What’s the word on Word catheters?

A brief review of the evidence in the management of Bartholin’s abscesses

One of the very first medical myths I encountered was the packing of abscesses. It is pretty clear that packing provides no benefit in small abscesses, but significantly increases pain for our patients. (Barnes 1988; O’Malley 2009; Kessler 2012) Knowing that, I have always been confused about the management of Bartholin’s abscesses. Although exquisitely painful, these are relatively small abscesses in an area of the body with excellent vascularity and healing. It makes sense to manage them exactly like any small abscess, but I have always been taught that these abscesses absolutely required packing – and not just any packing, but the special (and sometimes hard to find) Word catheter. Was this evidence-based teaching, or just another medical myth handed down from generation to generation? Let’s look at some evidence. Continue reading “What’s the word on Word catheters?”

Peripheral vasopressors: the myth and the evidence

The evidence for using vasopressors through a peripheral IV

You are working in a small, rural hospital staffed by one physician and one nurse. There are multiple sick patients, all of whom require your attention, but the sickest is probably the 62 year old female with pneumonia and a blood pressure of 75/40 despite 3 liters of normal saline. This is septic shock, and you need to start a vasopressor, but the hospital protocol is that norepinephrine should only be given through a central line. You just haven’t had time to get one started, and wonder if it wouldn’t be better to get the patient started on the vasopressor using their peripheral IV.

The myth: It is an absolute contraindication to administer vasopressors through a peripheral intravenous line.

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NPO for sedation? Don’t swallow the myth

A brief review of the evidence for fasting in sedation

When was your last meal? Yes, I know that your leg is currently bent at about a 90 degree angle, but I must know, when did you last eat? You had some chips an hour ago? Well I’m very sorry, but you are just going to have to wait. Next time, remember that you need an empty stomach if you are going to have an emergency… Continue reading “NPO for sedation? Don’t swallow the myth”

Petition to retire the surviving sepsis campaign guidelines

What follows is a post that you will see on a number of websites this week explaining the petition to retract the 2018 Surviving Sepsis Campaign guidelines. You can read the guideline here. Although many of the individual recommendations seems reasonable, I think these guidelines could end up harming patients. Continue reading “Petition to retire the surviving sepsis campaign guidelines”

Articles of the year (EMU 2018)

Hand out for the articles of the year lecture at EMU 2018

I love evidence based medicine, but I definitely understand the criticism that EBM nerds like myself can come across as very negative. Thrombolytics don’t work. BNP isn’t helpful. Stress testing is a sham. Idarucizumab? Yeah right. I think this scientific criticism is crucial, but I understand that it isn’t always fun. So when I was asked to present my favourite articles of the year at the North York General Emergency Medicine Update, I decided to stay entirely positive. I only chose papers that were potentially  practice changing, but more importantly, that could have a positive impact on clinical practice. These are the papers I chose.

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Most medical practices are not parachutes

I was invited on EMCrit to discuss my position on idarucizumab and I fear I didn’t do a great job explaining myself. I don’t want to spend more time discussing the specifics of idarucizumab, but I think the larger problem of declaring that a therapy works without study, or declaring that it would be unethical to study a therapy because we “know it works” despite a lack of randomized control trials, is worth pursuing. Continue reading “Most medical practices are not parachutes”

Magical thinking in modern medicine: IV antibiotics for cellulitis

A summary of the evidence comparing IV to oral antibiotics for cellulitis

“I’ve been on these oral antibiotics for 36 hours and my cellulitis isn’t improving. My doctor sent me in because I NEED IV antibiotics.”

“This patient has pretty mild cellulitis, but he does have a fever, so I think we should go with IV antibiotics.”

“That is a pretty big cellulitis. There is no way it is going to improve with just oral antibiotics.”

Among physicians and patients alike, it is generally accepted that IV antibiotics are better than oral. They are stronger. They will work faster. They will save the day when oral antibiotics have failed. But do the bacteria floating around in the soft tissues of your leg really care (or even know) whether the antibiotics entered your system through a vein or via the stomach?

Continue reading “Magical thinking in modern medicine: IV antibiotics for cellulitis”