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C'mon, can't we discuss some REAL medicine?


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As the risk of offending everyone, I'm tired of looking at unread threads and seeing nothing but contracts, how do I get in, will I get in if I'm number 200 on the wait list, etc.  Are we not capable of discussing observations, treatment variations, and even coming up with our own ideas as healthcare professionals on how to address a particular illness?  Case in point, earlier this week I started a thread on the clinical correlation of symptom variance during specific time periods of the 24 hour cycle with regard to odynophagia and coughs which may or may not help exclude possible dx. differentials.  Crickets are still chirping.  Occasionally we'll see some interesting case scenarios, etc. (kudos to those who post same) but I want to know why the heck we can't ask our own clinical questions and determine the relevance of same?

Why do simple interrupted sutures on a wound which has the risk of edge inversion and dehiscence as well as being time consuming as opposed to just closing most lacs with a running horizontal mattress?  Simple interrupted sutures on the summer license plate parking lot bites where the apex of the flap is distal SUCK with simple interrupted sutures.  Close those things with running horizontal mattresses that evert the edges and lessen the risk of that paper thin apex margin of popping open.

What about that scenario that I posted about cobblestone throats in EVERYONE that I'm seeing right now since every potential pollen is off the chart here in N. Texas?  Should you immediately be able to disregard strep and just treat the throat and cough with antihistamines/decongestants/nasal steroids, and the greatest treatment of all, aluminum hydroxide!  I had another family say today that it worked wonders!

What about a cough that is non-variable compared to one that peaks in the a.m. and p.m.?

Why do a rapid mono or strep test on someone who has only been sx. for a day or two (this is pertinent with mono especially) if we don't take the time to tell the patient/family what the precautions are and that additional sequential blood tests may be necessary?  Don't even get me going on what I consider to be one of the most worthless tests of all, my favorite, the rapid strep test.  Should we go old school and just culture everyone instead and tell them to suck it up for a day or so?  If you're so concerned about rheumatic fever, how long do you have to wait until it's too late to preventively cover them (not that they're going to get it anyway since the incidence of same is 1:10's of thousands of cases?  How long before a rapid strep converts from positive back to baseline negative for that patient that comes back 10 days later with recurrent sx.

I raised a question with my SP's yesterday on a patient chart that while looking at a prior visit revealed a 1 gm. b.i.d. dosing of amoxicillin for a positive strep screen.  Seemed quite excessive to me (since it's a self-limited disease anyway) and sure enough each SP uses a different dosing, neither of which matched up with Epocrates OR Hopkins!  We don't even know how to be constant in our treatment decisions for one of the oldest and most common disease processes that we see.  Anyone beside myself and those who briefly participated in the strep thread regarding concomitant dosing with same in addition to the antibiotic suck it up and since start giving a single 8 mg. dose of dexamethasone after the previous thread regarding same?

My first patient this morning has red bulbar conjunctiva O.S., what appeared to be ptosis O.S. (possibly due to STS), and pain with ocular movement.  What would YOU do with this patient if you don't have a slit lamp or ability to check IOP (do you know the normal range for IOP)?  She allegedly had experienced some discharge, but like most, there's nothing on the lashes.  No acute visual change.

We've got SO many seasoned folks on this site that can offer up an absolute wealth of information, especially to those who are just out or are a year or two out and still wet behind the ears.  C'mon, let's share some of this information.

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Nice thread . I think alot of people here if they are like me somewhat loose their passion for this around year 7. You seem to still have it. I wish I did. 

Your tx for cobblestone throats seems spot on . I believe those cobblestones are just inflamed lymphatic tissue on posterior pharyngeal wall. Treating for allergies/PND/LPR seems reasonable.

An interesting cause of throat pain I have seen twice is retropharyngeal calcific tendonosis. The patient basically presents like a retropharyngeal abscess without fever and appears well. Dx with CT scan . Tx is NSAIDs. 

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I still love it.  I read everything I can...there's always something more I can learn.  I have incorporated GMOTM sore throat treatment into my after visit summary.

Many of the people I work with are are "meh".  I saw a lady yesterday with a concern for pink eye, and for many providers, unfortunately, injected eye + discharge = conjunctivitis.  Ask a few questions, take a peek, and I'm thinking keratitis.  Anyways, it's early.  It would be nice to have a place to go to discuss clinical stories, I agree.

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I find most folks, when they have a presentation, know way more about the subject at hand than I do so I just soak it up and learn.

I had a long talk with a few Docs about treating strep or not based on a previous discussion. My medical director said we won't be changing anything because the public blowback would be huge. The pediatricians are all about limiting antibiotic use, and even fuss at us in the UC sometimes, but drew a hard line on not treating strep in the "traditional" sense.

I suspect a lot of folks are tracking these conversations but are slow to jump in.

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Here’s a great one for discussion:  Pediatrician colleague of mine (who has since passed away) in general conversation twenty-something years ago, was emphatic that the Johnson & Johnson campaign for treating kids’ fever with Tylenol, while spreading terror about ASA and Reye syndrome, was the greatest marketing ploy ever created.  

Don’t you guys and gals remember all of the kids in your neighborhood coming down with Reye’s, since we were all given aspirin for our fevers? (Me rolling my eyes)

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I think most of us are so burned out from day-to-day medicine that we come here to vent or talk about more career-related issues. Plus, the clinical interest level declines after a while. Just trying to get through the day and make good decisions.

Good to know on the suturing though. For flaps I like a combo of horizontal mattress and simples or a running suture.

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Had a one month hx of cough slide on in this morning with BPs approaching 190/110.  Hx of HTN, no meds, no PCP, and NO focal deficits (this was one of the greatest changes that we made when we stopped sending these folks to the ED because of numbers alone).  Texted SP, saw her for the cough/crud, and we agreed to put her on lisinopril 5 mg qd and f/u with their network fam med office next week.

Key take home, she didn’t get that way overnight (no, HR was normal) so if she blows a gasket it won’t be because it was an acute change.

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GMOTM, I love horizontal mattresses - drives the PCP\s around here nuts because nobody seems to know how to take them out or even what they're looking at sometimes, lol.  I use verticals a lot with knee and elbow lacs, especially transverse ones across the joints - keeps the tension down, especially if you do a bit of undermining prior to sewing.  I sometimes get invited to help teach med students they're recruiting here for rural primary care basic suturing - this is one I always teach them.

The ABx for sore throat thing is a bit of  a bug in my backside too - part of my job right now is checking the C&S results and doing call backs prn - I get into it a bit regarding what strep throats to treat, since GABHS is what leads to rheumatic fever, PSGN, etc - I was trained there is no need to treat anything but Group A in the throat - some docs are reluctant not to treat all Strep, regardless of Grouping.

Cobblestoning - I've noticed over time that I would attribute that to postnasal drip, sometimes GERD, but usually post nasal drip - the vertical tracking seems to coincide with the snot waterfalls.  Sinus rinses, clean the allergy issue up if that's the issue, hard candy of choice to keep the throat lubed up and wet - old school Cepacol lozenges used to keep the Canadian military functioning, but were taken out due to over use and actual piss poor evidence for use- the candy actually does the same thing with fewer side effects (other than DM) and is cheaper...plus, you can pick a flavour you like.  I will try liquid antacid though - I use that with Benadryl for mouth ulcers, don't see why shouldn't try it out for sore throats...

SK

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So yeah I'll admit I hate the treatment a lot of kids get in UC or primarily adult EDs.

For strep throat, thankfully we now have a PCR that comes back in 60 minutes so we've stopped doing cultures!  And I'm trying to stop doing the rapids.  I send them home and tell them I'll call it in if it's positive. 

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4 hours ago, GetMeOuttaThisMess said:

Had a one month hx of cough slide on in this morning with BPs approaching 190/110.  Hx of HTN, no meds, no PCP, and NO focal deficits (this was one of the greatest changes that we made when we stopped sending these folks to the ED because of numbers alone).  Texted SP, saw her for the cough/crud, and we agreed to put her on lisinopril 5 mg qd and f/u with their network fam med office next week.

Key take home, she didn’t get that way overnight (no, HR was normal) so if she blows a gasket it won’t be because it was an acute change.

um, maybe starting lisinopril with c/o cough is not the best option. Did you do CXR? any orthopnea? basal crackles? peripheral edema? smoker? asthma? PFTs? done dirt cheap

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See, this is a good question.  We don't have CXR capability and I doubt that an ACEI cough is going to superimpose itself over a one month cough within a matter of a couple of days.  We're snot/cough only, we don't get to practice 20th, much less, 21st century medicine.  You actually have to use your mind and clinical skills in my setting.  No other risk factors than just a month of snot/cough.

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I think one may by missing the key overarching point of the forum... a place to gather and talk about any and all things relevant to the profession.  This, of course, includes all of the things that are the primary focus of what most posts are, and even though there are a number of us who have significant experience, in my experience it isn't the reason why most people come here.  

I consider most of the members of this forum a subculture within the greater PA community - those who are plugged in at a deeper level than most within the profession itself.  This is part of their identity as a PA, which many PAs I know just don't ascribe to in any way, shape or form. Years ago, when traveling in the upper echelon of EM PA circles, the forum was considered something of an enigma, people didn't understand what it was and what it actually did.  Politically, this has translated into a different set of values between those who "hover" here vs. those that don't - the thought process to much of what people think in our profession can be roughly aligned along this dividing line.  Those who post here aren't afraid to push boundaries, try new things, or seek out different approaches to solve problems.  I cannot say the same of my colleagues who do not maintain an online presence in this community.  

Personally, I don't come here to vent cases, consider others cases (routinely) or consider treatment modalities for other disease processes (usually).  I do enough of that at work by doing journal review, keeping up with the literature, following a couple of fields outside my own (EM), and interacting with others in the field at conferences and CME opportunities.  I come here for like-minded folks who can offer solutions to issues I may encounter outside the everyday realm of what I treat in EM (I do wonder though if this is a function of the job I have).  

Don't get me wrong - if something is interesting I am all about discussing it.  But the ho-hum day-in, day-out medicine I do doesn't entice me to want to chat about it online.  I started a website for the good stuff several years back, focused it here and elsewhere with minimal interaction/feedback.  This taught me that folks aren't even genuinely interested in learning or discussing the cutting edge/advanced stuff in EM (and other aspects of medicine).  That's ok - our peeps are still here which is what matters.  

Just thoughts...

G

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