Nonsense - Caveats

[jmj11]

What were some medical caveats given to you as a young practitioner at CME meetings or otherwise, which now you know were pure B.S.

Here's one, "You can always tell if someone is in real pain by the dilation of their pupils."

Another, (From Doctor speaking at a AAPA conference in the 1980s): "I can cure all torticollis by this simple manual procedure." (He named the procedure after himself and it never worked)

Another, "Here is a simple physical exam that always proves if a patient is malingering or not."

 

 

[EMEDPA]

"just give them some sublingual procardia for their high bp and send them out the door"

"anesthetic eye drops can't be given to patients to take home"

"high dose epi can turn around most cases of cardiac arrest". circa 1991 when we gave everyone 10 mg of 1:1000 epi in codes and got lots of bizarre rhythms that persisted until they died anyway days later in the ICU...

"propofol is only safe for anesthesiologists to use"

"PAs never do XYZ, that is a Dr's job" heard this too many times as a new PA coming up the ranks in a lot of ERs where PAs were not appreciated.

[sk732]

21 minutes ago, EMEDPA said:

"propofol is only safe for anesthesiologists to use"

 

This was an article of faith in the Canadian Military for a lot of years - I remember working on a procedural sedation protocol for Navy PA's and got out ranked by my boss, despite what was common practice in the real world (and what WE did in the civvy ER's where we were based and what the Army guys were doing in Afghanistan) and what we were actually being taught in school.  Of the three of us working on it, 2 of us refused to allow our names to be attached - the senior guy attached his name to it, using morphine and midazolam as the main agents and tossed out what we'd written out as ours (fentanyl and propofol).  I understand propofol just got released to the mainstream general duty docs only about 3 years ago.

SK

 

 

[jmj11]

We were taught in school that a good clinician, even in a only partially darkened room, without the benefit of mydriatics, using the traditional Welch Allyn ophthalmic scope. should be able to assess: if there is any papilledema, the depth of the optic cup, if there is AV nicking, cotton wool spots, infarcts, macular drusen, or hemorrhages. I could not see those things at all once I started my clinicals, especially in the elderly (small pupils) or those who could not cooperate well (eg. kids). I felt like an incompetent idiot.

Then one day, I had the chance to share a patient (with papilledema, which I did see) with a neuro-ophthalmologist. He told me that no one can see crap with one of those, UNLESS mydriatics are used in a really dark room and the examiner is very lucky and the patient very cooperative. Then I asked, "But my (PA) instructor said that he could."  Then he laughed and said, "Every doctor or PA who says they see all these things are lying to you. They are pretending to do the exam."

I now have a panoptic. I can tell if there is even subtle papilledema in virtually all patients, but I still can't see many of the other things unless they have naturally large pupils (in their 20s) and are very cooperative. We don't use mydriatics in neurology.

I recently had a second year PA student. She also had been told that she should be seeing all those things with the old scope. I then had her look at the fundi of one of my patients using my panoptic and telling her what to look at. She, literally broke down in tears because she had felt incompetent before and now she could finally see those things she supposed to be seeing.

[Reality Check 2]

Our male OB/Gyn attending Chief of Dept told us as students that the female cervix is insensate.....

About 10 of us asked him if he had one. He just stared at us. 

To this day I think of that when I have to grasp a cervix with a toothed tenaculum to insert an IUD or do a biopsy if the cervix is too floppy. I spray hurricane before I do it and always warn the patient that they will feel something.  

Guess what - they FEEL it.

[sk732]

2 minutes ago, Reality Check 2 said:

Our male OB/Gyn attending Chief of Dept told us as students that the female cervix is insensate.....

About 10 of us asked him if he had one. He just stared at us. 

 

An old friend of mine was a (female) gynecologist and they were told this as an article of faith...by their otherwise male professors.

JMJ - I've managed I think once to see papilledema in one eye of a cooperative 14yo with BIH in the ED with a standard ophthalmoscope - couldn't in the other and the pediatric neuro fellow couldn't confirm.  I've seen AV nicking (I think accidentally) and I actually saw a cholesterol crystal in a retinal artery in an old dude that presented with amaurosis fugax.  Beyond that, haven't seen it, and I do look.

SK

[jmj11]

1 hour ago, Reality Check 2 said:

Our male OB/Gyn attending Chief of Dept told us as students that the female cervix is insensate.....

About 10 of us asked him if he had one. He just stared at us. 

To this day I think of that when I have to grasp a cervix with a toothed tenaculum to insert an IUD or do a biopsy if the cervix is too floppy. I spray hurricane before I do it and always warn the patient that they will feel something.  

Guess what - they FEEL it.

I remember helping with my first D & C and the family medicine doc who was doing it told me the same thing. He put this big clamp on her cervix and she screamed. He told me it was just anxiety because she can't feel a thing.

[GetMeOuttaThisMess]

Panoptic scopes are the bees knees and we should throw all ophthalmoscopic heads in the trash.

 

[Guest JMPA]

6 hours ago, jmj11 said:

We were taught in school that a good clinician, even in a only partially darkened room, without the benefit of mydriatics, using the traditional Welch Allyn ophthalmic scope. should be able to assess: if there is any papilledema, the depth of the optic cup, if there is AV nicking, cotton wool spots, infarcts, macular drusen, or hemorrhages. I could not see those things at all once I started my clinicals, especially in the elderly (small pupils) or those who could not cooperate well (eg. kids). I felt like an incompetent idiot.

Then one day, I had the chance to share a patient (with papilledema, which I did see) with a neuro-ophthalmologist. He told me that no one can see crap with one of those, UNLESS mydriatics are used in a really dark room and the examiner is very lucky and the patient very cooperative. Then I asked, "But my (PA) instructor said that he could."  Then he laughed and said, "Every doctor or PA who says they see all these things are lying to you. They are pretending to do the exam."

I now have a panoptic. I can tell if there is even subtle papilledema in virtually all patients, but I still can't see many of the other things unless they have naturally large pupils (in their 20s) and are very cooperative. We don't use mydriatics in neurology.

I recently had a second year PA student. She also had been told that she should be seeing all those things with the old scope. I then had her look at the fundi of one of my patients using my panoptic and telling her what to look at. She, literally broke down in tears because she had felt incompetent before and now she could finally see those things she supposed to be seeing.

I must disagree. I use a standard ophth scope daily and am able to get an adequate view on >90% of patients. True there are some patients with pinpoint pupils (dope eyes) but 4mm or greater should be more than adequate. There is some technique involved that many are not taught. Certainly keep the room dark but also important is to keep your scope light low. Try not to view the macular until the end of the exam. I also recommend for the difficult patients to have them lay flat and look straight at the ceiling, than you can comfortably view them from the head of the bed which provides a very stable patient, and a comfort zone being that your face is not in their face. 

[jmj11]

9 minutes ago, JMPA said:

I must disagree. I use a standard ophth scope daily and am able to get an adequate view on >90% of patients. True there are some patients with pinpoint pupils (dope eyes) but 4mm or greater should be more than adequate. There is some technique involved that many are not taught. Certainly keep the room dark but also important is to keep your scope light low. Try not to view the macular until the end of the exam. I also recommend for the difficult patients to have them lay flat and look straight at the ceiling, than you can comfortably view them from the head of the bed which provides a very stable patient, and a comfort zone being that your face is not in their face. 

All I can say is that you must be better at it than me. Especially with the elderly, I could barely visualize the optic nerve with the old scope.

[MCHAD]

Ya, in school we all just memorized “cup to disc ratio is blah blah blah” because we had to vocalize our physical exam findings while being tested...