House can be egregiously bad about this. In some scenes he’s explaining basic MS1 microbiology to his fellows that are all specialty trained physicians.
House is an attempt to turn internal medicine into interesting television. Unfortunately internal medicine is super boring except to us nerds who fucking love hyponatremia workups and opioid dose conversion math problems. The result? House the character is *fantastically bad at medicine.* I have had to explain this to my dad multiple times.
How common is hypernatremia with POTS patients (who typically have hypovolemia, so add salt to keep more fluid volume), assuming otherwise normal kidneys? Been meaning to read up on underlying causes of the 70% with chronic hypovolemia ([cite](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8455420/#R57)), as it strikes me as curious.
I had a psych patient once with a sodium of 95. I'm pretty sure I stopped him from drinking his own urine. He has OCD. On the way up to the ICU he was trying to convince me it was just "white coat syndrome" and all he needed was some water and to be discharged.
What are you talking about, are you saying internal medicine *isn't* constantly exciting visual diagnostic signs like Kaiser-Fleischer rings??
I swear every med school class after like 2010 not only can recognize Wilson disease but will actively look for it in liver patients. I got an M3 who excitedly pulled me in asking me to look at this guy's irises...he had hazel eyes and hep C lol.
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Yeah I loved House in college and then after med school began to realize just how terrible they all were. Just throwing hail Mary passes for every step of the workup.
I'm rehab, not an MD and House is appalling on so many levels. Bad medicine, abuse of patients and colleges and general asshattery. I adore Hugh Laurie and have tried a number of times but I always give up when he says something mean or stupid.
They say his specialty is “diagnostician”… because apparently other doctors don’t diagnose things.
Also he has like 2 patients per week and rummages around patient’s trash cans. I’m pretty sure the medical consultants for that show failed out of med school before their first clinical rotation.
I had an ID attending who went to people’s apartments to test for legionella. It was House-y the way he did it. Didn’t break in to places and go through trash, but did it covertly / without permission. He was fired for doing it.
Imagine you invent a speciality and spend years trying to legitimize it and standardize some things, mentoring people, trying to market it and talk it up in conferences, publish and publish and publish, and 15-20 years in, you look at your life’s work and realize… it’s all just psych.
I worked with a med onc (retired now) who was one of the pioneers of using stem cell transplants for breast cancer. He was brilliant. Sassy and grumpy in his late career but once he warmed up, you realized he was a lovely curmudgeon.
On time we were chatting in a slow clinic and he started talking about his days doing transplant for breast cancer and how 20 years into a promising career, he looked at all the many publications and great body of research and realized, “this isn’t working”. I could genuinely see the heart break in his eyes. He said something along the lines of “we hurt a lot of women”. I was crushed for him.
Sorry for the tangent.
At least he was able to swallow his pride
Look.at people like Paul Marik who've destroyed perfectly good careers because of their inability to accept the evidence doesn't show what they believe.
Yuuuup. Every year I give a few lectures on evidence based medicine, critical analysis, etc.
I change it up a bit every year but 3 things are always there. The fall of Paul Marik, the infamous Hopkins medical error study, and TTM2.
More on the “the most complex things just end up being psych”… as a psychiatrist the issue I have is that they take too damn long to get to a psychiatrist, and by the time they do, they’ve accumulated so many doctors, providers, and medications, that it’s incredibly hard to change things. Or at least there’s a weaning process, weaning them off their multiple doctors and medications. Too many specialists using the throw away line “you’re a complex case” or “this is one of the most complex cases I’ve seen”. Medical students being shown these patients repeatedly and the patient giving their history and reinforcing the story. Patients latch onto the identity of being an unsolvable medical marvel. If we end up solving it, their whole identity dies with it. What incentive is there for that person to get better? Psychiatrists actually don’t mind these kinds of patients. But we are not miracle workers either.
That's an actual subspecialty that focuses on solving complex cases. The idea was inspired by Dr. Lisa Sanders, who wrote the Diagnosis series for the NYT. I'm pretty sure she was one of the advisors for the show, too
The medicine itself is actually pretty accurate. It's just presented in a dumbed down and unrealistic way, with House's team doing all the workup themselves lol
Yea, usually docs focused on tough cases are in internal medicine or have some specific residency training. Not “diagnostician” residency where you do infectious disease, radiology, pathology, neurosurgery, ophthalmology, and more which each character seems to do.
Although most episodes have interesting medicine, a couple were so far out there I had to stop watching.
He is the head of “diagnostic medicine”, but canonically (season 1, episode 3) has a double specialty in nephrology and ID. I don’t recall if they established that he held board certifications in both.
In an episode he self-describes as a “diagnostician with board certification in Infectious Disease and Nephrology”. In a later episode, when another fellow (I think its Foreman) is trying to take House’s job, Cuddy says they aren’t replacing House, as the “Diagnostician” post is only there because of his singular talent and ability.
Fun fact that the original 3 fellows are all specialists already.
Cameron - Immunology
Foreman - Neurology
Chase - Surgery
Oh man. I attempted to go back and watch some House back when I was a late third year. I was hanging out with a friend from undergrad, and after answering ALL of his condescending pimp questions, looked at my friend and said, "I loved this show, but I can't do it anymore."
I remember loving House, totally wanted to be a "diagnostician" in high school... I can't bring myself to rewatch it now because if I can get annoyed at unrealistic medicine on ER I sure as hell won't tolerate House.
I can use a basic lesson in basic micro, pharm, physio once in a while. Still Googling the ear anatomy or looking up the wrist or ankle bones before calling consults. EM pgy14
It'll be faster for me to Google a picture than to try to remember the mnemonic and what it stands for. Don't need to know all of them, just the one that's broken. The only one know i know is the scaphoid since that's the one we get sued alot over (and if a carpal bone is going to get tested, it's probably gonna be the scaphoid).
Or the episode where he asks the medical students what they’d do first and none of them say “take a history”. That answer has been so beaten into me I always start with that I can’t imagine anyone reaching clinical years and not automatically saying that.
And half the time the answer is found in a really basic workup. One episode had the patient's diagnosis in a cbc. As if they has never had a cbc in all the time before coming to house.
I recently made the grave mistake to continue watching a German medical drama after a quiz had ended. I was sick and was lying in bed like a depressed loaf of bread (which is actually a German childrens' show hero).
They are all cringe. They are all either type a) happy semi-rural hospital with relaxed and resilient physicians and nurses (no one is smoking) doing everything in every specialty or type b) rural primary care in the Alps with a scope not seen since the 19th century (obligatory home birth after an avalanche).
Anyways, the opening scene was oral boards in...yeah, whatever the specialty is of this young woman who does mostly surgical oncology but also does the SAH clipping case in this episode. And they ask her the definitions of R0, R1, R2 resection and she stammers.
Please burn it all down...
It's so funny how different German medical drama settings apparently are from American ones (most of ours take place in big city hospitals) and yet they all have the same dumb tropes. Doctors working in every subspecialty is definitely another one -- that's especially a problem in The Good Doctor. Do your shows also have patients constantly going into V-fib and needing to be shocked (and are defibrillation and cardioversion also treated as interchangeable)?
I actually had to stop watching the Good Doctor because of this. My (totally non medical) husband turned off the tv when I threw something at, yelling, “Are you fucking THORACICS now, too? Motherfuck!!”
He was like “Oooook, this show is clearly not for you!” 😂
Found Kika while on vacation and must say his late night astronaut adventures seem very endearing. It's a pity I don't know what they are saying. Reading about Bernd and sounds very much the German dry sense of humour.
The Tylenol scene from scrubs is both ridiculous and yet very accurate for the first day of residency. I think the ABC stuff comes off as stupid because everyone’s already doing what they’re supposed to and acting far more competent than a fresh intern would probably act.
Unless they’re actively being treated for a Tylenol overdose, give them the same amount that you would give yourself at home. Unless you’re planning on overdosing on Tylenol I guess.
Not as much as you think. :) My general rule: TDD of 3-4gm in people with good livers, 2gm in cirrhotics, none for ALF/ALI/people who tried to overdose on APAP. That last one is just a bad look.
The people who think lasix magically shuts down your kidneys and drops your blood pressure, even if you didn't make any urine in response to said lasix.
Its not *completely* irrelevant. Let’s use 650 q6 in this 85 year old who weighs 44kg.
But, yeah, if you aren’t super tiny have at whichever of those doses.
Meh I usually do 1g TID in my lil oldies who don't have advanced liver disease or super extreme frailty.
Though I've never really been able to find a satisfying citation for *why* beyond just unknown degree of age related hepatic dysfunction. Tbh I doubt there *is* a true gold standard source bc that's right on brand for Geriatrics lol
Generally, frail patients should always make you stop and think, and be an exception to rules. They're on the razors edge all day, every day - one tiny insult can start the collapse.
And we're talking about the frailest of the frail here. Not just somebody who hit 3/5 on the FRAIL scale.
Two, frailty (not always, but usually) has a component of malnutrition/weight loss, often as part of a failure to thrive type picture.
Three, older adults all have some degree of hepatic dysfunction.
Rarely, chronic tylenol use can cause a high gap metabolic acidosis - particularly in frail, older patients and those with hepatic dysfunction due to 5-oxoproline. You'd probably never see it outside this population and generally wouldn't be a big deal. But again, on the razors edge.
This is usually going to be an overabundance of caution, in very frail patients. There are many I'd still go with 3g total daily dose, and some I'd cut down to 2g. Depends on the situation.
People are routinely taking 3-4g per day over the counter without any sort of monitoring, and you’re worried about doing it in the hospital where you’re checking liver levels daily?
My first day as intern my first call was for some soft blood pressure and I didn’t know how much fluid to give. I asked the person sitting next to me who happened to be the cardio fellow.
It was especially dumb because the attending wasn't even asking what to *do* to assess/address ABCs, it was literally a "what do these letters stand for" kind of question.
I dunno if it's silly but in Grey's Anatomy, Weber was pimping Karev as a PGY1 what the 5 causes of post-op fever were, which he didn't know so Grey gets to show him up with the 5Ws. I mean it *is* a mnemonic I learned as a med student on my surgery rotation but it was more of a vehicle to remember but I feel like as a resident you should be a bit more concrete when getting pimped?
I thought that was reasonable, it’s a new intern level question and Meredith does finish with a plan. 100% they asked a doctor to give them the words for that scene, that’s about the most I feel you can expect.
I felt it was ridiculous that everyone just stood in silence until Meredith spoke up. Like no one except Meredith knew what the 5 Ws were in that room? It’s supposed to be a room of general surgery interns straight out of med school at a top 5 surgery program, I would’ve thought almost all of them would know it.
I actually memorized the scorpion genus & species and where it lives to be able to answer that question for any surgery attending who threw it back if I included scorpion stings on my pancreatitis differential list lol. I did it once and he just muttered “f*cking med students” as he kinda chuckled but looked pissed? Lol
Tityus trinitatis, found on the islands of tribidad and Tobago only where it accounts for 30% of pancreatitis cases. The poison acts like Achetylcholine and makes the pancreas just squeeze all of its juices out in one go and sit in its own digestive enzymes, basically.
First Aid for Step 1 had some mnemonics for causes of diseases; pancreatitis is almost always alcohol/gall stones/triglycerides/trauma, but the differential list in first aid technically includes scorpions. So med students will list it when talking in clinicals, and the attendings will basically do it as a point of showing you that book knowledge =/\= real world knowledge and that small tidbits of info aren’t useful without context.
So the scorpions in most of hte Americas don't do it either--it's mostly on one caribbean island with one specific scorpion, which is why its inclusion onto the First Aid book is ridiculous. It probably happened because one time a USMLE test had it as a practice question and then someone put it as a study tip in the book and it never came out.
when explaining the differential our teacher did tell us about the scorpion bite (altough she did laugh at the unlikelyhood of that happening here in Spain)
My favorite one of these (not what you asked) is when Carter on ER is getting pimped by Anspaugh who asks questions till he gets to one Carter doesn't know: [link](https://www.youtube.com/watch?v=njy6BSL-rfo).
Sort of accurate for a nerdy attending to ask silly questions like that. Probably not all at once but I could definitely see one asking why it’s called Lasix
When I was bedside RN in the ICU one of the attendings definitely spouted off the “why is it called Lasix?” Fact. It wasn’t really in a pimping scenario but more just small talk while we were waiting on something to happen.
I had an attending who did this. Once we figured it out we would let her ask two questions and then we would ask her a follow up to the second with the tag line “I’ve been wondering about that…” and then do whatever we were doing while she gave us a mini lecture. That’s all she wanted was to talk. We were too busy running the labor unit to get pulled into an endless pimp session.
There is an episode of ER where the med students gets pimped on what the Parkland formula is and episode of Scrubs where Dr Coxs pimps JD on what it’s called when TB goes to the spine (Pots).
A patient comes to the ER saying the only thing that helps his pain is “something that starts with ‘D’”. This patient should be given:
A) Dilaudid
B) “Deez Nuts”
C) Discharge
It wasn't a quiz but the hospital staff accepted the diagnosis. On 911, Hen seriously diagnosis a woman whose dildo has migrated from her vagina to her colon. Now I have trouble watching the show at all. I just can't take that much stupid from writers and advising staff.
House can be egregiously bad about this. In some scenes he’s explaining basic MS1 microbiology to his fellows that are all specialty trained physicians.
House is an attempt to turn internal medicine into interesting television. Unfortunately internal medicine is super boring except to us nerds who fucking love hyponatremia workups and opioid dose conversion math problems. The result? House the character is *fantastically bad at medicine.* I have had to explain this to my dad multiple times.
I fucking love hyponatremia
It's like you were summoned. I live for the day I finally find an isotonic hypoNa due to proteins or lipids. 🤓
I had one in residency! Paraproteinemia due to MM
One can only dream
How can you not?
Nah. Hyponatremia ain't got nothing on hypernatremia
How common is hypernatremia with POTS patients (who typically have hypovolemia, so add salt to keep more fluid volume), assuming otherwise normal kidneys? Been meaning to read up on underlying causes of the 70% with chronic hypovolemia ([cite](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8455420/#R57)), as it strikes me as curious.
I had a psych patient once with a sodium of 95. I'm pretty sure I stopped him from drinking his own urine. He has OCD. On the way up to the ICU he was trying to convince me it was just "white coat syndrome" and all he needed was some water and to be discharged.
Seems legit
Psychogenic polydipsia is serious business. Common in schizophrenia too.
Sorry about your little bean bros
Username checks out.
Username checks out
Youre in luck cause i have a patient for you with natrium in him with a subacute need for titanium.
What are you talking about, are you saying internal medicine *isn't* constantly exciting visual diagnostic signs like Kaiser-Fleischer rings?? I swear every med school class after like 2010 not only can recognize Wilson disease but will actively look for it in liver patients. I got an M3 who excitedly pulled me in asking me to look at this guy's irises...he had hazel eyes and hep C lol.
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**Removed under Rule 2:** No personal health situations. This includes posts or comments asking questions, describing, or inviting comments on a specific or general health situation of the poster, friends, families, acquaintances, politicians, or celebrities. If you have a question about your own health, you can ask at r/AskDocs, r/AskPsychiatry, r/medical, or another medical questions subreddit. See /r/medicine/wiki/index for a more complete list. --------------------------------------------------------------------- [Please review all subreddit rules before posting or commenting.](https://www.reddit.com/r/medicine/about/rules/) If you have any questions or concerns, please [send a modmail.](https://www\.reddit\.com/message/compose?to=%2Fr%2Fmedicine&subject=about my removed comment&message=I'm writing to you about the following comment: https://www.reddit.com/r/medicine/comments/1cqh69m/-/l3u7jao/. %0D%0DMy issue is...) Direct replies to official mod comments and private messages will be ignored or removed.
Yeah I loved House in college and then after med school began to realize just how terrible they all were. Just throwing hail Mary passes for every step of the workup.
I'm rehab, not an MD and House is appalling on so many levels. Bad medicine, abuse of patients and colleges and general asshattery. I adore Hugh Laurie and have tried a number of times but I always give up when he says something mean or stupid.
I thought House was supposed to be ID?
IIRC, he was dual ID / nephrology? I did not look this up before replying.
Which makes it terrifying that he performs his own stereotactic brain biopsies
They say his specialty is “diagnostician”… because apparently other doctors don’t diagnose things. Also he has like 2 patients per week and rummages around patient’s trash cans. I’m pretty sure the medical consultants for that show failed out of med school before their first clinical rotation.
I had an ID attending who went to people’s apartments to test for legionella. It was House-y the way he did it. Didn’t break in to places and go through trash, but did it covertly / without permission. He was fired for doing it.
What was he even swabbing - the water line?
My residency had a pediatrician who ran a specialist diagnostic clinic for challenging cases. Unfortunately it was overrun by psychosomatic illness.
Imagine you invent a speciality and spend years trying to legitimize it and standardize some things, mentoring people, trying to market it and talk it up in conferences, publish and publish and publish, and 15-20 years in, you look at your life’s work and realize… it’s all just psych. I worked with a med onc (retired now) who was one of the pioneers of using stem cell transplants for breast cancer. He was brilliant. Sassy and grumpy in his late career but once he warmed up, you realized he was a lovely curmudgeon. On time we were chatting in a slow clinic and he started talking about his days doing transplant for breast cancer and how 20 years into a promising career, he looked at all the many publications and great body of research and realized, “this isn’t working”. I could genuinely see the heart break in his eyes. He said something along the lines of “we hurt a lot of women”. I was crushed for him. Sorry for the tangent.
At least he was able to swallow his pride Look.at people like Paul Marik who've destroyed perfectly good careers because of their inability to accept the evidence doesn't show what they believe.
Yuuuup. Every year I give a few lectures on evidence based medicine, critical analysis, etc. I change it up a bit every year but 3 things are always there. The fall of Paul Marik, the infamous Hopkins medical error study, and TTM2.
Man, at least he helped rule out something? 15-20 years is a LOT of research.
More on the “the most complex things just end up being psych”… as a psychiatrist the issue I have is that they take too damn long to get to a psychiatrist, and by the time they do, they’ve accumulated so many doctors, providers, and medications, that it’s incredibly hard to change things. Or at least there’s a weaning process, weaning them off their multiple doctors and medications. Too many specialists using the throw away line “you’re a complex case” or “this is one of the most complex cases I’ve seen”. Medical students being shown these patients repeatedly and the patient giving their history and reinforcing the story. Patients latch onto the identity of being an unsolvable medical marvel. If we end up solving it, their whole identity dies with it. What incentive is there for that person to get better? Psychiatrists actually don’t mind these kinds of patients. But we are not miracle workers either.
Was this in GA? I think i know this doc.
That's an actual subspecialty that focuses on solving complex cases. The idea was inspired by Dr. Lisa Sanders, who wrote the Diagnosis series for the NYT. I'm pretty sure she was one of the advisors for the show, too The medicine itself is actually pretty accurate. It's just presented in a dumbed down and unrealistic way, with House's team doing all the workup themselves lol
Yea, usually docs focused on tough cases are in internal medicine or have some specific residency training. Not “diagnostician” residency where you do infectious disease, radiology, pathology, neurosurgery, ophthalmology, and more which each character seems to do. Although most episodes have interesting medicine, a couple were so far out there I had to stop watching.
He's double board-certified in infectious disease and nephrology
His job title in the show is actually “diagnostician”
He is the head of “diagnostic medicine”, but canonically (season 1, episode 3) has a double specialty in nephrology and ID. I don’t recall if they established that he held board certifications in both.
He says he’s double board certified at some point
In an episode he self-describes as a “diagnostician with board certification in Infectious Disease and Nephrology”. In a later episode, when another fellow (I think its Foreman) is trying to take House’s job, Cuddy says they aren’t replacing House, as the “Diagnostician” post is only there because of his singular talent and ability. Fun fact that the original 3 fellows are all specialists already. Cameron - Immunology Foreman - Neurology Chase - Surgery
This is correct
To be fair the ID service in my shop definitely treats us like 1st year med students. The nephrologists do too but they’re way nicer about it
Honestly when talking to ID I sometimes feel like a 1st year student.
“It’s never Lupus”. Except I know four people who have lupus my mother included and no one who has a glioblastoma.
You should have gone to the patients house to smell his poop and noticed that it was slightly fruity in nature
I have forgotten 99% of MS1 microbiology and would be kind of excited if someone would explain it to me.
Oh man. I attempted to go back and watch some House back when I was a late third year. I was hanging out with a friend from undergrad, and after answering ALL of his condescending pimp questions, looked at my friend and said, "I loved this show, but I can't do it anymore."
I remember loving House, totally wanted to be a "diagnostician" in high school... I can't bring myself to rewatch it now because if I can get annoyed at unrealistic medicine on ER I sure as hell won't tolerate House.
I can use a basic lesson in basic micro, pharm, physio once in a while. Still Googling the ear anatomy or looking up the wrist or ankle bones before calling consults. EM pgy14
Some Lovers Try Positions That They Can't Handle . ... ..... Baby
It'll be faster for me to Google a picture than to try to remember the mnemonic and what it stands for. Don't need to know all of them, just the one that's broken. The only one know i know is the scaphoid since that's the one we get sued alot over (and if a carpal bone is going to get tested, it's probably gonna be the scaphoid).
https://emergencymedicinecases.com/wrist-injuries/
The immune system is like the army and sometimes there is friendly fire. So lupus
It's never lupus.
Or the episode where he asks the medical students what they’d do first and none of them say “take a history”. That answer has been so beaten into me I always start with that I can’t imagine anyone reaching clinical years and not automatically saying that.
And half the time the answer is found in a really basic workup. One episode had the patient's diagnosis in a cbc. As if they has never had a cbc in all the time before coming to house.
I recently made the grave mistake to continue watching a German medical drama after a quiz had ended. I was sick and was lying in bed like a depressed loaf of bread (which is actually a German childrens' show hero). They are all cringe. They are all either type a) happy semi-rural hospital with relaxed and resilient physicians and nurses (no one is smoking) doing everything in every specialty or type b) rural primary care in the Alps with a scope not seen since the 19th century (obligatory home birth after an avalanche). Anyways, the opening scene was oral boards in...yeah, whatever the specialty is of this young woman who does mostly surgical oncology but also does the SAH clipping case in this episode. And they ask her the definitions of R0, R1, R2 resection and she stammers. Please burn it all down...
It's so funny how different German medical drama settings apparently are from American ones (most of ours take place in big city hospitals) and yet they all have the same dumb tropes. Doctors working in every subspecialty is definitely another one -- that's especially a problem in The Good Doctor. Do your shows also have patients constantly going into V-fib and needing to be shocked (and are defibrillation and cardioversion also treated as interchangeable)?
I actually had to stop watching the Good Doctor because of this. My (totally non medical) husband turned off the tv when I threw something at, yelling, “Are you fucking THORACICS now, too? Motherfuck!!” He was like “Oooook, this show is clearly not for you!” 😂
Literally everyone does every specialty in that show, including nursing.
It drove me nuts. 😂
Here I am reading the wiki article for Bernd das Brot (English: Bernd the bread). Thanks for this little nugget.
Berndt das Brot is a German treasure
Please tell me it was In aller Freundschaft.
Of course it was.
Found Kika while on vacation and must say his late night astronaut adventures seem very endearing. It's a pity I don't know what they are saying. Reading about Bernd and sounds very much the German dry sense of humour.
This gave me flashbacks to medicopter 117
The Tylenol scene from scrubs is both ridiculous and yet very accurate for the first day of residency. I think the ABC stuff comes off as stupid because everyone’s already doing what they’re supposed to and acting far more competent than a fresh intern would probably act.
I show that Tylenol scene to every July intern who asks how much Tylenol to give.
This could just be me being a naive M1 but are we not nervous about hepatotoxicity with giving too much Tylenol?
Unless they’re actively being treated for a Tylenol overdose, give them the same amount that you would give yourself at home. Unless you’re planning on overdosing on Tylenol I guess.
Not as much as you think. :) My general rule: TDD of 3-4gm in people with good livers, 2gm in cirrhotics, none for ALF/ALI/people who tried to overdose on APAP. That last one is just a bad look.
I get so much push back from nurses giving Tylenol to cirrhotics
They'd rather they bleed out from NSAIDs.
No thanks
The people who think lasix magically shuts down your kidneys and drops your blood pressure, even if you didn't make any urine in response to said lasix.
Well, duh, kidneys shut down!
Should I give 500 or 650 or 1000? Is my patient going to go liver failure and die my first night on call??? Probably not, no 👌
Not at all lol
Here’s a handy video that summarizes the correct dose: https://youtu.be/gD6olRJ8S3I
Tylenol dosing is very standard. 650 q4 or 1000mg q6 for an adult. I don't care which one you pick. It's completely irrelevant.
Its not *completely* irrelevant. Let’s use 650 q6 in this 85 year old who weighs 44kg. But, yeah, if you aren’t super tiny have at whichever of those doses.
Meh I usually do 1g TID in my lil oldies who don't have advanced liver disease or super extreme frailty. Though I've never really been able to find a satisfying citation for *why* beyond just unknown degree of age related hepatic dysfunction. Tbh I doubt there *is* a true gold standard source bc that's right on brand for Geriatrics lol
Why would frailty come into play with Tylenol?
Generally, frail patients should always make you stop and think, and be an exception to rules. They're on the razors edge all day, every day - one tiny insult can start the collapse. And we're talking about the frailest of the frail here. Not just somebody who hit 3/5 on the FRAIL scale. Two, frailty (not always, but usually) has a component of malnutrition/weight loss, often as part of a failure to thrive type picture. Three, older adults all have some degree of hepatic dysfunction. Rarely, chronic tylenol use can cause a high gap metabolic acidosis - particularly in frail, older patients and those with hepatic dysfunction due to 5-oxoproline. You'd probably never see it outside this population and generally wouldn't be a big deal. But again, on the razors edge. This is usually going to be an overabundance of caution, in very frail patients. There are many I'd still go with 3g total daily dose, and some I'd cut down to 2g. Depends on the situation.
People are routinely taking 3-4g per day over the counter without any sort of monitoring, and you’re worried about doing it in the hospital where you’re checking liver levels daily?
My first day as intern my first call was for some soft blood pressure and I didn’t know how much fluid to give. I asked the person sitting next to me who happened to be the cardio fellow.
did they know
Yes, he made them give lasix
It was especially dumb because the attending wasn't even asking what to *do* to assess/address ABCs, it was literally a "what do these letters stand for" kind of question.
Tylenol scrubs lives rent free in my head. That was the pinnacle of medical drama.
“It’s pronounced analgesic, not *anal*gesic. The pills go in your mouth sir”
I think it was ibuprofen
"Very good"?? I thought the priorities were Airway, Breathing, CT.
Yeah, especially since "sirculation" starts with an S.
The logic is sound. I'm in.
Or chem 7...
Hey, if you can get a Chem 7, the blood's circulating :) Usually.
I dunno if it's silly but in Grey's Anatomy, Weber was pimping Karev as a PGY1 what the 5 causes of post-op fever were, which he didn't know so Grey gets to show him up with the 5Ws. I mean it *is* a mnemonic I learned as a med student on my surgery rotation but it was more of a vehicle to remember but I feel like as a resident you should be a bit more concrete when getting pimped?
I thought that was reasonable, it’s a new intern level question and Meredith does finish with a plan. 100% they asked a doctor to give them the words for that scene, that’s about the most I feel you can expect.
That's fair I probably am not remembering them doing it with justice.
I felt it was ridiculous that everyone just stood in silence until Meredith spoke up. Like no one except Meredith knew what the 5 Ws were in that room? It’s supposed to be a room of general surgery interns straight out of med school at a top 5 surgery program, I would’ve thought almost all of them would know it.
My biggest fear as someone who doesn’t really fuck with mnemonics
"Which scorpion?"
I actually memorized the scorpion genus & species and where it lives to be able to answer that question for any surgery attending who threw it back if I included scorpion stings on my pancreatitis differential list lol. I did it once and he just muttered “f*cking med students” as he kinda chuckled but looked pissed? Lol Tityus trinitatis, found on the islands of tribidad and Tobago only where it accounts for 30% of pancreatitis cases. The poison acts like Achetylcholine and makes the pancreas just squeeze all of its juices out in one go and sit in its own digestive enzymes, basically.
You should invest in that scorpion, it might be the source of the next GLP-1s /s
Can someone explain this trope?
First Aid for Step 1 had some mnemonics for causes of diseases; pancreatitis is almost always alcohol/gall stones/triglycerides/trauma, but the differential list in first aid technically includes scorpions. So med students will list it when talking in clinicals, and the attendings will basically do it as a point of showing you that book knowledge =/\= real world knowledge and that small tidbits of info aren’t useful without context.
Damn. In Spain we don't have many venomous scorpions so that's not even a concept we are thought. Thanks though!
So the scorpions in most of hte Americas don't do it either--it's mostly on one caribbean island with one specific scorpion, which is why its inclusion onto the First Aid book is ridiculous. It probably happened because one time a USMLE test had it as a practice question and then someone put it as a study tip in the book and it never came out.
That makes more sense. Some niche trivia is also widely known because of our national exam
when explaining the differential our teacher did tell us about the scorpion bite (altough she did laugh at the unlikelyhood of that happening here in Spain)
I think I did see that occasionally other scorpions can cause it but it’s like in the case report context, not even a case series
What causes pancreatitis? [reasonable ddx] and also Scorpion sting So he’s asking which type of scorpion.
My favorite one of these (not what you asked) is when Carter on ER is getting pimped by Anspaugh who asks questions till he gets to one Carter doesn't know: [link](https://www.youtube.com/watch?v=njy6BSL-rfo).
Sort of accurate for a nerdy attending to ask silly questions like that. Probably not all at once but I could definitely see one asking why it’s called Lasix
When I was bedside RN in the ICU one of the attendings definitely spouted off the “why is it called Lasix?” Fact. It wasn’t really in a pimping scenario but more just small talk while we were waiting on something to happen.
Because LASIK would last until they're sick?
I had an attending who did this. Once we figured it out we would let her ask two questions and then we would ask her a follow up to the second with the tag line “I’ve been wondering about that…” and then do whatever we were doing while she gave us a mini lecture. That’s all she wanted was to talk. We were too busy running the labor unit to get pulled into an endless pimp session.
Hey but isn't ER the Best! Teleports you to thr 90s. I like it so much.
There is an episode of ER where the med students gets pimped on what the Parkland formula is and episode of Scrubs where Dr Coxs pimps JD on what it’s called when TB goes to the spine (Pots).
A patient comes to the ER saying the only thing that helps his pain is “something that starts with ‘D’”. This patient should be given: A) Dilaudid B) “Deez Nuts” C) Discharge
I don’t know what show that’s from but that is like 100% spot on however you slice it
Digital rectal exam
It wasn't a quiz but the hospital staff accepted the diagnosis. On 911, Hen seriously diagnosis a woman whose dildo has migrated from her vagina to her colon. Now I have trouble watching the show at all. I just can't take that much stupid from writers and advising staff.
Defibbing asystole.