Hospital Medicine
Physician discussions on inpatient care, transitions of care, diagnostic reasoning, and hospital-based protocols.
Recent Discussions
Are you covering the tracheostomy site with a surgical mask due to COVID-19 to protect the therapist?
I have not routinely used masks over tracheostomy tubes, but it seems like a good idea in the current environment. Our staff, including physicians, nurses, and therapists, do use masks while taking care of these patients, including during suctioning of tracheal secretions.
For patients over 70 with elevated ASCVD risk but no prior cardiovascular events, do you ever recommend continuing or initiating low-dose aspirin?
Yes, I might still recommend low-dose ASA for primary prevention for someone over 70 if the patient is very functional.
What is your approach to volume resuscitation in patients who are third spacing fluids?
In patients with significant third-spacing (e.g., due to capillary leak in sepsis, severe pancreatitis, hypoalbuminemia, etc), we prefer balanced crystalloids (e.g., Lactated Ringer’s) as the first-line fluid for initial resuscitation in hypovolemic or septic shock with third-spacing. Typical initia...
How do you weigh the benefit of urinary catheter placement for strict I/O measurement with the risk of avoidable CAUTI?
Our hospital's approach, which is consistent with CDC guidance, limits urinary catheters (UC) for I/O measurement to critically ill patients. We clarify that the information from the UC should be used at least q1-2 hours, otherwise it can be obtained in other ways (noninvasive collection, bladder sc...
What do you recommend as a first-line antidepressant in patients with major depressive disorder and migraines?
In my clinical practice, I have found SNRI medication, particularly extended-release venlafaxine (dosed from 37.5 mg to 225 mg), to be helpful for patients with both comorbidities. Other medication classes I have seen used to good effect include TCAs (amitriptyline, nortriptyline) and some SSRIs (se...
How many days prior to elective major surgery do you recommend holding oral GLP 1 R agonist therapy?
Zero. Or, I suppose, if you're having surgery early in the morning, one.This has gone back and forth, but the most recent guidance from the ASA (with other societies concurring) has been that most patients can continue their GLP medications as normal preoperatively, with higher-risk people being rec...
What was the rationale for abrupt discontinuation of etanercept rather than gradual tapering in the SEAM-RA trial?
The main goal of this trial was to get RA patients off of therapy and to see whether they would flare or maintain remission. We didn’t expect that the ultimate likelihood of success or failure was going to be primarily related to how long it took to do that. While a gradual withdrawal of the drug ma...
When considering deprescribing antihypertensives in older patients, how do you approach prioritization of which antihypertensives to target first?
When deprescribing antihypertensives in older adults, my approach is individualized, goal-concordant, and iterative with close monitoring after each step. Every patient is a little different, so there isn't one class of antihypertensives I always deprescribe first. My general rule of thumb is that w...
How would you approach an asymptomatic older female patient with eosinophilia to 17,000, present for years, and normal eosinophilia workup including marrow and negative FLIP1?
Interesting case. Eos have been in the 17K range for years? Was it incidentally noted? Could just be idiopathic HES. I would worry about cardiac infiltration in an older patient, but if there have never been cardiac issues and no evidence of a myeloid variant, I would probably defer to the patient a...
What is your approach during DCCV if you have an obese patient with atrial fibrillation refractory to up to 3, 360 J shocks?
To some degree it depends on what happened with the first three shocks, (I would have applied pressure to shorten the AP diameter for the second and/or third). If the patient converted but it didn't stick, I would consider AAD loading followed by a repeat procedure. If the patient did not appear to...