How much medicine do anesthesiologists know?

[vector2]

sounds like a nice work environment. All the nephros I've worked with would have thrown a fit if some other specialty dared to order HD

Regardless, dialysis nurses pretty uniformly won't set up or fulfill HD (and/or CRRT depending on your institution) orders unless the orders came from nephro.

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Members don't see this ad.

 

[sevo00]

It is tho…

the answer to cardiogenic shock is levophed?

 

[ToKingdomCome]

I love medicine. It's the reason I am doing a CCM fellowship. I came into anesthesiology always wanting to do CCM. Anesthesia is truly medicine in action. ICU is medicine in action. Sure we miss the long term management of things or nitty details of certain disease processes but all in all, we get to actually practice what we learned pharm/physio in medical school nistead of worrying about dispo/most social issues/etc. Having said all that, like a poster said, IM and anesthesia are separate fields unless you only want to do CCM. Really think if you'd be willing to do clinic vs OR. I sometimes think that I regretted not doing the IM/Anes 5 yr track but I just didn't see myself doing IM residency after I had finished my prelim medicine year. However, if you pick only Anesthesia residency route, please keep brushing up on your general medical knowledge because it's so easy to fall into that trap of just get the patient through the surgery (Prop/roc/tube mentality). Also, do a prelim medicine year with plenty of MICU if you're so inclined. There are also combined Anesthesia/CCM programs which if you don't mind staying at one place is actually good since you can have more ICU time and elective time through your residency. I honestly donn't know much about those but it sounds good.

Where are you doing your fellowship and are you just starting ?

 

[vector2]

the answer to cardiogenic shock is levophed?

Lot of investigation and debate going on right now regarding the paradigm of pressors/inotropes and cardiogenic shock..............but the short answer is yes.

 

[pgg]

an ms3 that cant wipe their own ass making that statement. makes sense. murica.
lets go shoot a bunch of guns

Guns solve more problems than nurses

 

[dhb]

Guns solve more problems than nurses

...and kill less people

 

[nimbus]

During WW2, the saying was “Pentothal killed more men than bullets.”

 

[deleted697535]

I dont know what's going on here? I've never not seen someone in cardiogenic shock on norepi and ive seen a lot of shocky patients. Probably 100 per year

Theyre on loads of other stuff too plus mcs.

 

[Nivens]

I dont know what's going on here? I've never not seen someone in cardiogenic shock on norepi and ive seen a lot of shocky patients. Probably 100 per year

Theyre on loads of other stuff too plus mcs.

My understanding is the key here is in the definition of “cardiogenic shock”. The trials that showed a benefit of levophed over epi were looking at patients with acute MI -> LV failure prior to revascularization. This effect was probably due to relatively lower HR/higher DBP. Most of my patients in LV failure are post-revascularization/post CPB, which I still feel benefit from epi over levophed.

Been awhile since I looked into it but that was my gestalt at the time.

 

[coffeebythelake]

During WW2, the saying was “Pentothal killed more men than bullets.”

Today, the saying goes "VA nurses kill more veterans than bullets".

 

[vector2]

My understanding is the key here is in the definition of “cardiogenic shock”. The trials that showed a benefit of levophed over epi were looking at patients with acute MI -> LV failure prior to revascularization. This effect was probably due to relatively lower HR/higher DBP. Most of my patients in LV failure are post-revascularization/post CPB, which I still feel benefit from epi over levophed.

Been awhile since I looked into it but that was my gestalt at the time.

Yeah imo I think post-cardiotomy LCOS isn't what most people are thinking of when using the common parlance "cardiogenic shock." Mostly talking about the average person who comes to the ED post-MI or with a decompensated chronic HFrEF / HFpEF.

While both the 'just separated from bypass" and "walked into ED with 20 lbs of excess fluid" pts might share the fact that their CI is less than 2.2, that's about where the similarities end. As you imply, the immediate pathophysiology and treatments for each of them may differ significantly.

 

[vector2]

I would also add that "cardiogenic shock" is more complicated than "dont start levophed, it's the *pump* that's bad"

There's many mechanisms going on for why the MAP may be low in CS including low SVR/vasoplegia.

 

[deleted162650]

Today, the saying goes "VA nurses kill more veterans than bullets".

Cue the “Difference between a VA nurse and a bullet” jokes.

 

[T-burglar]

the answer to cardiogenic shock is levophed?

That’s part of the answer…

 

[T-burglar]

The people who think “levophed leaves em dead” have only a baby’s understanding of resuscitation

 

[coffeebythelake]

I would also add that "cardiogenic shock" is more complicated than "dont start levophed, it's the *pump* that's bad"

View attachment 340130

There's many mechanisms going on for why the MAP may be low in CS including low SVR/vasoplegia.

I think in the absence of solid data from advanced monitors, TEE, PA catheter to calculate cardiac output or contractility to guide treatment, most people would choose something more inotropic such as epinephrine and would NOT rely solely on levophed for cardiogenic shock.

 

[vector2]

I think in the absence of solid data from advanced monitors, TEE, PA catheter to calculate cardiac output or contractility to guide treatment, most people would choose something more inotropic such as epinephrine and would NOT rely solely on levophed for cardiogenic shock.

Who is "most people" and what context are we talking about?

No one has that advanced data when decompensated CHF is diagnosed in the ED or floor and admitted to the ICU. In the ED it might be based on history, physical exam, a wet CXR, and elevated BNP (+- a POCUS TTE). That person is getting norepi by the ED if they're hypotensive and that norepi is going to be continued by cards/CCU with possible dobutamine added based on how organ function / ScVO2 is looking etc.

 

[chocomorsel]

Sometimes I don’t worry at all about CRNA encroachment. I’ve practiced for 9 years now… solo jobs and supervision jobs…. I’ve seen crnas kill people, cause aspiration, negative pressure pulmonary edema, anoxic injury, miss airways and consistently, fundamentally not understand wtf they are doing. Many of the new grads lack the icu rn depth of knowledge some of the older ones do. Most of them have a devil may care it’s someone else’s problem and want to go home promptly at the end of their shift… even if that means signing out the last 10 minutes of the case.
I think you need to decide if you like the OR, ICU or the clinic environment. I like the OR, my bud chocomorsel hates it and likes the icu better. Anesthesia is very useful that it can go in many different ways -
Choco and I started our careers at the same time… it’s taken awhile for us to get to the place they are. She’s found balance w locums and a mix of anes and ccm. That would never work for me.
I put in the time in the partner track and made partner, something she would never have wanted to do. Now my days are trauma and plastics lol…. Now some Seniority has landed me the Cush plastics solo days in between my crazed trauma and safari anesthesia days.
I have another friend who makes way less than choco and me but has a cushy asa 1-2 type gig. Another friend runs her own pain practice, another mommy tracks ans still does better than medicine people. Anesthesia, at least for now is very customizable to what’s a good fit for you…

That’s my girl. Spitting the truth in all her wisdom.

 

[chocomorsel]

I dont know what's going on here? I've never not seen someone in cardiogenic shock on norepi and ive seen a lot of shocky patients. Probably 100 per year

Theyre on loads of other stuff too plus mcs.

Seriously? Never? I start with it and add dobutamine. In fact that is what we had this morning on the the unfortunate patient who died because she was not a candidate for an angio.

 

[chocomorsel]

Who is "most people" and what context are we talking about?

No one has that advanced data when decompensated CHF is diagnosed in the ED or floor and admitted to the ICU. In the ED it might be based on history, physical exam, a wet CXR, and elevated BNP (+- a POCUS TTE). That person is getting norepi by the ED if they're hypotensive and that norepi is going to be continued by cards/CCU with possible dobutamine added based on how organ function / ScVO2 is looking etc.

Exactly. Mine was a combo of hemorrhagic shock and cardiogenic shock. Hemorrhage led to the MI that just kept getting worse. One I rescusitated w blood and realized EF was in the crapper added Dobutamine and we stopped pushing as much Epi.
Why would one not use Norepinephrine in cardiogenic shock? Obviously not alone.

 

[coffeebythelake]

Who is "most people" and what context are we talking about?

No one has that advanced data when decompensated CHF is diagnosed in the ED or floor and admitted to the ICU. In the ED it might be based on history, physical exam, a wet CXR, and elevated BNP (+- a POCUS TTE). That person is getting norepi by the ED if they're hypotensive and that norepi is going to be continued by cards/CCU with possible dobutamine added based on how organized function is looking / ScVO2 etc.

Well there you go. Something I did not know. I guess I don't take care of enough people with cardiogenic shock, but I never use norepi alone

 

[deleted697535]

Seriously? Never? I start with it and add dobutamine. In fact that is what we had this morning on the the unfortunate patient who died because she was not a candidate for an angio.

Not never but very rarely. dob/mil and basically every nonMCS treatment for cardogenic shock B-E are inodilators.
Afaik the actual SCAI definition of C.S. includes hypotension and pressors in it

Im not aiming for massive BP increases just offsetting the side-effects of other drugs.

There were some weeks this year where all i did was impellas and heart transplants. very often on 5-6 agents for BP incl cyanokit and blue. tbh i dont know any research on norepi or not. i thought we were so far beyond that by now.

 

[Hork Bajir]

I agree with the point made above that “cardiogenic shock” is fairly heterogeneous patient population, and the management isn’t one-size fit all. For example, with acute RV failure in the context of pulmonary HTN, RV perfusion is compromised and one of the keys to restoring normal RV geometry and function is maintaining an adequate systemic pressure/SVR. In that scenario, norepi arguably has a place in the resuscitation. In other patients where the SVR is already maxed out and the toes/gut are turning blue, maybe not so much. Cardiogenic shock is more complex than just saying “pump bad, need epi”

 

[chocomorsel]

Not never but very rarely. dob/mil and basically every nonMCS treatment for cardogenic shock B-E are inodilators.
Afaik the actual SCAI definition of C.S. includes hypotension and pressors in it

Im not aiming for massive BP increases just offsetting the side-effects of other drugs.

There were some weeks this year where all i did was impellas and heart transplants. very often on 5-6 agents for BP incl cyanokit and blue. tbh i dont know any research on norepi or not. i thought we were so far beyond that by now.

Please tell me what all the above abbreviations mean. It’s my week off and I am on my third glass of wine. And just had a near death experience.

 

[The kitchen sink]

I agree with the point made above that “cardiogenic shock” is fairly heterogeneous patient population, and the management isn’t one-size fit all. For example, with acute RV failure in the context of pulmonary HTN, RV perfusion is compromised and one of the keys to restoring normal RV geometry and function is maintaining an adequate systemic pressure/SVR. In that scenario, norepi arguably has a place in the resuscitation. In other patients where the SVR is already maxed out and the toes/gut are turning blue, maybe not so much. Cardiogenic shock is more complex than just saying “pump bad, need epi”

I've seen an epi + vasopressin strategy used for isolated RV failure, depending on the amount of information you have (PA catheter and PA , PCWP values) which as you said can increase SVR without negatively affecting the pulmonary vasculature as much as the other agents such as norepi (may cause an elevated in SVR and PVR that may not be valuable in isolated RV failure), bottom line is i think more advanced hemodynamic monitoring may be useful in these pt populations (even if the studies haven't born it out) like a PA catheter, POCUS (VTI, TAPSE, valve assessment etc) cause you can't necessarily predict the outcomes each pressor or inotrope will truly have on these critically ill pts without them, just my 2 cents though

 

[Drwine]

There's a reason they call it leav-em-dead.

That is only the case for those who use it as Jackson Pollock used paint.😁. There is a role for judicious use of it.
As far as the post our ability to apply medical information in the perioperative period is what makes us unique. I could train many people with no medical background how to stick a tube in a trachea.

 

[anbuitachi]

MS3 here considering anesthesia but concerned about issues such as CRNAs and boredom. How much medicine do anesthesiologists know?

How much do you know compared to CRNAs (i.e., how much medicine do they know)?

The science of medicine and pathology is really cool. Do you guys feel like you still make use of it in your day-to-day work?

Edit: Didn't mean my question to sound rude. I feel bad

as much as possible...

just yesterday i had a lady go for emergency surgery with severe pancreatitis, all types of lab abnormalities etc. its very helpful to know general idea of what it is, what you should do, what you shouldnt do, what may make it worse, etc. you dont need to know as much detail as IM though.

day before that i had a severe cholangitis elderly guy that had to get ERCP. on pressors, acidotic to 7, etc. after surgery he stayed in my pacu for 8 hours. I had to manage him, so having more medical knowledge definitely helps.

you dont just want to be a prop pusher!

 

[vector2]

day before that i had a severe cholangitis elderly guy that had to get ERCP. on pressors, acidotic to 7, etc. after surgery he stayed in my pacu for 8 hours. I had to manage him, so having more medical knowledge definitely helps.

Man, you must've been really short of ICU beds if this guy was still hanging around the PACU that long. Ascending cholangitis after ERCP instrumentation usually gets a lot worse before it gets better. Most of our PACU nurses aren't really CC nurses so having a guy in decompensated septic shock with a Tbili of 12 wouldn't fly in my PACU very long.

 

[anbuitachi]

Man, you must've been really short of ICU beds if this guy was still hanging around the PACU that long. Ascending cholangitis after ERCP instrumentation usually gets a lot worse before it gets better. Most of our PACU nurses aren't really CC nurses so having a guy in decompensated septic shock with a Tbili of 12 wouldn't fly in my PACU very long.

i think the issue is just not enough icu beds for our level of acuity. they are building another ICU though... but will take few years to finish

 

[GassYous]

as much as possible...

just yesterday i had a lady go for emergency surgery with severe pancreatitis, all types of lab abnormalities etc. its very helpful to know general idea of what it is, what you should do, what you shouldnt do, what may make it worse, etc. you dont need to know as much detail as IM though.

day before that i had a severe cholangitis elderly guy that had to get ERCP. on pressors, acidotic to 7, etc. after surgery he stayed in my pacu for 8 hours. I had to manage him, so having more medical knowledge definitely helps.

you dont just want to be a prop pusher!

Why can't the icu physician manage in the pacu? I'm not about to start running a mini icu in pacu.

 

[BLADEMDA]

Sometimes I just wonder about you guys. Have you never used low dose Epi on a routine case? My point is that low dose epi can be very helpful when added to the Norepi drip as can Low dose Vasopressin. When you start maxing these drugs out I think it hurts more than helps. I am fortunate to be able to "fine tune" many of these patients at my gig over the decades. I can tell you turning up the EPI won't help and makes things worse many times. Norepi is great but adding a bit of inotropic support with dobutamine can be quite helpful at times.

Sometimes the answer is how you use it and not just how much (big) you use.

 

[anbuitachi]

Why can't the icu physician manage in the pacu? I'm not about to start running a mini icu in pacu.

they dont actively manage patients on waitlist due to bed shortage here. They can be consulted for help though

 

[BLADEMDA]

​

Hemodynamic response to low-dose epinephrine infusion during hypotensive epidural anesthesia for total hip replacement​

N E Sharrock 1, R Mineo, B Urquhart
Affiliations expand

• PMID: 2291884

Abstract​

The hemodynamic response to reduction in blood pressure after epidural anesthesia in elderly patients is poorly defined. Therefore, hemodynamic measurements using radial artery and thermodilution pulmonary artery catheters were performed in 85 patients undergoing total hip replacement in whom blood pressure was allowed to decrease in order to minimize blood loss. Measurements were made in the lateral position prior to and after induction of epidural anesthesia to T4 or above when mean arterial pressure (MAP) had fallen to 50-55 mmHg. Four non-randomized groups of patients were identified: those requiring zero, less than 1 microgram/minute, 1-2 micrograms/minute or 2-5 micrograms/minute, respectively, of intravenous epinephrine to maintain MAP at 50-55 mmHg. In patients receiving no epinephrine, MAP, heart rate (HR), stroke volume (SV), cardiac index (CI), pulmonary artery diastolic pressure (PAD), left ventricular stroke work index (LVSWI) and systemic vascular resistance (SVR) fell significantly from baseline. Low-dose epinephrine infusions modified this response by increasing SV and CI and reducing SVR, but had little consistent effect on PAD, HR and LVSWI. Increases in SV and CI were significantly related to the dose of epinephrine administered. Low-dose intravenous epinephrine infusions preserve cardiac output during hypotensive epidural anesthesia in elderly patients.

 

[BLADEMDA]

Now, before you go off blasting me for not posting an article related to Heart Failure my point was to prove adding a little EPI or Dobutamine to the NOREPI is helpful in the Critical Care setting. Low dose EPI doesn't cause tachycardia (typically) nor does it increase SVR.

 

[BLADEMDA]

The hemodynamic and fibrinolytic response to low dose epinephrine and phenylephrine infusions during total hip replacement under epidural anesthesia​

N E Sharrock 1, G Go, R Mineo, P C Harpel
Affiliations expand

• PMID: 1448777

Abstract​

Lower rates of deep vein thrombosis have been noted following total hip replacement under epidural anesthesia in patients receiving exogenous epinephrine throughout surgery. To determine whether this is due to enhanced fibrinolysis or to circulatory effects of epinephrine, 30 patients scheduled for primary total hip replacement under epidural anesthesia were randomly assigned to receive intravenous infusions of either low dose epinephrine or phenylephrine intraoperatively. All patients received lumbar epidural anesthesia with induced hypotension and were monitored with radial artery and pulmonary artery catheters. Patients receiving low dose epinephrine infusion had maintenance of heart rate and cardiac index whereas both heart rate and cardiac index declined significantly throughout surgery in patients receiving phenylephrine (p = 0.0001 and p = 0.0001, respectively). Tissue plasminogen activator (t-PA) activity increased significantly during surgery (p < 0.005) and declined below baseline postoperatively (p < 0.005) in both groups. Low dose epinephrine was not associated with any additional augmentation of fibrinolytic activity perioperatively. There were no significant differences in changes in D-Dimer, t-PA antigen, alpha 2-plasmin inhibitor-plasmin complexes or thrombin-antithrombin III complexes perioperatively between groups receiving low dose epinephrine or phenylephrine. The reduction in deep vein thrombosis rate with low dose epinephrine is more likely mediated by a circulatory mechanism than by augmentation of fibrinolysis.

 

[BLADEMDA]

Inotropes and Vasopressors - StatPearls - NCBI Bookshelf

 

[BLADEMDA]

Critical Care Fundamentals: Management of Shock Part 2A - REBEL EM - Emergency Medicine Blog

Shock is defined as circulatory failure leading to decreased organ perfusion. In this 15 minute and 46 second video, I will review the management shock - part 2a (Norepinephrine, Epinephrine, Dopamine, Phenylephrine, and Push-Dose Pressors).

rebelem.com

 

[deleted697535]

Please tell me what all the above abbreviations mean. It’s my week off and I am on my third glass of wine. And just had a near death experience.

3rd glass is the sweet spot for working!
If you cant do something drunk, should you really be doing it at all??

Im sure you're probably winding me up but anyways...
Well SCAI is the classification for Cardiogenic shock right? With E being extremis

MCS is mechanical circulatory support, which can be VA ecmo, centrimag or impella most commonly these days. Impellas are usually 5's and left sided but there is a CP and and Right sided device. Or you could go straight to durable VAD or biVAD in some circumstances. IABP probably lives in there too

What else? After that well cyanokit is hydroxocolobamin - vitb12 and scavenges nitric oxides, dose is 5gm and cost is 5grand too!
blue is methylene blue similiar MOA.

Ive seen both work well and also fail miserably. Vasoplegia post CPB can be wicked

 

[nimbus]

​

Hemodynamic response to low-dose epinephrine infusion during hypotensive epidural anesthesia for total hip replacement​

N E Sharrock 1, R Mineo, B Urquhart
Affiliations expand

• PMID: 2291884

Abstract​

The hemodynamic response to reduction in blood pressure after epidural anesthesia in elderly patients is poorly defined. Therefore, hemodynamic measurements using radial artery and thermodilution pulmonary artery catheters were performed in 85 patients undergoing total hip replacement in whom blood pressure was allowed to decrease in order to minimize blood loss. Measurements were made in the lateral position prior to and after induction of epidural anesthesia to T4 or above when mean arterial pressure (MAP) had fallen to 50-55 mmHg. Four non-randomized groups of patients were identified: those requiring zero, less than 1 microgram/minute, 1-2 micrograms/minute or 2-5 micrograms/minute, respectively, of intravenous epinephrine to maintain MAP at 50-55 mmHg. In patients receiving no epinephrine, MAP, heart rate (HR), stroke volume (SV), cardiac index (CI), pulmonary artery diastolic pressure (PAD), left ventricular stroke work index (LVSWI) and systemic vascular resistance (SVR) fell significantly from baseline. Low-dose epinephrine infusions modified this response by increasing SV and CI and reducing SVR, but had little consistent effect on PAD, HR and LVSWI. Increases in SV and CI were significantly related to the dose of epinephrine administered. Low-dose intravenous epinephrine infusions preserve cardiac output during hypotensive epidural anesthesia in elderly patients.

I remember those papers out of HSS. They were putting PA catheters in total hips. Anything for science….lol

 

[Radetzky]

Interesting discussion. Important to note that in the epinephrine vs norepinephrine study one of the definitions of persistent shock was lactic acidosis - which we know is caused by EPI even when it improves everything else.

I think we understand only a fraction of the physiology we think we do and try make simplistic decisions based on this e.g. high SVR=bad. Who knows what the right answer is. There’s definitely patients who are harmed by norepi and there’s definitely patients who I think decompensate when you drive their oxygen demand up with epi.

 

[T-burglar]

Norepinephrine, like most temporizing drug therapy in resuscitation, is excellent for buying time while you fix the underlying problem.

most anesthesiologists and doctors in general forget to aggressively seek and address the underlying problem. Hence the r3tarded conclusion that levophed leaves em dead

anytime you start a pressor or ANY drug therapy for a clinical abnormality you should continually ask yourself if you are sure you know what the underlying diagnosis is and if you are doing the right or wrong things to address it

 

[chocomorsel]

3rd glass is the sweet spot for working!
If you cant do something drunk, should you really be doing it at all??

Im sure you're probably winding me up but anyways...
Well SCAI is the classification for Cardiogenic shock right? With E being extremis

MCS is mechanical circulatory support, which can be VA ecmo, centrimag or impella most commonly these days. Impellas are usually 5's and left sided but there is a CP and and Right sided device. Or you could go straight to durable VAD or biVAD in some circumstances. IABP probably lives in there too

What else? After that well cyanokit is hydroxocolobamin - vitb12 and scavenges nitric oxides, dose is 5gm and cost is 5grand too!
blue is methylene blue similiar MOA.

Ive seen both work well and also fail miserably. Vasoplegia post CPB can be wicked

Thanks. I did not know about SCAI.
And why the hell is Vit B12 cost $5k? Never heard of it called cyanokit.

 

[chocomorsel]

Why can't the icu physician manage in the pacu? I'm not about to start running a mini icu in pacu.

They have probably a ton of other patients in the regular ICU.

 

[GassYous]

They have probably a ton of other patients in the regular ICU.

So if a patient is admitted to the floor from the ED with no beds, they are suddenly not the hospitalist's responsibility because "they have probably a ton of other patients". Yeah no, that doesn't fly. Do your job.

 

[chocomorsel]

So if a patient is admitted to the floor from the ED with no beds, they are suddenly not the hospitalist's responsibility because "they have probably a ton of other patients". Yeah no, that doesn't fly. Do your job.

Doesn’t sound like this patient was admitted to the hospitalist. So how about you do your job and resuscitate? And check on them when you can?
If they were admitted to the hospitalist I bet you that’s is what is going to happen.

 

[drmwvr]

The people who think “levophed leaves em dead” have only a baby’s understanding of resuscitation

the 'leave em dead' label comes from the late last century practice of empirically restricting fluids while squeezing the crap out of patients. The resulting pile of bodies with black and blue limbs, since their last gtt was levophed, was thus associated with the drug itself mostly by residents and nurses. Funny how a dark aphorism really did contribute to the decline of the drug because for years it had been considered archaic.

It wasn't until a more sophisticated understanding of stuff like venous return and MSFP was added to the mix (and their practical application) that NE made a comeback even within the last 15 years or so I'd say depending on where you were.

I don't think I'd even know where to find a bag of dopamine without asking a pharmacist today.

 

[epidural man]

MS3 here considering anesthesia but concerned about issues such as CRNAs and boredom. How much medicine do anesthesiologists know?

How much do you know compared to CRNAs (i.e., how much medicine do they know)?

The science of medicine and pathology is really cool. Do you guys feel like you still make use of it in your day-to-day work?

Edit: Didn't mean to have my question to sound rude. I feel bad

I do medicine all the time.

My friend asked me about a friend that was acting strange. I suggested drug abuse, or a brain tumor....got the scan...turns out it was a tumor.

My other friend had cold fingers all the time after exercise....I diagnosed Raynaud's.

I was showing someone some some utlrasound stuff, and saw a scary looking nodule on the thyroid....it was cancer.

I am always doing medicine.

 

[GassYous]

I do medicine all the time.

My friend asked me about a friend that was acting strange. I suggested drug abuse, or a brain tumor....got the scan...turns out it was a tumor.

My other friend had cold fingers all the time after exercise....I diagnosed Raynaud's.

I was showing someone some some utlrasound stuff, and saw a scary looking nodule on the thyroid....it was cancer.

I am always doing medicine.

I hope you billed them for changing their lives

 

[dhb]

I hope you billed them for changing their lives

He probably got blamed for the cancer since you know anesthesia...

 

[vector2]

I do medicine all the time.

My friend asked me about a friend that was acting strange. I suggested drug abuse, or a brain tumor....got the scan...turns out it was a tumor.

My other friend had cold fingers all the time after exercise....I diagnosed Raynaud's.

I was showing someone some some utlrasound stuff, and saw a scary looking nodule on the thyroid....it was cancer.

I am always doing medicine.

"Honey, how'd your prostate exam go?"



"Great. The anesthesiologist said it was smooth as an apple"