Open Mic Weekend


I have several posts half-finished and needing some polishing, but just haven’t had the time to get to them lately. That being said, I also haven’t had an open microphone in over a month.

So what medically-related is on your collective minds?

Spout off in the comments section.

Remember to be civil. No ad hominem attacks. And please no politics. I don’t mind discussing political issues as they relate to medicine, but also know that elections are coming up and don’t want to hear attacks on Obama, the Tea Party, or that flying witch lady.

I’ll try to re-group on Monday and respond to your thoughts.


  1. Our institution has been under the threat of a CMS audit for the last several months and they are finally underfoot. Supposedly, all they want to do is ensure that patients are getting appropriate care. However, some of the hoops we’ve had to jump through don’t seem to make too much sense. I mean, how is it harmful to patients for the salt and pepper packets to be kept in the same container? Because of CMS, they now have to be kept separate — with clearly noted expiration dates! It’s this kind of petty garbage that makes me suspicious of CMS’s actual purpose. Personally, I think they want to shut us down so that they don’t have to reimburse us for the vast amount of Medicare/Medicaid patients we treat.

  2. Emergency Mental Health care. I think there needs to be better SOP for this. I want to hear what regular hospitals do (psych ER’s are equipped-but small ER’s etc.) Especially with children.

    • This is a HUGE issue throughout the country. Psychiatric facilities are closing due to underfunding and psychiatric patients can wait in the emergency departments for days before finding placement. Facilities without psychiatric coverage are at the mercy of the facilities that do have such coverage.
      Until some catastrophic event occurs due to the inability of a psychiatric patient to get care, I don’t foresee any changes.

  3. I was working on research for a well known emergency physician. I originally thought I was working on a “public health study”. Somewhere into the study I realized that was not the underlying purpose of the study. The emergency physician/principal investigator is an expert witness in a multi-million dollar court case. He is testifying on behalf of companies that produce a product that causes cancer. He initiated the study to produce research that would support his expert testimony. Certain hospital execs rely on cancer beds to subsidize other departments, and it may impact profitability if companies producing the cancer causing products lose business. Would you continue to work under questionable premises of a study that was initiated to produce research to support the expert testimony for the companies producing the known cancer causing product? Would you say anything about the legally dubious potential bomb? Is the “do no harm” portion of the Hippocratic Oath of any relevance or has the standard changed? Would you not say anything and “forget” about it? Would you do something else? What would you do?

    • I assume you’re talking Tobacco. Do the research, obtaining knowledge is in itself not harmful. It becomes harmful if you lie about it, or if you decide what the results must be before you even do the research.

      The reason for initiating the research isn’t significant unless it is allowed to influence the research results – and that’s a separate ethical breach which the NIH will investigate (and prosecute). If you think that is going on, there are specific whistleblowing provisions in the OSI (Office of Scientific Integrity) rules.

    • I agree with Tarl. The research will help you learn something.
      The problem will arise if you compromise your research to come to a pre-conceived conclusion.

    • OK to tell patients a study is for the benefit of future patients when actually the research will be used to kill future patients?

  4. Superstition in medicine – how can words have an effect on the future?

    “Boy, I had an easy night on call last night” ==> BAM, STEMIs everywhere (are they contagious?) + crashing ward patients + refractory shock on 4 pressors with MAP 40 , pH 7.01, pCO2 90

    “Sure is quiet around here” ==> BAM, waiting room is full

    “My cloud is either black or white” ==> BAM, oh, wait, no pages all night? Is my pager working?

    Was Hippocrates superstitious? When and how did these superstitions arise? Are they found in all cultures? Are there equivalents in other professions?

    • I think that superstitions developed in medicine the same way that they develop in other aspects of our culture. People fall into the logical fallacy of “post hoc, ergo propter hoc.”
      Patients want antibiotics because a Z pack is the only thing that helps my nasal congestion.
      Baseball players don’t shave or wear the same clothing on a hitting streak.
      Craps players pull their bets when a die gets rolled off the table.
      I’m still amazed at that whole Candyman Phenomenon, though. It still happens on a regular basis.

  5. Two little tips for patients that will make your ED doctor love you:

    1) Blood pressure and pulse rates that you measure at home are just numbers. Please be ready to talk in terms of symptoms instead of numbers when you arrive to the ED.

    2) Please don’t try to tell us what you think you have- that’s our job. If we want to know whether this pain is similar to the last time you had X,Y, or Z, we will ask. Otherwise, leave the detective work to us- it’s not a pride thing- we just don’t want to pigeon-hole you into a diagnosis.

    • Both good points, but keep in mind that patients aren’t necessarily well versed in medicine or medical lingo, so by describing a diagnosis to you, they may just be trying to be helpful.
      Just last night, a patient told me that she kept going in and out of “a-fib.” She was trying to describe “palpitations,” but didn’t know the medical term.
      When patients give me diagnoses, I always ask them “What kind of symptoms were you having that made you think that you were having ____?” It usually helps both of us get on the same page.

  6. Instead of cursing ‘Dr. Google’, please suggest reputable sites to your patients. If they weren’t using the Internet, they’d be getting their info from library books, magazine articles, or relatives. Patients who research their maladies (and turn a cold into Ebola) have always been around.

    My doc tried a new med on me, and suggested I go to places like to learn more about it. Most of the sites Google pulled up were from people who believe all meds are evil or who blamed their weight on the med instead of their piehole. It was very helpful.

    • And I would like more sites devoted to symptoms…not diagnoses. If you have a certain symptom, should you go to the ER (I mean ED), Urgent care, your primary care. Should you wait a few days? Etc….etc…

      • You could always call your primary care physician’s office and ask if it was appropriate to wait for an appointment or if you should go to the emergency room. If it’s after-hours, you can do the same thing by calling an urgent care center, but a lot of physicians’ offices have one of the physician’s on phone calls anyway. Just a thought.

  7. I have a question. Have any of the docs that come to this site seen a case of IBC where the patient had no symptoms other than noticing one breast is enlarged? What kind of work-up would you do, in that case? (I am using this for writing a paper.)

    Hormone levels, mammogram, ultrasound, blood tests?

    I am looking at the why and how of the protocols for dx and treatments in some diseases and how it is that one can get a physician to listen when a patient appears more knowledgeable than most and the symptoms don’t follow what is the norm for said disease.

    • I am assuming that “IBC” = invasive breast cancer.
      We don’t do a lot of these workups in the ED, so my personal experience on this front is limited.
      Your best bet would be to check some of the online medical texts for management. Especially and
      Write me offline if I can help.

  8. Yesterday, I picked up a shift in a small hospital in an upper-echelon suburb. At least 50% of my patients had “anxiety” and all of its various iterations as a chief complaint. At one point, I had three anxiety patients at the same time. Yawnnnn….

    I’ve worked at similar hospital before, and it’s seriously all-anxiety, all the time. Why are all these rich housewives and their sons/daughters so damned anxious? You got it good, calm down and be happy about it.

  9. This morning I heard a story on the radio about a town in Ontario voting to stop fluoridating their drinking water. It was a very small majority – 50.3%. I looked it up when I got home, and apparently more and more water sources aren’t being fluoridated and many people feeling the fluoride is “poisoning” their kids despite what research says. Is this the new thimerosal?

    • I would also recommend the website FluorideAlert .

      Loads of links to good journal articles on the subject and testimony from some world-class scientists on the uselessness of continuing to fluoridate drinking water. The practice was born of very bad science.

      It’s the only medicine I can think of that is dosed the same no matter what the weight or age of patient, and without requiring a doctor exam. It is prescribed by your clueless neighbors and administered by water treatment specialists, a fair number of whom are against the practice.

      Water treatment fluorides are not pharmaceutical grade products, they are by-products of manufacturing that would otherwise be disposed of in toxic waste dumps. They are not the same compound used in toothpaste. Google hydrofluosilicic acid or sodium silica fluoride.

      Even the union of the EPA scientists came out against this practice.

      • I meant to emphasize “”.

        The is important because the American Dental Association snapped up the domain to counter those who have the science to kill fluoridation programs.

        So do your research at

  10. I have chronic pain from “real” diagnosised conditions. When I go to my Physiatrists I get to color a bunch diagrams in and use a bunch of pain charts…

    I find those difficult to do. I have chronic pain, so I am generally always in some kind of pain…
    Is that pain at rest, pain after taking a crap load of IBU, after walking 30 minutes, after washing dishes… when having pain that wakes you up?

    I find myself wanting to scream.
    Or put myself averaging between 3-6

    But then I realize that I have slowly been able to do less and less without being in pain.

    I take OTC meds most of the time, and flexeril maybe twice a week.

    What do you think about pain charts… (not my medical issues).

    What is your experience with people who have chronic pain and come in with an acute injury…how do they describe their pain?

    • Personally, I think pain charts are, for the most part, a creation of the clipboard clinicians that has little bearing in clinical practice.
      If you want to see how a single person’s chest pain is responding to treatment, fine. When the clipboard brigade tries to compare pain scores from different people and create some type of data set from it, they are being immensely naive.

      Unfortunately, chronic pain patients are often lumped in with drug seekers because of the subset of people who use complaints of chronic pain as a means to obtain narcotic pain medications. Pain complaints tend to show up as a bright blip on the radar in most emergency departments. I think that most patients with chronic pain realize this fact and are therefore unlikely to come to the emergency department unless their pain is extreme … and this is coming from someone who has chronic pain. By that time, the patients don’t have to “rate” their pain. Any provider worth a darn is pretty good at picking out patients in real pain. We get fooled sometimes, but we also have good memories.

      Live with the pain, don’t live for the pain.

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