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?”
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.
Continue reading “Peripheral vasopressors: the myth and the evidence”
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”
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”
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”
A review of the BNP literature
In the most recent episode of Emergency Medicine Cases Journal Jam, Rory, Anton, and I cover the evidence for (for against) using BNP in the emergency department. These are my notes. Continue reading “BNP in the emergency department: The evidence”
A critique of the current science supporting idarucizumab
Optimism is essential. Few things are as powerful as hope for the future. When facing an onslaught of critically ill patients, optimism allows emergency physicians to persist. Optimism, however, can cloud also cloud our judgement; allow us to focus only on the good, not the bad. As physicians, we cannot afford optimism blindness. We need to be objective. We need to be scientists.
This month I was distressed to hear overly-optimistic, unscientific statements about idarucizumab on two of my favourite emergency medicine education programs: EM:RAP and EM Cases. I have incredible respect for these sources. EM:RAP has been irreplaceable in my emergency medicine education. On EM Cases, the statements were made by Dr. Walter Himmel, who is one of the smartest individuals I have ever had the opportunity to meet. But in this instance, I think that they were both wrong.
Continue reading “Idarucizumab: Plenty of optimism, not enough science”