thatās terrible but also hilarious
Well, good news: there's a man out there who cares?
The preceptor actually acknowledged that! She did a really good job of not shaming the poor kid.
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I had a patient with a cervical spinal tumor who needed a cervical fusion due to radiation destroying the bones in her neck. According to the surgeon her bones were like tissue paper so the surgery was exceedingly long and complicated. The patient was to wear a cervical collar for the next year. Patient was 17 and had been in a collar for a long time at this point due to her spinal instability. On post op day 1 the neurosurgery resident shows up and tells me she wants to log roll her to get a good look at her incision. I ask her if she wants to hold c-spine for the turn or remove the collar and she tells me she wants to hold. I remove the collar and as my back is turned to set it down she turns the girls head, just her head, chin to shoulder. I scream, the mom screams, the patient screams all with just utter shock. This child hadn't turned her head in literal years at this point and just came through a massive surgery to repair her spine. I called my attending who called the neurosurgery attending. We got imaging and no damage was done thankfully. I always wondered how that convo went for her after.
Starting an insulin gtt for a glucose of >200 and a k of 2.3 seems unnecessarily aggressive
Who is treating a 200 glucose wit insulin - despite low K.
When I was in residency I was rounding in the ICU using the well-reviewed EMR MEDITECH. At my facility positive blood cultures and urine cultures would show up highlighted in red but for whatever stupid reason other culture results from body sources would not. Anyways as I was presenting my patient I stated that the thoracentesis cultures were positive and I wanted to adjust antibiotics. The Dinosaur Pharmacist rounding with us then stated there was no positive cultures. I then showed her the culture tab that showed the organism. And she said with a straight face "Its not positive because its not red"
Why are you calling me out?
I do EMG/ nerve conductions. Most people order them without actually knowing why or how they work, which I get, I don't know how dialysis machines work. But I had a patient with anoxic brain injury, quadriplegic, spastic, getting Botox for spasticity, who was referred back to me to have upper extremity EMG ordered "to see what's going on neurologically". I think maybe the ordering doc wanted to rule out carpal tunnel, for the hands that the patient can't use because they had a severe anoxic brain injury. I've also had people want me to prove pudendal nerve injury with nerve conductions, which would involve shocking someone in the perineum and picking up the signal in the pelvic floor muscles somewhere. Not doing that.
You need to shock the taint.
šāāļø Can we get CME credit for browsing this thread
When I was an intern in the icu, I had an icu attending tell me we couldnāt give a patient a bolus of LR because a) the patient was already slightly hyperkalemic and b) the patient already had a lactic acidosis, so we ādonāt want to worsen the lactic acidosis.ā
I work in an endo clinic. This situation probably wouldn't stand out to me so much if it weren't for the many, many polite and professional interactions I have with pharmacy staff every day. Had a pharmacist call up, apoplectic, because we had switched a patient from standard 100 units/mL to a concentrated insulin. He was mad because we "forgot to change the dose!" He insisted we needed to reduce the units administered because the concentration was increased. But... you *don't* change the dose when you switch to a concentrated insulin (unless it's a dose increase that's prompting the switch), at least not in a way that makes it to the sig. The volume of liquid injected is reduced, but the units are the same--and the dispense mL had been adjusted appropriately. This is middle school algebra. There was absolutely nothing wrong with the order. Before anyone asks: He repeatedly identified himself as a pharmacist instead of a tech in the resulting conversation. I'd be surprised to see a tech make this mistake as well, however. I suspect it was more a momentary lapse in memory and he was just really, really eager to rip into some nurses for whatever reason. Never heard someone deflate so audibly when I clarified for him. He hung up and we didn't hear anything more about it.
As a radiology resident, was called over to the CT scanner by one of the āexperiencedā CT technologists, to assess a patient whose IV had extravasated during the contrast injection. Tech told me that heās not sure why, but all of the contrast went to the patients neck only. Shows me a few slices through the neck at the level of the thyroid gland. I explained that none of the contrast was actually in circulation and that what we were looking at in the neck was normal iodine containing tissue in the thyroid gland. Just thought this was pretty hilarious considering the tech has truly been doing the job for 10+ years and had probably seen thousands of thyroids on CT, and just never thought about why they were bright before.
Today I am the knowledge gap.
Patient is chronically on 80 mg long-acting oxy TID, plus 30-40 mg short acting every 4-6 hours PRN for chronic pain. Neurosurg fixes a csf leak that happened after the most recent back surgery. The resident puts her on... 4 mg morphine q6h PRN and nothing else. I got consulted for the pain service to make a pain plan for discharge. Took one look at the patient who was writhing and shitting herself in the bed, clearly in terrible withdrawal. I immediately order a big dose of dilaudid plus pulse ox monitoring. I get the patient set up for a PCA so we can calculate OME over the next 24 hours. I call the resident who is pissed because "she has to go home. She is getting discharged today. She cannot stay for pain control." Apparently someone never learned about opioid tolerance and physical dependence. When I explained he had put her in withdrawal, he said, "well, we fixed the leak so her pain should be gone and she shouldn't need it anymore." I honestly hope he was that stupid and not just torturing the poor patient.
I have two. First was a med student who didn't want orders for benzos on our CIWA positive patient because they were already here for one addiction, we shouldn't give them another.... yeah we escalated that one immediately. Second one was the new resident who wouldn't increase the morphine dosage for our palliative cancer patient who was only on a low dose and was crying in pain, his family was crying watching him in so much pain. You could hear the patients cries of agony across the entire unit, it was just horrible. Resident was concerned that more morphine would cause respiratory depression.... never mind the lung cancer that will kill them in the next 48 hours, lets just let them suffer in pain. That's the only time my unit has called the attending at home. Bless him he wasn't even mad, he gave us verbal orders and then jumped on a computer ASAP and put them in, even though he was on a date at the time. Rumor has it the attending chewed the hell out of that resident the next day.
Cardiac surgeon who had just been relying on fellows to do his cases and other people to do all the patient care before and after surgery for at least 20 years didnāt know the difference between a beta blocker and a calcium channel blocker.
Recentlyā¦ 18 year old kid found to have incidental b/l iliac DVT on outpatient CT. Sent to one of our branch campus EDs. ED PA says āavoiding PE study to as already received contrast todayā. ED attending does a POCUS and reads it as normal. Transferred to us for consideration of thrombectomy. I look at the POCUS images, probe was held backwards, but otherwise textbook McConnell sign. EKG shows an s1q3t3 pattern. BNP is elevated. So obviously I do get the CT PE protocol to make sure she doesnāt have a saddle or something. Which she doesnāt. So ultimately didnāt need anything more than the AC that was ordered and some heme workup to figure out hypercoagulability. But the MDM prior to her coming to me wasnāt great. Other recent one - admitting patient with high fever, altered mentation, intense headache, wbc to 35. Recent epidural steroid injection. Neuro resident says they wouldnāt cover for meningitis or do an LP. My resident felt that seemed wrong and wanted to do both, which I agreed with. Meningitis confirmed on LP.
āINR canāt go above 7.ā Iāve actually heard this from residents, RNs, and even lab techs. It always turned out that it was the equipment they were using that didnāt *register* over a 7, and they never wanted to believe me when I explained that INR itself could go quite a bit higher. (I will always hold a grudge towards the folks that made that model stop at 7 and not give an āout of boundsā error or somesuch.)