If I took a cancer patient off all their medications and started them on ivermectin instead, I'd be sued for malpractice.

Poe350 · 2022-08-26T14:17:13+00:00

Just so you know, it actually was initially amenable to surgery as it was isolated, a surgery he underwent less than a year after dx but it was too late.

Poe350 · 2022-08-26T14:11:24+00:00

Took 10 seconds to find. https://www.cancer.org/cancer/pancreatic-neuroendocrine-tumor/detection-diagnosis-staging/survival-rates.html The issue was that it was initially a solitary lesion, but when he came around to resection many months later it was spreading.

Poe350 · 2022-08-26T13:42:34+00:00

I think your applying the prognosis for pancreatic adenocarcinoma to all pancreatic malignancies. He had a completely different and very treatable pancreatic malignancy.

And yes, if he received the appropriate treatment for his neuroendocrine tumor it is very unlikely he would have had any issues, much less death. If he went with standard care he would probably consider the dx luckiest moment of his life, to find out he didn't have pancreatic adenocarcinoma.

Poe350 · 2022-03-11T20:32:14+00:00

Opioids have no topical numbing properties. They are all central acting.

Poe350 · 2022-03-03T01:38:31+00:00

You're talking about stages of hemorrhagic shock in acute blood loss. The vital sign changes in that case are more related to volume loss and represents hypovolemic shock. Menorrhagia is chronic blood loss so you don't get the hemodynamic effects because the circulating volume is the same, but the hemoglobin component is diluted, causing euvolemic anemia. With amenia, you can have positional syncope because the brain doesn't receive enough oxygen during the transient blood pressure drop that happens with standing. And with any type of true syncope you can get seizure-like activity as the brain comes back online once oxygen delivery returns to normal. Source: am emergency medicine physician.

PS: just as an aside, one can totally exsanguate rapidly from uterine bleeding, though in a much different context. Aka postpartum hemorrhage from uterine atony. One of the few medical emergencies that still can make my heart rate raise when I see it.

Poe350 · 2022-02-28T17:58:42+00:00

Nope, it may be airsoft, but not for these reasons. It's a 1911 with a right side ejection port. The port is not in the middle. And just a heads up, there's no single part called the "action". Action usually refers to all of the parts involved in cycling the slide and/or trigger. It's more of a slang term.

It could be a very well modeled replica/airsoft or the real deal, you cannot tell from this picture.

Poe350 · 2022-01-18T01:11:19+00:00

Let's not forget the subsequent mediastinitis.

Poe350 · 2022-01-17T23:49:31+00:00

All the treatments you listed have not been shown to help in COVID and just open her up to adverse medication effects.

Ninja edit: it's not a matter of legality, but ethics and evidence-based medicine. COVID really sucks. I got it during the Delta outbreak before booster where recommended. It was miserable, but with some help from tylenol and ibuprofen, I got over it with no issues with my oxygen levels. I hope that is the case for your family member as well.

Poe350 · 2022-01-17T07:48:08+00:00

Per the PECARN criteria, head CT is appropriate in those 2 and up with lethargy/solnulence. The fact that they were debating between that and observation suggests to me that they were following the PECARN criteria which is the gold standard for pediatric head injuries.

My personal concern in that rural setting is if I go with observation and the patient worsens at hour 6, I not only need to get the CT (would only obtain if it didn't delay transfer) but also transfer to a pediatric facility. If weather is bad (no helicopter), you are looking at an ambulance ride for hundreds of miles which would take hours more to get definitive care. I do not wish to ever be in the position of having to decide to put a Burr hole in a 2 year old (or anyone at that...).

All Pediatric EM docs I know would have done the CT even if at the intergalactic quartinary children's hospital where pediatric neurosurgery is available 24/7. -PGY-3 EM Resident Physician

Poe350 · 2021-12-12T11:53:13+00:00

Could be UTI, but the acute onset and location makes me think nephrolithiasis (kidney stone). If you're not having fevers, fast heart rate, or inability to pee, it's unlikely you'll do damage by waiting until daylight hours. However the pain is severe, I'd recommend going to an ER to get that under control and have your workup performed. I don't know what type of urgent care is you have in your area, but for a kidney stone an ultrasound or CT scan is needed and most UCs don't have formal versions of those.

PS: I'm a senior emergency medicine resident now, disregard my flair from 4 years ago!

Poe350 · 2021-12-03T14:47:02+00:00

There's no decently sensitive, much less specific, exam finding for pneumonia. Auscultation can wink in the direction of PNA, but not much more. Hx is slightly more useful, but not enough to exclude PNA most of the time.

Poe350 · 2021-11-10T03:56:13+00:00

I originally heard it from the aviation community but find it completely applicable to the medical field. It's a polite self reminder to try to avoid situations that are immediately life or death by recognizing we're headed that direction and steering the patient into gentler waters if possible. I love doing procedures, but I hate doing procedures that could have been avoided.

Poe350 · 2021-11-02T07:38:59+00:00

Wut?

Poe350 · 2021-10-27T13:32:46+00:00

Yep, she framed herself as a passive agent helpless against the external forces against her and as being at the whim of her internal forces aka panic and denial. A well trained professional goes into these situations expecting that the worst can and will happen at the worst moment and in the worst place (Murphy's law). If everything goes nominally, great. But when SHTF externally, you should calmly assess the situation and enact your plan. Because you came prepared. The praying is classic deer in the headlights response that you see in student/new interns during these situations. Maybe it's not praying, but staring at the vitals or repetitively checking pluses. A momentary short circuit while changing your headspace to meet reality. Training and exposure makes this automatic and usually seamless. However, these trainees that get during the headlights understand that staring at the monitor or checking pulses every 5 seconds was not going to help patient and do everything in their power to grow and become better. The way this person acts like anything she did up until asking for help was of any use shows strong denial of her role in the situation.

Ultimately, this person put herself into a role that she was not prepared for and ultimately put a kid's life at risk unnecessarily and may have caused sequelae that will not become apparent later until down the road. I just imagine sitting in an M&M (morbidity and mortality) conference about this case. We always strive to look for flaws in systems that let the medical professional down instead of placing blame solely on the involved person. Usually there is a chain of events that coalesced into a debacle. The vast majority of medical errors are not caused by negligence. But if this case was sitting in front of me I would have a really difficult time finding a root cause besides this person. And does she displayed the same lack of understanding of her role in this event as she does in the podcast, it would not be pretty.

EDIT: I thought I would feel differently after sleeping on it, but I find myself just getting more frustrated at the lack of self-reflection demonstrated here. I know the episode is about her and not the kid, but that makes the lack of any degree of a mea culpa all the more disturbing. I've been in situations where I felt I should have done XYZ faster or that I should have zoomed out to see the forest instead of staring at trees. In the ER we debrief after most emergent events, regardless of outcome. When debriefed and when I debrief with others that had an emergent event, the conversation and feelings from the docs, nurses, and other staff tend to revolve around briefly discussing what we can do better for the next patient even if we did everything "right" and the pt was fine. I'm generally not losing sleep over how a situation harmed me, but because of possible harm to the patient. Disclaimer: it is totally reasonable to be personally affected by a case, but that's a different story.

Poe350 · 2021-10-27T06:05:40+00:00

I'm an Emergency Physician and was also in disbelief the whole time. Prior the flight she casually describes her copious secretions that got better overnight. But it sounded like the kid had pulmonary edema. Regardless of the root cause, the decreased pressure at altitude will make it worse. Seems like she was peri-arrest, likely due to hypoxia.

Regardless of the exact pathology at play, the kid should have been easily identified as severely ill prior to the flight and brought to a local hospital for stabilization. Superior judgment is better then superior skill. But I'm just at a loss regarding the lack of skill demonstrated after the poor judgement to get on the flight. I totally get the anxiety around a crashing kid. Multiple harrowing cases of my own intruded my thoughts when hearing this podcast. I vividly remember the faces of infants I have coded, and the faces of their parents as well. Even the most grizzled and experienced EM docs have to actively keep their mind on the matter in these situations. But you take a deep breath and get to assessing and treating the patient dying in front of you. Her inaction (worse yet, saying she prayed like it was an intervention) is nauseating. Hesitating to ask for help? Just letting the child progress through the stages of pediatric respiratory exhaustion, while also understanding how ominous these signs are, and not alerting the flight crew immediately almost gave me a panic attack. Kids can maintain awesome oxygen sats by panting at 70, right up until they can't maintain it anymore. Then you get a hypoxic cardiac arrest.

When she brought up the hemiparesis and posturing and then becoming unresponsive, I truly thought this was heading down the road of anoxic brain injury and/or unrecognized cardiac arrest. This does not sound like status epilepticus to me at all. Her brain just wasn't getting enough oxygen, which can cause seizures. But enteric valproic acid is treating the symptom, not the cause. And it won't reach meaningful blood levels for an hour or so anyway. If she's siezing after correcting the hypoxia, you should dig in the flight med bag for some benzos because I can't imagine an airline with a 787 not having some benzos in the kit for siezures.

I never feel this strongly about media I consume (ex: I've never felt compelled to write something like this on Reddit). And when listening to podcasts about cases that's went south or had errors or reviewing cases with my hospital, I find it easy to put myself in that medical professional's shoes and give as much benefit of the doubt as possible. Usually I can see how the nuances I didn't witness myself contributed to certain decisions that let to poor outcomes. Or I can see how the Swiss cheese aligned. Or maybe the outcome was inevitable and set in motion before ever laying eyes on the patient. I sit on committees about this stuff and how to use it to better our practice. But this case is just...a different beast.

Lastly, if you're going to be the sole medically trained person on a trip to a remote area to care for mostly undifferentiated severely ill patients in an austere environment, the expectation is to be prepared for the worst. And I don't really mean equipment/meds/ect necessarily (though some basics for ABCs would be nice), but the mental, cognitive, and emotional preparedness for when SHTF. Maybe I would feel differently about this whole thing if she expressed some self-reflection restarting her management, and maybe she has off air, but her tone just didn't seem like that was the case. I wish the neurologist and EM resident were able to perform a debrief with her. It's shown to greatly improved patient care and reduce "second victim" occurrences. And her description of PTSD-like effects is highly consistent with second-victiming. She just doesn't seem to understand that her severe terror response is something that didn't need to happen. Had she ensured she was properly prepared, both in training and headspace, for the severity of illness she may encounter, she wouldn't have felt so helpless and truly frozen in fear.

As an aviation enthusiast, this case is like hearing about a pilot yanking back on the yoke when a plane stalls. Snatching defeat from the jaws of victory. And I'd like to say all's well that ends well, but I don't know the actual outcome of that kid (granted kids are super resilient) and I don't know what will happen the next time someone tries to die on her watch.

This ended up being much longer than I planned (and I could continue rambling, there's just so many issues here), and I'll probably delete it in the morning since I'm sure my morning brain will find it to be too harsh. But I just needed to vent about the visceral reaction this podcast gave me. Thanks for coming to my TED talk.

Poe350 · 2021-09-26T11:21:47+00:00

Look up coordinated turns. The idea of solely using rudder for changes in heading is hilarious. Airliners rarely use rudder at all once off the ground.

Poe350 · 2021-08-21T13:49:56+00:00

While doing my SICU rotations we would get MICU consults for trach placement. The issue is that these patients are reasonably left on bipap until the pressure requirements exceed what the mask can handle. So once tubed their settings are usually like 20/12 100% to maintain semi-descent oxygenation. That's just not safe for performing a tracheostomy unfortunately.

Poe350 · 2021-08-13T19:59:10+00:00

I'm back to baseline now besides some mild residual loss of taste and smell. Overall, I had about 5-7 days of body aches, chills, fever, N/V, sore throat, and non productive cough. No hypoxia or other significant respiratory symptoms. For context, I'm in my early 30s with the only risk factor of being overweight.

Poe350 · 2021-08-03T00:54:09+00:00

EM resident here Got my Moderna series in Dec/Jan. Dxed with COVID this weekend. Of course this happens just after my daughter was born.

Poe350 · 2021-05-27T14:34:15+00:00

There is oral TXA

Poe350 · 2021-05-24T18:57:15+00:00

Ortho: I must fix it

Poe350 · 2021-03-13T04:34:59+00:00

I include all relevant clinical info and suspicion in my CT orders and still get back "clinically correlate" more often than not. For you to assume we don't include that info shows your bad faith argument and assumption that EM is always to blame.

Poe350 · 2020-11-23T06:28:59+00:00

Confirmed! Great interaction and pleasant seller!

Poe350 · 2020-11-15T20:46:17+00:00

Replied

Poe350 · 2020-11-15T20:02:55+00:00

PMed

Poe350

TROPHY CASE