Josh Davis
@MedFactChecks
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EM doctor, personal trainer/fitness instructor, research nerd -- views here are my own and are not medical advice
Joined April 2020
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LINGORM MENTION TO U
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anaerobic coverage is not needed for routine aspiration pneumonia (without abscess etc.). Anaerobic bacteria need an area without oxygen to thrive. Lungs are full of . . . OXYGEN. . . Let alone that most aspiration doesn’t even need Abx
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@EM_RESUS
Lifestyle has a much bigger effect on long term health than medical interventions
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@maraantonoff
@WomenInThoracic
@WomenSurgeons
@AcademicSurgery
@ABCTS_1999
@TSRA_official
@ThoracicStudent
Also unfortunate that you have to clarify “I was dressed professionally”
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Have a surgeon consulted for every jaundice case? 😂
Can you tell this ivory tower guy is out of touch with real world community practice — just a little?
Repeat after me:
1. Jaundice is a surgical disease until proven otherwise.
2. Surgical disease does not mean surgery is necessary or sufficient, it means a surgeon should be involved in the decision making early to help guide workup and management.
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@DuaLipoma
Why does that fall on the ED doctor who has 20 undifferentiated patients in the WR? The ED doctor is responsible for stabilization and disposition. That job has been done. There is no reason to held the patient physically or mentally in the ED and it’s a disservice to the pt.
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Make ED boarding a quality measure tied to reimbursement and it’ll get fixed real quick. I’m pressured to give antibiotics and waterfalls of fluids to hundreds of patients without sepsis because it’s a metric.
Imagine we withheld antibiotics from patients with sepsis...this would be malpractice...bc ppl would die..
And yet everyday patients spend >24hrs in our EDs...also increasing their odds of death
Conclusion: "long stays in the ED should not be allowed"
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@Jubilee4Jesus
Atelectasis is a normal finding and is treated by taking slow deep breaths.
It sounds like the drs actually gave you good evidence badness medical care and the NP did more tests (and associated risks) to give you false hope
That’s what the data suggests as does you’re experience
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This is your routine
#medtwitter
PSA: Please call the ED when sending a patient from anywhere.
It’s a
#patientsafety
issue. Poor communication is a top cause of medical errors every year. Don’t let it be your fault.
Including nurses on triage, PCP, UC, specialists…Everyone!
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@CatDocMD
You know what makes people anxious? Feeling like they can’t breathe or have severe pain bc their having a PE. Or an AMI. Or a dissection. Etc.
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@DShadowgazer
“Patient is in ED. History and exam non contributory. Please rule out all emergencies”
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@Wehave2Bkind
@generalorthomd
I think that’s a perfectly reasonable take and they should be liable for their decisions legally and in reports to the medical board.
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@blondemedSJW
This is US healthcare these days in a nutshell. . . Broken system, hyper focus on useless patient satisfaction tools and invalid “quality metrics”, and lawsuit happy
Like sue the elected officials who keep the system the way it is
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@AndrewJensen2
@kathryniveyy
Critical theorem of emergency medicine
#3
: if your potassium is higher than your hemoglobin, you’re in trouble.
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Wrongest post on the internet today.
Although any blood gas is probably unecessary in most cases, a venous is perfectly fine. And safer, less painful, and preferable to patients. Just bc u don’t like it or aren’t used to it doesn’t make it wrong.
There’s no data ABG is needed
We CANNOT use the carbon dioxide level on a VENOUS blood gas (VBG) to accurately assess the need for BiPap or intubation
Ventilation problems cannot be assessed on a VBG
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@elle_gayar
What a bad take! Not always necessary. Data shows inaccurate and unhelpful (in most instances). Definitely doesn’t need to be done twice in the ED most of the time.
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@FOX29philly
Was this that magical “police targeting” fentanyl the cartels are making that only affects law enforcement despite higher exposure in the suspects?
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@Linherski
@MDaware
The whole concept of how the insurance company (who has a vested interest in not paying for anything) gets to be the final arbiter of these decisions boggles my mind.
#americanhealthcare
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@TraumaSoapBoxes
I recently had a patient yell and curse at a nurse “why can’t they hire more nurses, then”. The answer “because we continually get treated like shit by patients and families”. 😳
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ED boarding needs to be a quality metric and tied to reimbursement!
@First10EM
The problem is, on the hospital side, no one feels the disincentives for boarding other than the ED.
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@ttuhscmed
Where you can learn to be anti science and racist and learn zero evidence appraisal or professional growth skills!
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@GuilfoilPR
OMG 😳 do your homework. This is not how fentanyl works. How did the suspect have no symptoms?
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@joshmcgoo
Wait till these PA “residents” prevent you from getting your required procedures in residency or takes your job. Come back in 5 years when you’ve actually been there and we’ll see . . . Otherwise save the virtue signaling.
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This is about right and probably pretty low actually given our current med mal climate.
Most people would put the testing threshold around 2% for most major diagnoses.
Lawyers would put it at 0%.
Regardless if only 18% have actionable findings they may not be doing enough CTAs
82% of CTA head and neck scans in 1 emergency department had no actionable findings
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@PharmaBlue
I just don’t understand people who have this view??!? Like — if we wanted someone to just fill the rx, we wouldn’t require graduate training to do the job. We could put monkeys or machines in the pharmacy. Pharmacists play a critical role in our “healthcare system” and Pt safety.
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@DGlaucomflecken
And listen if anyone on the team has a concern. May or may not need to be corrected, but never blow it off without listening.
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@ScholerinED
I used to think this wasn’t done and was frustrated by it. Turns out it is done often but often the patient doesn’t “hear” it because they’re not ready to.
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@IM_Crit_
Clearly has failed, but there are a lot of issues with this hyperK treatment — why are we still using Kayexekate in 2022? Insulin 5 equally as effective as 10U, and much safer if AKI. HCO3 not helpful unless acidiotic and 2 Amps overkill. Isotonic drip would be better.
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@DGlaucomflecken
In case you r looking — Slit lamp is supposed to be in a corner but it’s actually in a closet covered in dust and the bulb is burnt out and melted into the socket.
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@SaltyEMNY
I hate this shit. Also I’m relatively confident the patient didn’t actually need any actual “saving” for whatever they came to the ED for if they wrote a comment like that.
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@bfhermann
@CDCgov
@DEAWashingtonDC
Street fentanyl also doesn’t have a dermal absorption mechanism 🙄
Do you really have an MD?
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I wanna make a series of those med mal legal commercials about medical myths and then hit them with the truth:
Like
[big loud narrator]: WERE YOUR KIDNEYS INJURED BY IV CONTRAST IN THE ED?
CALL 554-1234
Then they call and it’s like:
“No they weren’t” [click]
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@anonymousRN12
There’s innumerable false positives and negatives for UDS, which is why they’re rarely helpful and mostly harmful to order for patients. Often ordered just to be judgmental particularly in the ED/inpatient.
Much better to build trust with the patient and do history and exam
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My summary tip on orthostatic vitals: STOP 🛑 checking them. They’re useless. Very little diagnostic accuracy and no data it improves outcomes. Symptoms matter. Vital sign numbers do not.
Summary: tips on orthostatic vitals/hypoTN:
- skip the sitting and check the first standing BP within 1 min
- BP ⬇️ and HR ⬆️ supports low-preload. HR ↔️ supports autonomic failure.
- meds can cause orthostasis or confound VS pattern
- orthostasis often an incidental/asx finding
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@JordyGrewal
My parents: so when you graduate and get your 9-5 job 🙄 (I’m in Emergency Medicine)
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Is there any planned date on when medical professionals will stop sending non-pregnant patients with asymptomatic hypertension to the Emergency Department?
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@olderpets
@EM_RESUS
You can’t. That’s where the word “heartburn” comes from. In the olden days, people with “heartburn” would just drop dead (from their MI)
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@RogueLou18
@arghavan_salles
Vaccination reduces risk of death, particularly for high risk patients like those immunocompromised for transplant. Try reading science and not conspiracy.
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@DuaLipoma
Okay. Then send them there. Currently they are sitting in the ED (probably in the WR) with 10:1 or worse staffing. Getting them a bed and starting them then moving them is better than making them wait in ED.
This is one of the biggest logical fallacies in hospital medicine
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@MattSegar
@UTSWVascular
@UTSW_Surgery
I dunno. If im that intern, I’d get a laugh outta this for a while — but I get that’s not true for everyone.
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@3onyourside
This is so embarrassing for
@3onyourside
. Can you not do basic journalism research? 🤮
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@EKing719
Unclear why you think an ED doctor could not perform equally as well if not better than a plastics trainee. I’m sure they did well, but it could have turned out just as well if done by ED doctor.
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@bbheinz
IM ketamine and stealth retrieval procedure.
I think it’s in Harrison’s if you need more detail?
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Wait till I tell you about the 5-10% of aortic dissections that are painless!!!
I literally lose sleep over this stuff
ICU/ED case: Middle age patient with DM2/HTN/anxiety-depression presented to the ED due to "high glucose readings". Had an almost "pan-positive review of systems". For those not familiar w the term, it means that there are concerns/symptoms from almost every organ system. Due to
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@AaronGoodman33
If only it were that easy . . . Data shows Most EDs are full because of hospital overcrowding. It’s not usually an ED problem. It’s a hospital system problem. The ED is already one of the most efficient places in healthcare.
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@SaltyEMNY
The concept is what is really shocking. Patient is perfectly OK to send home from the office to go get labs the next day and the result 2 days later. But, the second the DIMER results, it is emergent and they must go directly to the ED or they could DIE.
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@RNSuperHero
I mean. . . Who really needs the niceties like neuro checks, meds on time, or patient education. They’re really overrated anyway, right?
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@MontxuLarr
This is dangerous thinking. So many other differentials that are very common.
>11K— or cancer or inflammation or stress or vomiting or steroids/meds
<4.5K — or infection or Duffy-null or meds
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@DrBerk
@SeattleiteLeo
@DrGRuralMD
@pan_accindex
@ModelAyshaMirza
@TTUHSC
@ttuhscmed
This is not one tweet — it’s a clear pattern of misinformation and shaming the profession and the school. If you continue to let him graduate, all Future students from
@TTUHSCEP
will have to defend why they came from an institution with such poor standards and cowardly leadership
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@bfhermann
@CDCgov
@DEAWashingtonDC
I have yet to see a confirmed report of someone who had opioid exposure and toxicity by the method you describe. The exposure by that route is so infintisemly low to even be detected or cause symptoms. These reports are people who have panic attack symptoms not opioid toxicity
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@bfhermann
@CDCgov
@DEAWashingtonDC
HCW handle fentanyl all the time without issue. Where do u work?
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@IM_Crit_
PICC probably okay here too. Less risk than large vein access and you got time once they’re relatively stabilized.
But if you’ve seen limb ischemia from pressor extrav, you’ll never forget it.
It’s the stuff of nightmares.
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@TransNursing
Very clear guidelines against routinely treating HTN in ED unless organ damage. It is a long term, primary care issue
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@mommy97giraffe
@Jubilee4Jesus
It’s actually not ridiculous at all.
CT has lots of risks and atelectasis is literally a common finding whose treatment is to take deep breaths.
It has no associated risks in healthy people.
Now this person has false hope of something that is not causing symptoms
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@GarrettBartonMD
@DrOBrienMD
@SCGOP
@DecentFiJC
You’re disgusting. This is absolutely reality in much of America.
Our community ED definitely sees this.
Just because you choose to ignore it doesn’t make it not true.
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@PhysicianDoodle
@MoxieMixie
So there is an exception for ED and a reasonable time frame to release results. Doesn’t have to be 100% real time. If your institution is doing this real time, that’s their decision to interpret it that way
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@stkirsch
Yes I think the problem is people like you misconstruing data to the public, entering false claims, encouraging misuse of the VAERS system, and fostering misinformation to the public.
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@EMPAthy_atrophy
They purposely scheduled me off on the day of the JCAHO/THC visit because I would have had some select words for them if they said anything even close to that to me.
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@Dallas_Holladay
I’m young and healthy and would likely have surgery and be dc same day. Not true of some higher risk patients. Risk of recurrence with ABX is high, but I would consider if I were, say, traveling out of town or had some life event I wanted to be at so I could delay surgery.
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@RNSuperHero
So many thing wrong —
Let alone it not having to do with nurses
Residents are training and should be supervised.
Why do we have to have a hyper-reactionary culture to every single error? Why not fix the system instead of ban the use of the tool that actually IMPROVES safety?
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@RyanMarino
But what about “my brain on drugs”
It’s not a scrambled egg????!??
You mean the government lied to me??!??
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@oatsdoc
There’s actually evidence this is of no benefit in Emergent basis in most patients and what we’re taught.
When I’m seeing 40 patients in 8 hours and 38 of them only in triage and ICU patients in the WR waiting for beds, it’s not a priority if itdoesn’t change emergent management.
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@ScholerinED
@BurgerKing
It’s weird. The majority of people who are gracious and caring enough to donate their own blood for the goodness of others happen to also be the vaccinated ones.
Couldn’t think of a reason why?
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I literally had this case in residency.
This is why the stroke metrics are hurting patients.
Data now shows antiplatelet as equal to lyrics for non disabling stroke. (This pt needs anticoagulant).
Rushing to lyrics with questionable benefit hurts patients.
Stroke neurologist tip of the day: stroke alert - patient with afib off anticoagulation has sudden onset numbness weakness and pain of the left hand , onset 1 hour prior to being seen. NIHSS 2. Ct unremarkable. Bp <185/110 and sugar 180. No contraindications to lytics. What next?
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When they make ED boarding a quality metric is when this will change
I’d rather that be a metric than than 150 point sepsis checklist or the stroke thrombolysis metrics with little to no evidence
There is such indignity to hallway placement of patients.
It should never be considered normal to have patients at their most vulnerable left in a hallway.
Being in the hospital can already feel dehumanizing without also feeling like you’re on display.
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This is why the UDS is almost always ordered by doctors who want to project their stigma and judgment onto their patient.
If you routinely order UDS and think this tweet is not about you, it is.
Please stop.
UDS is incredibly inaccurate and almost never changes management.
Fun fact: I tested positive on a UDS while pregnant because I had eaten a poppyseed bagel within the last 24hrs. It had been more than 3 years since I had taken an opioid (post knee surgery).
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@mommy97giraffe
@Jubilee4Jesus
People with limited to no medical training thinking more testing is always better is a huge problem in our healthcare system.
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@DxRxEdu
HR and BP are not really static.
It really depends if HR is lowest at 43 or highest at 43.
Really HR in the mid 40s should not normally cause BP drop in most.
But if it’s range is like 35-45 it could be the HR.
I’d use epi as the first line pressor either way though
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@RogueLou18
@arghavan_salles
I’m gonna cite actual data that answers my assertion and not random political graphs. You probably won’t care because you just want to parrot what you’ve heard instead of learn
Strong evidence of mortality benefit.
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Nebulized ketamine is equally effective as IV ketamine for pain control in a small double blind RCT
@SAEMonline
#SAEM23
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@RNSuperHero
The well known religious OB issue “Fiber in the Eucharist”
And the delicious anti seizure medicine “peanut butter balls”
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@pedsmd2b
@Opa_opa_yall
To be fair they actually usually get crappier care including overtesting. They just happen to get their crappier care in a private room or floor with a private nurse and butler
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@mommy97giraffe
@Jubilee4Jesus
She didn’t get any answers. She has no answer for her symptoms. She got an unnecessary test with an incidental finding from a poorly trained clinician.
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@emergcasey
Well — U shouldn’t call them “PA/NP residents” bc that’s just further obscuring their lack of training
Also “providers” — like the term Nazis used to devalue physicians? Now used by private equity to obscure our training?
There’s mult natl guidelines on this
Super sketch of u
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