“Hey doc, we can’t get a line on the kid in room 7, he’s going to need an US IV” is one of the last things I want to hear while working a peds shift. I’ve put US lines in teens, but they aren’t much different than adults in this regard. But what about youngerRead more

Calculous Cholecystitis: Early vs Delayed Cholecystectomy

Prompted by our M&M yesterday, below are the data surrounding delayed vs early cholecystectomy in patients with acute calculous cholecystitis.   TL;DR: Current evidence supports early cholecystectomy provided the patient is medically stable for surgery. All sources I found recommended admission. I could not find any sources that recommended discharge from the emergency department.   MetaRead more

EtOH Withdrawal: Ketamine, Precedex, and Other Pearls

Case: Unk-FrequentFlyer is rushed back to you in the cardiac room by Unk-Intern. He was found in the back corner of the B side shortly after 7am sign out. The patient is in florid alcohol withdrawal, combative, hallucinating, and of course does not have an IV. What’s your game plan?   Initial Sedation: This patientRead more

Lidocaine Pretreatment in Asthmatics

In asthmatics requiring endotracheal intubation airway stimulation can induce severe reflex-mediated bronchoconstriction. This reflex is neurally mediated in part by the vagal nerves. Is there any evidence for the use of lidocaine pretreatment to prevent reflex bronchoconstriction?   TL;DR: Based on the studies below, pretreatment with lidocaine prior to intubating asthmatics is not recommended.  The evidenceRead more

Bandemia with Normal WBC Count

Is bandemia with a normal WBC count concerning?   TL;DR: Bandemia is concerning even in the absence of leukocytosis and/or abnormal temperature   Drees et al evaluated whether patients admitted to the hospital with a normal WBC and elevated bands were at higher risk for infection or in-hospital death -Retrospective cohort study including all admittedRead more

Google Deep Learning for EHR

Google recently published a study online (not peer reviewed) of its AI system that predicts medical outcomes such as in patient mortality, readmission, etc There is a lot of technical jargon in the paper, but here is a brief summary: -Previously, predictive models required selection of variables and standardization of data, which is generally veryRead more

“Tamiflu: A Nice Little Earner”

This post is meant to be an update to yesterday’s post on the CDC recommendations regarding Tamiflu.  Most of this information will be based off of a 2014 Cochrane Review. Toward the end of this post I will delve into the controversial story of how Roche turned Tamiflu into a household name, and netted theRead more


There is a lot of controversy surrounding the use and efficacy of Tamiflu. Below is a brief review of Tamiflu per the CDC.   TL;DR -Likely some benefit in elderly (>65y/o), young (<2 y/o), chronically ill, or hospitalized patients   Benefits -Shorten duration of fever, illness symptoms -May reduce complications from influenza (OM, PNA, respiratoryRead more

ED Treatment of “Complex” Atrial Fibrillation

Case You receive RESUS signout on a 60F DMII, HTN here with urosepsis s/p abx, lactate downtrending, BPs holding in the 90s-low 100s systolic with IVF. Only thing left to do is talk to the MICU. You note the patient to be in persistent afib with HR 130-150, no h/o afib. When you call theRead more


Should patient with severe sepsis receive steroids? Multiple trials have evaluated this question with varying results The ADRENAL Trial sheds some light on this question. The answer: Probably not   TLDR: Does hydrocortisone reduce mortality among patients with septic shock? 3800 ventilated patient’s with septic shock were randomized to receive 200mg of hydrocortisone or placeboRead more