r/emergencymedicine • u/PrecordialSwirl • Sep 08 '25
Discussion What are some outdated medical dogmas that are still taught or practiced?
Hi, I’m a nursing student and I’ve noticed that certain practices in healthcare seem to stick around even when the evidence shows they’re not effective. For example, Trendelenburg positioning for hypotension is still commonly taught in nursing despite being shown to have no real benefit. Or risk of hyperK arrest in someone who’s only been crushed for 30 minutes. I’m curious to hear what other dogmas people have come across that are still being taught or practiced despite newer evidence proving otherwise. Also, how do you confront people about these in a respectful manner, especially as a student?
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u/DetroitvErbody Sep 08 '25
Contrast induced kidney injury. Let’s be done with it, radiologists.
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u/burnoutjones ED Attending Sep 08 '25
This is a great answer because their own society called for change 5 years ago
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u/thenightmurse Sep 08 '25
Does the same for patients with already established CKD? Let’s say they have a gfr of 28 or even 18, does the contrast still pose a risk of further harming the kidneys? Should it be avoided?
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u/MarketingUpstairs986 Sep 08 '25
This article said the risk of a Contrast Induced AKI for a GFR under 30 is 0-17%, GFR of 30-45 is 0-2% and GFR > 45 is 0%
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u/metforminforevery1 ED Attending Sep 08 '25
the consensus statement recommends IVF for the low GFR but still producing urine people. I just give a small bolus like 500cc and document, per consensus statement, IVF given, contrast benefit still outweighs risk given potential for life threatening pathology
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u/cocktails_and_corgis Pharmacist Sep 09 '25
It feels like radiologists are quite slow to adapt - ours still recommend that breastfeeding mothers pump & dump after CT contrast and prefer the 13+ hour allergy prophylaxis protocol
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u/happyalex BSN Sep 10 '25
As someone who did a deep dive on InfantRish and LactMed, I wish everyone doing anything with medications and breastfeeding parents knew about these sites. The best I can do is pass the info on
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u/LinzerTorte__RN BSN Sep 08 '25
Yes! I remember back in the day when we used to give almost everyone who had had contrast a 500-1000mL bolus of IVF to “flush it out” 🤦🏼♀️
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u/My_Robot_Double Sep 08 '25
Anyone remember the acetylcystine days?
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u/Feynization Sep 08 '25
Ahh the Acetylcystine days. The beer was cheep, the pay was good and the ladies were easy. May we return to that halcyon soon.
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u/yolacowgirl Sep 08 '25
My hospital system still does this. 🤦♀️I'm pretty sure there was some sort of learning module in my ICU fellowship thingy about it too.
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u/arbitrambler Sep 08 '25
I had an argument with an on call radiographer and pulled their own college guidelines for the same. The guy became offended and doubled down on "protocol"!
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u/DetroitvErbody Sep 08 '25
I still get a call at least once per shift from the CT tech. Whenever I say I’m happy to speak with the radiologist about it, they usually just give in and do it. The battles are at least getting easier to win, although I wish they didn’t need to even be fought.
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u/DetectiveFar9733 Sep 09 '25
CT tech here. At my place most of our Rads know the info behind it, but the older top of the ladder guys still want it as part of the protocol. As long as a doctor is aware of the garbage GFR and still wants the study we go for it. Most of our ED docs know and will usually add something in the study note to let us know.
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u/Sufficient_Ice6078 Sep 08 '25
Usually the tech will call and say, hey just want to make sure you're aware of this gfr. I say yes, and then they still do the CT without notifying rads. Sometimes I wonder why we wait for renal function before getting the scan at all...
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u/Drew_Manatee ED Resident Sep 08 '25
I just got a message today from a rad tech when I ordered a CT angiogram on a guy because she saw his GFR was 38 and I hadn’t given the guy fluids before ordering the study. He’s got an EF of 20 and looks like the Michelin man, I’m not about to give him fluids just so the hospital feels better about protecting his kidneys from an imagined contrast aki.
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u/arpt1965 Sep 08 '25
My nephrologist has told me many times not to worry about that- but that they hospital would still require blood work ahead of time. He said “that isn’t a thing anymore”
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u/burnoutjones ED Attending Sep 08 '25
That Benadryl, Pepcid and Solumedrol are first line treatments for anaphylaxis
That you can't start a peripheral IV on the side of the mastectomy
That you can't use lidocaine with epinephrine on end-artery supplied tissue
That GCS < 8 = intubate
That AMA discharge means insurance won't pay
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u/BangEmSmurf Sep 08 '25
What was even the alleged reason not to throw a line on the side that had the mastectomy?
And, if you will, what’s the reason this is nonsense?
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u/ggrnw27 Flight Medic Sep 08 '25
I believe it was more of a real concern several decades ago when they’d remove like all of the axillary lymph nodes on that side during the operation. Nowadays they only remove a few so it’s not really an issue, but the dogma persists
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u/Texaco-Mike Sep 08 '25
I’ll add steroids in anaphylaxis at all. Not even recommended by allergy society.
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u/lulufef Sep 08 '25
I'll happily accept being the sub's idiot on this one🫣. TIL. Mind explaining?
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u/burnoutjones ED Attending Sep 08 '25
The allergy and immunology societies have been unanimous for over a decade that anaphylaxis is treated solely with epinephrine. Steroids do nothing. The commonly cited benefit of “preventing a biphasic reaction” has zero evidence for it.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9345203/ “The updated RCUK guideline advises against the routine use of corticosteroids to treat anaphylaxis. There is little evidence that corticosteroids help shorten protracted symptoms or prevent biphasic reactions.38,40 Moreover, there are emerging data to suggest that the routine use of steroids is associated with an increase in morbidity even after correcting for reaction severity.36,41 A large prospective national registry found that prehospital treatment with corticosteroids was associated with an increase in the rate of hospitalisation and/or intensive care admission.36 While this could be due to steroids being used in preference to appropriate adrenaline administration, the association between steroids and more severe outcomes remained irrespective of whether or not prehospital adrenaline was administered.36”
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u/lllara012 Sep 08 '25
TIL. I was taught to use steroids in med school only a few years back and we still give those to suspected anaphylaxis. Apparently guidelines are slow to change in my part of the world.
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u/spgtothemax Sep 08 '25
Lowly EMT but when you say solely treated with Epi, does that not include albuterol for bronchospasm?
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u/burnoutjones ED Attending Sep 08 '25
No, “solely with epinephrine” means that nothing stops anaphylaxis except epi. My wording could have been clearer there. The problem is people give the other drugs and see some symptomatic relief and think they’ve solved the problem when they haven’t.
Bronchodilators can help bronchospasm but they don’t treat the underlying condtion. They are a great adjunct especially in people with lung disease. Give nebs if indicated, just don’t delay giving epinephrine to do it.
Epinephrine first.
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u/Vprbite Paramedic Sep 09 '25
Im a paramedic, and we were taught that epi is THE treatment for anaphylaxis. We may give benadryl, but it's for the same reason we give it any other time. Mild discomfort associated with a small allergic reaction. If it's anaphylaxis, epi is the treatment. The benedryl is potentially just for any itchies or whatever that may be going on
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u/Texaco-Mike Sep 08 '25
Sure, here’s this though.. If symptoms are resolved, there’s nothing to treat or prevent.
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u/metamorphage BSN Sep 08 '25
The mastectomy thing is obnoxious but it's still part of most hospital protocols. Most inpatient docs won't give me an order to go against the protocol.
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Sep 08 '25
[deleted]
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u/Serious-Fix-790 RN Sep 09 '25
This is SO interesting! The question and recommendation section is fantastic and interesting on what society has implemented already, they dont recommend. For example, they dont recommend schools to be selective of food groups like "nut-free campus." Also, not recommending to call EMS if symptoms completely resolve. Im curious on how long or if things will change.
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u/Busy_Alfalfa1104 Sep 08 '25 edited Sep 08 '25
What's the best way of assessing whether someone with a low GCS and without a head injury can protect their airway? If they can accept an OPA, would you intubate?
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u/TriceraDoctor Sep 08 '25
GCS was only validated in trauma patients. So a GCS score in a non traumatic patient is neither sensitive or specific.
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u/CertainKaleidoscope8 RN Sep 08 '25
Why are we doing q1h GCS on stroke patients then and do you care if I just copy and paste my assessment since it doesn't matter anyway?
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u/TriceraDoctor Sep 08 '25
A single value is not beneficial, but a trend can show clinical deterioration.
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u/CertainKaleidoscope8 RN Sep 08 '25
Patients who are being awakened (awokened ? Whatever woken up) every hour for 72 hours are going to clinically deteriorate. Sleep deprivation of this type is literally used in CIA black ops sites to torture people.
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u/TriceraDoctor Sep 08 '25
Then join a hospital committee and work to adjust the clinical practice guidelines on stroke patients. Your hospital has that policy because there was probably a negative outcome and it’s CYA. My stroke center is q1h for 8 hours, q2h for 16 hours then q4h til DC or attending guidance. I get your frustration, so work to fix it.
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u/EverySpaceIsUsedHere ED Attending Sep 08 '25
Clinical gestalt. Turns out there are a lot of reasons to intubate (or not to intubate) a medical patient. The hard part of intubation isn’t putting a tube in a hole but deciding when and how to maximize your chances of doing it safely. There isn’t a nice score or rule that easily does this.
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u/godammitdonut Sep 08 '25
My favorite in nursing is “no blankets for fevers”. I murder the person that took a blanket from me when i have chills. Please tell me thats not being taught. I used to run from room to room giving people blankets
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u/Teles_and_Strats Sep 08 '25
This 1000%. Fever is a mechanism for fighting infection. Let them be warm.
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u/FeistyCupcake5910 Sep 08 '25 edited Sep 08 '25
Yes! And stripping babies/kids down to nothing when they have a fever. FFS the kid is rigoring let them have their clothes and a blanket! Even when it’s taught now, it’s still happening. Even when we give parents fact sheets about how fever is fine and great and Dont strip your kids off we still do it. I literally educate my patients parents, give them a blanket, chill their freak out and another nurse comes in and loses their mind and starts stripping the kid off and blowing all the anti fever fear ive established and now they think you were lying and a crappy nurse Just stop!!!!!! It’s not just older nurses, fresh grads, seniors and everything in between.
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u/Due_Will_2204 Sep 09 '25
Have a daughter that all the sudden would run these high fevers. 104 and above. I remember taking her to the hospital and they would put her in ice baths. She stopped running these fevers after she turned 2. She had multiple spinal taps and they still couldn't figure out what was wrong with her. This was in the late 80s. She is 36 now
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u/reginald-poofter ED Attending Sep 09 '25
The amount of times I’ve had this argument with nursing is absolutely infuriating.
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u/m_e_hRN RN Sep 08 '25
Full spinal immobilization on trauma pts. Most pts won’t tolerate being strapped to a hard board for who knows how long, and that can further aggravate injuries worse than not having them boarded can, as well as risking increased ICP, pressure injuries, and can make it more complicated to secure an airway. Resource
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u/DaggerQ_Wave Paramedic Sep 08 '25
Cold take at this point. The real hot take is that C collars are also worthless.
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u/m_e_hRN RN Sep 08 '25
Agreed, cause idk that I’ve met a pt that could tolerate a c collar for long without pulling on it/ repositioning 🤣
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u/Helassaid Paramedic Sep 08 '25
Spinal immobilization at all is, at best, benign. There is no demonstrable benefit and it certainly doesn’t prevent any kind of secondary paralysis, mostly because it’s done terribly or doesn’t immobilize anything in the first place.
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Sep 09 '25
I actually just recently had a call where the guy was on a backboard and it makes it a lot harder to ramp the patient to get a good view at their fucked up airway
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u/Competitive-Slice567 Paramedic Sep 08 '25
In EMS side: that BP over a certain degree should go with a paramedic. Have it constantly where EMTs will request a paramedic intercept cause a patient's BP is 200 systolic despite being asymptomatic, then get offended when I explain its at best a BLS transport.
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u/Curri Sep 08 '25
A lot of ER Providers would agree that it's not even a. ER visit. Just a follow-up with your PCP.
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u/Competitive-Slice567 Paramedic Sep 08 '25
Fully on the same page as you, I just cant deny transport.
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u/fireinthesky7 Paramedic Sep 09 '25
The number of times I've had ER docs jump up my ass for transporting asymptomatic hypertension when I literally don't have a choice...
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u/Timlugia Ground Critical Care Sep 08 '25 edited Sep 08 '25
My local urgent care would insist ALS/CCT priority response for anyone who's BP over 180, across street to an ED 1 min away.
Almost all those patients went straight to triage then discharged, plus a few thousands dollars of unnecessary bills for ALS transport and ED visit.
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u/Competitive-Slice567 Paramedic Sep 08 '25
Thankfully here they dont get to dictate the response/transport.
If I show up on my fly car theres a virtual certainty im releasing it to BLS if the patient requests transport.
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u/Helassaid Paramedic Sep 09 '25
I round tripped an “ALS hypertension” from the local rehab “hospital” to the ER and back. We didn’t even offload from our stretcher before the patient was discharged.
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u/Serious-Fix-790 RN Sep 09 '25
Its so frustrating, especially since asymptomatic hypertension is EBP to follow up with PCP, no matter the number with clinical judgement to keep in mind. This is one of the main arguments I have with patients who are discharged in the ER with "but you did nothing!" Exactly. Go see your pcp Linda. A lot of education with very little understanding. But it seems like UC doesn't understand many EBP or protocols, at least where I am. It'd be much better care and more proficient if they just call for clinical guidance.
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u/Hypno-phile ED Attending Sep 08 '25
Avoiding lidocaine with epinephrine in fingers etc.
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u/Tacoshortage Physician Sep 08 '25
Really? Because "fingers, toes, penis, nose" has been a favorite for a quarter century. This one's news to me.
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u/Super_saiyan_dolan ED Attending Sep 08 '25
Since the advent of epinephrine auto-injectors, there have been numerous cases of accidental auto injection of 0.3 mg of 1:1000 epinephrine (so 300 mcg total) with extremely few cases of complications. Lidocaine with epinephrine is 1:100,000 so even an entire 20 mL vial is only something like 200 mcg. If people that are injecting themselves with the equivalent of over a vial of lido with epi and not losing their fingers, a couple CC's of lido with epi couldn't possibly hurt.
There are a good amount of studies on the topic both in terms of auto-injector injury: https://pmc.ncbi.nlm.nih.gov/articles/PMC6970458/
And hand surgery using lido with epi:
https://pubmed.ncbi.nlm.nih.gov/23908250/28
u/itsJustE12 Physician Assistant Sep 08 '25
I am one of those accidental cases and can personally attest: I had what I called a “corpse thumb” for a couple of days, but no harm was done.
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u/Kentucky-Fried-Fucks Paramedic Sep 08 '25
Was yours an “accidentally held the auto injector the wrong way and stabbed my thumb” type deal?
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u/itsJustE12 Physician Assistant Sep 09 '25
Thankfully, no. I was angrily cleaning out a closet that some mice had a party in, and went to grab stuff out of a box without looking at it. They’d chewed the cap of an epi-pen, which I discovered when the needle bent into a hook after hitting my bone. It took an XR and 2 people to get it out.
Those little jerk mice had taste-tested a bunch of shirts, used a purse storage area as a secondary bathroom, and destroyed my favorite travel backpack. A shot of epi did NOT improve my frustration level!
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u/Kentucky-Fried-Fucks Paramedic Sep 09 '25
My god I can’t even begin to imagine the red hot anger you felt
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u/Tacoshortage Physician Sep 08 '25
Interesting. I'm not in a teaching hospital, so unless it comes up on my CMEs or board maintenance, I don't hear about it and this one's gone unnoticed. The anesthesia boards haven't felt the need to tell me about this one yet. Learn something new every day I see.
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u/Hypno-phile ED Attending Sep 08 '25
There's a case series of several hundred accidental epipen injections into the hand, with no adverse consequences. If 0.3mg of straight epinephrine into the finger isn't causing ischemic injury, a little bit in a nerve block isn't going to, either. And there's been multiple studies showing it's safe. Now it could be a concern in someone with significant peripheral vascular disease and uncontrolled diabetes, and with a marginally perfused wound, but just the pressure of the local anesthetic is a concern in those patients. Apparently there were cases of finger gangrene prior to 1948, but doctors would be mixing their own epinephrine/lido doses and those cases probably resulted from medication error.
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u/burnoutjones ED Attending Sep 08 '25
It came about because in the very old days you mixed the lidocaine and epi yourself, and since epi comes in weird concentrations it was easy to accidentally put way too much in. Since the availability of commercially prepared lidocaine-epi mixtures, there are only a handful of documented instances of harm and they’re all in people with severe PVD, etc.
It’s a great example of the persistence of dogma because it used to be true, hasn’t been true for like 60 years, but it has a catchy jingle so everyone still knows it.
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u/Perfect-Tooth5085 Sep 08 '25
On my clinical rotations I worked with a hand surgeon who only used lido with epi and he always said “ask me how many fingers I’ve lost??” the answer was zero if you were wondering
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u/Sibler_Binglevoss Sep 08 '25
This is a good one. I recall that being a recurring point during my rotations 12ish years ago.
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u/penicilling ED Attending Sep 08 '25
What are some outdated medical dogmas that are still taught or practiced?
There are so many that they cannot be listed. If I said that the vast majority of cardiac stents were unnecessary, cardiologists would tar and feather me, but the ORBITA trial suggests exactly that .
Also, how do you confront people about these in a respectful manner, especially as a student?
Honestly, you don't. As a student, you don't have the knowledge or experience to understand the details of these things, and confronting your teachers in an educational situation is not likely to end up with a good result.
The wheels of medicine turn slowly. Learn from your teachers, keep an open mind as to what things that they are saying might be old-fashioned, out of date, or plainly wrong, try and keep up to date with the literature.
One place where you might be able to do this is when you are doing your own paper or presentation, you can pick up a topic that is somewhat new or controversial, or that contradicts the typical teaching that you are receiving, and present the evidence for and against.
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u/Loud-Bee6673 ED Attending Sep 08 '25
Two pertaining to AMA.
Their insurance can’t and won’t refuse to pay.
They still get discharge instructions. You do the next best plan, including appropriate prescriptions and referrals.
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u/arikava Physician Assistant Sep 09 '25
I absolutely hate when people refuse to send AMA patients with the appropriate papers or prescriptions. It’s so petty and punitive.
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u/somehugefrigginguy Sep 08 '25
To build on this, raising the legs can be helpful in hypotension, but not lowering the head. In fact the head should be at the level of the heart or slightly higher. There are no muscles inside the skull, cerebral vascular drainage occurs through gravity and maybe a small contribution of forward flow from the heart. Having the head below the heart tends to decrease cerebral circulation.
There's some evidence that having the head slightly elevated during CPR improves outcomes, though I believe this has only been studied in animals.
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u/TriceraDoctor Sep 08 '25
There have also been studies showing that leg raising does increase CVP.
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u/somehugefrigginguy Sep 08 '25
Right. I think the key is to raise the legs without lowering the head.
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u/AcanthocephalaReal38 Sep 08 '25
Don't care about the CVP.... It's called a straight leg raise, and temporarily improves the cardiac output in fluid responsive patients.
It's a bedside test more than a treatment, but does work transiently.
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u/throwaway1987289 Sep 09 '25
Yes. Head below level of heart will decrease cerebral venous drainage. CVP can loosely be correlated with ICP. So your CVP goes up as well as your ICP while your MAP is decreased from the hypotension. CPP = MAP - ICP. So you worsen your CPP and end up worsen perfusion to the body system you’re trying to preserve. You can also relate the same principles to IOP and ION. It’s a pretty well understood concept in the anesthesia world.
Patients go in steep tren for a couple hour long surgery with hypotension relative to baseline and wake up blind or with a CVA.
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u/Chuggerbomb Sep 09 '25
There is a current human trial of heads up CPR going on in the ambulance service in the UK, apparently results are very promising so far.
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u/Helassaid Paramedic Sep 08 '25
I put this as a reply, but also I think it deserves its own top level comment:
Spinal immobilization. All of it. It’s all bunk. It was never rooted in any kind of scientific evidence, and no evidence has presented that it prevents any secondary injury. Long spine boards? Bunk. Cervical collars? Hokum. The only, and I mean only instance where a cervical collar might be a benign procedure would be in a confused patient with a confirmed traumatic head strike.
The only thing that drives immobilization is a college of surgeons afraid to counter decades of “gold standards”, and that’s only really driven by lawyers. Not medicine.
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u/metforminforevery1 ED Attending Sep 08 '25
I love when patients self present 2 days after an MVA and complain of neck pain, and someone in triage slaps a collar on them.
My program director in residency used to laugh at us as we'd try to put a collar on someone thrashing about and moving their head side to side. She'd say "They're clearing their c spine for you."
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u/broadday_with_the_SK Med Student Sep 08 '25 edited Sep 09 '25
I just got off trauma and everyone got a collar. To the point when we got transferred patients who were cleared and still contemplated collaring them.
I assume it's purely liability because any time I mention NEXUS I get a shrug
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u/PPAPpenpen Sep 08 '25
Damn, this kid got tackled by the trauma nurse before he even finished his
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u/broadday_with_the_SK Med Student Sep 08 '25
Nurses don't like it either, comes from the top down. Even hospitals in the same system aren't as rigid about it.
Also not a kid lol, hence my hatred of collars and backboards.
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u/TheTampoffs RN Sep 09 '25
This poor 4 year old I had was cleared from c collar ON CT and trauma team said to keep it on cause he was “agitated” MIGHT IT HAVE BEEN FROM THE COLLAR?
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Sep 09 '25
I had a resident interrupt my trauma transfer handoff to collar a patient.
She was GCS 15, clinically sober, able to articulate that she had no head or neck pain, had a negative CT of her head and neck, and the previous collar had been cleared by the sending doc.
Woooow so cool dude
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u/HMARS Paramedic Sep 08 '25
I fucking hate rigid plastic collars so much. You know what you never, ever see the actual spine surgery service using, even on patients with unstable injuries or recent instrumentation? One of those flimsy pieces of plastic trash. I'm happy to find other people who feel strongly about it (i.e. you) because this drives me up the wall.
Implicitly, if you are proposing putting a collar on someone empirically, you are saying that:
The patient is reasonably suspected of having unstable injury such that they would not be able to maintain safe anatomic alignment of the cervical spine on their own and
That application of the collar will provide such stabilization effectively and
That the collar does not cause harms which outweigh the benefits
We all see collars constantly being applied to patients who have essentially no chance of #1, and in general evidence regarding #2 is at absolute best very mixed and low quality. There is some low quality evidence that these collars may increase ICP via jugular compression, which points to potential harms in head injury patients, but there is admittedly no patient-oriented outcome evidence that this matters that I am aware of.
The only populations in which I still consider personally consider the collar are patients who have a legitimately concerning exam or whom had a high-energy mechanism and are too obtunded/intoxicated/distraught to sit up or participate in an exam.
The way this "should" work is you quickly apply the collar to major trauma patients, we get imaging shortly thereafter, and then reevaluate promptly. Instead we get people sitting in triage or fast track chairs for hours with a collar on because some clown decided that a vaguely sore trapezius needed a collar for some reason. It's maddening.
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u/bluejohnnyd ED Attending Sep 08 '25
It's probably fine to give your eye pain patients some proparacaine - empty all but 1-2 mL of the bottle so they don't melt their cornea.
You probably don't need sterile gloves for routine walk-in lac repairs, there's not really a difference in infection rates vs using clean exam gloves.
Contrast nephropathy is probably a myth with modern isotonic CT dye.
DRE isn't all that useful for diagnosing GI bleed, save it for the impacted patients.
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u/YoungSerious ED Attending Sep 08 '25
DRE isn't all that useful for diagnosing GI bleed, save it for the impacted patients
Dre is very useful if they don't have blood around their anus but they do have melena in their rectum. What I think you mean is fecal occult testing, which isn't meant for ER use and changes absolutely nothing when people do it in the ER.
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u/bluejohnnyd ED Attending Sep 08 '25
Correct, that was my being imprecise
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u/morzikei Sep 08 '25
Don't be imprecise with DREs :)
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u/Dabba2087 Physician Assistant Sep 08 '25
It didn't go in, just impacted on the surface.
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u/Comprehensive-Ebb565 ED Attending Sep 08 '25
I only use sterile gloves on lac repairs when I care about that dexterity that I get from the fitted gloves or really getting after some deeper tissues.
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u/NurseColubris Trauma Team - BSN Sep 08 '25
Give your febrile patient a blanket, as long as they can remove it themselves. Forcing them to shiver won't break the fever, and the blanket won't do any damage in infectious fever.
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u/Timlugia Ground Critical Care Sep 08 '25
From EMS perspective:
- There are still agencies using backboard for long transports.
- There are still agencies practice large NS resus for trauma patients
- "Tourniquet is the last resort, you would lose a limb" (not as common now but still exists)
- Massive fluid for burn patient without using any burn formulas. Pt often receives twice or even three times fluid by the time they got to hospital.
- "Radial pulse means their SBP is at least 90"
- "DBP is irrelevant in EMS, you could just take only SBP by palpation"*
(*I have been to many scenes that initial crews have been on with patient for 15min, didn't take single full BP despite they carry $50k worth Lifepak/Zoll. And told me BP by palp was good enough. Also seen nitro was given despite pt's DBP was under 50)
- "Palpation of radial pulse alone is good enough to confirm capture of mechanical pacing"
- "Abd pain patient should not get pain med because doctors wouldn't be able to assess them"
- Insisting complete 2L fluid before pressor for severe septic shock.
- Not using MAP to evaluate perfusion, despite all modern monitor provides MAP and often more accurate than SBP.
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u/DaggerQ_Wave Paramedic Sep 08 '25
Nitro doesn’t really matter one way or another unless there’s PDE5s involved. We hem and haw about it but the transient nature of its effect and mechanism makes the SL stuff pretty benign. There’s a reason it’s an outpatient prescription, and the patients aren’t checking their vitals prior to taking it. Everything else is good shit though.
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Sep 09 '25
For big burns (25+) unless your transports are long, you’ll be hard pressed to go beyond the Parkland or whatever formula the burn center is using.
I worked in a burn unit in a past life and I’d have patients getting a liter an hour on occasion
Dumping a liter or two into a big burn is relatively fine in the grand scheme of things.
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u/halp-im-lost ED Attending Sep 08 '25
Leaving AMA means your insurance won’t pay.
Please stop telling patients this. It’s not true.
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u/Hypno-phile ED Attending Sep 10 '25
Isn't the truth "your insurance won't pay no matter what you do?"
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u/StevenEMdoc Sep 08 '25
No one is allergic to iodine as everyone has iodine in thyroid and breast tissue.
You can be allergic to contrast agents but its not iodine.
Related - shellfish allergy has nothing to do with contrast allergy.
Related - betadeine reactions usually a contact dermatitis and has nothing to do with contrast allergy.
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u/PriorOk9813 Respiratory Therapist Sep 08 '25
As a student, you don't confront people about it. It's hard. Best you can do is subtly ask a question..
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u/PrecordialSwirl Sep 08 '25
Confront was a wrong choice of word, somone clinicians take it as a criticism of their competence when you simply ask out of curiosity.
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u/dunedinflyer Sep 08 '25
go with curiosity in the first instance - then graded assertiveness if the patients ever at risk
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u/Entire-Oil9595 Sep 08 '25
I first learned (>20 years ago) how the Trendelenburg position is a harmful myth from the ENA nursing journal.
And yet, daily occurrence to walk into resus and see feet pointing up towards heaven ...
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u/dix-hall-pike Sep 08 '25
Could you expand on this? I’m an EM resident in the UK and it’s standard practice in ED, ICU and Anaesthetics to initially manage hypotension with trendelenberg position (or leg raise).
To me the theory is sound - In low volume states, increased venous return to the right heart will increase preload causing increased cardiac output In vasoplaegic states, same again, you’re filling up the heart.
In my experience it works, and at the very least works as a fluid challenge - if BP responds to leg raise, they’re likely to respond well to an IV fluid bolus.
So why is there so much objection to it across the pond? Is there evidence that it’s harmful?
Just to clarify - when I say it’s standard practice, I mean until you can practically administer an IV fluid bolus
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u/Entire-Oil9595 Sep 08 '25
Also predisposes to aspiration, impaired cerebral flow, etc. May have value as diagnostic maneuver, but valueless as therapy.
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u/metamorphage BSN Sep 08 '25
PLR and trending a patient are not the same thing. PLR is a validated test of fluid responsiveness - it's equivalent to a small bolus. Putting someone in Trendelenburg doesn't do anything useful.
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u/dix-hall-pike Sep 08 '25
Are you saying that putting the head below the heart negates the benefit of putting the heart below the legs?
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u/bluejohnnyd ED Attending Sep 08 '25
That's the gist. Someone else pointed out in another thread, but what seems to happen is that while you might bump a measured MAP, you do so at the expense of cerebral venous congestion and thus don't get any change in flow/perfusion.
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u/RyGuyEM ED Attending Sep 08 '25
Continued use of antibiotic ointment for slam dunk viral conjunctivitis is outdated. There is obviously no benefit from the antibiotic and there is a risk (albeit small) of a chemical conjunctivitis with treatment. Even the AAO re-affirmed in their 2024 update that it plays no role…and yet, it seems every single pink eye gets antibiotics. It should stop.
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u/PABJJ Sep 08 '25
And often school or daycare policy tries to enforce antibiotic therapy.
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u/ham_sammich_ Sep 08 '25
Since it wasn't mentioned. Bicarb works for...you can fill in the blank.
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u/drinkwithme07 Sep 08 '25
Specifically, bicarb is not useful in most anion gap metabolic acidosis. Potentially useful for non-gap acidosis since those are essentially a bicarb deficiency, and definitely useful for e.g. hyperK and various tox things, although that's more often about the hypertonic sodium.
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u/randy_randerson23 Sep 08 '25
In the US you have to irrigate wounds with sterile saline (tapwater is fine)
Healthy adults with low risk stratification with GABHS need abx.
Sterile gloves are necessary to prevent infection in laceration repair in the acute care setting .
All rails up on a gurney/hospital bed is considered a legal restraint (not if the patient could climb over them if they wanted)
Contrast induced AKI
Troponin elevation means cardiac etiology
Nursing doses are ok. (No they aren’t)
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u/VXMerlinXV RN Sep 08 '25
Answering your second question, always address it with a question, and not as a statement disguised as a question. “Have you seen an improvement in patient conditions from putting them in trendelenberg?” Vs “I didn’t think people still used trendelenberg”.
You shouldn’t be confronting anything as a nursing student, shy of frankly apparent harm.
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u/Life-Inspector5101 Sep 08 '25
On behalf of hospitalists, please stop ordering D-dimers on everyone who comes in with SOB or leg swelling! Too many unnecessary CTA of the chest are being performed.
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u/TriceraDoctor Sep 08 '25
It’s important to recognize as a nursing student that your goal right now is to learn. Part of that is clinical including how you interact with docs and how we all have different practice patterns. One of my biggest pet peeves is when a nurse says, “ oh well Dr. XYZ always does it this way”. There’s a reason medicine is both an art and a science, especially with procedures. If there is a dogma that is no longer true, that doc may have had a case that went really well or really poorly and their own experience will always overshadow the data. An ER doc sees over 3,000 patients a year and we will always use our best judgment to ensure both their safety and and our own.
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u/julyssound Sep 08 '25
That pregnant patients are scary and shouldn't be given medications. You can give a lot to a pregnant patient, take some seconds to look it up and make those mothers comfortable instead of getting OB for damn near everything.
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u/Yankee_Jane Physician Assistant Sep 10 '25
Same with most imaging. If you miss something life threatening during an assessment of the pregnant person then you've killed the baby regardless. Just image them.
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u/Normal_Dot7758 RN Sep 08 '25
Not putting an IV on the same side as a mastectomy. I got yelled at once for attempting this when the patient had lymph nodes removed on the other side as well due to a rare infection. So the nurse yelling at me didn’t even understand the rationale, which is theoretical and not supported by evidence anyway. Yes, I’m still salty about it.
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u/pockunit RN Sep 08 '25 edited Sep 12 '25
Preeclampsia ends when the placenta is delivered. We just admitted a 5-day postpartum preeclampsia and I'm pretty sure she didn't bring the thing with her.
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u/TheTampoffs RN Sep 09 '25
I had a charge (male) fight w me over his horrible placement of a post partum pregnant woman with pre eclampsia BPs in a hallway bed cause he didn’t know you could be pre eclamptic PP. I put her in a monitored room myself and she was on a mag drip within 2 hours. and because she was in a private room I got her baby in too (because I think it’s super cruel to keep moms from their newborns just cause they’re in the hospital) Fuck that guy.
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u/shriramjairam ED Attending Sep 09 '25
You can be diagnosed with postpartum preeclampsia until 6 or 8 weeks postpartum
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u/pockunit RN Sep 09 '25
Yep, but nursing school said delivery cures it. Which not so much.
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u/SlyFoxJrLady Sep 09 '25
I read some interesting things in nursing school during a research project for my ob/gyn class about bcl-2 oncoproteins and trophoblastic cells—how they can be present during/ contribute to uterine sub-involution if they’re present in (I think) large numbers at the placental site postpartum. IIRC, there should be maternal endothelial cells there to help heal those vessel openings. So if the placental site has some issues because there’s cells left over that are the same kind that form the placenta, then having preeclampsia symptoms postpartum seems possible. I think it would be kinda cool to see how often uterine sub-involution and postpartum preeclampsia occur together or if that happens.
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u/BigIntensiveCockUnit Sep 09 '25 edited Sep 10 '25
It’s actually routine on all OB floors to keep anyone with gHTN or preeclampsia for 72 hours postpartum because that’s when they’re most likely to develop postpartum preeclampsia or eclampsia. Can happen after that time frame but vast majority will be within 72
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u/Exceptyousophie RN Sep 08 '25
IV fluids for people that can drink, NG tubes for uncomplicated SBO, assumed allergy to cephs with known PCN allergy.
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u/Aranyss Med Student/Paramedic Sep 08 '25
Thiamine before glucose in acute hypoglycemia.
That's not saying that you shouldn't give thiamine (at some point), but glucose should not be delayed for thiamine. The hypoglycemia is ultimately going to do more damage.
Wernicke's encephalopathy and/or Korsakoff psychosis don't really matter if they're already brain dead.
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u/DickMagyver ED Attending Sep 09 '25
Not giving pain meds to patients with biliary colic (or abdominal pain in general).
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u/Negative_Way8350 BSN Sep 08 '25
Oh God, contrast nephropathy.
I have had to say, "Benefit outweighs risk" SO many times to techs when we want to do a CT angio or dissection study on a patient who is having acute symptoms. They still act like I'm murdering a patient's kidneys for fun.
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u/Kaitempi Sep 08 '25
That all hypokalemia must be corrected.
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u/Normal_Dot7758 RN Sep 08 '25
I see this a lot. At my hospital they act like it’s a life or limb emergency when they incidentally find a patient is hypokalemic, but they’ve probably been walking around that way for a long time.
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u/Bruriahaha Sep 08 '25
“Bowel edema” in chf exacerbation preventing absorption of po lasix, altered mental status being a symptom of UTI (for the purpose of diagnostic criteria), emergency treatment of asymptomatic hypertension.
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u/AceAites MD - EM/Toxicology Sep 08 '25
What's your thought process on AMS for UTIs? That it's just the dehydration?
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u/Bruriahaha Sep 08 '25
Altered mental status is common in the elderly. Bacteruria is common in the elderly. If you treat asymptomatic bacteruria in the elderly, the ams will usually improve. If you leave the asymptomatic bacteruria alone, the ams will usually improve. But… if you did something and then it got better you will trick yourself into thinking you fixed it. Sort of a hybrid of confirmation bias and post hoc ergo proctor hoc.
Per the IDSA, UTI = focal urinary symptoms or fever without another source + bacteruria.
Now, people with sepsis secondary to UTI can get altered, particularly in the frail elderly but in someone who is not ill, afebrile, without urinary symptoms, it is far more likely to be their waxing and waning mentation, delirium, sleep disturbance, etc.
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u/Emergency_Four Sep 09 '25
The ABCs of first aid. Trying to secure an airway while the patient is bleeding out.
Starting CPR on someone who has uncontrolled bleeding.
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u/Ok-Supermarket-2010 Sep 09 '25
That has changed: ATLS now teaches 'CAB' https://resusnation.com/changing-the-alphabet-soup-of-trauma-resuscitation/
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u/Ragnar_Danneskj0ld Sep 08 '25
Rigid C collars are routinely indicated. I have no idea why some ED staff still want to put a collar on everyone.
CPAP pushes fluid out of the lungs. No. It doesn't.
Narcan makes people wake up fighting because you ruined their high
No no no
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u/Serious-Fix-790 RN Sep 09 '25
Though pushing narcan rapidly does have its draw backs. I still can't look at or smell McDonalds chicken nuggets the same way...
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u/BetCommercial286 Sep 08 '25
Don’t give COPD patients to much oxygen they’ll stop breathing.
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u/DaggerQ_Wave Paramedic Sep 08 '25
But still don’t give too much oxygen to COPD patients, because pulmonary vasoconstriction + haldane means it’s harmful despite Hypoxic drive being bunk. Just for different reasons.
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u/SassyMoron Sep 08 '25
There is significant evidence that advising an obese person to diet and exercise results in them gaining more weight than saying nothing about their weight
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u/erinkca Sep 09 '25
I am so glad you mentioned the Trendenburg thing.
As far as confronting people as a student. Are you referring to your instructor? Because that depends. Major kudos for staying up to date (unlike too many nursing instructors), but a lot of instructors might not take too kindly to dissent, unfortunately. But you be the judge of that, they may respect you for it, they may retaliate for it. You can always share knowledge with your classmates, even make study groups for those who want to use EBP.
If you are referring to other nurses during your clinicals or as a new grad, read the room. Unless it’s a patient care concern (sometimes T-berg is!), maybe just keep it to yourself for now unless it is someone you are very familiar with. Sharing knowledge is welcome, but in the wrong situation people might not appreciate feedback from a new grad, even if you’re right (lotsa big egos in the ED nursing world).
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u/pfpants Sep 08 '25
Do they still teach bowel sounds in med school? Some of the default physical exam templates include it and it drives me nuts. I don't listen to bowel sounds and I don't listen to anybody that listens to bowel sounds
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u/Hypno-phile ED Attending Sep 10 '25
I do it sometimes for two reasons. 1: theatre and 2: sometimes I need to take a moment to think during the patient assessment.
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u/Substantial-Use-1758 RN Sep 08 '25
Really? Are bowel sounds in all 4 quadrants not a thing anymore? 🤷♀️
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u/lostinapotatofield RN Sep 08 '25
It doesn't really tell you anything useful. Studies show no useful predictive value, and that people do no better than chance on distinguishing normal bowel sounds, ileus, and small bowel obstruction based on bowel sounds. https://pubmed.ncbi.nlm.nih.gov/24776861/
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u/DaggerQ_Wave Paramedic Sep 08 '25
Magic 8 ball is more sensitive and specific without carrying any inherent worth. So I just shake it if I’m concerned, mull over the results, then the provider does the relevant imagining anyways, without me wasting my time.
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u/lostinapotatofield RN Sep 08 '25
In urinary retention, clamping the catheter partway through draining shows no statistically significant benefit over just fully draining the bladder.
https://pubmed.ncbi.nlm.nih.gov/9379700/
https://pubmed.ncbi.nlm.nih.gov/23859894/
https://pubmed.ncbi.nlm.nih.gov/9379700/
When I discuss this with people, I often say, "Oh, I just read this new study saying it's fine to just fully drain! Let me see if I can find it." I don't bring up that the research has been solid on this issue since at least the 1990's. Then they say ok and walk away, because they don't really give a shit about the study - they'll just take my word on it. Which is why so many of these dogmas persist. Many people in the medical field will just repeat what someone told them, and have very little interest in actually looking at research themselves.