BRom

I’ve seen it in the liver. Maybe people who have had so many central lines everything is stenosed. I remember looking at this young man and his IJ was humongous. I was a resident. The transplant surgeon said no way. It’s big because it’s stenosed. You stick that and you’ll have a real mess. I got an EJ.

Why Venous access in this location? What vein is it?

Every time I saw the heart surgeon pull a vein out of the leg it was tan. And when he filled it with heparinized blood until he needed it, it was still tan. So what’s all this talk about color of blood? Just reflecting on this a little. Shine a little light on the subject. Make the discussion more colorful. Maybe I’m on the spectrum.

Why do veins appear blue under your skin even though the blood inside them is always red?

Higher energy red light is absorbed. Blue is reflected. Just like our sky. Red light penetrates to ground while blue light is scattered and makes the sky blue. At sunset or sunrise when the suns light is more tangential to the atmosphere, only the light towards the red side of the spectrum is getting through - red/orange. The ocean absorbs almost all of the light making it look black or blue-black. Right now the Pacific equatorial waters are heating up to record levels, aka El Niño. Sierra mountains in California are going to have apocalyptic snow this next winter I’m betting. But I digress.

@OGdukeneurosurg There are no days off in neurosurgery.

Can we normalize doctors taking a day off of work without feeling guilty or apologizing. I can never do this someone teach me how!

I have a life outside of the hospital. I see medicine as just one branch of my journey. I insist on being called doctor inside the hospital and I insist on not being called doctor outside of the hospital. When I leave in a few years I won’t look back. All sorts of wonderful educational endevours await. Engineering was my first love and it will be my last albeit in a very limited scope.

Doctors beware - You may hate retirement.

@MahmoudAhshad Make sure it’s an MI. Decades ago I received a higher up in the criminal underworld world who got aspirin and plavix thinking he was having an MI. He had liver failure and bleeding esophageal varices. It went about like you can imagine - very poorly.

إلى الأطباء في practical point مهمة في الطوارئ نبي ننبه عليها بخصوص ال aspirin و بالذات في حالات MI قبل ما تعطي 300mg crushed aspirin لحالة acute MI على طول، تعود أنك تسأل ثلاث أسئلة سريعة: أول سؤال: مهم جدا وهو أكثر سؤال منسي تسأل المريض: هل عندك حساسية من Aspirin؟

@sweatystartup Physicians have a higher suicide rate than the general population. Men commit suicide 3-4x that if women in the general population. Amongst physicians the suicide rate reaches parity.

My advice to young people: 1) don’t vape and stop smoking weed. It’ll crush your energy and ambition, your only two things you have going for you. 2) don’t become a doctor or a lawyer. You’re too likely to end up unhealthy, unhappy, divorced and rich. 3) entrepreneurship isn’t about new ideas. Don’t follow your passion. Do common things uncommonly well. 4) get married young and have more kids than you can afford. 5) life is sales. Learn to sell or don’t expect to earn real money. 6) start small. Trade your time for money. Passive income is a myth. 7) decision making is a muscle. The only way to get better is to lift the weight. Books aren’t the answer. 8) you get to choose your competition in life. Silicone valley is electing to play basketball against LeBron James. Sweaty startups are playing basketball against a 5th grade girl. The choice is yours. 9) look down the hall. What does it look like to win the game you are about to play? What does your boss look like? Are they happy? That is where you are headed.

Oh sorry. To answer your question I usually get the airway. ENT can back me up but I’ve done lots of awakes. Although I do remember a case I don’t even attempt the airway - a guy with neck radiation and maybe one more. I asked ENT to do awake trach. A radiated neck to me is scarier than angioedema because even if you get to posterior pharynx you may not know what you’re looking at.

@BRom970 Thanks for these insights. How do you decide on intubation versus tracheostomy?

An emergency medical condition. What is this?

Experience maybe. I think Mallampati is rather simplistic. Kid last week had a lot of swelling in submandibular space. He couldn’t open his mouth. People with limited mouth opening are really scary. I assumed correctly it was from pain. No massive overbite or any other airway red flags. I asked him if he could lie flat comfortably. He said he could. Had he said no way that would have been a red flag. I judged him to be doable with induction and oral intubation. Saw no reason I couldn’t bag mask ventilate so worse case scenario I could wake him up and do awake intubation. Had I been concerned at all awake oral intubation for him. Being more concerned I could do awake nasal. What scares me is someone with angioedema leaning forward in the bed, motionless, drooling, and hearing air whistling through their airway. I remember a guy in residency who was so air hungry and in distress my attending said let me just try and look and he intubated with no sedation or topicalization. My recipe for topicalization : 1) Glycopyrolate is most important. If membranes aren’t dry topical won’t work. 2) nebulized 4% lidocaine. About 5 cc. Mask and nasal phenylephrine if doing nasal 3) dollop of lidocaine cream on a tongue depressor and place it dollop side down. Tell them let it dissolve naturally. When they start coughing a little it means it’s getting into their trachea which is good. 5) After cream is dissolved or I’m tired of waiting I take the tongue depressor and tap the posterior pharynx. If no response you are golden. 6) I prefer Berman airways to facilitate flexible bronchoscope. I can also sometimes bend an ETT and pass that around the tongue with the scope in it. 7) nasal can be easier because once you get into the upper pharynx it’s straight shot. Better make sure your tube is long enough. 8) Slide the ETT in over the scope and have the patient wave to educate people that awake intubations aren’t that bad. Had two separate heart surgeons tell me the patient wouldn’t be able to tolerate awake intubation.

@Mr_Husky1 Are those PAF pickups? Look like humbuckers to me.

Eddie Van Halen was attending a high-end vintage guitar auction at a Beverly Hills Gallery, looking for a specific 1959 Les Paul burst that had caught his eye in the catalog. When the lot came up and Eddie raised his paddle to bid, the auctioneer paused and spoke directly to him. Sir, I want to make sure you understand what you're bidding on. This is a 1959 Gibson Les Paul standard burst in exceptional condition valued at $50,000 to $75,000. This isn't a player's guitar. It's a collector's instrument. Are you sure you understand the significance of this piece? Eddie lowered his paddle and said calmly. I understand vintage guitars. I'd like to continue bidding. The auctioneer looked skeptical but continued. When Eddie bid $60,000, the auctioneer stopped again. Sir, do you have the means to complete this purchase? We require immediate payment for items of this value. Eddie nodded. I can pay. What happened in the next 10 minutes became the most talked about moment in vintage guitar auction history. It was a Saturday afternoon in November 2009, and Eddie Van Halen was doing something he rarely did, attending a public auction. Usually, if he wanted a specific vintage guitar, he'd have a dealer handle it privately. But this particular 1959 Les Paul had an interesting history. According to the catalog, it had belonged to a session player in the 1960s who'd used it on several famous recordings. Eddie wanted to examine it in person before bidding, and he was curious about the auction scene. The auction was being held at Heritage Fine Instruments, an upscale gallery in Beverly Hills that specialized in rare guitars, violins, and other collectible instruments. The crowd was maybe 70 people, wealthy collectors, dealers, a few musicians, and some investors who treated vintage guitars like stocks. Eddie had come alone, dressed in jeans, a sport coat, and a button-down shirt, nicer than his usual t-shirt, but still casual for Beverly Hills. He'd registered for a bidding paddle under E Van Halen, but the registration clerk hadn't made the connection. Eddie was just bidder number 47. He sat in the back row and watched the first several lots sell a 1950s Martin acoustic, some vintage Fender amps, a rare Gretch. The auctioneer was a man in his 50s named Richard Peton. Very professional, very knowledgeable about the instruments, speaking in that rapidfire auction style. The crowd was competitive. Several dealers were bidding against each other, driving prices up. Collectors were jumping in at the last moment. It was entertaining to watch. Lot 23 came up. The 1959 Les Paul burst that Eddie wanted. The auctioneer's assistant, wearing white gloves, carefully brought it out on a velvet line display stand. The crowd leaned forward collectively. Even in a room full of valuable instruments, a 59 burst commanded attention. Richard began his description with the reverence these guitars deserved. Ladies and gentlemen, lot 23. A 1959 Gibson Les Paul standard in what we call burst finish. That beautiful tobacco sunburst that's become the holy grail of vintage guitars. This particular example is in exceptional condition. The flame maple top shows extraordinary figure. You can see that even from your seats. Minimal fret wear indicating it was played by someone who knew what they had. Original PAF pickups, both measuring correctly on our resistance tests. Original Clusen tuners with the correct double ring design. Original ABR1 bridge. Original hardware throughout. Serial number authenticated. And the kicker original brown case with pink interior, also in excellent condition. He paused, letting the crowd absorb the details. This guitar is documented providence showing it was owned and played by session guitarist James Morrison in the early 1960s.

@docakx None of that advice is the root of the problem. It’s true but the American food supply is absolutely poisoned and that is the foundation of obesity in America. Normal weight people from other countries come here to live and many become obese.

Dr. Solomon

@louisanicola_ Except for doctors. They are exempt for some reason.

You think your decision quality drops under pressure. It doesn’t. It drops under sleep deprivation. This meta-analysis across 39 studies shows a precise failure pattern inside your brain. Working memory declines first. That is your ability to hold multiple variables, model outcomes, and think in layers. Then inhibitory control weakens. The impulse to act starts to feel like conviction. By the time cognitive flexibility degrades, you are no longer updating your models. You are defending them. This is not fatigue. It is prefrontal cortex suppression. The market calls it a bad quarter. Biology calls it a brain operating below its decision-making threshold

@RowlandAkpan Not mine but he was my man for pres.

Every medical student's role model was Ben Carson at some point 😂

Unpopular opinion: Dentistry is harder than medicine and surgery

@WatcherGuru @PeterSchiff Said, says, will say.

JUST IN: Peter Schiff says Bitcoin $BTC will crash "close to zero."

@jtrebach Sounds about right.

one time in med school I asked a doctor for feedback and he told me that I was stapling the patient lists together with the staple in the incorrect orientation and that a diagonal staple was not appropriate and it needed to be a horizontal staple so I laughed but he did not laugh

@reverendofdoubt I do get a little frustrated to get called in from home for a difficult airway only to be told we’re just going to watch him. I feel like someone better offer up a trachea somewhere in that ED.

Seeing specialists critique the Pitt is amazing. It's just like real life! No one wants to come down to the ED to help and yells at us when we call for help, but everyone has opinions on how to do it. *I don't watch medical TV shows anyway and haven't watched the Pitt 🤷‍♂️

@kh505043 What’s the medical term for hiccups?

What is the only FDA-approved drug for persistent hiccups? A) Metoclopramide B) Baclofen C) Chlorpromazine D) Gabapentin

@docakx So what you are saying is we are always getting exposed to someone’s fecal-oral route but they don’t have communicable disease. And that’s why I don’t eat out.

Do not buy anything from a baker or a fresh juice vendor, if their eyes look like this. I cannot emphasize this enough.