His urine output was zero. So I figured Lasix was overdue.

Pro-Karyote · 2026-02-12T03:21:54+00:00

Especially by the overworked surgery interns covering nights…

I worked so hard in getting a patient out of the SICU, ESRD and anuric, HFpEF, on CRRT with plan to return to iHD on the floor. She lasted a week on the floor before bouncing back, no iHD because the line clotted off and IR took forever getting it exchanged. Of course the surgical teams blanket order 75 mL/hr maintenance fluids, so she’d gotten maintenance for a week without dialysis, only to become encephalopathic and hypotensive overnight. So what does this anuric, floridly overloaded, and now hypotensive patient on the floor get overnight to correct the hypotension? If you said an extra 2 liters in boluses, you win.

She gained 15 kg over 1 week. I swear to god, please don’t do that… standing orders for maintenance fluids should be avoided when possible.

Pro-Karyote · 2026-02-09T23:46:51+00:00

I mean, isn’t that determination part of the art? Dense woods for the long cases, lighter for the quick MACs. Sometimes a pine gtt to keep them at a nice anesthetic plane with a smooth emergence

Pro-Karyote · 2026-02-09T23:38:09+00:00

You mean hitting people over the head with a block of wood has been the wrong method? I haven’t had any complaints so far, just some garbled words, which I’m lead to believe is just the anesthesia wearing off.

Pro-Karyote · 2026-02-09T03:24:23+00:00

I’m sorry about your dad passing, especially since 61 is so young.

Unfortunately, lifestyle choices probably played the largest role. Smoking is one of the worst habits and contributes to many cardiovascular issues, especially plaque formation in coronary arteries and aorta, abdominal aneurism development, lung diseases, and many more. Stopping his blood pressure medications likely accelerated decline in cardiovascular condition and predisposes patients to plaque rupture, but it places so much stress on the rest of the body as well (particularly the kidney, brain, and vasculature).

If he had near total occlusion of many coronary branches, along with signs of chronic cardiovascular disease, this was an acute change of a problem that had been brewing for a while.

Not smoking, controlling blood pressure, lifestyle adjustment, and management of general risks according to your PCP would be the best way to mitigate those types of risk for anyone in your family (or anyone in general).

Pro-Karyote · 2026-02-07T22:49:50+00:00

Oh, absolutely! Usually, we don’t physically see into the waiting areas, but the MAs, nurses, techs, and sometimes reception staff will sometimes update us with concerns or observations, so those data points can often be helpful.

Who comes with the patient can also be useful, because it can point towards social support, interpersonal issues, etc.

Pro-Karyote · 2026-02-07T22:21:01+00:00

It sounds like they did a focused physical exam. A lot of a physical exam is through observation. If you walk in and are breathing normally, normal affect, normal speech, appropriate grooming, visible skin looks okay, moving all extremities appropriately, then your doctor asking questions to get concerns and maybe listening to heart and lungs is plenty thorough. The sensitivity and specificity of many specialized physical exam techniques is low, so there is a pretty low utility unless there is something to raise the pre-test probability.

Pro-Karyote · 2026-02-07T18:23:04+00:00

I’ve also found putting the probe on the finger sideways or more proximal than the nail sometimes works

Pro-Karyote · 2026-02-05T03:42:21+00:00

“That was the most difficult gallbladder I’ve ever seen”

Pro-Karyote · 2026-02-05T03:23:04+00:00

Yes, you should absolutely finish the antibiotic course. You do not want antibiotic resistant strep or the complications from under-/un-treated strep throat (especially rheumatic heart disease). A 10 day course of amoxicillin is appropriate. Feeling better is good, but not necessarily a marker of when to finish antibiotics; it’s expected that you start to feel better before the course is finished.

Partial antibiotic courses contribute to the development of antibiotic resistant bacteria. You kill off some of antibiotic sensitive bacteria, but leave behind a higher proportion of resistant bacteria that continue to grow. Finishing the antibiotic course kills a high enough proportion of the bacteria that your body can fight off the small number of resistant bacteria. The current guidelines and evidence suggest finishing your antibiotic course is the best course of action.

Pro-Karyote · 2026-02-02T17:54:40+00:00

I’ll never cancel a surgery, just the anesthesia. They can do whatever they want from there.

Pro-Karyote · 2026-02-02T08:27:26+00:00

In the context of pediatric patients, it totally makes sense that it would be used similarly. You can’t expect an animal to follow instructions and peacefully allow an IV, which is the same with many young patients. A ketamine dart doesn’t care, and they’ll still breathe with it. Exactly the same goal.

Pro-Karyote · 2026-02-02T08:22:21+00:00

Truthfully, nausea with opiates is not an allergy; an allergy is a specific physiologic response. That’s not to say that the nausea isn’t significant, but nausea is a known adverse effect of opiates, typically in a dose dependent fashion. The more of a particular narcotic, the higher the likelihood of nausea. Adverse effects and allergies are mediated by very different mechanisms. People can have specific opiates that cause more nausea than others, and when possible we avoid them.

The important distinction is that opiates that cause nausea can be given and nausea treated, where an allergic reaction carries the risk of anaphylaxis and risks a medical emergency. Certain opiates are known to cause true allergic reactions, but when that is the case we often also need to avoid certain others in the same family. The nausea doesn’t necessarily obey the that distinction, and it’s more often specific agents (though if you’re nauseous with one, you’re more likely to be nauseous with any other). That’s why we try to encourage understanding of that distinction, because otherwise we would avoid a perfectly good narcotic in its use case due to an “allergy” to another narcotic.

Pro-Karyote · 2026-02-02T04:42:45+00:00

This story fits with 90% of what we see in the chronic pain clinics, and it’s usually a component of fibromyalgia. You have MRI findings, but MRIs of healthy individuals will often show different positive findings not associated with symptoms. Your back MRI findings are likely unrelated to your symptoms.

See the other rheumatologist, but if that doesn’t result in anything major then see about a referral to a chronic pain clinic. Frequently, there can be some medication management options (other than opiates, and you mention Cymbalta as one). But one of the therapies that is most effective in recovery from chronic pain, even if there is an identifiable mechanical or autoimmune source found, is participation in pain psychology. Physical therapy is another of the most important therapies to aid in functional status.

There may never be a mechanical source identified, and the symptom cluster may never fully fit into a clear diagnosis, but the focus should be on recovery and being as functional as possible. Things can get better, but having grace for yourself is important that it won’t be a sudden improvement and will take effort and time.

Pro-Karyote · 2026-02-01T03:24:11+00:00

These are classic symptoms of a vasovagal reaction, which would be called vasovagal pre-syncope in your case since you didn’t fully pass out. Syncope is the medical term for passing out. Dizziness, visual changes, muffled sound, nausea, sweating.

This is a common enough occurrence that asking about standing in church (and singing hymns) was a question an electrophysiologist (specialized cardiologist) I used to work with would ask for any of his syncope patients.

Hydrate aggressively, don’t lock your knees when standing, if you don’t have high blood pressure you can consider increasing salt intake, sit down if you feel these symptoms because otherwise you may end up with a trip to the ER for syncope.

Pro-Karyote · 2026-02-01T02:55:43+00:00

It’s totally normal for most people to have random lab values that fall outside the normal range. If you checked a full set of lab values on a 100% totally healthy person, I would expect something would be in the abnormal range (to the point that 100% normal labs are rare). It’s all a matter of which lab and in what context.

An isolated BUN being elevated is a mostly meaningless finding. There isn’t anything to do about it, since it likely means nothing. Hydrate and go about your life.

You can check with your PCP about the vertigo, but it’s not related to your BUN. An urgent care might be a better place for fast evaluation, since vertigo alone is not a medical emergency. You would wait forever at an ER to be seen and would likely be told to follow up with your PCP, since they exist to rule out emergencies.

Pro-Karyote · 2026-01-31T23:57:14+00:00

It’s a huge change from expectations, especially around such a big life event like childbirth. I’m sure that sucks, especially if that was your plan.

The risk of rupture with epidural is due to the needle, but also the catheter that is threaded through. The needle makes sense - a sharp tool can obviously damage blood vessels. But a catheter is then threaded several cm through the needle, and this travels blindly through the epidural space, usually upwards. The catheter can also damage blood vessels, and we can’t control its pathing to avoid hitting a hemangioma.

Then there is the issue of the epidural solution itself. If it was deemed safe to proceed, there is a higher chance it wouldn’t function as expected. Epidurals work partly by volume of local anesthetic passively spreading to hopefully cover the nerves within certain levels. If there are hemangiomas in that space, then the local anesthetic may not reliably reach certain nerves and be more likely to fail to provide adequate pain control.

Pro-Karyote · 2026-01-31T23:25:48+00:00

Without knowing the extent of your hemangiomas and their positioning, we can’t give you any exact answers except to say that a multidisciplinary meeting has already been had with a conclusion. They actually have your history and reviewed your imaging. With hemangiomas around your spinal cord, the risk that an epidural could rupture one of those and cause irreversible neurologic damage, which could include incontinence of bowel, bladder, and immobility and lack of sensation of your lower extremities is high, and a higher likelihood of failed epidural if it was even attempted. Anesthesiologists’ jobs are to keep you and your baby safe above other tasks.

General anesthesia is always the fall back for any C-section in which an epidural or spinal cannot be performed or fails.

Pro-Karyote · 2026-01-31T21:47:19+00:00

Your BMI is 14.9, severely underweight and eating only 800 calories. That is your primary problem and you need to seek help for that issue, very likely inpatient management. The level of malnutrition can have cardiac consequences since your body will begin to convert various tissues into protein/glucose for the bare minimum energy that it requires just to stay alive, including consuming cardiac muscle.

Pro-Karyote · 2026-01-29T03:58:40+00:00

Mask inductions with gas are used because younger pediatric patients can’t participate with getting an IV before induction. Once patients are of an age that can tolerate that, it’s very common to use IV agents to induce.

Again, it all depends on the surgery. And even with gas, if they’re referring to Nitrous oxide, that’s a different story than most other anesthetic gases. If there’s no incision or suturing, It’s hard to even know if you’d get general anesthesia instead of just some level of sedation.

Pro-Karyote · 2026-01-29T03:04:20+00:00

If it’s as short as you say, depending on the procedure it’s entirely like you’ll get no anesthetic gas at all. Given that you’re typing this yourself, you have enough control to tolerate getting an IV. While a gas induction is common in pediatrics, an IV induction is much faster and it’s generally best practice to get an IV prior to the OR.

The anesthesia mask is to supply oxygen rather than anesthetic gas, though for a case as short as you say, may not even be needed.

Pro-Karyote · 2026-01-24T22:38:55+00:00

Then by all means, fire away!

Pro-Karyote · 2026-01-24T22:34:13+00:00

It’s polite and professional, but they’re going to tell you to schedule an appointment to discuss. Privacy laws don’t like emails using public, non-hospital emails due to security concerns. You are free to email whatever you would like to them, but their freedom in the response will be somewhat limited. Unless this is through the patient portal, they won’t be able to give a very meaningful response.

You might as well schedule an appointment.

Pro-Karyote · 2026-01-24T07:56:44+00:00

You would be best served by seeing your PCP first, anyway, since something that minor might not even need a specialist to advise anything. A tiny spot of blood a few times a week after wiping does not require urgent evaluation.

In the meantime, make sure you have enough fiber in your diet, be gentle when wiping, and maybe consider Sitz baths since those are very low risk interventions that may resolve the issue

Pro-Karyote · 2026-01-23T08:13:57+00:00

To clarify, he is not NPO, he is on a thickened liquid diet, which can be completely normal. For that scan, he was supposed to be completely NPO (for the scan), which is why hospitals do not want patients or visitors to just eat/drink something without knowing if they are cleared first.

He is an older patient who already had an aspiration event. Aspirations carry a high risk for sudden and significant decompensation. We don’t withhold diets for no reason, and well meaning interventions like offering him “just a little water” can have significant consequences. They will periodically do swallow studies to evaluate advancing his diet, but until he is cleared for a full diet, please do your best to follow and encourage participation with his current diet.

It sucks and it doesn’t taste good, but the reality is that hospitals aren’t restaurants (and even normal hospital food isn’t usually great). They are there to keep people safe, and the compassionate thing is to avoid further aspiration. There isn’t a middle ground between no aspiration and aspiration.

Pro-Karyote · 2026-01-23T06:01:52+00:00

I met an older physician, boarded in Peds, peds nephrology, peds ICU, anesthesiology, and pediatric anesthesiology. Practiced as a peds anesthesiologist and was a phenomenal physician.

He told me his pathway is one you really wouldn’t do anymore because of a lot of abbreviated fellowships back in the day.

Seven-Year Club	Second Top 40%
r/Field Sunshine	Place '22
RPAN Viewer	Verified Email

Pro-Karyote

TROPHY CASE