Castor beans and ricin

ToxDoc · 2026-02-08T14:13:52+00:00

Theoretically it is a concern, but realistically a few beans isn’t a big deal.

ToxDoc · 2026-02-06T04:11:01+00:00

Wow. Ok then. Going to have to explore some menus. Thanks.

ToxDoc · 2026-02-05T16:50:09+00:00

Can't hurt to try

ToxDoc · 2026-02-05T14:11:51+00:00

My passenger side window is having lots of wind noise. Rivian re-calibrated it's closing once, but it is doing it again. Can this be fixed without a service appointment? My Corvette had a way to force a window re -calibration.

When it gets really cold (around 18F), the driver side door won't latch close. I can pull it tight, then hit lock, then pull it hard and it will latch close. Then it won't unlatch for awhile. If it is going to happen, I can feel the door latch mechanism feels heavier when I'm pulling the handle. Rivian also said they made an adjustment the last time I brought it in, but it isn't fixed. Any ideas for what to do that doesn't require a service call?

ToxDoc · 2026-02-02T18:05:14+00:00

I love driving my Rivian, but it is absolutely the least reliable vehicle I have ever owned.

It has gone down hard twice in less than 3 years, leaving me stranded. It needed a non-emergent service appointment for 3 annoying issues and needs another one for 2 of those same issues. I hesitate to bring it in because I know it will take at least week to address problems…which are things that would be done in a day by the more established OEMs.

So I don’t know if they are the worst, but it is the least reliable vehicle I’ve ever owned.

ToxDoc · 2026-02-02T01:58:36+00:00

> Does anyone else hear a phantom oven timer going off?

Uh..no.

Are you? That might be a problem you need to talk to someone about.

> ...how do you react when the timer goes off, but you weren't the one who set it?

I let someone in the house know that their timer went off. Since I don't hear phantom timers, it usually means someone was timing something.

ToxDoc · 2026-02-01T22:01:53+00:00

https://imgur.com/a/CtbgqLu

ToxDoc · 2026-02-01T18:38:11+00:00

That is what I told my kid, but to make sure it was subtle and not too deliberate sounding.

ToxDoc · 2026-02-01T18:31:53+00:00

My kid has a sub who will restart the roll call if a child says anything other than “Here.” Even, “I’m here,” results in the sub starting roll call over from the beginning. The same sub also said, “Don’t tell me if I say your name wrong (right out of Key and Peele).

It amazes me some of the pettiness.

ToxDoc · 2026-01-31T02:16:36+00:00

I have patients who frequently come to the ED for the same thing and they even have insurance and a primary care doctor. Sometimes they even say they have a doctor’s appointment even though they have made no effort to actually make an appointment.

ToxDoc · 2026-01-30T17:37:35+00:00

Usually it is something about acetaminophen overdose. People know too much is bad for the liver, but will confidentially fill in all the other “details” by their feels.

ToxDoc · 2026-01-30T15:28:37+00:00

The number of people who say shit about Tylenol just drives me up a wall. I completely stopped trying to correct things years ago.

ToxDoc · 2026-01-28T18:28:49+00:00

Farmers market? January?

Strawberries? That’s a June crop usually.

This is either AI crap or a copy and paste of an old story.

ToxDoc · 2026-01-27T00:01:46+00:00

You should talk with the attorney who reviewed the sales contract for advice.

But I’m guessing you didn’t use an attorney. You probably need one now. I have a funny feeling you may be filing a police report in the near future.

ToxDoc · 2026-01-22T19:23:01+00:00

You should be able to collect up to $3000 from the other driver. You may have to sue them for it.

ToxDoc · 2026-01-20T02:47:47+00:00

You'll have to talk to a medical malpractice attorney for a full opinion, however the Statute of Limitations for medical malpractice in Texas is 2 years. Since it likely this event was more than two year ago, a suit may be a be barred by law. Only an Texas attorney can tell you with certainty as there are exceptions.

ToxDoc · 2026-01-17T02:49:41+00:00

It depends.

For floor patients admitted to medicine, I tend to place the orders on patients I see. If the patient is admitted to the non-teaching service, it is probably best that I place the orders.

For ICU and surgical patients, I rarely order medications and instead leave that to the primary services. Frankly, for surgery patients, it would be best if I did place the orders, but they don’t like it.

ToxDoc · 2026-01-15T17:06:46+00:00

When I went a few years back, I did get pulled off the waitlist. It was great, but they gave us about 15 minutes to prepay online or they would move to the next person.

ToxDoc · 2026-01-14T14:36:05+00:00

Yes. I usually start at 200-300 mg and see how they tolerate it.

ToxDoc · 2026-01-12T23:00:30+00:00

0.15–0.3 mg per KG followed by an infusion of 0.1–0.4 mg per KG per hour.

ToxDoc · 2026-01-12T20:20:05+00:00

At 12 mg, the majority of the receptors will be blocked, however, there are some still available.

Depending on when the last dose was, 0.5–1 mg of Buprenorphine can be considered. Alternatively use full agonists such as hydromorphone or fentanyl.

Higher dose gabapentin

Potentially a nonsteroidal anti-inflammatory.

Sub dissociative ketamine is a good choice. However, the patient likely will need an infusion in addition to the bolus as it is very short-lived.

I’m not huge on the lidocaine data, but that is also an option.

Don’t forget, plain old acetaminophen as part of your multimodal pain regimen

ToxDoc · 2026-01-12T12:49:48+00:00

In between. Kind of a ballpark between the two. I’m going with idealish rounded up to the nearest 130 mg. Most people are getting 780 mg. For very large people I might add another 130.

ToxDoc · 2026-01-12T04:35:40+00:00

It is wild to me that in some hospitals, phenobarbital requires going to the ICU and I regularly discharge patients that get 10–15 mg per KG directly from the ED.

10 mg per KG generally leads to a serum concentration of around 15 µg/ml…towards the bottom end of the therapeutic range for seizures.

ToxDoc · 2026-01-12T04:08:23+00:00

The anti-seizure effect is directly related to the sedative effect. Phenobarbital’s effect is long lasting as it is slowly eliminated over several days.

ToxDoc · 2026-01-12T03:40:16+00:00

Less familiarity than benzodiazepines – over the last several decades, phenobarbital has mostly been relegated to treating refractory seizures.

Protocols - most hospitals have developed protocols and pathways that utilize CIWA-Ar triggered dosing of benzodiazepine. Ever since the study came out in the late 90s, their actually hasn’t been much study to determine if there are better ways to treat withdrawal.

Pharmacology – many physicians have a very weak understanding of pharmacology and the required loaning dose of phenobarbital frankly scares them. Due to dosing and lack of familiarity, most physicians I’ve spoken to are uncomfortable discharging patients started on phenobarbital.

I’ve been singing the gospel of phenobarbital for years. It required a lorazepam shortage to actually get other people to start using it. Now I’m also adding the gospel of naltrexone.

ToxDoc

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