Procedure legends?

[EMhawkeye]

ah the ol' "I don't have an argument to stand on but I am the attending and you are the med student" defense

Much to learn you have young padiwan

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[Siggy]

My very first day as an attending I had such a similar story. We had a code and I got ROSC. I could give a whole long story on all the "cultural" things there that made that ROSC go poorly, but leave it at I was so worried part way through the CPR effort that I said "Okay just get me a central line and I'll get access right now so we can give pressors if they come back." I guess no one had ever asked for a TLC midway through cpr and the code rooms (in a mind blowing bit of oversight) didnt have any. So a tech is running across a big ED to find one and I just go "is that a central line right there?" and the tech sees a kit in a corner and tells me that it is and gives it to me.

It was the trauma cordis. I didnt realize until I had fully gotten the guide needle and guide wire in. So I just sheepishly continued forward as all the techs and nurses just were baffled at this crazy new doc putting in the firehose on the CPR patient. I thought maybe the culture here was cordis on everyone because no one told me that it was odd to see that monster IV go in. It took me a solid 3 months before I admitted to the tech who handed it to me that I had zero intention of putting that line in and that maybe we should stock regular TLCs in the resuscitation rooms.

Every place I've been has had a TLC in the crash cart.
Almost every code I've been in, no one knew it was in there. The amount of times I've had to show nursing supervisors where various odds and ends (normally the central line kit, OG tube, and french suction catheter) during or immediately after a code boggles the mind.

 

[The Knife & Gun Club]

Amazing rebuttal to my ridiculous claim that a general surgery resident is better at cutting than an ED resident. I don't know how I sleep at night after telling such lies

My best friend is an ENT. He is the first to say he wants nothing to do with a crash cric. They do not much receive training in that procedure, and it’s more or less a historical anecdote to them.

Subspecialist surgeons are the un-debated masters of the anatomy and functioning of their chosen system. They are not however the masters performing extremely time sensitive procedures in an uncontrolled ED environment.

Ask anesthesiologists how many despise intubating in the ED. Or OBs coming to the ED to do a peri-Mortem section. It’s an uncontrolled environment which requires its own set of skills to function well in.

 

[YCAGA]

My best friend is an ENT. He is the first to say he wants nothing to do with a crash cric. They do not much receive training in that procedure, and it’s more or less a historical anecdote to them.

Subspecialist surgeons are the un-debated masters of the anatomy and functioning of their chosen system. They are not however the masters performing extremely time sensitive procedures in an uncontrolled ED environment.

Ask anesthesiologists how many despise intubating in the ED. Or OBs coming to the ED to do a peri-Mortem section. It’s an uncontrolled environment which requires its own set of skills to function well in.

All three of your examples (ENT, anes, OB) are about how much the specialists don't want to do something or despise doing it; that has nothing to do with their technical ability to do it.

Why ever call anesthesia or OB to an emergency airway or c-section if EM docs are the master's of all things emergent? ED residents need 10 deliveries to graduate from an ACGME residency so they should be able to handle a peri-mortem delivery just fine--10 deliveries is far more ED thoracotomies than the average ED resident gets, and we have already established that EM is the first choice for that procedure.

It is insulting to your colleagues, especially in anesthesia and OB, to think that they just because they don't like **** shows in the ED (who would?), that they are less competent than you in their own fields. Do you really think OB and anesthesia don't get a lot of experience in train-wreck situations? You would have to do a virtual OB rotation to think that. Why is it so hard for you all to admit that while they are very good at many things, they are not the master at something just because it is "emergent"?

The opinions in this thread are nothing like those of the attendings I have worked with, so I know that "ED is best at everything if it is hectic" is not a universal opinion in EM.

 

[The Knife & Gun Club]

So in other news, here’s a story, because poo flinging is boring.

Setting - community site where the average age is in the triple digits and every person is full code and their nearest family member is 1,000 miles away in Long Island and wants EVERYTHING DONE.

So right around 6 pm we get a call that EMS is inbound from a well known local nursing home. Let’s call it Substandard Acres Nursing. It’s a cardiac arrest, CPR in progress. He’s a 94 year old *garble garble* history of end stage Parkinson’s *garble garble* recent CVA *garble -*

They roll in with the LUCAS going to town on this dude who’s nothing but skin, bones, and contracture. He’s in PEA, gets some epi, a little more CPR. I grab the scope and go to intubated this dude while the PGY3 practices his cool new “I get to run the code” voice.

Glide-scope goes in, and I’m immediately greeted by a Boulder field of peas, corn, and some ungodly excuse for meat. Hook around the tongue and there, between the chords, is a gigantic piece of chicken. Boiled, unseasoned, half-heartedly chewed chicken.

Yelled for ring forceps, and by some miracle they were actually produced from some crevice of the code cart. Went in, grabbed that chicken, and delivered it like a half digested baby.

Tube went in, and I $hit you not 10 seconds later we got ROSC.

I high-fived the PGY3, and we argeed that would have been super cool if we didn’t just revive a functionally dead dude who had multiple terminal end stage conditions.

Anyway, here’s a picture of that unholy excuse for chicken.

 

[dadaddadaBATMAN]

ah the ol' "I don't have an argument to stand on but I am the attending and you are the med student" defense

A couple things.

Cool your jets: it’s possible to make a point without being caustic or obnoxious. So far you haven’t been able to do so once in this string.

The attending above was probably exaggerating. It was probably less the attending ed physician holding down a screaming surgical resident while an ed resident makes the incision and more a strong ed presence in the trauma bay led to their Attendings appropriately advocating they do a procedure we are all credentialed to do.

I have done zero ed thoracotomies. I still know the indications and the basics of the procedure, and I would attempt it if I had the right patient. Those patients would be a lot better off if I had the opportunity to do one of the five or so of these that happened in the department while I was a resident on the case.

If it’s a question of an ed resident or a general surgery resident doing the procedure, there’s actually a reasonable argument that could be made that the ed resident will be more likely to have to do it in the future than a general surgeon: even if they are on call, likely the patient will be dead long enough to make a procedure futile by the time they get there.

And lastly, the “attending is right because their an attending” argument favors the attending 9/10 times when I see a resident arguing, and 99/100 times when it’s a med student arguing.

Have you even rotated in the ed yet? Even if you have, do you really think you understand the ins and outs of procedures in residency and the politics of who gets them?

As an example you could look at chest tubes. I aggressively pursued these as a resident and got enough to be competent. I’ve done 5 since I left residency in my first few months as an attending. My general surgery friends who mostly went on to fellowship, or to community medicine? Zero. They can turf to pulm, Ir, etc. I am sure there are plenty of places where gen surg is still expected to do these, but every ed physician is expected to do them (Often emergently) and they can rarely turf them to someone else.

Your arguments are pretty specious, and could be made for almost every procedure we do. Perhaps we should have plastics do every lac repair, ortho do every reduction, cards read every ekg, surgery see every belly pain, peds see every kid, and im see everything else.

 

[DocEspana]

Your arguments are pretty specious, and could be made for almost every procedure we do. Perhaps we should have plastics do every lac repair, ortho do every reduction, cards read every ekg, surgery see every belly pain, peds see every kid, and im see everything else.

Suddenly HCA/Envision administration just had a brilliant idea for profits.

 

[southerndoc]

Please do not feed the trolls.

 

[EMhawkeye]

Hey, I was an arrogant jackass as a student, too.
Don't let me stop you.

Much to learn the young padiwan does

 

[RustedFox]

Much to learn the young padiwan does

He either deleted his posts, or he got thwomped.

 

[YCAGA]

Not gone, just got my posts removed. I think my initial argument understandably got lost in the 10 layers of sarcasm I used. What spurred me to keep arguing is the notion that EM is better at a procedure than specialists just because something is emergent. EM trained doctors are very competent in basically everything they do, but that doesn't mean they are the best at everything they do. I haven't done my EM rotation yet but I did work in multiple EDs before med school and spoke to a lot of EM-trained attendings about this exact topic, or at least I was a fly on the wall while they discussed this with EM residents, off-service residents, med students, etc. Why did this topic come up to much? EM loves procedures and shooting the **** and discussing this is a way to do both. The consensus among 10+ attendings who trained at a variety of respected programs was this:

1A - EM is the undisputed best of many things, including but not limited to: medical resuscitation of the undifferentiated patient, diagnosis of the undifferentiated patient (especially when really sick), POCUS (at most places)

1B - the disputed best of ("challenger" field in parenthesis): emergent airway (anesthesia)*, running codes (critical care)

2A - the undisputed second best of (1st best in parenthesis): reading EKGs (cards), trauma resuscitation (trauma/general surgery), chest tubes (CT/trauma/general surgery), surgical airway (ENT), ED thoracotomy (CT/trauma/general surgery), LP (neuro/IR), fractures/dislocations (ortho), procedural sedation (anesthesia)

2B - the disputed second best of (undisputed 1st then "challenger" field in parenthesis): vaginal deliveries (OB, FM), anything pediatric (peds/PEM, FM), art lines/central lines (anesthesia, critical care)

Honorable mentions: loads of knowledge about literally every field in medicine ("best 20 minutes of every specialty")

*this one was particularly controversial among EM attendings and anesthesiologists so don't kill me

This list is not at all comprehensive of the many things EM can do at a high level. You all might disagree with what went where, but we can all agree that being the best or the 2nd/3rd best in medicine at so many skills is incredibly impressive. ED docs do things from 1A to 2B all the time and do a great job. (I lumped trauma and general surgery together a few times because, at least at my institution, all of the trauma attendings say that a general surgery resident should graduate being able to handle trauma call in a community setting).

Sarcasm and aggressiveness aside, I still don't buy that the 3 sim-lab crics an EM doc did in their residency is enough to be more proficient than an ENT who cut into peoples necks for 5 years of residency alone. Yes, a planned trach is a different procedure than a cric, but it is not like ENTs just do planned trachs and never mess around with anything else in the neck. They have seen more HENT anatomical variation and have mastered anterior neck landmarks better than any EM doctor could ever hope to. That isn't a knock on EM, that is just the nature of medicine and specialization.

Your arguments are pretty specious, and could be made for almost every procedure we do. Perhaps we should have plastics do every lac repair, ortho do every reduction, cards read every ekg, surgery see every belly pain, peds see every kid, and im see everything else.

Saying cards should read every ekg, surgery should see every ab pain, etc is a straw man argument and something I never said. EM doesn't need to consult for every issue in the ED, but that doesn't mean they are gods of any procedure in the ED either. EM can reduce the vast majority of shoulder dislocations without help, but if you can't get a shoulder back in, are you really going to call in another ED doc over ortho? Are you going to call another ED doc for a second opinion on an iffy EKG or would you call cards? If your kid had a lac and you could choose between an ED doc and a plastic surgeon suturing it, who would you chose? Now, the counter-argument is that it is not practical or necessary for EM to call in a specialist anytime a specialist could help. I agree with that, but let's remember the context. I initially replied to a situation where EM and gen surg were both already in the trauma bay, ready to help.

Every ED doc told rotating med students some variation of this next line when they were asked about pros/cons of EM: "it is an awesome field, but you have to be ok with being a jack of all trades and a master of a few." I am paraphrasing but having that experience in real life and then coming on to this forum to see EM docs claim to be the best in the business at everything they do makes me feel like I am banging my head against the wall.

Why does it even matter if EM is or isn't the best at things if they are competent? I would never have said something if the original commenter hadn't done as many or more ED thoracotomies than a newly minted trauma surgeon. I can understand that EM needs to get experience with ED thoracotomies and I will walk back what I said about "a surgeon should crack a chest if they are in the room." By that logic, no medical student or resident would ever get training because the procedure would go to the most experienced person. But the comment I replied to heavily implied that trauma/general surgery was actively kept away from supervising ED thoracotomies. In my opinion, that is a dangerous turf war that is appropriate to call out. Probably should not be called out in the way I did it, but it isn't unreasonable to comment that it is a bad situation for everyone involved, especially the patient.

 

[dadaddadaBATMAN]

Saying cards should read every ekg, surgery should see every ab pain, etc is a straw man argument and something I never said. EM doesn't need to consult for every issue in the ED, but that doesn't mean they are gods of any procedure in the ED either.

EM can reduce the vast majority of shoulder dislocations without help, but if you can't get a shoulder back in, are you really going to call in another ED doc over ortho?
——-
100% I would take an experienced em doc over Ortho for a shoulder. If we call them it’s because we think the patient might need general anesthesia

Are you going to call another ED doc for a second opinion on an iffy EKG or would you call cards? ———-
——-
Again, I run iffy ekgs by colleagues all the time. I would take an interventionalist over an em doc, but probably not a gen cards person. They are unquestionably better at ekgs overall but not necessarily at finding ischemia. If I call a gen cards on an iffy ekg I am doing so to limit my liability/Monday morning quality assurance committee ————-
—————
If your kid had a lac and you could choose between an ED doc and a plastic surgeon suturing it, who would you chose?

Idc on this one, probably the em doc for speed to dispo. Outcome will probably be similar unless there is need for extensive repair. Plastic surgeon is better, but it doesn’t change that most of the time the scar will be similar: also, plastic surgeon isn’t gonna do it, it will be the poor pgy2 resident on call, so I’ll take an em doc.

This is going to be my last response as this is an otherwise good thread (going to go with benefit of the doubt regarding trolling). I exaggerated your argument which encompasses multiple procedures to demonstrate that there is clearly a line at which it becomes absurd.

I included responses above. Honestly, it’s kind of exhausting arguing with someone who seems to have the baseline assumption that working with a couple em docs puts them in a position to argue with people with years/decades more experience than they have.

Have a good night, and good luck in your clinical years

 

[dchristismi]

Not to change the subject back to the topic, but I'm going to change the subject back to the topic. I also have a memorable chicken-in-the-airway experience.
Almost identical setup (ahem, Florida)

Went to tube and WTF... except it was a whole breast. I grabbed it with my fingers, and flung it on the floor. Nurses screamed. More chicken. Two additional chickenectomies via ring forceps later and I could actually see the cords.
Got ROSC, but if I remember right, family withdrew care a few days later.

Ah, old people not chewing.

 

[dadaddadaBATMAN]

Not to change the subject back to the topic, but I'm going to change the subject back to the topic. I also have a memorable chicken-in-the-airway experience.
Almost identical setup (ahem, Florida)

Went to tube and WTF... except it was a whole breast. I grabbed it with my fingers, and flung it on the floor. Nurses screamed. More chicken. Two additional chickenectomies via ring forceps later and I could actually see the cords.
Got ROSC, but if I remember right, family withdrew care a few days later.

Ah, old people not chewing.

Doctors don’t want you to know this one simple trick that brings life to the dead!

Or

Avoid THIS one food to avoid sudden death!

 

[DocEspana]

Not to change the subject back to the topic, but I'm going to change the subject back to the topic. I also have a memorable chicken-in-the-airway experience.
Almost identical setup (ahem, Florida)

Went to tube and WTF... except it was a whole breast. I grabbed it with my fingers, and flung it on the floor. Nurses screamed. More chicken. Two additional chickenectomies via ring forceps later and I could actually see the cords.
Got ROSC, but if I remember right, family withdrew care a few days later.

Ah, old people not chewing.

Coworker of mine swears she saved a person's life by right mainstem-ing a grape in the trachea. Said person simply couldn't be oxygenated and stomach kept getting bigger so she went for a ultra-rapid sequence intubation (aka, just tube the "dead" guy. No pre-ox. No meds. Just go). States she hit resistance right at/after the cords and just gave it a real hard push and the tube just suddenly went.

Apparently the ICU did a bronch the next day and got the grape out of the right mainstem, so working backwards guy had created a ball-valve in their trachea.

Similar story but with a sad outcome about a case I *know* happened (because we had an m&m in residency) of a psych patient who aspirated a nitrile glove in the psych ER and got a finger in each bronchus and cause if death was found on autopsy. No way anyone was making that diagnosis and saving them.

 

[Siggy]

Bronched steak out from the carina using the biopsy forceps like a tiny claw game. Then we got the CT brain showing loss of gray white differentiation.

 

[leviathan]

Hit an IJ dialysis line in the ICU after 3 NPs had attempted every other site and deemed the line “un-gettable”. Walked off to jay-Zs 99 problems in my head

Mismanaged a bunch of chronic GERD and other nonsense, but hey. Gotta take the wins as they come.

Anyone else have any good procure stories? I’m not gonna have a job in 2.5 years so hey, gotta live it up.

Similar story as an ICU fellow, flew by air ambulance into a community hospital to put in a dialysis line that the nephrologist, anesthesiologist and local internist (not ICU trained) couldn't get.

 

[AlmostAnMD]

Bronched steak out from the carina using the biopsy forceps like a tiny claw game. Then we got the CT brain showing loss of gray white differentiation.

I've always fantasized about doing this, but I always imagined it would end up the way yours did. By the time you get suspicious, set up the bronch and put the forceps adapter into it and get down there you're already at a down time >10 minutes, assuming they came in unresponsive to begin with. Seems like the only inevitable conclusion.

 

[Siggy]

I've always fantasized about doing this, but I always imagined it would end up the way yours did. By the time you get suspicious, set up the bronch and put the forceps adapter into it and get down there you're already at a down time >10 minutes, assuming they came in unresponsive to begin with. Seems like the only inevitable conclusion.

It was non-occlusive. The patient was admitted overnight after an extended downtime at a steak house, just no one bothered to get the CT brain and, prematurely in my opinion, wrote off TTM because of the downtime alone.

 

[WheezyBaby]

Had a torsades arrest in the unit, pushed a gram of mag and defib x1, patient awake and lucid 5 minutes postarrest, no airway, started on isuprel. Most gratifying arrest I've had, though not really a procedure I suppose.

Strictly from a procedure standpoint, nothing by this forums standards but probably a 1st look rescued infant airway after several failed attempts by colleague

If I did a thoracotomy on someone and they survived, I would consider that to be the absolute pinnacle of my career.

One of the residents at my institution when I was in training had a perimortum c/s where both the mom and baby came out neuro intact. If I remember right it was on L&D and OB did the bedside section while an EM resident on a NICU rotation ran the arrest. I think that's probably about as good as it gets.

 

[clibby]

One of the residents at my institution when I was in training had a perimortum c/s where both the mom and baby came out neuro intact. If I remember right it was on L&D and OB did the bedside section while an EM resident on a NICU rotation ran the arrest. I think that's probably about as good as it gets.

 

[Apollyon]

Wow - Isuprel! Who's the OG here??

 

[WheezyBaby]

Wow - Isuprel! Who's the OG here??

With cards blessing not cowboying it

 

[Apollyon]

With cards blessing not cowboying it

Everything old is new again! I remember Johnny on Emergency! getting orders to hang up isoproterenol, and that was around 1973. The first time I took ACLS, in 1993, it was mentioned in the book that it was on the way out; it was a double edged sword, as, it's all alpha, so, it can increase cardiac output, but, also, it can increase the size of an infarct. And, now, it's coming back in style!

And, it was respect with my OG comment!

 

[RustedFox]

Everything old is new again! I remember Johnny on Emergency! getting orders to hang up isoproterenol, and that was around 1973. The first time I took ACLS, in 1993, it was mentioned in the book that it was on the way out; it was a double edged sword, as, it's all alpha, so, it can increase cardiac output, but, also, it can increase the size of an infarct. And, now, it's coming back in style!

And, it was respect with my OG comment!

So, I was a resident from 2009-2012. Isoproterenol was still in the ACLS algorithms back then - unbeknownst to my PGY-1 self.
I must have had an "old copy" of those flowchart algorithms to memorize.
Bradycardic patient, I tell attending I want to order Isoproterenol.
Nurse looks at me like I have a penis on my forehead.
Attending looks at me and says: "Freaking brilliant, man. OLD-school!"

It was "new-school" to me.
I went home confused.

 

[turkeyjerky]

So, I was a resident from 2009-2012. Isoproterenol was still in the ACLS algorithms back then - unbeknownst to my PGY-1 self.
I must have had an "old copy" of those flowchart algorithms to memorize.
Bradycardic patient, I tell attending I want to order Isoproterenol.
Nurse looks at me like I have a penis on my forehead.
Attending looks at me and says: "Freaking brilliant, man. OLD-school!"

It was "new-school" to me.
I went home confused.

I had cards ask me to put a patient on it a few years ago (stable complete heart block but rate in the 20s) but we ended up going with dobutamine c as yea they didn’t stick it.

 

[RustedFox]

I had cards ask me to put a patient on it a few years ago (stable complete heart block but rate in the 20s) but we ended up going with dobutamine c as yea they didn’t stick it.

Forgive me, what's dobutamine c?

 

[Apollyon]

Forgive me, what's dobutamine c?

I'll bet imagine bucks that that is something like my phone does (i.e., the "c" doesn't mean anything).

 

[Siggy]

I had cards ask me to put a patient on it a few years ago (stable complete heart block but rate in the 20s) but we ended up going with dobutamine c as yea they didn’t stick it.

I just infuse a transvenous pacemaker. I have a much higher success rate with that then with the cardiac drips for heart blocks.

 

[turkeyjerky]

Forgive me, what's dobutamine c?

Typo, I’m on my phone and have fat fingers

 

[Apollyon]

Typo, I’m on my phone and have fat fingers

That's what I said!

 

[turkeyjerky]

I just infuse a transvenous pacemaker. I have a much higher success rate with that then with the cardiac drips for heart blocks.

Do you do them on stable patients?

 

[Siggy]

Do you do them on stable patients?

Pretty much if they're consistently in the 40s or lower with any symptoms, hypotension, or an elevated lactic acid I'll put a transvenous pacer in. If they're chilling in the 40s then I don't... but I wouldn't start them on dopamine either. Of course CCB and BB toxicity gets some calcium and/or glucagon (with Zofran) first.

 

[turkeyjerky]

Pretty much if they're consistently in the 40s or lower with any symptoms, hypotension, or an elevated lactic acid I'll put a transvenous pacer in. If they're chilling in the 40s then I don't... but I wouldn't start them on dopamine either. Of course CCB and BB toxicity gets some calcium and/or glucagon (with Zofran) first.

Ok, yeah my practice too. BRASH gets dopamine or low dose epi drip though.

 

[jw3600]

Ok, yeah my practice too. BRASH gets dopamine or low dose epi drip though.

Ugh dopamine? We’re not done with that yet?

 

[turkeyjerky]

Ugh dopamine? We’re not done with that yet?

Am I crazy for still using it in mildly bradycardic, mildly hypotensive patients?

 

[DocEspana]

Had a torsades arrest in the unit, pushed a gram of mag and defib x1, patient awake and lucid 5 minutes postarrest, no airway, started on isuprel. Most gratifying arrest I've had, though not really a procedure I suppose.

Strictly from a procedure standpoint, nothing by this forums standards but probably a 1st look rescued infant airway after several failed attempts by colleague



One of the residents at my institution when I was in training had a perimortum c/s where both the mom and baby came out neuro intact. If I remember right it was on L&D and OB did the bedside section while an EM resident on a NICU rotation ran the arrest. I think that's probably about as good as it gets.

I'm a combined 1/4 for my two perimortem c-sections.

 

[The Knife & Gun Club]

I'm a combined 1/4 for my two perimortem c-sections.

If that 1/4 survived Neuro-intact I’d call that pretty darn good TBH.

Number of quality live years saved for that patient is likely pretty substantial.

 

[SpacemanSpifff]

Am I crazy for still using it in mildly bradycardic, mildly hypotensive patients?

No.

 

[DocEspana]

If that 1/4 survived Neuro-intact I’d call that pretty darn good TBH.

Number of quality live years saved for that patient is likely pretty substantial.

No idea if the neonate was neuro intact. But it cried and moved limbs so that's good. But any number of years with four moving limbs is probably superior to prenatal death

 

[thegenius]

Am I crazy for still using it in mildly bradycardic, mildly hypotensive patients?

I would put it on without any pause, call cardiology and admit.

 

[DocEspana]

Am I crazy for still using it in mildly bradycardic, mildly hypotensive patients?

I'll say that I mostly relegate it to the world of "only use if someone recently robbed your pharmacy and there is no other pressors left".

but the exception is literally bradycardia that is just sort of smiling at me with a narrow complex rate of 30-36. Too slow to just ignore. Too healthy to convince anyone to place an *immediate* pacer in. Too nice too torture with transthoracic pacing. and I'm too busy to float a pacer.

This is actually not the most uncommon patient and those various "too" situations arent all that uncommon. So I do get some use for dopamine because of this.

 

[YCAGA]

Everything old is new again! I remember Johnny on Emergency! getting orders to hang up isoproterenol, and that was around 1973. The first time I took ACLS, in 1993, it was mentioned in the book that it was on the way out; it was a double edged sword, as, it's all alpha, so, it can increase cardiac output, but, also, it can increase the size of an infarct. And, now, it's coming back in style!

And, it was respect with my OG comment!

Hopefully just a typo but isoproterenol is a non-selective beta agonist, not "all alpha"--it has little to no alpha activation. And beta-1 increases cardiac contractility and HR, not alpha. In addition to increasing cardiac muscle O2 demand, isoproterenol decreases MAP (increased systolic BP due to beta-1 activation, but greater decrease in diastolic due to beta-2 activation).

 

[dadaddadaBATMAN]

Hopefully just a typo but isoproterenol is a non-selective beta agonist, not "all alpha"--it has little to no alpha activation. And beta-1 increases cardiac contractility and HR, not alpha. In addition to increasing cardiac muscle O2 demand, isoproterenol decreases MAP (increased systolic BP due to beta-1 activation, but greater decrease in diastolic due to beta-2 activation).

Clinical years are going to hit you like a truck.

 

[Apollyon]

Hopefully just a typo but isoproterenol is a non-selective beta agonist, not "all alpha"--it has little to no alpha activation. And beta-1 increases cardiac contractility and HR, not alpha. In addition to increasing cardiac muscle O2 demand, isoproterenol decreases MAP (increased systolic BP due to beta-1 activation, but greater decrease in diastolic due to beta-2 activation).

Yeah, not a typo - directly, exactly wrong!

Vaguely, 20+ years ago, I now, with your encouragement, recall that Isuprel is B1 B2, so, "all beta".

Oops! My bad!

 

[RustedFox]

Yeah, not a typo - directly, exactly wrong!

Vaguely, 20+ years ago, I now, with your encouragement, recall that Isuprel is B1 B2, so, "all beta".

Oops! My bad!

I drew a huge "four quadrant/crosshair" diagram and taped it to my bathroom mirror to remember which drugs acted on which receptors back during preclinical years.

I was cleaning out my office last month... and found the diagram tucked into the back cover of an unrelated book.

Man. My handwriting was far different.

 

[RustedFox]

Okay, so it wasn't the drugs, it was just which receptors had which physiologic effects.

This sheet of paper is mad old.

 

[Radetzky]

Dopamine is a perfectly fine inotrope when used at inotrope doses for cardiogenic shock. People hate it because they extrapolate the data from presser doses used in septic shock, which is completely different.

 

[DocEspana]

Dopamine is a perfectly fine inotrope when used at inotrope doses for cardiogenic shock. People hate it because they extrapolate the data from presser doses used in septic shock, which is completely different.

I hate it because it owes me money. Don't tell me why I hate it.

 

[RustedFox]

I hate it because it owes me money. Don't tell me why I hate it.

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