Most common examples of medical voodoo and urban legends?

Started by DeadCactus
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DeadCactus

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There was a thread floating around for a year or two called "Help build my 'so there' file" that seems to have died and gone to the archives. I'm sad to see that because I really liked the idea so with a similar concept in mind I thought I would ask:

What are some of the most prevalent examples of tests, procedures, and exams still done when solid and long-standing evidence against them exists? What are some of the most commonly held "clinical pearls" that have little basis in fact?
 
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Rectal before heparin on every patient. Even before going to cath lab for STEMI.
 
1) That tPA works for stroke . . . .

2) That Willie Sutton robbed banks "because that's where the money is . . . " You hear this phrase in medical lectures all the time as "Sutton's Law," but a reporter made up this quotation while Sutton was on trial.

Sutton actually said "Why did I rob banks? Because I enjoyed it. I loved it. I was more alive when I was inside a bank, robbing it, than at any other time in my life. I enjoyed everything about it so much that one or two weeks later I'd be out looking for the next job. But to me the money was the chips, that's all."

3) That improvement of Sx with nitro is diagnostic of ACS

4) That atropine is necessary in all pediatric intubations

5) That you need to be NPO for 8 hrs prior to sedation
 
When the guy comes in who has been smoking "wet," that he's dipped his weed in "formaldehyde" or "embalming fluid." Those are just names that have somehow been adopted for straight-up, ordinary PCP. Get the haldol and the 4-points.
 
That you give all people with bronchitis antibiotics.

That you have to clamp a foley after 1L out in urinary retention.
 
"stone heart"; concept of Ca++ is contraindicated on hyperkalemia with dig toxicity... or is the verdict still out? many of my attendings are still preaching this.
 
TheBlueBlazer said:
When the guy comes in who has been smoking "wet," that he's dipped his weed in "formaldehyde" or "embalming fluid." Those are just names that have somehow been adopted for straight-up, ordinary PCP. Get the haldol and the 4-points.
Click to expand...

Have you done a lit search on this? Did you even do an SDN search on this? The legend has become truth. Someone not "in the know" takes it literally. Saw it 10 years ago in Jersey City (ironically, I remember that a hit song at the time was Afroman's timeless classic "Cause I Got High").

That's the thing about urban legends, and a problem with this thread - people shoot out a topic, but don't expand, so you don't really know what they are saying. t-PA doesn't work for stroke? It has a low success rate, but is not on the level of gators in the NYC subway or Bigfoot. One hallmark of the urban legend in oral tradition is "I knew someone who knew someone" - no first-hand knowledge. More than one person here has seen t-PA work with their own eyes. So, for people that are more junior or not so nuanced, they get the wrong idea, or don't see the humor or sarcasm.
 
If you're certain of this, I am more than willing to stand corrected. What I was taught was that, at least locally, that the use of actual formaldehyde was spurious and the colloquial use of "embalming fluid" was twisted, and has confused people everywhere. Did a quick, shallow search, being saturday and all, and it looks like what I saw very well could have been done by docs who took people on face value that they were actually smoking formaldehyde-laced weed. There's no gas chromatography results looking a what was actually there or manufacturing process verification. haha. I'm definitely willing to learn if you can enlighten me though.
 
Apollyon said:
Have you done a lit search on this? Did you even do an SDN search on this? The legend has become truth. Someone not "in the know" takes it literally. Saw it 10 years ago in Jersey City (ironically, I remember that a hit song at the time was Afroman's timeless classic "Cause I Got High").

That's the thing about urban legends, and a problem with this thread - people shoot out a topic, but don't expand, so you don't really know what they are saying. t-PA doesn't work for stroke? It has a low success rate, but is not on the level of gators in the NYC subway or Bigfoot. One hallmark of the urban legend in oral tradition is "I knew someone who knew someone" - no first-hand knowledge. More than one person here has seen t-PA work with their own eyes. So, for people that are more junior or not so nuanced, they get the wrong idea, or don't see the humor or sarcasm.
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Thanks for being part of the no-fun-police but I do see your point, as I was being somewhat sarcastic about the tPA comment.

I can't help but find it interesting though when neuro pushes tPA and are dumbfounded when the patient doesn't magically return to his/her baseline and start playing the piano despite never playing before. It's hard not to gently remind them of the 90-day outcome aspect of NINDS . . .
 
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EM2BE said:
That you give all people with bronchitis antibiotics.

That you have to clamp a foley after 1L out in urinary retention.
Click to expand...

Actually a general surgeon just taught us this a month ago in class... that when you put a foley you should watch the patient and clamp it after 500 ml of urine (for 1-2 min and then release) and then every 250 ml after that .. the logic being that if you don't the bladder will contract so much it's lumen will be virtually zero and the patient will hemorrhage into the foley ... so whts with the foley thing true or not????
 
Tiger26 said:
Thanks for being part of the no-fun-police but I do see your point, as I was being somewhat sarcastic about the tPA comment.

I can't help but find it interesting though when neuro pushes tPA and are dumbfounded when the patient doesn't magically return to his/her baseline and start playing the piano despite never playing before. It's hard not to gently remind them of the 90-day outcome aspect of NINDS . . .
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Where are you that neuro would be "dumbfounded" that the patient didn't drop down to 0 on the NIHSS after the bolus? And if they are as clueless as you claim, why in the world would you cede the decision to give tPA to them?
 
Arcan57 said:
Where are you that neuro would be "dumbfounded" that the patient didn't drop down to 0 on the NIHSS after the bolus? And if they are as clueless as you claim, why in the world would you cede the decision to give tPA to them?
Click to expand...

Yeah, my experience, across a varied swath of the US, has been neuro just dumping clear statistics about bleeding, recovery, and no response.

Apologies for being the "no fun police".
 
What about oxygen "therapy" for postical patients? I'm not even sure what the desired effect is. Prevention of another seizure? Quicker return to baseline? Providing millions of dollars in business to the makers of nasal cannulas?
 
ihearttriangles said:
What about oxygen "therapy" for postical patients? I'm not even sure what the desired effect is. Prevention of another seizure? Quicker return to baseline? Providing millions of dollars in business to the makers of nasal cannulas?
Click to expand...

During the seizure I'll give 'em O2 because they're ventilatorily impaired. After the seizure there's no reason for O2. However I might not remember to take it off.
 
You should get an EKG before IV haldol. It wasnt that long ago that people were on haldol drips.
 
LebDoc said:
Actually a general surgeon just taught us this a month ago in class... that when you put a foley you should watch the patient and clamp it after 500 ml of urine (for 1-2 min and then release) and then every 250 ml after that .. the logic being that if you don't the bladder will contract so much it's lumen will be virtually zero and the patient will hemorrhage into the foley ... so whts with the foley thing true or not????
Click to expand...

I had a pt last night with acute urinary retention x 2 days. I placed the foley and got 1.3 L out and bladder completely emptied on US. About 2 hours later he did have some hematuria. I did a lit search and came across the paper mentioned just by EM2BE. I was glad to find out it likely wasn't of any clinical significance.

As for O2 during seizure. Two nights ago, my co-resident had a pt go to CT who had a seizure in the scanner. We rushed over, nurses fumbled for the ativan. I looked at the monitor and saw the pt brady down to 30s and O2 undetectable. Did compressions as the pt was in PEA while RT searched for a bvm, had ROSC within a min, return of spontaneous breathing and AAO x 3 within 4 minutes. Not sure if this was a game changer in my book but I think I'll be reaching for O2 more often on seizing pts.
 
Apollyon said:
More than one person here has seen t-PA work with their own eyes. So, for people that are more junior or not so nuanced, they get the wrong idea, or don't see the humor or sarcasm.
Click to expand...

Without making this a tPA topic, I will argue that more than one person here has seen standing there doing nothing work with their own eyes as well.
There are more papers out there than the ones Genentech references. The new 4.5 hour window really scares me.
 
Rapid Step test has any clinical utility in the ER.

I'll expand: Keeping a patient an extra hour for a "rapid" test for a level 4 visit complaint is ridiculous. Especially when at best the test has 80% sensitivity, which is low enough to render it worthless in my opinion. If I think it's Strep, I'll go ahead and treat. Do a few viral syndromes get antibiotics? Yes.
 
xaelia said:
Oxygen and aggressive hydration of sickle cell patients.

NPO in pancreatitis (last night, found out apparently someone taught one of our EM PGY-3s to do this).
Click to expand...

References? Just curious. I know our hospital is stuck in a time warp, but the first I see done at big academic centers too.
 
Dr.McNinja said:
Without making this a tPA topic, I will argue that more than one person here has seen standing there doing nothing work with their own eyes as well.
Click to expand...

That CVA with occlusive clot resolves with no intervention over a matter of minutes, with no sequel? That sounds like a TIA. And if you are saying that you have seen CT-proven CVA, with neurologic sequelae, resolve completely in a matter of minutes, and that more than one person has seen that, I would like to hear more.
 
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Apollyon said:
And if you are saying that you have seen CT-proven CVA, with neurologic sequelae, resolve completely in a matter of minutes, and that more than one person has seen that, I would like to hear more.
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CT-proven? As in hypoattenuation, or loss of gray/white interface? Or a specific finding such as MCA sign?
Because I have not had a radiologist call that in anybody in the 3 hour window since I have started working here at the "stroke center of excellence" that happens to not have neuro coverage 50% of the days.
Our CT results are either "no acute disease", "old stroke", or "hemorrhagic stroke." Only the first group gets tPA. Thus, there is no way to differentiate between TIA and CVA reversed with tPA in that group.
Sorry, but the data isn't as cut and dry as they would like us to believe. That being said, unfortunately, the onus is on us to give it rather than withhold it. tPA is one of the few things I would not give to my family in all of the same instances I give it to the community. There are some instances that I would still do it, but nowhere near as broadly as it is done.
 
Dr.McNinja said:
CT-proven? As in hypoattenuation, or loss of gray/white interface? Or a specific finding such as MCA sign?
Because I have not had a radiologist call that in anybody in the 3 hour window since I have started working here at the "stroke center of excellence" that happens to not have neuro coverage 50% of the days.
Our CT results are either "no acute disease", "old stroke", or "hemorrhagic stroke." Only the first group gets tPA. Thus, there is no way to differentiate between TIA and CVA reversed with tPA in that group.
Sorry, but the data isn't as cut and dry as they would like us to believe. That being said, unfortunately, the onus is on us to give it rather than withhold it. tPA is one of the few things I would not give to my family in all of the same instances I give it to the community. There are some instances that I would still do it, but nowhere near as broadly as it is done.
Click to expand...

Count me in as a skeptic of TPA. I think most of the "clinical improvements" we see with TPA are in fact resolving TIAs. The only way to demonstrate the effectiveness of TPA would be to do a clinical trial ONLY on patients with vaso-occlusive clot causing CVA. The only way to do this would be to do a CT-angiogram or MRI/MRA on every patient with stroke-like symptoms prior to administering TPA. Logistics aside, I think the "n" of patients with proven stroke and who get TPA would be so low as to make no relevent statistical analysis possible.
 
The only way to demonstrate the effectiveness of TPA would be to do a clinical trial ONLY on patients with vaso-occlusive clot causing CVA. The only way to do this would be to do a CT-angiogram or MRI/MRA on every patient with stroke-like symptoms prior to administering TPA.
Click to expand...

We do that at a hospital where I work -- CT, CTA with perfusion study for every stroke I. This has led to an interesting phenomenon: we had a patient with right-sided weakness that was almost completely resolved at 2-hours post-onset. The only residual defect was moderate dysarthria. However, she had definite vaso-occlusive clot on CTA. Our neurologist elected to push TPA (after convincing her). I'm not sure I would have wanted that in my family member given the mildness of the symptoms.
 
turkeyjerky said:
Do you have a reference for omitting hydration in SCD? Thanks.
Click to expand...

I do not believe a euvolemic patient will benefit from isotonic fluid resuscitation in sickle cell pain crisis. A dehydrated patient may be treated and may benefit.

Over-hydration is an independent risk factor for acute chest.

In vitro studies show improvement in intra-erythrocyte dehydration with hypotonic fluids.

There's a lot more complexity to the vaso-occlusive crisis than simple blood viscosity. The key to resolving dense-cell formation is figuring out how to encourage intracellular rehydration. Aggressive isotonic intravascular resuscitation doesn't necessarily change intracellular fluid content. So, the best I can come up with in an attempt to help a patient without harming them, my typical practice is isotonic resuscitation until euvolemic, and then maintenance rate hypotonic fluids.

If you're looking for evidence to support my practice vs. current practice, the most recent cochrane review regarding fluids in sickle cell pain crisis identified zero relevant articles.
 
"I have a concussion and my doctor/office/nurse/pediatrician/Brother-who-is-a-EMT sent me in for a CT scan."

If I had a quarter for each of the above, well...
 
Dr.McNinja said:
CT-proven? As in hypoattenuation, or loss of gray/white interface? Or a specific finding such as MCA sign?
Because I have not had a radiologist call that in anybody in the 3 hour window since I have started working here at the "stroke center of excellence" that happens to not have neuro coverage 50% of the days.
Our CT results are either "no acute disease", "old stroke", or "hemorrhagic stroke." Only the first group gets tPA. Thus, there is no way to differentiate between TIA and CVA reversed with tPA in that group.
Sorry, but the data isn't as cut and dry as they would like us to believe. That being said, unfortunately, the onus is on us to give it rather than withhold it. tPA is one of the few things I would not give to my family in all of the same instances I give it to the community. There are some instances that I would still do it, but nowhere near as broadly as it is done.
Click to expand...

As to the bolded, yes. Have you seen that resolve on its own? I haven't, but have seen it, people get t-PA, have their signs resolve, and follow up CT and/or MRI shows reperfusion.

I can't tell if you are serious about the "stroke center of excellence" that doesn't have 24-hour neuro coverage. If that is sarcasm, it is missing. If it is true, that is either scary, or shows any "center" designation to be a farce.

As to those with no bleed on CT, then I do not know if it is "post hoc, ergo propter hoc" - that it would have resolved anyways. It does make one wonder, though. Well, at least I wonder.
 
xaelia said:
Oxygen and aggressive hydration of sickle cell patients.

NPO in pancreatitis (last night, found out apparently someone taught one of our EM PGY-3s to do this).
Click to expand...

whoa, this is new to me, maybe I need to be uptodate on this. But, NPO in pancreatitis is a myth? all our admissions of acute pancreatitis have surgical consult, and they all are placed on NPO by the surgical residents. And on the floor, they remain NPO until the lipase trends down.
 
Foster23 said:
whoa, this is new to me, maybe I need to be uptodate on this. But, NPO in pancreatitis is a myth? all our admissions of acute pancreatitis have surgical consult, and they all are placed on NPO by the surgical residents. And on the floor, they remain NPO until the lipase trends down.
Click to expand...

The earlier you can initiate enteral feeding in acute pancreatitis, the better the outcomes.

Including immediately.

And, if they can tolerate PO immediately, their pain is controlled, and they have an uncomplicated etiology for their pancreatitis, they can go home from the ED.
 
Apollyon said:
Have you done a lit search on this? Did you even do an SDN search on this? The legend has become truth. Someone not "in the know" takes it literally. Saw it 10 years ago in Jersey City (ironically, I remember that a hit song at the time was Afroman's timeless classic "Cause I Got High").

That's the thing about urban legends, and a problem with this thread - people shoot out a topic, but don't expand, so you don't really know what they are saying. t-PA doesn't work for stroke? It has a low success rate, but is not on the level of gators in the NYC subway or Bigfoot. One hallmark of the urban legend in oral tradition is "I knew someone who knew someone" - no first-hand knowledge. More than one person here has seen t-PA work with their own eyes. So, for people that are more junior or not so nuanced, they get the wrong idea, or don't see the humor or sarcasm.
Click to expand...

Didn't read the rest of the thread before I posted, so if I repeat someone here, I apologize. If anyone has "seen t-PA work with their own eyes," then what they've seen is a TIA they gave lytics to. Even in the original studies, the only patients who saw benefit had improved stroke scores 3 months or more after their event.
 
jethro136 said:
Didn't read the rest of the thread before I posted, so if I repeat someone here, I apologize. If anyone has "seen t-PA work with their own eyes," then what they've seen is a TIA they gave lytics to. Even in the original studies, the only patients who saw benefit had improved stroke scores 3 months or more after their event.
Click to expand...

As I said in post #36 (as you state, you didn't read the rest of the thread), I have seen patients with affirmative CT signs of ischemic CVA get t-PA, improve clinically, and show reperfusion on follow up CT and/or MRI. It's anecdote, but to say black-letter that it doesn't happen, in my experience only, is not borne out.

But, no matter what you do, you'll get sued. Science be damned, but people don't want to hear that you didn't try.
 
AbbyNormal said:
Here is one that became popular during WWI: using Trendelenburg position to treat shock.
Click to expand...

This is a particular annoyance of mine. We get called to do all the in house intubations. So when someone is circling the drain on the floor I invariably get there to find them in trendelenburg. It doesn't help the cerebral perfusion but it does greatly increase gastroesophageal reflux which has always been bagged to a full blown aspiration by the time I get there.
 
xaelia said:
The earlier you can initiate enteral feeding in acute pancreatitis, the better the outcomes.

Including immediately.

And, if they can tolerate PO immediately, their pain is controlled, and they have an uncomplicated etiology for their pancreatitis, they can go home from the ED.
Click to expand...

Despite my program being good about eeking out myth from fact, I actually wasn't fully aware that you can do early feeding on pancreatitis patients (unless you mean through the NGT). I've also never thought to send a pancreatitis pt home. do you have a good lit reference for that? Although part of the reason my program would never do that is that a Family Medicine Attending a few years back came in with pancreatitis, supposedly very benign with no signs of badness, and then died a day or two later. So my institution is very fearful of the disease as a whole
 
i'm with Rendar... have admitted more than a few pancreatitics who looked rather benign in the ED who ended up in the ICU tubed w/ ARDS and more than a couple died... not a chance i'm willing to take!!
 
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docB said:
This is a particular annoyance of mine. We get called to do all the in house intubations. So when someone is circling the drain on the floor I invariably get there to find them in trendelenburg. It doesn't help the cerebral perfusion but it does greatly increase gastroesophageal reflux which has always been bagged to a full blown aspiration by the time I get there.
Click to expand...

This drives me nuts also...I see it occasionally in the ED !

In addition to the aspiration/peri-RSI risks, it just kills oxygenation...the worst is when you have some obese guy with poor ventilation and oxygenation who is placed on a NRB and then put flat or near trendelenburg "awaiting intubation"...then people wonder why the sats are in the 80s.

Leave them sitting up before and after intubation as much as possible...hell, I leave them at about 20-30 degrees during RSI and intubation.

HH
 
Rendar5 said:
Despite my program being good about eeking out myth from fact, I actually wasn't fully aware that you can do early feeding on pancreatitis patients (unless you mean through the NGT). I've also never thought to send a pancreatitis pt home.
Click to expand...

Especially in recurrent pancreatitis, if the pain and vomiting are not intractable, and the patient looks well, I won't admit them. Keep puking or sucking up the Dilaudid, they stay.
 
Rendar5 said:
Despite my program being good about eeking out myth from fact, I actually wasn't fully aware that you can do early feeding on pancreatitis patients (unless you mean through the NGT). I've also never thought to send a pancreatitis pt home. do you have a good lit reference for that? Although part of the reason my program would never do that is that a Family Medicine Attending a few years back came in with pancreatitis, supposedly very benign with no signs of badness, and then died a day or two later. So my institution is very fearful of the disease as a whole
Click to expand...

My group has an institutional fear that has most of us giving antibiotics for uncomplicated kidney stones. Has to do with one bad case from a few years back. Data be damned.
 
Rendar5 said:
Despite my program being good about eeking out myth from fact, I actually wasn't fully aware that you can do early feeding on pancreatitis patients (unless you mean through the NGT). I've also never thought to send a pancreatitis pt home. do you have a good lit reference for that? Although part of the reason my program would never do that is that a Family Medicine Attending a few years back came in with pancreatitis, supposedly very benign with no signs of badness, and then died a day or two later. So my institution is very fearful of the disease as a whole
Click to expand...
From my medicine rotation, I was under the impression that you feed them enterically as soon as possible through an NJ tube. NJ feeds are fine because they're distal to the pancreas. Apparently NG feeds are less commonly accepted, but still might be fine.
 
Rendar5 said:
Despite my program being good about eeking out myth from fact, I actually wasn't fully aware that you can do early feeding on pancreatitis patients (unless you mean through the NGT). I've also never thought to send a pancreatitis pt home. do you have a good lit reference for that? Although part of the reason my program would never do that is that a Family Medicine Attending a few years back came in with pancreatitis, supposedly very benign with no signs of badness, and then died a day or two later. So my institution is very fearful of the disease as a whole
Click to expand...

What's the benefit of the NGT? You aren't bypassing anything other than the mouth and esophagus. Didn't think that an NGT would be of any benefit. I've not seen it done at any place I've been (unless pt intubated, then they get OGT for aspiration, but not for feedings). If anything goes in the stomach, you are still stimulating pancreatic enzyme release.
 
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