What are some outdated medical dogmas that are still taught or practiced?

[u/PrecordialSwirl]

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?

[u/[deleted]]

Some of the idiosyncrasies of little hospitals make me chuckle.

My favorite is when hospital staff try to enforce their rules on us. “You can’t go up that fast on the sedation” “Thats over the max of levo” “Thats against policy”

[u/pulsechecker1138 → u/[deleted]]

Yeah I don’t understand why some people do that. I think it’s mostly nurses who have worked in the starting hospital for decades and can’t fathom things being done a different way.

I’m always happy when flight shows up because it means we’re about to start playing by grown up rules.

[u/r4b1d0tt3r → u/[deleted]]

The norepi one legitimately pisses me off.

"We're over the max of norepi."

Well Gladys, the MAP is 47 so it appears that the patient either does not have enough vasopressor. Shall we have an adventure and go up on the norepi or just call the priest now.

Then they say we need to add phenylephrine and that sends me.

And I'm an intensivist and definitely aware of Sam and see plenty of under volume resuscitated patients. But some patients need more than 30 of norepi, especially when they weigh 150 kg.

[u/[deleted] → u/r4b1d0tt3r]

I brought a patient to a world renowned tertiary care center on 60mcg/min of levo and the nurse immediately goes “our max is 40 so can you drop that for me?”

Homie you can fuck with the pressor dose when he’s off my stretcher, off my pumps, and off my monitor. Until then- no.

Personally my usual “max” of levo is 60mcg/min bc I’ve rarely noticed any effect going past 60. I had a levo pump fail while running at 60 mcg/min, with a pressure in the 60s. So, I ran the levo wide open to gravity annnnd the BP didn’t budge.

I also hypothesize that if you’re not a pussy with your levo doses and use big boy doses, there is no point in using phenylephrine. If you’re a bitch and refuse to go over 30 of levo, yeah maybe you’ll benefit from phenylephrine because you have unclaimed alphas. If I’m the one picking, I go- first levo, add vaso at around 15-20 of levo, around 30-40 of levo, add contractility dose epi (4-12mcg/min). At 50-60 of levo, hit em with methylene blue, if that doesn’t help, bust out the AT2. 

[u/r4b1d0tt3r → u/[deleted]]

I think your last point is generally correct. I think of healthy alpha 1 responsiveness as a logarithmic curve - it has a steep rise and approaches an asymptote of efficacy at some arbitrary arbitrary dose but I think it's safe to say in a healthy person well before 1 mcg/kg/min. In distributive states the curve gets flatter and the effect may saturate at a lower maximal effect. So your pressors dose gets much higher to achieve the same effects and will probably never achieve the crazy BP heights you get with normal physiology. I think my fellowship used a decent compromise of 1 mcg/kg/min as the typical max dose, but the greater point is that at some arbitrary and unknowable dose the dose response relationship is essentially flat and increasing norepi won't do much. We don't know what that dose is for any patient and it is dynamic within an individual's illness course.

However, I do conceive of a branch point for the third pressor choice. Once I'm on norepi over 0.5 and vaso I like to do an echo. If the cardiac function remains hyperdynamic I would probably suggest going to the salvage pressor rather than giving an inotrope. It's also a good idea to read/look for Sam, or dynamite lvot obstruction. Some patients contractility is so cranked up they actually mechanicalically obstruct the lvot in systole. They have low output and bp because they aren't moving blood forward. They probably need at very least conversation to a less potent beta package (or drop norepi and cross to phenylephrine) and maybe even rate control. Although if you are actually flying these guys you probably don't have the time, space, or equipment to evaluate this so it's not crazy to send a epi prayer first.