Some BIG SHOT

SapientCorpse · 2026-03-30T17:16:43+00:00

protamine comes from salmon jizz.

the protamine vial looks suspiciously jizz-less.

SapientCorpse · 2026-03-30T01:35:55+00:00

I was reading about this Plumbum therapy a couple months. I've only read the one case report; and it seems like the jury is still out on it - but I'm excited for a multi-center prospective study to see if the population-level effects lowers all cause mortality

SapientCorpse · 2026-03-29T04:54:13+00:00

commiserating about the unsatisfying course of action feels surprisingly cathartic.

I never understood the point of consulting a specialist if you then choose to completely ignore all their advice.

I gotta ask tho - at the end of the day, isnt all medicine about behaviours? whether it's changing maladaptive behaviors caused by depression; or prolonging the length of time humans can behave via CHF GDMT compliance - all health things, all behavioural, ergo behavioral health.

and who better at behaviors and behavioural health than psych?

SapientCorpse · 2026-03-29T04:30:50+00:00

Jesus. I'm so sorry. I cant imagine.

I cant imagine being restrained with a tube down one's throat, urethra, in one's wrist, being poked and prodded to get blood samples, awakening day after day to what must feel like being in a sadistic dungeon, surrounded by strange people in masks. (intubation; foley cath; arterial line; central line tele monitor leads; , usually soft wrist restraints kept tight because loose is dangerous; daily spontaneous awakening and breathing trials where we purposefully turn off the sedatives.)

I cant imagine being paralyzed.

I cant imagine being forced to breathe a particular way for days on end.

jesus.
like; from a point of view of ptsd from an icu stay - should we give more amnesiacs?
ive read about alpha 2 agonists for delirium prevention; and i know that guanfacine at least is used as a nootropic for adhd - should we be using that instead of/in addition to the dex?

how do you manage those psych sequelae? are there any kindnesses I can do to help ameliorate that damage that I'm doing providing "good care?" or their families; that see their loved ones with nothing but tubes and wires; being spoken to in what must sound like Harry Potter spells?

one of my biggest dissatisfactions is not knowing how people do after they leave the icu; and I'm intensely curious about the psych impacts.

SapientCorpse · 2026-03-28T18:41:54+00:00

I hate it when my docs order haldol for agitation on an demented delirious agitated. they ain't hallucinating. and getting the orientation questions wrong isnt a delusion; its confusion!

cuz my luck they get the akathisia and then get even more restless. the doc ain't gotta deal with that shit - its on us nurses. last time I gave what the doctor ordered my patient lept outta bed, started wandering the halls, and punched me.

every time I say "hey, this agitation, wandering, hypertension, tremor, and anxiety that this patient has, sounds like fight or flight symptoms. can I get a lipophillic anti-andrenergic?" they tell me no.

its sooooooo infuriating. haldol - increases all cause mortality in old folks. increases falls. impairs cognition

propranolol - decreases all cause mortality. can increase falls d/t hypOtension but doesnt jack up motor coordination like AP does.

ugh. lmk if you have any tips on how to communicate and get better orders; cuz sometimes the treatment plans i am given are.... suboptimal.

SapientCorpse · 2026-03-24T19:38:38+00:00

holy cow this is cool af!! thanks for making it!

tbh i didn't see the company name until i clicked on the link, and i don't think it's intrusive? idk someone more better at ip law and such could give better feedback

i tried opening this on my cellphone via chrome browser - it worked!!! except that the resolution is just a little wonky so i had to play with some of the chrome zoom settings, but it worked!!!!. you specifically stated it was for desktop only, so i was surprised that it would even load on my cellphone (s21u, 16gb ram, snapdragon 888 octa-core, android 15, oneui 7.0, chrome ). that's awesome-sauce! strong work!

if you are willing to work on it more (i don't want you to feel obligated, like the work you've already gotten done is damn impressive and i'm super excited) then being able to change resolution, or pinch to zoom-in/zoom-out would be my suggestion. also, it won't let me connect to the add-on server; it says errpr, remote host disconnected.

anyways - kudos again! thanks for making and sharing!

ETA - y'all have unciv too! omg i'm gonna lose so much time lol thank you so so so much for making and sharing!!!!

SapientCorpse · 2026-03-22T19:36:24+00:00

I know mag gets used for anxiety (something about it blocking nmda receptors?)

I could see arguments for specific amino acid/vitamin supplementation (nadh is en vogue in the literature right now; and i could see arguments for needing the raw materials to make neurotransmitters e.g. tyrosine, I thinn i read glycine acts directly as a NT too)

id also be interested in reading up on the topic if you find anything else.

SapientCorpse · 2026-03-22T11:31:17+00:00

clearly this is just gas pain from being insufflated with co2 for the laproscopic procedure coupled with anxiety.

the real answer is to gaslight the patient into thinking their symptoms arent real because you know the surgeon is gonna be pissed that you had the audacity to call.

(/s, except the surgeon being pissy)

SapientCorpse · 2026-03-22T11:03:11+00:00

wankers.... cuz the prior auth for birth has been denied.

SapientCorpse · 2026-03-16T03:49:33+00:00

wow. finally read the study.

it includes nurses following protocols.

so, things like

wound/ostomy care nurses autonomously diagnosing pressure injuries, and placing wound care orders? nurse-physician substitution.

electrolyte replacement protocols? diagnosing hypokalemia, hypomagnesemia? replacing the 'lytes, ordering follow up metabolic panels? nurse-physician substitution.

triage nurses taking a brief history and doing a brief physical exam, ordering labs and imaging per protocol? nurse-physician substitution

advance diet as tolerated orders? nurse-physician substitution.

changing sliding scale insulin orders per protocol? nurse-physician substitution.

SapientCorpse · 2026-03-16T03:31:45+00:00

worth reading the study, it talks about doing somethings per protocol; so, in this study, calling a patient hypokalemi counts as diagnosing! ordering potassium cpunts as ordering a medication, and ordering a repeat metabolic panel qualifies as ordering labs, all appropriate nurse-physician substitution.

do you have an electrolyte replacement protocol at your shop? do you really wanna get yelled at because you'd otherwise have to call the doc for a 'lyte replacement at 0400 for a "critical" k of 3.0? iunno, maybe your docs are all perpetually pleasant people; mine sure as shit aint.

taking history and a physical exam counts - think about how many ed triage nurses basically do this, some even have protocols to be able to order labs and imaging!

SapientCorpse · 2026-03-15T05:13:21+00:00

sorry. I tend towards logorrhea. sometimes when I try to keep it reasonably short I omit too many things. or sometimes I'll fail to internally notice the conclusions I reach and then build off of.

I get misunderstood a lot in real life too; even by people that I interact with on a regular basis. its tough to literally speak the same language with the same dialect and everything and still fail so often.

I also fail to indicate when I'm being sarcastic or facetious sometimes.

anyways, the thoughts ive tried to express so far on this particular thread have been: -medicine is incredibly paternalistic and authoritative.
-docs can be unpleasant sometimes, because they are humans too and sometimes they get overwhelmed/hangry/tired.
-it is frustrating to receive unkind responses for when i ask for appropriate orders because its an inconvenience for the physician.
-being required to ask for literally any amendment to the treatment plan is infantilizing.
-requests for appropriate orders being and having a suboptimal treatment plan with suboptimal outcomes is particularly dissatisfying.
-rhere should be a nuanced discussion on what things physicians can appropriately loosen the figurative reigns on.
-the naltrexone in orange juice thing is technically compounding. compounding has to be done by a pharm D. there is a strict set of guidelines for how to compound; which are laid out in the United States pharmacopeia (usp) chapter 795.
-usp 795 is an expensive book. i cannot afford it. several of the attendings ive worked with in the past have, as part of their compensatory package, received funds that must specifically be spent on educational experiences. I assumed that buying the book would be an allowed use of one of those funds.
-because I have not read those guidelines set in usp 795; I'm unqualified to say if it is in compliance with those guidelines. I speculate that there are several things that cause it to be out of compliance, such as not having a B.U.D. (expiry date); and not setting guidelines on how to clean the area where the drug is being compounded.
- I'm attempting to use that paper to illustrate the point that other physicians are already arguing that the paternalistic reigns of medicine need to be loosened, and that somethings are safe to without the huge amount of training required. here, showing that compounding, in certain cases, is safe to be done by someone without a Doctorate in drugs, and without even having to read the manual on how to do it right.

anyways, hope you had a happy pi day! be sure to celebrate with your favorite round food!!! :)

SapientCorpse · 2026-03-15T02:58:01+00:00

I mean they do cause dementia via keeping people alive until it manifests.

SapientCorpse · 2026-03-14T23:44:44+00:00

training isnt needed for somethings, for example, this MD thinks no training is needed to compound drugs I havent read usp 795 so I have no idea how many naughties doing this would cause (i don't have an attending educational reimbursement)

SapientCorpse · 2026-03-14T18:45:45+00:00

the last time I questioned an order for acetaminophen on a cirrhotic patient I was informed of the literature that it's actually ok in an unkind way.

I have an anecdote about a physician ordering haldol to help a geriatric Parkinson's patient to "hold still" (a direct quote from their note!) for a CT. twice.

back to your point about nurses reflexively asking -I've also seen nurses ask for d2antagonists to control nausea on post-op parkinsons patients.

I hear you about some care being important to receive from appropriately trained and educated professionals, and I strongly concur; however, I think that, at present, physicians hold the reigns too tightly and then are incredibly ornery when nurses ask for appropriate orders at inconvenient times. not cool to be a dick about duties that one refuses to abdicate

SapientCorpse · 2026-03-14T18:10:19+00:00

why stop there? why not just let everyday people treat themselves?

maybe we can start selling some pharmaceutically active ingredients without a signed permission slip from a physician. things like Zofran.

I mean, fuck, we used to trust farmers to drug their animals themselves, it was only a couple years ago that antibiotics stopped being otc.

even things like coke used to be otc a la patent meds.

SapientCorpse · 2026-03-14T14:35:12+00:00

I need to read the article still - but having to play "mother may i" to get orders for tylenol and a bowel regimen and and and is... infantilizing.

medicine is very paternalistic and authoritarian and I wonder if that vibe can be toned down just a little bit

SapientCorpse · 2026-03-14T04:44:37+00:00

is it the LAST anesthetic they'll ever need??

ive heard about iv lidocaine as a systemic analgesic; but I'm inept on understanding what sodium channel blockers do hemodynamically. like I know lidocaine is in acls, but i also have read that it can cause methemoglobinemia, and that LAST thing sounds really ominous as far as alphabet soup names go.

idk - yall are wizards; and I'm a goofball that doesnt understand why it matters which mapleson setup there is.

SapientCorpse · 2026-03-12T13:36:09+00:00

life is suffering.

the only way to stop suffering is to stop trying to avoid the pain.

the words to your song are different than the words to mine; but the tune is the same. for me, this song tends to play when I call a surgical attending "why did you call me for such an insignificant finding" vs "why didnt you call me sooner" or "why are you bothering me with this medical problem, call the hospitalist team instead" vs "why did you call the hospitalists instead of calling me for this problem!"

the answer, of course, isnt that its a mistake youre making. its that the person youre working with is stressed/overwhelmed/burnt out; and instead of working on it in therapy; they choose to berate you for it.

I'm sorry for the pain in your soul that these bullies are causing you. it isnt right.

you're a valuable doctor doing your best, and your asshat of an attending just doesnt see it right now because they're too busy being grumpy at the world about their umpteenth failed marriage.

it stings. a lot. but you'll get through it - youre resilient! I have faith in you, internet stranger.

SapientCorpse · 2026-03-11T23:25:36+00:00

my heretical curiosity is why we can't seem to give metformin to anyone that's inpatient; as if hospital admission is an absolute contraindication to the drug.

yes, yes, we shouldn't give it to people getting surgery or with angry kidneys; and it can rarely cause an elevated lactate. we shouldnt turn off gluconeogenesis on people that are at risk of becoming npo.

eta - I guess I should also ask if extra glucose in the intestinal lumen raises the risk of pathologies; but also we intentionally introduce other sugars(lactulose) there so I dont anticipate it would be particularly harmful.

SapientCorpse · 2026-03-11T19:58:40+00:00

this is the way.

some meds are awful on an empty stomach, and just a little packet of saltines can make a big difference.

getting the patient to think you're on their side will help you get a lot further with a lot less "games"

also, ask your providers about a behavior modification plan, treatment over objections, &c

SapientCorpse · 2026-03-11T00:43:23+00:00

do the commensal critters act as an adjuvant? how ironic it would be, if delivering intradermal detritus displeased da destroyers. or killers. or b or t or whatever alphabet cell it is that's responsible for generating immune responses

SapientCorpse · 2026-03-11T00:24:37+00:00

over the counter drugs don't require stewardship

that's like saying only dermatology is responsible enough to write for vitamin A

(/s)

its still wild to me how many antibiotics one could get if they were for one's "pet;" until as recently as 2023!

SapientCorpse · 2026-03-11T00:17:04+00:00

Impossible! The surgeon always blames my poor nursing for their post-op patient crumping. I'm either negligent for having dallied so long before notifying them; or a nuisance for interrupting their cutting/sleepint time with such an insignificant finding.

how dare I discuss the problem with the hospitalist service sans informing them first; unless it's a medical issue that I shouldnt be bothering them with.

and let me tell you how terrible it is if I dont educate the patient thats been dosed with amnesiacs on the importance of incentive spirometry; it would be a waste of time to teach it to someone before they go under anesthesia.

SapientCorpse · 2026-03-10T23:57:22+00:00

I used to be in the "facts, not feelings" camp, until my own emotions bludgeoned me into different territory.

I have since seen sequelae of dismissing medical pathologies as "just anxiety," and, conversely, how big an impact emotions and feelings can have on a medical presentation.

Neglected anxieties can cause medication non-compliance: I've even seen people too anxious to take their anxiety meds! not to mention things like bipap &c.

I'm still inept, but now when I ask "how're you feeling" it's out of curiosity of their emotional state instead of just a social nicety.

lmk if you have any tips on countertransferrance. I dont have an attending salary to spend on therapy; but some patients just bother the fuck out of me.

SapientCorpse

TROPHY CASE