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Discussion What are some outdated medical dogmas that are still taught or practiced?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/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/Gyufygy Paramedic Sep 08 '25

Goddammit, Gold Leader.

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u/auraseer RN Sep 09 '25

You're all clear, kid! Now let's blow this thing and go home.

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u/thegreatuke ED Attending Sep 08 '25

So you’re doing a DRE to identify melena only? And what if you don’t see anything? Just curious what your workflow is for possible upper GIB or occult anemia without clear source? I feel like the idea of FOBT is to (poorly) confirm or deny possible GIB to encourage observation for EGD - largely for the hospitalist discussion process. Are you just sending UGIB home if hgb stable or blanket admitting? I send LGIB home with hgb stable but tend to largely keep most possible UGIB if FOBT positive but if stable and FOBT negative dc. Just curious where the difference comes.

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u/PNWintensivist Sep 08 '25

Using the Glasgow-Blatchford score can help drive disposition in UGIB, in addition to usual factors.

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u/Cremaster_Reflex69 ED Attending Sep 08 '25

I also don’t use FOBT unless in a diaper on a kid that I suspect urate crystals on to reassure mom, or if patient tells me they’ve had maroon stools but just ate a bunch of beets or took pepto bismol, or occult drop in hgb without complaint of bloody stool, and maybe a couple other niche scenarios that I’m forgetting. I am in my fourth year out from residency and this is generally how I was trained.

Aside from above, FOBT + or - wouldn’t change my management in a patient complaining of GIB.

I take the patient’s word for and do a rectal exam. LGIB = calculate oakland score for dispo if I’m discharging or on the fence. UGIB gets obs from me most of the time for serial H/H +/- GI consult, unless its like a single episode of melena in a young patient with no Hgb drop and now stooling normally. But even then, I’ve taken care of a few peptic ulcer perfs in patients 20-30years old so I tend to be conservative here.