Without exaggeration, this is a harder feat for me to accomplish than almost anything I do as a pediatric pulmonologist. Complicated ventilator management, management of the myriad of CF concerns, interstitial lung diseases, complex structural airway disorders are all easier than this.

I'll be accepting awards all day.

Has anyone come up with any creative strategies to prevent the foreign body frequent flyers from coming back?

Mine are almost always men from the jail/prison who shove a piece of plasticware up the urethra to get a free ride to the hospital and a change of scenery.

I have a guy right now who came back within 12 hours of discharge. FML.

I’m not sure how well this is going to go over but figured I’d post it. Throw away alt account. And to add this has not been my experience with community medicine rotations that I had during residency, although we would get some wild transfers from the boonies.

Fresh out of training, first attending job. Trained at a large academic center that has every kind of transplant and sent absolutely nothing out. Great specialists. Everyone was up to date, including the in system PCPs. Midlevels were involved a lot but the care still seemed great.

First job is in an academic affiliated community health system as a IM trained PCP. Great access to specialists and resources. Partners are great and seem to be up to date on the standard of care. That’s not the issue. The issue is that there are tons of mid levels managing care independently and even the attending care is just wild. generally when I’m precharting im like actually saying what the fuck are we doing out loud to myself. The care difference between what I was seeing in residency and here is just stark and frankly concerning.

I’m really not trying to shit on community medicine but like at the same time there have been a dozen instances where I have considered messaging the provider in question. I’ve only been here for a few weeks.

For example: cards NP dropping someone’s diuretics completely even though their BNP is increased from the hospitalization they are following them up for, new EF drop with WMA on the echo that nobody addressed during hospitalization or at the cards follow up in a patient with known CAD. They were concerned that he had pneumonia, didn’t order any imaging and just punted to “pcp follow up” even though they acknowledged the pneumonia in their notes. Attending physicians not checking LFTs on a patient with HH for years, doing thrombectomy for minor dvts, etc.

I know not my monkey, not my circus. I’m really not trying to seem like I know everything. I ask my partners for advice several times a day. Just the whiplash between the level of care has been stark and I’m looking for some advice on how to navigate it a bit better or if I should just do my best and let what other people do happen.

The Boston Globe, Oct 13: ‘A massive betrayal’: Former Steward Health Care clinicians face financial ruin as insurer implodes:

Dr. Peter Rees, a longtime primary care doctor in Haverhill, is 82. He’d hoped to be retired by now, spending more time with his wife, kids, and dozen grandchildren.

But he has a huge financial threat hanging over him: a malpractice lawsuit dating from when he worked for Steward Health Care.

The bankrupt hospital chain’s in-house malpractice insurer, TRACO, is effectively broke, leaving Rees with tens of thousands of dollars in legal fees and the possibility of a multimillion-dollar judgment that could cost him everything, including his home.

He is among the scores of former Steward doctors, nurses, and other clinicians who face the prospect of financial ruin over the implosion of TRACO, which was looted by Steward executives as the for-profit chain spiraled downward. Some medical workers are raiding savings and retirement accounts to pay for their own insurance; still others are holding the bag for hefty legal settlements TRACO had agreed to pay but failed to honor....

The rest is available at the above link behind a paywall, but happily you can read the whole thing where the good folks at the Boston Globe posted it in r/massachusetts, here: https://www.reddit.com/r/massachusetts/comments/1x4yj0m/comment/pgho9ia/ .

This was said by my patient, a semi-retired health professional, at a routine followup visit. I have a policy of not debating with cult members and crazy people, but I did voice my support for Dr. Fauci. On with the visit, come back in 6 months. Later, I was thinking, I could have said, "Listen, this is where you and I part ways." It somehow feels right, but even cult members deserve healthcare. On the other hand, does it have to come from me? I sort of feel that I'm enabling a truly harmful point of view, but I know I can't talk him out of it. (see Carl Sagan re bamboozle) What do you good people think?

https://link.springer.com/article/10.1007/s00101-012-1999-z I m posting here as local laws in my country requires any safety issue to not be public and since this is documented in reasearch under other drug names, my safety reports were denied escalation.
So this is about a safety issue with Buccolam 10 mg, which is under-documented in psychiatry and the drug used mainly by caregivers of people with epilepsy without the relevant precautions. The legal issue is neither the package leaflet nor the Summary of Product Characteristics (SmPC) mentions it, thus making it an issue equivalent to the Depakine/Sodium valproate case.
Anaesthetists know that the drug's active substance (midazolam) can, in rare cases, alter memories into memories of sexual assault. One dose of Buccolam roughly corresponds to the dose that can produce a false memory of sexual assault in the operating theatre (sodomy in men), and it is slightly higher in women because of the difference in body weight. The url is a review cited several times, published in a peer-reviewed Springer Nature journal. In Germany, the review recommends that patients should never be anaesthetised or sedated without qualified healthcare staff present as an independent witness or filmed. This matters because the risk of a prison sentence is particularly high when a memory of sexual assault is involved: innocence is particularly difficult to prove, and the use of midazolam is not proof that no sexual assault took place. There is also a case similar to mine involving another drug used for the same purpose: Jodin Froeber, in Wisconsin, who did not, however, make the connection. The Europpean Union Buccolam package leaflet and SmPC only mention hallucinations, but in psychiatry, where patients with epilepsy are concerned, people think of things like pink elephants, not of a legal risk, or of having to kill oneself or be killed in order to protect your familly who now dislike you. I acknowledge, however, that I do not have the means to survey psychiatrists to assess what proportion of them are aware of this: if the number is high, then this is medical school knowlwedge and the problem only concerns caregivers of people with epilepsy.

Consequences: For the patient: post-traumatic stress. Suicidal thoughts, or even suicide. Breaking off relations with the family or the relative concerned, while ultimately being glad to have made that decision, in the sense that the false memory leads to a false or genuine realisation of how terrible such a person is in reality.
For the accused: a sentence of decades in prison for sexual assault of a vulnerable person, and/or a vendetta, or even, in the most extreme cases, gjakmarrja. Since the latter cannot be stopped by the police or the courts, the only way to escape it remains to emigrate or to pay for a squad of round-the-clock bodyguards for each of the family members who need protecting.

The problem is within countries under the EMA authority from the Europpean Union. The Canadian SmPC do mention the risk.

Because my angry uterus could use some cheer. And I just had a real memorable one.

Guy comes in for a completely elective ortho surgery. 60s, white, totally mobile and oriented. His case is scheduled for noon but he shows up at 7am because “He doesn’t want to wait around all day for this bullshit” Lobby calls me but I say I don’t have any room for him until 10, his scheduled arrival time. He tells the desk girl who is sweet as pie that he doesn’t like that and continues to ask every 20 min when “everyone else will have their shit together”

So at 0957 I go out to retrieve this peach and he is huffy and mutters “it’s about time” We begrudgingly go through his meds and history because why can’t we just look at the chart why do we always have to ask him questions and why does he need an IV because he supposed to get the gas stuff etc. Wife looks embarrassed, but also like she’s used to Harold’s rants and raves.

Now it’s 1130. He’s consented and cozy in his gown. But we’re a level 1 trauma and he gets bumped for some open femur fractures in a pedestrian vs motorcycle incident. I go through my usual “sorry guy. It sucks, but if the tables were turned you’d want us to do the same for you right? It shouldn’t be too much longer. Thanks for your patience”

No. He does not agree. He rips every monitor off his very hairy chest, gets super red faced and looks me dead in the eye “I DONT CARE ABOUT OTHER PEOPLE!! I ONLY CARE ABOUT MEEEEEE”

Like in theory, I know people are selfish but damnnnnn.

He did not get his surgery. He chugged a contraband coke and ate 3 snickers out of his Fanny pack then asked me for a coffee for the road. The OR called me exactly 3 minutes after he stormed out to tell me they were ready for him. Poor Harry. I hope his shoulder survives this.

​Public health discourse frequently frames spatial access, such as food deserts and food swamps, as a core driver of the obesity epidemic and metabolic disease.

However, as causal inference methodologies, health economics, and longitudinal epidemiology have advanced, the empirical consensus has shifted sharply away from spatial infrastructure interventions.

When controlling for individual-level socioeconomic status, income, education, genetic predisposition, and total energy expenditure, spatial proximity to healthy or unhealthy food outlets demonstrates a near-zero causal effect on individual BMI, total caloric intake, or glycemic control.

​A comprehensive review of causal studies by Groom et al. in Social Science and Medicine found that once strict causal inference tools are applied, changes to local food environments produce no generalizable impact on adult obesity rates.

You can review this study at https://doi.org/10.1016/j.socscimed.2022.114879.

​so, landmark national tracking study by Allcott et al. in The Quarterly Journal of Economics demonstrated that spatial availability accounts for less than ten percent of the nutritional gap between high and low income households. Over 90percnt of dietary choices were dictated by income, education, and entrenched individual demand preferences.

You can access the paper at https://doi.org/10.1093/qje/qjz015.

​Prospective longitudinal tracking of communities following government funded supermarket additions in designated food deserts yielded similar conclusions. Cummins et al. in Health Affairs (https://doi.org/10.1377/hlthaff.2013.1206) and Elbel et al. in Health Affairs (https://doi.org/10.1377/hlthaff.2015.0667) revealed no measurable reductions in BMI, daily caloric consumption, or sugar intake compared to control communities.

Multi-decade longitudinal tracking by Boone-Heinonen et al. in Archives of Internal Medicine (https://doi.org/10.1001/archinternmed.2011.283)

also confirmed no consistent association between spatial exposure to fast food or grocery outlets and diet quality or weight status over a fifteen to twenty year span.

​While building local infrastructure provides urban convenience and community satisfaction, treating physical proximity as a primary clinical or public health intervention for obesity and metabolic disease is largely unsupported by prospective causal data.

Look, given that individual purchasing power, educational background, and behavioral preferences dominate dietary choices, should structural health interventions pivot away from spatial zoning and retail subsidies, and instead move toward direct financial support, nutritional literacy, and targeted metabolic clinical care?

~6yo boy being titrated on ADHD meds. Just started at the lowest dose. At first, it helped. And then: "He is back to his wiggly old self." Apparently, he took Sia's song a little too literally, although it was a ceiling fan instead of a chandelier. Needless to say, he pulled it out of the ceiling. No injury, fortunately.

I moved him up to the next dose.

-PGY-22

…I’m sorry if you were joking.

So I’m a medic and sometime around 2019 we got a cool new hospital that could do cool new mechanical thrombectomies.

And I took a patient with an LVO and I excitedly asked if I could watch the procedure.

You were cool with it so I posted up on the wall and tried to be polite: be silent, don’t touch blue. Probably watched you like a hawk.

And you said: “You wanna keep it?”

I very overly excitedly like a kid at Christmas said yes. Yes yes omg yes.

So while retelling this story today, my friend goes, “wait, was he joking?”

And I realized… you were probably joking. Especially since you then looked to the nurse, yall tried to find a specimen container, couldn’t find one, and the nurse produced a UA specimen collection cup, in which you placed the mechanically removed thrombus.

Anyway. It’s been sitting on my wall for almost ten years. Anytime a medical nerd comes to my house I proudly show them my stroke, questionably preserved inside a UA collection cup. I love it.

And it took me ten years to realize that you were probably joking, then I awkwardly called your bluff, and was so excited that you suddenly had to figure out how to transfer ownership of a CVA, so….

…I’m sorry.

Oopsies?

I am honestly confused. How do functional medicine providers order labs that they don’t know how to deal with? For example, a functional medicine provider ordered many hormones on a patient and then once they came back as mildly abnormal, recommended the wrong interim treatment and referred them to us (reproductive endocrinology) for additional assessment and treatment.

Edit just to say: This is StatPearls.

Dear Medical Student Contributors:

We currently have assigned an active author and editor to each of 6,200 CME/CE articles, who regularly update the article on a 3-year cycle. The CME/CE revenues fund the $750 per-article copyeditor and production editor expense.

We are now shifting our focus to recruiting replacement authors to update ~ 5,000 non-CME/CE topics (like basic sciences) that are on a 6-year update cycle. Many of these are easier topics that take as little as 10 hours to update. While they are free in PubMed and read over a million times a year, they do not generate any revenue to cover the copyediting and production expenses. We have a limited budget to update them.

If any of you are interested in becoming the update author, you will receive free lifetime access to board review and CME/CE ($3000 value), but I apologize; you must pay a $500 copyediting fee per article to help defray our copyeditor costs. Most are published in under 2 months after it is submitted.

If any of you are interested, please send me a summary of your training completed to date and a CV, and let me know how many articles you are interested in completing over the next 6 months. We are currently focused on basic science topics.

Thank you,

[editor's name]

It astounds me that the MAHA movement, self-described as promoting health, actually sees bypassing the medical, quality assurance, and regulatory public health protections enforced by the FDA, as progress.

The article describes adverse reactions experienced by consumers of unapproved peptide products (many of which are labeled for research use only). But because such "miracle" remedies are produced at sites which do not undergo FDA inspection, it cannot be determined whether these dangers are inherent in the drugs themselves or represent contamination / substandard quality.

https://kffhealthnews.org/public-health/peptides-experimental-drugs-patient-harms-maha-medical-freedom/

Case here: https://expertwitness.substack.com/p/lung-lobectomy-after-oral-surgery

tl;dr

53-year-old woman undergoes extraction of 20 teeth to make way for dentures.

A few weeks later she goes to the hospital with a cough.

Chest x-ray shows a tooth in her left lower lobe.

Pulm tries to get it out via bronchoscopy but can’t.

She undergoes left lower lobe lobectomy.

Files lawsuits against the oral surgeon but her attorney botches the whole thing, gets a dentist expert instead of OMS, refiles but it’s after the statute of limitations.

I’ve published a few gross negligence cases against doctors, I thought this was interesting bc the judge basically accused the plaintiffs attorney of gross negligence.

Also, as people on the article comments pointed out, a Ct showed multiple relatively recent rib fractures. Nobody in the entire lawsuit addressed that. I honestly have no idea how that happened and I’m all ears if anyone has any theories. I can’t think of any reasonable way it would be connected 🤔

Just-for-fun discussion post.

Everyone, please boast to the utmost of your ability :)

I’m an executive physician, recently a board conversation regarding downsizing our clinical team to expand our AI footprint. Translation: they want to fire physicians and keep a handful to supervise an expansive AI deployment within clinical operations partnering with AI PE. I naturally opposed in addition to the other physician board members but the majority were in agreement. What seems to have prevented this move, tort liability. I find it incredibly ironic that the very thing we complained about, has appeared to be job protective.

Send them an OE "article" on how to manage a common clinical scenario in their field while simultaneously asking for tailored recommendations for your patient.

I tried looking through this sub and the residency subreddit, and couldn’t really find many folks talking about how the pandemic impacted their training.

Only one post mentioned that the pandemic sort of short changed them (at the moment in time) in their early residency because the cases were all the same. ARDS, pneumonia, etc etc.

So I’m curious to hear from folks that had their training during the bulk of the pandemic and from clinicians that work with COVID-era residents on how/if their growth as physicians was notably different. What was the reality of your program and how did they manage to make sure you hit all of your competencies?

Incoming a patient with massive lower GIB. Hypotensive. HH dropped several units. GI won't do a colo since pt is unprepped. CT angio positive for active bleed. I call IR:

IR: We need the patient to be stable before we do a visceral angiogram/embolization

< Patient gets rapidly transfused blood, is stabilized; good BP. I call IR back >

IR: The patient looks stable now. In that case go ahead and prep for colo; they no longer meet criteria for urgent angiogram

I'm not criticizing IR here but just wanted to see if I'm missing something? Patient met criteria for an angiogram because they're too unstable to undergo prep. I stabilize the patient per IR request but now they're too stable to meet criteria?

Crosspost from /r/Psychiatry.

Some patients with BPD make conditional threats that they will commit suicide if you do not admit them (or extend their admission). I send a lot of these people home.

Some of them do try to commit suicide and end up on a medical or surgical ward. The direction I tend to give is that they should be stabilised and sent home rather than to the psych ward, especially if the act was because a previous admission wasn't extended. IMO this makes it abundantly clear admission is not benefiting them if they are continuing to present like this despite a recent stay, my feeling is there is probably some iatrogenic harm there as there would not have been an extinction burst at the point of discharge if there had never been an admission, and I certainly do not want to reinforce behaviour that high-lethality suicide attempts are tickets to previously-declined admissions.

However, what do we do if a patient attempts to leave while being medically stabilised, and demonstrates capacity to do this? They are aware they are being stabilised, that they are unwell, and that the risks of leaving include death.

I've seen two schools of thought from attendings.

One is that we should not allow people to commit suicide, and that having BPD impacts capacity. However, I would argue that many people are allowed to deny lifesaving treatment in ways which essentially amount to suicide, and that there are clearly disordered personality-driven processes contributing to these in some people, e.g. I am going to leave before being treated for my MI because I am annoyed that someone else was seen before me. We still allow them to leave.

I find myself aligning more with the second school of thought which is that leaving is a stupid decision, but it is their stupid decision and they are free to make it - thus this should be handled along the DAMA pathway, they should not be detained, and they should be allowed to leave with thorough safety netting and return instructions (and a signature on the DAMA paperwork). If we detain them, often I see that they are detained until stabilisation, are sent home, and then promptly end up in hospital again with another suicide attempt. Conversely when it becomes clear you will not detain them they tend to stop threatening to leave (or come back if they have already left).

What are your thoughts on this? Keen for some discussion.

I was reading a case -- Medina v. Hochberg, 987 N.E.2d 1206 (Mass. 2013) -- that held that a medical professional other than a mental health professional owes no duty to third persons to warn her patient of the risks of dangerous driving associated with an underlying medical condition.

A google search resulted that forty-four U.S. states do not have laws that mandate physicians to report or warn state motor vehicle authorities about patients with epilepsy.

I thought that most states would mandate reporting (since physicians have a duty to warn others of their patients' contagious diseases) but I'm surprised by the findings.

October is the best month to be a pediatrician.

-PGY-22

I'm a hospital nurse. I got sick recently with an infection I've never had before. I've taken care of many pts with this infection. It was interesting to be on the other side. I'll be changing my nursing practice based on what I've experienced.

(I apologize for being vague/not expounding more - this is a very recent development, and I don't want to provide too many details and risk someone connecting the dots to my account.)

https://www.inquirer.com/health/penn-medicine-wills-eye-scheie-partnership-talks-20261008.html

Any residents/staff have any insider information? Seems like potentially another Dana Farber situation unfolding. Only a preliminary agreement between Wills and Penn but would be a big loss for Jefferson even if Wills is losing money. Per the article Jefferson is already replacing Haller as chair of their Ophthalmology department.