1. Yeah, it’s pretty disturbing to me how that poster can be so nonchalant about people existing in misery. And opioid’s definitely aren’t the end all be all, or correct option for many, etc etc… I’m not in this discipline at all, but I do wonder if the pendulum has maybe swung too far with regards to the utilization of opioids?

  2. Agree 100%, The pendulum has absolutely swung too far in the utilization of opiates. It’s incredible how many truly Unindicated opiates people are on and I wish we could swing the pendulum back to the side of sanity!

  3. It’s true, but no one wants to hear it.

  4. We’re open to hearing it, this is just a weak argument people use to continue prescribing opiates. The risk of death and suicide amongst those addicted to opiates is massive. I get that it’s hard to totally separate these populations but narcotic abuse MASSIVELY increases suicide risk.

  5. Well, you’re an attending. Everyone’s financial situation is different, but it’s not that big of a cost.

  6. Why don’t you not assume peoples financial situations. $100 for what could be a free pair of clothes is a huge rip off

  7. I’m a hints skeptic, I can’t help myself. I find it vague, poorly supported by literature for use in the ED. I don’t think it generalizes or is usable in an ED setting.

  8. Important to note that HINTS isn't really "positive for a central cause", more that it "doesn't confirm a peripheral one".

  9. Agree but people sell it as BETTER THAN AN MRI for

  10. I would personally bring this issue up with their PD. I’d document times you saw them on social media, specific residents and how late notes are.

  11. This is one of the worst pieces of advice I have seen here. You do not rat on other residents for things like this. What is wrong with you?

  12. I’m not ratting I’m providing constructive feedback

  13. Are the residents working 6 out of 7 days and the apps work 3 days a week?

  14. Residents do 5 days a week on days for 3 weeks, 1 week nights for 5 nights (Monday - Friday) then there’s 24 hour call on weekends. It gives the residents more true weekend days off at the expense of a 24 hour call.

  15. I think you have your answer right there. Are you so far detached from residency that you don't remember what its like?

  16. No I remember very well. It was hard, my class mates and I got through it together. We didn’t have apps to offload our work the way current residents do, so we just grit our teeth and ‘got it done’

  17. The funny thing is I’m one of the top 10% nicest most straightforward attendings. Everyone in medicine has this complex where it’s ok to crap on everyone else but at the first hint of negative feedback they’re a victim

  18. Why don’t you just try to explain your reasoning if someone gives you pushback, explain them the whys you feel so strongly the pt should be admitted, if you have reasonable point they will listen, be professional and not confrontational, you don’t have to go behind people back like a little snitch, sounds to me like you were the unpopular kid in high school and now that you have a little bit of power you use it every time you can, you must be a real pleasure to work with

  19. Oh I often do explain my reasoning very well and the patient is subsequently admitted. I don’t admit unnecessarily. But I still discuss this behavior if it’s a pattern. Regardless of whether the patient is ultimately admitted, inappropriate pushback is unprofessional and I will make sure it is not tolerated.

  20. It's kind of a red flag when it seems most EM attendings are out of medicine by age 50.

  21. EM sucks and I can say that as an ED attending. It’s soul draining and miserable. The only thing worse than the patients are your fellow physicians being non stop jerks to you

  22. Shock Trauma Center at the University of Maryland in Baltimore is a dedicated trauma hospital. Best is a relative thing, but that hospital does trauma pretty much exclusively

  23. I don’t know why people get so excited about trauma and trauma training. From an EM standpoint it’s just all the same after you do it a little while. Airway, access, +/- chest tubes, surgery.

  24. Pathology attendings where I am seem really happy

  25. Because they don’t have to see patients.

  26. I am not using HINTS and timing/triggers methodology to rule out posterior circulation CVA in 80 year olds that cannot walk. I don't think anybody is arguing for this strategy. I'm also an ED provider. I totally agree with having clear pathways and dispositions for lengthy workups like stroke ruleouts to occur inpatient and/or obs. I'm on your team. It's just better hospital operations and medicine. Also the comment about 'less trained' providers is about APPs and early career MDs/DOs that did not have to learn more about this topic. You probably are not in either of those groups.

  27. I certainly have more to learn every day. I have no ego or arrogance. I’ve been humbled and learned the hard way not to mess with neurologic complaints in old people. Just image them. Don’t talk yourself out of it, it’s not gonna be a quick dispo. Just bite the bullet and image them. My personal favorite was intermittent vertigo no headache with a normal neuro exam and no reported trauma who had a huge subdural with acute on chronic components and shift. As I get older I image less and less belly pain but more and more neuro complaints. The things you find are just annoying and humbling.

  28. No need to start being condescending, I can very easily take that approach with you too. Just because you aren’t educated on the issue and don’t trust your own neurological exam doesn’t mean we’re all at the same level.

  29. Correct a significant amount of posterior strokes are missed on initial mri. I have a low threshold to admit for PT and neuro personally.

  30. MRI seems like overkill for "dizziness" unless you're truly concerned about central vertigo... It's an easy enough thing to clinically rule out in a low-intermediate pretest probability population. Do people not utilize the HINTS exam where you work?

  31. Nobody should be using the HINTS exam it’s trash.

  32. Yes, this study showed that if you have untrained ED docs assess the patient with HINTS they often do it on the wrong patients.

  33. The problem with HINTS is it’s useful when performed in a high stroke prevalence population with a high pretest probability for stroke, and the patients we see in the ED are too undifferentiated for it to be useful. I think it’s a fun academic exercise to use a physical exam maneuver to diagnose strokes more accurately, but in a patient with a high enough pretest probability to be effectively evaluated using a HINTS exam I’d argue should be just getting vascular imaging and MR imaging anyway.

  34. 🤣 sick burn. Why you stalk me? You can’t have the D

  35. Go back to the premed sub. You can’t have me

  36. It does make a difference. For one thing secondary prevention is not the safe for all types of stroke. Some get just aspirin, some get DAPT, some get anticoagulation. So determining the etiology does affect management.

  37. So you’re telling me a patient with known paroxysmal a fib on warfarin with a negative CT/CTA for lvo with mild L arm numbness who can walk and perform ADLs would benefit from having their stroke diagnosed?

  38. No, we don't do a full workup in every case. Your case for example probably doesn't need everything.

  39. Very reasonable. My neuro consultants have mri’d literally that patient then admitted when mri positive. I just don’t get why

  40. Okay. I’m glad I’m not the only one. Like I said in the post, I had 2 experiences where an intern underestimated urgency of certain nursing issues and I was ultimately responsible for the outcome so I now prefer to be notified for almost everything but I guess that’s “micromanaging” by some interns.

  41. Interns are completely incompetent until March-April of the year.

  42. You shouldn’t steal books. You’re only hurting the authors, some of whom you probably know or have some attachment to.

  43. Why are you so obsessed with me it’s honestly weird I genuinely wish you’d leave me alone

  44. You’re more than welcome to stop commenting haha

  45. It definitely is an identity illness. Looks like the pseudo crowd won this round though.

  46. Let them have it I’ll enjoy my life and not argue with someone who clearly has baggage and bias

  47. Statements like this only serve to perpetuate stigma and discourage people from seeking care and belittle those with disorders beyond their control.

  48. How so? Patients with complex vague partially understood disease with a functional component who are often profoundly frustrated with the stigma from the traditional medicine community and preyed upon and patronized to by the ‘alternative medicine’ community are challenging.

  49. I used to get cafeteria food but it would make me feel so bad. I usually just bring a salad or some veggies. Would recommend trying it!

  50. Cuz not everyone cares about working out. Some people care about having a family, a healthy work life balance, and hobbies.

  51. As an ultra runner I agree with this. Working out is not wellness, it’s just another activity to do. People who are swole or really fit are probably less ‘well’ than people who aren’t and live a more balanced life

  52. Sorry, but acupuncture is worthless nonsense, as are nearly all marketed supplements.

  53. Eh as a fellow intensivist (well you’re not really an intensivist yet) I guess I just can’t really muster the strength to care that much about acupuncture

  54. My practice post-PRISMS: If their stroke scale is 5 or less and symptoms are non-disabling (numbness, face droop, etc), then the risk of tPA most likely outweighs the benefit.

  55. Can we talk about why it didn’t reach its endpoint and was stopped early?

  56. Haha as I give TPA sometimes I do sort of wonder to myself “wow I hope this isn’t one of those things that we look back in 30 years and say ‘man I can’t believe pharma convinced us to to that’”

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