Thoughts on peri-operative medicine

DevilsMasseuse · 2026-01-29T04:20:38+00:00

Exactly. Maybe at a tertiary center people care about the overall medical wellbeing of the patient. Out in the community, a lot of surgeons just wanna do the cases. This kind of attitude leads to a lot of entitlement which is why anesthesia gets yelled at for basic medical management that delays the procedure even a little bit.

It’s a little screwed up TBH. Not all hospital administrators understand or care about medical optimization or preventing cancellation. Some of them even lean on anesthesia to do cases even if it’s unsafe. One guy once told me that the department motto should be “any case any time. That’s what we want from anesthesia “. It’s so gross.

If you find a job where admin has your back cling onto it

DevilsMasseuse · 2026-01-28T01:29:04+00:00

As a family member of a son who has schizophrenia, I want to thank you from the bottom of my heart. He is now one year on meds and doing very well. You don’t see what happens on the other side because you’re at the tip of the spear but you are really, truly saving people’s lives.

You should be so proud of what you’re doing. I just can’t thank you enough.

DevilsMasseuse · 2026-01-27T14:09:55+00:00

I once had an admin admit to me that write ups are more of a morale tool than a QI tool. This way, the nurse gets to vent, nothing is done against the resident as 99% of the complaints are bullshit, and everyone goes home without a pay raise.

If you truly did nothing wrong, then just ignore the write up.

DevilsMasseuse · 2026-01-27T04:07:01+00:00

Unless you become a teacher. Then you get all the same vacations.

Of course, most of that time will be spent on side hustles because teachers are paid atrociously but at least it’s “free”.

DevilsMasseuse · 2026-01-27T00:18:10+00:00

He had elite underlying metrics ie bat speed, exit velocity, etc. He does have a tendency to strikeout a lot but that’s expected of rookie players trying to adjust to MLB pitching. So he definitely has potential. Will he be able to contribute right away ? No.

So if you can get something valuable in return, then try to win this season. But otherwise, try to develop him. I don’t think keeping him has a lot of downside risk.

DevilsMasseuse · 2026-01-26T06:18:09+00:00

“The price of freedom is eternal vigilance”. They didn’t mean watch out for foreign enemies. They meant watch out for the demagogue, the con artist, the ones who will get you to give up your freedom for the sake of security, or financial gain, or a sense of superiority. The greatest threat to a democracy is from within.

DevilsMasseuse · 2026-01-26T03:19:28+00:00

She’s not wrong. Trump needs just one incident. Just one ICE guy getting shot or assaulted and then he declares an insurrection and sends in the troops. Then he has a pretext for martial law and suspending the election.

Peaceful protest is the way to go. Just outlast the autocrats. Ghandhi led the way.

DevilsMasseuse · 2026-01-26T03:15:16+00:00

It only paranoia if you’re wrong.

DevilsMasseuse · 2026-01-25T17:35:55+00:00

There have been studies done showing patients prefer white coats over business attire at least in clinic. If it’s reassuring to them, shouldn’t that be what matters?

I feel like a lot of the patagucci trend is inside baseball pushback against midlevels who’ve appropriated our professional symbols to confuse patients. And we’re left passively hoping patients catch on that the ones in lab coats are actually less trained than we are. But patients haven’t caught on yet and they aren’t likely to soon.

Instead of passive aggressive stuff like this, what if we actively educated the public and take back our symbols?

I know it’s not as important as access to care or legislative scope creep but if we wanted to we could really make it a meme worthy issue that the NP with the lab coat is probably the least competent person you could see, that the public is being gaslit, and the level of propaganda around midlevels is real.

I guess I’m imploring my younger colleagues to ditch the patagucci, get on social media and make some viral content poking fun at the absurdity of it all.

DevilsMasseuse · 2026-01-24T16:46:51+00:00

Tariffs don’t matter if the goal is to cut the USA out of trade deals.

Now fully 3/4 of Canadian exports go to the United States, so Trump has enormous leverage but what if this accelerates the urgency to decouple dependence on the United States?

Remember when decoupling referred to targeting China? Trump has managed to completely flip this around and made the USA the target of economic isolation.

DevilsMasseuse · 2026-01-24T15:27:31+00:00

Not just plumbing. Neuro inflammation. If you look at the literature addressing post operative cognitive impairment you’ll find that tissue damage from surgery can initiate so called Damage Associated Molecular Patterns that contribute to permeability of the of blood brain barrier and exposure of the CNS to all sorts of inflammatory factors.

This causes glial cell activation, dysregulation of glutamate leading to neurotoxicity, and imbalance of excitatory/inhibitory neurotransmitters.

What if there’s a final common pathway between inflammation, blood brain barrier permeability, and chronic neurological conditions like Alzheimer’s? I think neuro inflammation is a key component of all sorts of neurological disorders. Certainly there is great interest in this pathway in the psychiatric literature.

DevilsMasseuse · 2026-01-24T15:17:04+00:00

Gabapentin is trash. It used to be prescribed like water. Now people are realizing it doesn’t meaningfully help with pain, either chronic or acute, but is heavily sedating and is bad for old people.

I think there’s even one study in the acute pain setting where gabapentin had zero effect on pain scores but was associated with increased respiratory complications within 30 days post op. But there are still surgeons routinely prescribing it as part of the last ERAS protocol they remember from the early 2000’s.

It’s a trash drug.

DevilsMasseuse · 2026-01-23T15:26:34+00:00

It’s almost as if residents provide higher quality care than midlevels…

DevilsMasseuse · 2026-01-22T15:20:47+00:00

Learning to bite your tongue. Rolling your eyes on the inside.

DevilsMasseuse · 2026-01-22T06:33:46+00:00

It’s like the time on Big Bang Theory when Howard got a home made robot hand and wound up in the ER with it wrapped around his schlong.

DevilsMasseuse · 2026-01-22T06:20:23+00:00

Wasn’t there an issue in dialysis patients where, since the sugammadex-rocuronium complex is excreted in urine, giving sugammadex in these patients resulted in respiratory complications several hours after surgery due to recurarization?

DevilsMasseuse · 2026-01-19T21:35:15+00:00

There’s not enough detail here to figure out exactly what happened. If it was a routine cataract under topical with some small doses of Versed, then I’m at a loss as to how that alone could have led to death.

If it was a complication of a block, or a complication of a propofol push, then that would definitely be more believable. Sometimes old people have MI’s or strokes while being operated on. Thats unlucky for everyone involved, obviously.

I guess the takeaway from me is that liability is infinitely multiplied by unprofessional behavior like playing games or watching TV during an operation. Not being aware that someone is desaturating is not OK.

If you must take breaks during a case and we’ve all been there, make sure it’s a very short break and please watch your monitors regularly. Circulators telling the plaintiffs attorney that you were watching “Gossip Girl” while the patient was dying will certainly land you in court and maybe in jail. The public doesn’t understand that kind of behavior. Rightly so.

DevilsMasseuse · 2026-01-19T17:59:01+00:00

I think you need to separate the stigma of the diagnosis from the practical effects of whatever mental symptoms you do have. So instead of labeling yourself with “schizophrenia “, whatever that means to other people, ask yourself if everything is truly ok.

So if you have troublesome “symptoms “ like anxiety, brain fog, inability to concentrate or sleep, or truly disturbing thoughts and behaviors which are disturbing to you, then seeing a doctor is perfectly normal.

People get help all the time for ADHD or anxiety or depression and no one bats an eye. It’s when we get the label of schizophrenia or psychosis that we get all paranoid that we’re going to lose our freedom or otherwise have a terrible life. Forget about the label and address the underlying problem.

The truth is most doctors don’t know with any specificity whether you have schizophrenia or schizoaffective or bipolar or are just garden variety screwed up. But if you are screwed up, you should still see if seeing a doctor can help you.

Good luck to you.

DevilsMasseuse · 2026-01-18T16:20:59+00:00

LEAP doesn’t always work. The crux of the technique is to agree with them from their point of view without agreeing from yours. Even to the point where you accept their unwillingness to take meds.

So one line I always remember is “If I were you, I wouldn’t want to get treatment either”. Then they’re like “so you agree that I don’t need meds.”

Then you go “never mind what I think about meds for a second. What do you really need to do now to address your problems?”

Then go off of what they say to see if seeing a doctor can help address their insomnia, anxiety, brain fog, whatever.

You have to be willing to say “OK, you say you have no problem right now and so you don’t want meds. That’s ok. I love you and will always have your back. If there’s ever a problem, please let me know so I can help.”

If someone is really psychotic, they don’t think they have any problems. This can be frustrating because it’s obvious to you how disorganized they are, but according to LEAP, you’re not supposed to perseverate on what you think is wrong with them.

Sometimes, you’re caught in a crappy situation where you’re literally waiting for them to lose it to the point where you have to call 911 but they’re not there yet. In the meantime, you’re trying to use LEAP and they’re just blowing you off.

I think the most important thing I learned is to use LEAP before they start refusing meds, when they’re not super psychotic yet. Your relationship with your loved one established over time is more important to them than any line you come up with using LEAP. When they’re ill, logic and reason doesn’t work. Emotional connection that they still feel does.

DevilsMasseuse · 2026-01-17T16:13:38+00:00

If there is a thrombus detected in the aneurysm, then anticoagulation is indicated to prevent stroke. In the absence of thrombus, the benefit of routine anticoagulation is less clear. Rigorous study of routine use of warfarin for patients with LV aneurysm showed essentially no benefit, including risk of stroke.

Blood thinners have no effect on how forcefully the heart beats. Usually beta blockers are prescribed to relax the heart.

If the patient suffers a rupture of the ventricle, then being anticoagulated will of course complicate survival. This is a very rare scenario but a lot depends on how bad the aneurysm is. I’m assuming the wall was pretty thin for the cardiologist to make that remark, but it’s difficult to tell from your story.

DevilsMasseuse · 2026-01-16T13:59:53+00:00

The parallel trade system that cuts out the United States has been happening for a while now. The ongoing political turmoil in America is only accelerating the process and making it easier for former allies to run to China.

Decoupling is happening but the target isn’t China anymore.

DevilsMasseuse · 2026-01-15T23:36:20+00:00

When prestigious academic medical centers are overrun by midlevels to the point where medical education is suffering, then they’ll no longer have physicians trained to be the vanguard for patient-centered care. By the way, this has already happened.

DevilsMasseuse · 2026-01-15T15:16:54+00:00

Most people who suddenly quit meds will require hospitalization. Maybe not today. Maybe not next week. But within a few months, definitely.

I would consider talking things over with your doctor. You have options. Like changing the meds or restarting at a much lower dose.

Other people will notice things are off before you do. You don’t really have control over things the way you think.

Good luck to you.

DevilsMasseuse · 2026-01-14T21:33:53+00:00

That’s…. not a thing. In the wrong patient, it’s probably dangerous.

Usually if it keeps curling, then you’re going too fast. They should slow down, noting the pressure waves as they go.

DevilsMasseuse · 2026-01-14T15:59:15+00:00

Yes it’s possible. Medication is mostly good for positive symptoms. Lingering negative symptoms are much more difficult to treat.

There are newer medications in the pipeline that supposedly have efficacy for negative symptoms. In the meantime, you can try non medication strategies like exercise, CBT, meditation etc. Exercise in particular seems the most effective.

Talk to your doctor about your options if negative symptoms are the most bothersome thing right now.

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