Still happy to be an employee

Absolutely sick of the paperwork though

Med students & senior residents talking about talking about using student loans to travel.

“The real power move is to max out your loans and buy bitcoin. Not that I know anything about that.”

They laugh. I laugh. We all laugh. What a silly idea.

Didn’t recognize most of the anatomy today

Obsidian dashboard for hospital work. Some of the med-student-era stuff needs to go 🤔

#Obsidian with embedded iframes is next level. Bilitool in my sidebar?!?!

Orientation—re: #ehr skills, a lot of this would be better taught in case-based sessions.

#deathbypowerpoint

Cerner is great 👍

Be on time

Be alert

No excuses

No regrets

Residency day 2

Just orientation, and honeymoon period still , but it’s wonderful to be an employee again

We in the US spend more on healthcare yet have discordant health outcomes relative to other countries.

Yet people are worked up about budget cuts.

Recent cohort study, showing humans with ADHD had a shorter life expectancy than matched controls. Further investigation to ID risk factors; I wonder if it’s over-medication. Now I need to put “look up UK adhd med overprescription” on my low priority dolist…😰

Rationale:

O'Nions E, El Baou C, John A, et al. Life expectancy and years of life lost for adults with diagnosed ADHD in the UK: matched cohort study. Br J Psychiatry, 2025. doi: 10.1192/bjp.2024.199

The #EHJ just published a study looking at over 40,000 U.S. adults and found that those who drank #coffee exclusively in the morning (0400-1159) had a 16% lower risk of all-cause mortality and a 31% lower risk of cardiovascular disease-specific mortality compared to non-coffee drinkers.

*All-Cause Mortality*

• Lower in morning coffee drinkers vs. non-drinkers (HR 0.88, 95% CI 0.81–0.96).

• Lowest with 2–3 morning cups/day (HR 0.71, 95% CI 0.60–0.86).

• No difference in all-day drinkers vs. non-drinkers (HR 0.99, 95% CI 0.90–1.10).

*Cause-Specific Mortality*

• Lower #CVD mortality in morning drinkers (HR 0.69, 95% CI 0.55–0.87); #cancer mortality similar (HR 0.97, 95% CI 0.75–1.25).

• No difference in CVD/cancer mortality for all-day drinkers.

• Effects similar for caffeinated/decaf.

It was suggested that as drinking coffee later in the day may disrupt circadian rhythms and melatonin production, potentially increasing inflammation and blood pressure, thereby muting coffee’s health benefits in all-day coffe drinkers. However, regular, controlled morning coffee consumption could just be a marker of health-conciousness or a lower-stress life, i.e., several significant confounding variables were not addressed in the study. The study was funded by the National Heart, Lung, and Blood Institute; National Institute of Diabetes and Digestive and Kidney Disease; and National Institute of Health. I did not check to see if any of the members of these organizations, or if the Thor’s themselves, own coffee farms, roasteries, or coffee making equipment businesses, or have stock in publicly traded coffee companies.

Wang X, Ma H, Sun Q, et al. Coffee drinking timing and mortality in US adults. Eur Heart J, 2025. doi: 10.1093/eurheartj/ehae871

Chainsaw running on bench, because adjusting carb

Running chainsaw vibrates bench, causes phone to begin to slip

Grabs phone which is near blade, ends up with 3cm macerated lac

#ed #chainsaw

Urolithiasis Pearls

- Presence or absence of hematuria alone cannot be used to diagnose or exclude nephrolithiasis

- Most stones ≤5 mm (70–98%) will pass spontaneously. Stones >5 mm have smaller chance (25–51%) of spontaneous passage & are more likely to need urologic intervention. (J Urol. 2015;194:1009)

- Send pts home w/ strainer, esp 1st-time stone formers for stone analysis

- Cx: Obstructed infected kidney (urologic emergency requiring urgent decompression), renal insufficiency, failed expulsion

Excerpt From

Pocket Notebook: Pocket Emergency Medicine, 4e

Erica Ashley Morse, MD

#em

Prolonged #tourniquet use during #venipuncture can lead to significant alterations in the concentrations of various analytes due to hemoconcentration and the movement of analytes from surrounding tissues into the bloodstream. The literature indicates that even short-term venous stasis can cause clinically significant changes in several analytes.

**Duration and Impact:**

- 1 minute: Statistically significant changes can be observed in albumin, calcium, and potassium.[1] The AHA recommends that a tourniquet should not be applied for more than 1 minute to avoid significant increases in triglyceride levels.[1][2]

- 3 minutes: significant increases in alanine aminotransferase, total cholesterol, glucose, and potassium. Hemoconcentration effects are more evident[1][3]

**So**

- It’s recommended to keep tourniquet application to less than 1 minute.[2]

- Waiting for 5 minutes with the needle in situ after removing the tourniquet can help reduce hemostasis-induced variability.[4] But this is never going to happen.

Basically, tourniquet application should not exceed 1 minute if you want to minimize the risk of significant alterations in analyte concentrations.

**Rationalization**

[1] Lippi G, Salvagno GL, Montagnana M, Brocco G, Guidi GC. Influence of Short-Term Venous Stasis on Clinical Chemistry Testing. Clinical Chemistry and Laboratory Medicine. 2005;43(8):869-75. doi:10.1515/CCLM.2005.146.

[2] Miller M, Stone NJ, Ballantyne C, et al. Triglycerides and Cardiovascular Disease: A Scientific Statement From the American Heart Association. Circulation. 2011;123(20):2292-333. doi:10.1161/CIR.0b013e3182160726.

[3] Cengiz M, Ulker P, Meiselman HJ, Baskurt OK. Influence of Tourniquet Application on Venous Blood Sampling for Serum Chemistry, Hematological Parameters, Leukocyte Activation and Erythrocyte Mechanical Properties. Clinical Chemistry and Laboratory Medicine. 2009;47(6):769-76. doi:10.1515/CCLM.2009.157.

[4] Devi S, Pasanna RM, Nadiger N, et al. Variability of Human Fasted Venous Plasma Metabolomic Profiles With Tourniquet Induced Hemostasis. Scientific Reports. 2021;11(1):24458. doi:10.1038/s41598-021-03665-2.

#olas #testflight link for iOS

https://testflight.apple.com/join/2FMVX2yM

So fun to zap from iPadOS

The Vermont Health Information Exchange keeps health records in one place. Most Vermonters have a health record created for them, without their consent, in the Vermont Health Information Exchange. Doctors and other health care providers can view information about patient in their care for whom the Vermont Health Information Exchange has created a record. This centralized health record is intended to put providers on the same page.

vitl.net

A patient’s record in the Vermont Health Information Exchange may contain (but is not limited to):

- Patient demographics – name, age, sex, date of birth, address, home phone, etc.

- Problems and conditions

- Allergies

- Medications

- Laboratory test results

- Radiology reports

- Transcribed reports

- Patient care summaries

There are several ways to **opt-out** of having your information viewable to your providers in the Vermont Health Information Exchange:

- Call the Vermont Health Information Exchange Hotline at 888-980-1243

- Fill out an opt out form online

- Download, print, complete this opt out form, and mail it to VITL, Attention: VHIE Support, 150 Dorset St., Suite 245, PMB 358, So. Burlington, VT 05403

- Natural Medicine Comprehensive Database

naturalmedicines.therapeuticresearch.com

- LactMed

ncbi.nlm.nih.gov/books/NBK501922

Phenformin doesn’t matter

Better alternative to MUDPILES for high anion-gap metabolic acidoses:

Iron/Isoniazid

D -

K - DKA

A-

Methanol

Ethylene glycol

Aspirin

Lactic acidosis

What causes high anion gap metabolic acidosis?

IDK, a meal?

Thanks 🤜🤛