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So You've Decided to Tweet

As the new medical-academic year begins, I'm guessing a bunch of new interns will learn about how great FOAM is, and at the same time,...

July 25, 2016

So You've Decided to Tweet

As the new medical-academic year begins, I'm guessing a bunch of new interns will learn about how great FOAM is, and at the same time, get an orientation lecture on "threats to professionalism." Obviously I think there is a ton of potential benefit to using social media as a medical professional, and here are some of the ways I "maintain professionalism" (read: keep myself out of trouble).

One of my big keys is to not try to "not violate HIPAA" – that's easy and too low of a bar.
The real key is to not piss off the carpetwalkers: I don't want to have to defend myself in a meeting with Risk Management. Instead, I want to maintain a general profile I can defend to my dean and my department chair (and maybe someday to the promotion & tenure committee).

Twitter is a Giant Elevator
My big overall philosophy is that social media is like talking on an elevator. But: my mom, department chair, medical school dean, the patients' family, and a million other people are in the elevator. Obviously that doesn't mean that I'm always banal and polite. Rather, I recognize that people will see what I write and it is always tied to me.

Patient Privacy
Easy version: never talk about real patients.

Slightly tougher but still easy: if I do want to talk about real patients, I change enough of the details so that if the actual patient were to see it, the patient wouldn't recognize that it was them.

Two mistakes people make: date of service and age over 90 are HIPAA-protected PHI. The number one thing I do if I am referencing something that happened to a real patient is that I don't do it the same day (or even the same week).

I never even reference "oh look what happened on my drive to work today" so there can't be a real connection between anything I say and a real patient. And I don't share pictures from work or of patients without all of my ducks in a row (if at all).

On Anonymity
I'm not opposed to being anonymous, but I'm very much intentionally not. This is partially as a check on myself -- I know whatever I say is tied to me. A big part of it is to avoid the fear of people discovering my secret identity.

I'm not recommending anyone be anonymous on social media, but if I were, I would tell all my relevant bosses (e.g. program director, chair). If something serious "goes down," i.e. there's some sort of scandal, and it's a total surprise and secret to everyone, I imagine that there will likely be a big sense of betrayal.

But I don't want to be anonymous, it means you are giving up a lot of the upside. I imagine the benefits are possible but a lot harder if anonymous. Because the bottom line is that there are legitimate career, academic, and potentially financial benefits to being active on social media as a medical professional.

April 8, 2016

Urine Drug Screen False Positives

Urine drug screens aren't completely useless, but they have a number of limitations. Here is a table where I have compiled all of the false positive causing drugs I could find (pdf):

Update 4/22/2016:
Here are my sources:

I started with this paper which was I originally heard on EM Abstracts (Jan 2011):

Brahm NC, Yeager LL, Fox MD, Farmer KC, Palmer TA.
Commonly prescribed medications and potential false-positive urine drug screens.
Am J Health Syst Pharm. 2010 Aug 15;67(16):1344-50.

Special thanks to Jon Cole from Hennepin who made this fantastic video.

Other sources include:
UMHS Guidelines for Clinical Care May 2009

Standridge JB, Adams SM, Zotos AP.
Urine drug screening: a valuable office procedure.
Am Fam Physician. 2010 Mar 1;81(5):635-40.

Reisfield GM, Haddad J, Wilson GR, Johannsen LM, Voorhees KL, Chronister CW, Goldberger BA, Peele JD, Bertholf RL.
Failure of amoxicillin to produce false-positive urine screens for cocaine metabolite.
J Anal Toxicol. 2008 May;32(4):315-8.

Ly BT, Thornton SL, Buono C, Stone JA, Wu AH.
False-positive urine phencyclidine immunoassay screen result caused by interference by tramadol and its metabolites.
Ann Emerg Med. 2012 Jun;59(6):545-7.
doi: 10.1016/j.annemergmed.2011.08.013

Swift RM, Griffiths W, Cammera P.
False positive urine drug screens from quinine in tonic water.
Addict Behav. 1989;14(2):213-5.

Updates 5/1/2016
Reordered alphabetically
Added lamotragine -> PCP
Geraci MJ, Peele J, McCoy SL, Elias B. Phencyclidine false positive induced by lamotrigine (Lamictal®) on a rapid urine toxicology screen. Int J Emerg Med. 2010 Dec; 3(4): 327–331.

Added a few more -> PCP
Phencyclidine (PCP) Test Systems Executive Summary. Chemistry and Toxicology Devices. FDA
2013 Apr 25, Link.

December 30, 2015

And I Didn't Know It

Inspired by Saurabh Jha:
Not exactly op notes, but some ED limericks I wrote:

Mr. Jones ate some bad guacamole
press on his belly, he shouts "holy moley!"
we did a CT
and what could it be?
then he went for a lap'r'scopic chole

Mrs. Smith was awoke from her nappy
her belly was feeling quite snappy
white count? twasn't high
a fever? tad shy…
but the CT, of course, showed an appy

there once was a man from Bologna
thought he had caught a touch of pneumonia
he seemed like whiner
and he got a d dimer
no PE; just some bad allodynia

Of course the cake goes to:

November 16, 2015

Roc vs Sux Revisited: Cochrane Update

I’m not going to reinvent the wheel, so a sweeping summary:
Traditionally, succinylcholine has been the paralytic of choice for RSI. However, succinylcholine can (rarely) lead to hyperkalemia, particularly in patients with chronic neurological problems.* Proponents of rocuronium for RSI suggest avoiding potentially fatal hyperkalemia by routinely using roc, summarized superbly by Reuben Strayer here. When dosed properly (1.2 mg/kg or higher), time of onset and intubating conditions are equivalent to between rocuronium and succinylcholine.

Defenders suggest that succinylcholine's shorter duration of paralysis is an advantage: if you can’t get the tube, the patient starts breathing. Unless the patient critically desaturates before return to an unparalyzed state:

Note the title of the source of this familiar graph: Critical Hemoglobin Desaturation Will Occur before Return to an Unparalyzed State following 1 mg/kg Intravenous Succinylcholine (Benumof, Dagg, Benumof. Anesthesiology. 1997 Oct;87(4):979-82.)

In the original 2008 Cochrane review, the authors (including Perry & Wells) find that time of onset and intubating conditions are inferior to succinylcholine… when dosed inadequately. Cochrane just released another update and reached the same conclusion with mostly same data, but again, note that when dosed appropriately, rocuronium is just as good as succinylcholine, with a p-value of 1.00.

Of course that’s only 86 patients dosed at 1.2 mg/kg, but the results were identical. The Cochrane authors further find that even some lower doses of rocuronium (down to 0.9 mg/kg) are just as good:

but then come to the same conclusion:

This is a bit odd. When I can’t intubate or ventilate a patient, they don’t nicely wake up in 9 minutes. In fact, more paralysis may even be preferred, particularly to optimize further attempts at mask ventilation, including EGD placement. And more importantly, to stop a panicking, suffocating patient from stopping me from stabbing them in the neck. But the bottom line is that if the succinylcholine has worn off, then they’ve probably already critically desaturated.

A number of Very Smart People (including Rob Huang, Minh Le Cong, Chris Nickson, and Reuben Strayer) have all pointed out that Cochrane is supposed to summarize the data, not editorialize:
There are some situations where I still reach for succinylcholine, primarly when I don’t want to lose my neuro exam for an extra half hour, mostly severe head trauma and status epilepticus. Also, if I can’t get a line or an IO and need to use IM drugs for RSI, rocuronium is probably too dilute.**

Ultimately, this isn't that big deal. Hyperkalemia is bad, but rare. But if we can avoid it without worsening time to onset or intubating conditions, why not?

My biggest problem with rocuronium? It comes in 50 mg vials. One*** great tip I learned from Reuben Strayer : when I ask a nurse for rocuronium, I always clearly specify that I need 2 (or 3) vials.

*Most of which are fairly rare and I (fortunately) don’t need to intubate very frequently. But when that relative zebra is really sick, I have enough on my mind and I don’t want to have to think to hard about which drugs may be dangerous. Note that in MG, you can use succinylcholine but have to use more; you can use a lower dose of rocuronium but a normal dose will just paralyze them longer, which is much safer than me having to remember this whole paragraph and do math when the chips are about to hit the fan.

**Bad day for everyone. Not ideal but I prefer to have my quiver more full than my diaper.

***One of too numerous to count. Read and watch everything at emupdates.com

Special thanks to Minh Le Cong & Reuben Strayer for their prepublication peer review.

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