My favorite genre of medical humor is preventable catastrophe. Someone in my recent flumazenil thread described it as “brainbros hate this one trick,” and I (IM doc) have been entertaining myself on my commute ever since by compiling a list of other things we all hate.

A few contenders:
- Haldol in PD: Patient has a dopamine deficiency. Have we considered making it worse?
- Dilt in pre-excited AF: An accessory pathway! Let’s make sure all the traffic uses it.
- Steroids before biopsy in suspected primary CNS lymphoma: We need a tissue diagnosis. Have we considered dissolving the evidence first?
- Continuing an SGLT2i thru surgery: DKA is so much easier to recognize when the glucose is 500. Let’s make it euglycemic and keep everyone guessing.
- High-dose steroids in unrecognized Strongyloides: The parasite’s been quietly living in the intestine for twenty years. Let’s give it the opportunity to travel.

No one has a monopoly on this particular flavor of suffering. What are the orders, medication combinations, or baffling clinical decisions that make YOUR specialty say “oh, for fuck’s sake”?
Extra points for catastrophes with particularly elegant pathophysiology. Also the tox people in my last thread actually taught me things, so apparently this counts as CME.

As the title suggests, it seems like a practice we've grown complacent to accepting. There's no reason why an employer would not cover even high end stereoscopes when it is quite clear that it is a crucial tool for work and, all things considered, is relatively inexpensive for the employer and requires very little maintenance, if at all. Anybody ever challenged this with hospital or health system administration? If so, how did it go? I think we need to start demanding at least the basics as clinicians.

I'm watching through old episodes of ER and I'm laughing at and being reminded of some practices that have thankfully been retired, such as spinning crits, not being allowed to paralyse in ED for RSIs, and the heavy reliance on x-ray imaging for things we now rely more on CT imaging for.

What do you remember from 20-30 years ago that we no longer do, either because it's been replaced by something better or because it was just a bad idea in the first place?

This was such an unexpected answer from the defense expert.

Kambat v. St. Francis Hosp. 678 N.E.2d 456 (N.Y. 1997)

In August 1986, defendant physician Ralph Sperrazza performed an abdominal hysterectomy on decedent, Florence Fenzel, at defendant St. Francis Hospital. Ten laparotomy pads were marked and available for the operation, and Dr. Sperrazza placed several of these pads in decedent's peritoneal cavity, next to the bowel, during the surgery. The patient was unconscious throughout the procedure.

In the months following the operation decedent’s condition was at first unremarkable. Eventually, however, she began to complain of stomach pain, and on November 30, 1986 X-rays taken at another hospital revealed a foreign object in her abdomen. On December 5, a laparotomy pad measuring 18-by-18 inches—similar to those used during the hysterectomy—was discovered fully or partially inside decedent’s bowel, and it was removed by Dr. Robert Barone. This finding was so unanticipated that a photographer was called to document it. Decedent’s condition continued to deteriorate, and she died on December 29, 1986, from infection-related illnesses.

Plaintiffs, decedent’s husband and children, commenced this medical malpractice action against Dr. Sperrazza and St. Francis Hospital, alleging that defendants were negligent in leaving the laparotomy pad inside decedent’s abdomen. At trial, plaintiffs presented evidence that the pad removed from decedent was the same type and size as those supplied to St. Francis Hospital in 1986 and commonly used during hysterectomies. Plaintiffs also adduced testimony that the pads were provided only to hospitals with operating rooms, where patients would not have access to them.

Plaintiffs called three expert witnesses, who disagreed as to the precise abdominal area where the pad was discovered. Two experts testified that the pad was both partially inside and partially outside decedent's bowel. A third testified that the pad had originally been left outside the bowel, in the peritoneal cavity, where it caused an abscess to develop outside the bowel, which in turn created an artificial opening through which the pad had migrated into the bowel. According to this expert witness, the pad was completely within the decedent’s bowel when removed.

In response, defendants introduced evidence that standard procedures were followed during the operation, and that the number of sponges, medical instruments and laparotomy pads used and removed were counted several times, carefully and accurately. Defendants’ experts, moreover, opined that the pad had not been left inside decedent but, rather, that she had swallowed it. According to defendants’ witnesses, laparotomy pads were frequently left in places accessible to patients in hospitals; decedent suffered from chronic depression; overuse of sleeping pills could suppress the gag reflex and permit her to swallow the pad; and the human gastrointestinal tract would allow the pad to pass to the small bowel. Plaintiffs’ expert witnesses, by contrast, agreed that it would be anatomically impossible to swallow the laparotomy pad or for a swallowed pad to reach the bowel.

I can't imagine the kind of mental gymnastics the defendent experts would have to go through to make an argument like that.

I work inpatient with several other PAs for a subspecialty service, inpatient only. It’s a high complexity specialty and we constantly deal with consultants and have our own big team. Teams are made up of attendings, fellows, residents, other PAs, and various other roles including specialty nurses, pharmacists, etc. I will say, at least half of the other PAs, my groups’ attendings, RNs and pharmDs, I am extremely lucky to consistently get along with well.

Which brings me to what we could call “the other half.” PAs with shall we say more challenging personalities, residents and much less commonly attendings on other services with egos the size of the large charting room I spend half my day in (surrounded by colleagues)… it feels like some of these people are just constantly on the hunt to pick a petty argument, one up me in a way that isn’t helpful for patient care, or find an inventive way to be snarky in a chat they were added to where I thought I was previously free to talk candidly.

I’ve been a PA a long time. So I know navigating personalities while managing sick patients is as much of the skillset as knowing how to perform a difficult procedure or unravel a diagnostic dilemma. But unlike those things, which get easier with years of practice, there still are people who rub me the wrong way, no matter how many of them I’ve dealt with.

I work long shifts, and for the most part, having worked in many settings, I’d say I’m lucky to get along with people pretty well. But at the end of the day, a challenging personality can feel worse than a bad patient outcome, a day in the weeds, a mean patient and demanding family member all put together.

Share your advice, vent, victories, defeats, any and all thoughts on the matter. I want to hear it.

Restrictions on prescription opioids were immediately followed by increases in heroin overdoses.

Crackdowns on heroin were immediately followed by increases in fentanyl overdoses.

Increased penalties for fentanyl analogues were immediately followed by the emergence of novel opioids and adulterants, as well as increases in fentanyl overdoses.

States that criminalized the tranquilizer xylazine, a common opioid adulterant, saw medetomidine, an even more dangerous tranquilizer, emerge with force.

Drug scheduling and criminalization has never made the street drug supply safer. And yet lawmakers keep relying on it.

https://www.whatsitlike.me/failed-strategy-drug-supply-safer/

You are 26 years old, and you watch your mother die of prion disease.
You test positive for the gene.
It's not really a matter of if you succumb to the same fate, but a matter of when.
What's a girl with a law degree to do?

Fuck law. Biomedical research it is.

She makes it her life's mission - a race against time to find a cure.

A new drug candidate designed to slow the progression of prion disease is entering a phase 1 clinical trial, which will evaluate the potential medicine for safety and tolerability.

Read more here.

It's too soon to say if we'll be privy to a great feat in human history, thanks to Dr Sonia Vallabh and her team.

But you can't blame a guy for being optimistic. The results we've seen so far (and I know it's very early) are more promising than anything we've seen at all. It's prions, after all.

Pending the results of these trials, we may have the most promising treatment against prion disease, and the only treatment in human history against an entire class of this disease at all.

We may have our first weapon against the prion.

Her team is dedicated to keeping their findings completely open source. There is already another drug trial based off of her work undergoing with Ionis Pharmaceuticals with their drug ION717.

“Standard drug development is, for all sorts of reasons, not well set up to be a learning system,” Vallabh said. “But we can’t afford to treat each shot on goal as a self-contained unit – everything needs to feed the mission. I wish the absolute best for this exact molecule, and I also know that however it performs in the clinic, this experience must move us forward. It’s our job to figure out how.”

What a champ.
We'll have a few metrics to compare.
Here is a link to her AMA she did over 10 years ago for those curious.

I've been rooting for her since I was a teen. Keep her and this trial in your hearts.

It's time humanity got its revenge on the prion.

...and likely nuke any setups where you have a work laptop connected to WiFi that you open Epic/Cerner/whatever with via Citrix or another app.

That may not last forever but at the current pace I do think we'll have at least a period of it incoming. I'm not the biggest AI doomer but the number of possible security vulnerabilities is huge. Right now the "no security guard rails, locally hosted" AI space is better than it was a year ago, it can crack your TV's operating system to remove bloat, but it will only get better. I'm sure commercial systems like Anthropic could very easily cause enough of a problem to make any of our hospitals go back to paper charts for a time, but they're heavily safeguarded. The ones that aren't will catch up.

It seems likely to me that at some point here soon some random hospital system will get hit with a vulnerability that accesses HIPAA-privileged information, it'll get patched, then another will get hit, and we'll go full intranet for a time.

The other security implications are all of the EMR->INTERNET access points, like CareWeb/IHIE and the myriad of likely poorly secured AI services that integrate into EMRs. As much as I love my AI scribe I anticipate that getting halted at some point in the not so far future.

The biochemical reality of mammalian sustenance reveals a fascinating labyrinth where nutrition meets neurochemistry.

When we examine the enzymatic cleavage of bovine beta-casein within the gastrointestinal tract, we observe the liberation of specific exorphins, notably beta-casomorphin-7.

These bioactive peptide sequences possess a structural affinity for mu-opioid receptors, sharing a molecular kinship with endogenous endorphins and exogenous narcotics. Yet, to leap from receptor binding to clinical addiction in adult human consciousness is to misunderstand the profound filtering mechanisms of our biological body.

In the neonate, these mild opiate-like signals serve an evolutionary imperative, reinforcing nursing behavior and creating a tranquil neurochemical feedback loop during early development.

As a ordinary nobody my observation is, adult blood-brain barrier and systemic enzymatic degradation pathways, including active dipeptidyl peptidase activity, act as vigilant gatekeepers.

Systemic administration studies demonstrate that circulating fragments lack the pharmacokinetic velocity and concentration required to hijack the mesolimbic reward circuitry in the manner of true psychotropic agents.

While the lexicon of molecular neurobiology reveals opiate sequences hidden within our daily bread and cheese, human primates neural architecture remains remarkably adept at translating these nutritional inputs into metabolic reality without succumbing to chemical enthrallment.

🙏

https://pmc.ncbi.nlm.nih.gov/articles/PMC11085506/?hl=nl-NL

MedPage Today

Annals of Internal Medicine and the accompanying editorial

___

Interpretation

The study authors did not actually check for hallucinations/errors/omissions nor the time spent editing notes in Heidi before transferring them to the EHR (presumably EPIC used by BIDMC). They also could not quantify how many patients refused AI scribing nor reliably differentiate between AI-generated and clinician-written notes.

With an absolute difference of -2.4 minutes per note opened in the EHR, over a 20-patient day, this would be about -48 minutes per clinic day on average.

With an absolute difference of +333 characters before and after Heidi implementation (and presuming 5-6 characters per letter with spaces included), this roughly translates to 55-70 additional words per note.

There was no significant difference in the number of days with all notes signed by the end of the day nor the RVUs produced.

I will soon be taking overnight call. I'm looking for a watch that will vibrate for the duration of a call so that I can be woken up and go to the other room (without waking my partner). I bought a Garmin venu4 but didnt realize you cant control the vibration intensity or duration and it stops vibrating after just a few seconds. I'm also open to other suggestions if people have them (I have an android if that makes a difference).

https://timesofsandiego.com/education/2026/10/25/uc-san-diego-sent-hundreds-of-dead-bodies-to-the-military-families-say-they-never-knew/

EXCERPT (click on link for full article):

According to records covering April 2024 to December 2025, UCSD loaned 517 donor bodies — over half, 273, went to the Department of Defense — the university has not yet released records of transfers outside this period.

The military received more cadavers from UCSD than any other organization, whether a university or private facility. 

Despite this, UCSD’s body donation forms, obtained by Times of San Diego, make no mention of the program’s ties to the Department of Defense.

our multi-provider clinic has been dealing with constant turnover in the billing department, and more than 20% of our outstanding ar in now over 90 days old. we're considering outsourcing, but the partners are split between hiring someone local and going with a larger remote rcm team. the local option sounds appealing because we could meet face to face, while the remote providers seem to offer broader specialty coding and denial management resources. for those who've evaluated medical billing services near me versus national firms, what mattered most in the final decision? i'd be interested in actual reporting access, aged or recovery plans, coding credentials, service-level agreements, and how difficult it is to get a real person involved when a payer issue escalates.

Never knew this before and no cardiologist or nephrologist has ever mentioned this to me as far as management goes. Read this on uptodate on the article "Causes and treatment of refractory edema in adults":

Benefit from a supine posture — Diuretic responsiveness can be influenced by posture, although the effects of posture have not been specifically studied in patients with refractory edema. Patients with heart failure, for example, cannot increase cardiac output normally with assumption of an upright position. As a result, kidney perfusion and presumably urinary diuretic delivery further diminish. In addition, renal salt and water reabsorption increase.

The efficacy of assuming a supine position was evaluated in a randomized trial of six patients with heart failure and six with cirrhosis and ascites [59]. After staying in bed overnight, the patients were treated with 1 mg of bumetanide IV and then assigned to either continued bed rest or normal daily activity for the next six hours. The procedure was repeated two days later when each patient was assigned to the opposite group. The supine position was associated with higher mean creatinine clearance (100 versus 66 mL/min) and diuretic response (1133 versus 626 mL at six hours). The upright position was associated with significant increases in plasma norepinephrine, renin, and aldosterone.

Has anyone used this principle to augment diuresis in their patients? I would think that putting the already immobile anasarca patient in a bedbound/supine position isn't going to be beneficial in the long-run if they're going to get deconditioned by the time of their discharge.

I asked this question in r/nursing and the range of answers have been interesting.

I live in NYC - my coworkers are mainly liberal. All the 100% anti-COVID vaccine employees were let go/resigned when the COVID vaccine first came and was mandated.

I still get my yearly COVID booster, and I've gotten it every single year. The vaccine-related reactions suck (I usually get chills/myalgias about 8 hrs after administration, and that then lasts for several hours), and I have to make sure I don't work the next day when I get it, but I 100% prefer feeling icky for a bunch of hours rather than chancing a case of COVID that's more than mild.

It's required flu vaccine season. My hospital does not require yearly COVID boosters. When I listen or ask my nursing colleagues about the booster, many of them are outright against it or just don't care for getting it. It surprises me because - again - we're all pretty liberal.

So: what are your thoughts on receiving the COVID booster yearly? Why do you get it? Why do you not get it? What do your colleagues think? Why do they get it or not get it?

It's been nearly a decade since one of the most inflammatory papers in the history of geriatric medicine/palliative medicine was published. No one man has angered nurses in the United States more than Dr Miller SM "The Death of the Kennedy Ulcer"

which prompted this scathing reply "The Terminal Kennedy Ulcer - Alive and Well" by Joy E. Schank, a boots-on-the-ground figure in wound-care research (SCALE panel).

For those unacquainted with the discourse:
The Kennedy Ulcer is a enigmatic pressure sore that appears at the end of life. It is often pear/butterfly/horse shoe shaped and near the buttocks/coccyx/sacrum area. It cannot be prevented, no matter the measures taken, it is simply a sign the patient has approached irreversible stage of EOL.

Miller claims that this is pseudo-scientific and there is no definitive empirical evidence that such an ulcer exists. He claims it is figment of imagination, one partial to the pockets of hospital admin and share holders. They are simply pressure ulcers that arose from insufficient care to prevent the formation.

What's your take?

Here is a partial review for your reading to help inform your perspective - https://pubmed.ncbi.nlm.nih.gov/30933013/

I take a few issues with it, but I'd like to hear from the health care community.

If you have any.

What do you think is currently a matter of practice preferences that is going to change into a standard recommendation across the board?

Lots of debates on management, but I'm curious about different perspectives in different fields.

Anything you're calling now?
Have you been right about anything in the past? I've been right about pain management in IUD insertions. Quite chuffed.

My own prediction atm is HSV-1 symptom management. I know, spicy.
Only clinicians who I find share my sentiments are ophthalmologists. They're quick to write a valacyclovir script.

I'm in Aus - not sure how yanks do it, but most pts I run into are not aware the drug exists and can be taken proactively. They are very happy to find out. We can destigmatise without minimising the issues, IMO.

We hand out masks and anti-viral medication. Especially for street medicine - lots of opportunistic impetigo from untreated outbreaks.

curious to hear yours!

https://www.beckershospitalreview.com/finance/administrative-savings-alone-will-not-be-enough-mass-general-brigham-cuts-more-jobs-amid-300m-budget-shortfall/

MBH is still what I think of when I hear MGH. I'm particularly aware of this because I was part of a layoff when my hospital closed multiple clinics and service lines earlier this year, but my jaw dropped to see it happening at Mass General-Brigham too. This isn't just the rural hospitals and public hospitals, but the Goliaths also.

https://www.instagram.com/reel/De2lKYnhJGy/?mdxt=MXNzajFnZjN6MTJxdg==

No physician and it seems the injectors are unlicensed with the exception of the PA owner and are doing these various procedures to people. The other video of them doing face lifts seems off to me as well.

This was something I had thought about when discussing denials of coverage but never looked into (not that it matters much to me since nothing I order in the hospital gets denied).

In Aetna Health Inc. v. Davila, 542 U.S. 200 (2004),

Respondents both suffered injuries allegedly arising from Aetna’s and CIGNA’s decisions not to provide coverage for certain treatment and services recommended by respondents’ treating physicians. Davila’s treating physician prescribed Vioxx to remedy Davila’s arthritis pain, but Aetna refused to pay for it. Davila did not appeal or contest this decision, nor did he purchase Vioxx with his own resources and seek reimbursement. Instead, Davila began taking Naprosyn, from which he allegedly suffered a severe reaction that required extensive treatment and hospitalization.

Calad underwent surgery, and although her treating physician recommended an extended hospital stay, a CIGNA discharge nurse determined that Calad did not meet the plan’s criteria for a continued hospital stay. CIGNA consequently denied coverage for the extended hospital stay. Calad experienced postsurgery complications forcing her to return to the hospital. She alleges that these complications would not have occurred had CIGNA approved coverage for a longer hospital stay.

Apparently under ERISA (Employee Retirement Income Security Act of 1974), state law claims that conflict with federal employee benefit rules are "preempted" (overridden) such that patients cannot sue employer-sponsored health plans for tort damages (such as pain, suffering, lost wages, or wrongful death) resulting from a bad coverage decision.

Exceptions to ERISA preemption include

• any insurance not subsidized by a private employer
• individual health plan policies or self-paid plans
• government employee plans (insurance provided to federal, state, or local government employees)
• church-sponsored plans
• government programs (Medicare, Medicaid, VA)

I don't know what the takeaway is: don't get employer-sponsored plans?

New attending looking to make a big boy purchase on a mattress, any recs for one that’s comfy and helps you sleep with the crushing weight of your questionable decisions and mistakes?

Dear fellow dermatologists of Reddit,

I would like to purchase a 308 nm excimer device for my practice, and I’d love to hear your recommendations.

Which devices have you had good experiences with in terms of efficacy, reliability and maintenance? What should I look out for before making a purchase?

I’d really appreciate your advice!

I'm having a hard time counseling people to the risks and benefits of tx with all of the conflicting studies out there. It's hard to give people even a 2-sentence answer about what the data shows. It's driving me crazy....

It was an interesting read on an older malpractice case involving informed consent. It's standard practice these days to discuss all the possible adverse outcomes of a procedure, even if rare, but seems like it wasn't the case back in the days.

Largey v. Rothman, 540 A.2d 504 (N.J. 1988)

In the course of a routine physical examination plaintiff’s gynecologist, Dr. Glassman, detected a “vague mass” in her right breast. The doctor arranged for mammograms to be taken. The radiologist reported two anomalies to the doctor: an “ill-defined density” in the subareola region and an enlarged lymph node or nodes, measuring four-by-two centimeters, in the right axilla (armpit). The doctor referred plaintiff to defendant, a surgeon. Defendant expressed concern that the anomalies on the mammograms might be cancer and recommended a biopsy. There was a sharp dispute at trial over whether he stated that the biopsy would include the lymph nodes as well as the breast tissue. Plaintiff claims that defendant never mentioned the nodes.

Plaintiff submitted to the biopsy procedure after receiving a confirmatory second opinion from a Dr. Slattery. During the procedure defendant removed a piece of the suspect mass from plaintiff’s breast and excised the nodes. The biopsies showed that both specimens were benign. About six weeks after the operation, plaintiff developed a right arm and hand lymphedema, a swelling caused by inadequate drainage in the lymphatic system. The condition resulted from the excision of the lymph nodes. Defendant did not advise plaintiff of this risk. Plaintiff’s experts testified that defendant should have informed plaintiff that lymphedema was a risk of the operation. Defendant’s experts testified that it was too rare to be discussed with a patient.

Plaintiff and her husband ... advanced two theories of liability. … They claimed that they were never told that the operation would include removal of the nodes and therefore that procedure constituted an unauthorized battery. Alternatively, they claimed that even if they had authorized the node excision, defendant was negligent in failing to warn them of the risk of lymphedema and therefore their consent was uninformed.

It was also interestingly noted what the proper standard is for obtaining informed consent

the proper standard is one that focuses not on what information a reasonable doctor should impart to the patient (the “professional” standard) but rather on what the physician should disclose to a reasonable patient in order that the patient might make an informed decision (the “prudent patient” or “materiality of risk” standard).

Perhaps the strongest consideration that influences our decision in favor of the "prudent patient" standard lies in the notion that the physician's duty of disclosure "arises from phenomena apart from medical custom and practice": the patient's right of self- determination. Canterbury, supra, 464 F.2d at 786-87. The foundation for the physician's duty to disclose in the first place is found in the idea that “it is the prerogative of the patient, not the physician, to determine for himself the direction in which his interests seem to lie." Id. at 781. In contrast the arguments for the "professional" standard smack of an anachronistic paternalism that is at odds with any strong conception of a patient's right of self-determination.

Edit: There are some comments indicating that it would be impossible to disclose every risk. To this the court said this

A second basic justification offered in support of the “professional” standard is that “a general standard of care, as required under the prudent patient rule, would require a physician to waste unnecessary time in reviewing with the patient every possible risk, thereby interfering with the flexibility a physician needs in deciding what form of treatment is best for the patient.” Ibid. (footnotes omitted).

The breadth of the disclosure of the risks legally to be required is measured, under Canterbury, by a standard whose scope is “not subjective as to either the physician or the patient,” id. at 787; rather, “it remains objective with due regard for the patient’s informational needs and with suitable leeway for the physician’s situation.” Ibid. (emphasis added). A risk would be deemed “material” when a reasonable patient, in what the physician knows or should know to be the patient's position, would be “likely to attach significance to the risk or cluster of risks” in deciding whether to forego the proposed therapy or to submit to it. Ibid.

The court in Canterbury did not presume to draw a “bright line separating the significant [risks] from the insignificant”; rather, it resorted to a “rule of reason,” id. at 788, concluding that “[w]henever non-disclosure of particular risk information is open to debate by reasonable-minded men, the issue is one for the finder of facts.” Ibid. The point assumes significance in this case because defendant argues that the risk of lymphedema from an axillary node biopsy is remote, not material. Plaintiff’s experts disagree, contending that she should have been informed of that risk. Thus there will be presented on the retrial a factual issue for the jury’s resolution: would the risk of lymphedema influence a prudent patient in reaching a decision on whether to submit to the surgery?