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.

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?

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.

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/

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.

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

I can recount how many "doctors" in this sub have become the William Lane Craig, Gary Habermas, Wes Huff, and Lee Strobels of AI, be it generic AI like Claude, ChatGPT, or Gemini. Or even the likes of Open Evidence. The way big tech presented Gen AI to the world, they promised so much but delivered too little much like religions and cults. And it is not a good thing.

I can go on right now and I am currently elbows deep on several history books and papers but the bottom line is that Gen AI be it the commoner AI like Claude or medical AI like Open Evidence will likely never get better simply because of the fundamentals of how it works. Not to mention even relying on simple tasks to Gen AI like brainstorming a differential diagnosis is already causing you cognitive debt. That doesn't include things like neocolonialism where big tech and the American government are plundering the natural resources of other countries just to make sure Timmy won't stop generating slop food truck posters, or that an AI is there to generate differential diagnosis for you instead of thinking it yourself.

Edit: and just like that the comments prove my point, AI has become a religion and it has proven my point that many of you have became its many apologists. What a shame.