Clinicians hit dead ends on complex cases with contradictory guidelines

“You are almost certainly identifying symptoms in your retros and not causation. You're applying Band-Aids and the aggregate weight is slowing you down. Without any insight, most likely is incomplete discovery. Right up there is a lack of architecture and confusion of architecture and design. Testing that tries to break things instead of showing they work when used exactly as intended. Too many meetings and too much mindless process. Agile by itself is inherently part of the problem.”

“I could really use some input from nurses who have worked in different inpatient settings because I’m not sure if I’m overthinking this or if my concern is reasonable. I work in a lower acuity inpatient setting with no telemetry or continuous cardiac monitoring. Nurses can have 7 patients and we may have one CNA covering 14+ patients, so it’s not really an environment where you can keep a close eye on one patient for an extended period of time. Recently we had a patient with a potassium over 6.5”

“I have a Medicare patient traveling abroad for an extended period of time and they have a prescription for Nexlizet. Insurance will only cover a 30 day supply for travel but they will run out mid trip. The host country does dispense the drug under a different name but how does that process work? Would they need to visit a healthcare facility abroad for a new prescription or could their provider in the US write one for the drug under the host country’s name? I’m in retail and don’t normally do th”

“Practice…. And you can get rusty after a while for sure. I’ve never accessed a port- my educator said if we want she can schedule us some hours at the infusion clinic to get comfortable with that, since they do it alllllll day there. Maybe they could let you go stick people in ER for a few hours here and there? Or day surgery, or somewhere they do it a lot?”

“Can anyone shed light on this? My electrophysiologist recommended I also get care from MFM for IST as he suspects it will get worse (I’m 9 weeks) and due to medication. I just don’t know what they would do or what they do differently than am OB submitted by /u/Impressive_Moose6781 [link] [comments]”

“I am MD, run my own FP clinic for 20+ years, first time on this issue for me. Basic issue is that a pharmacy told a patient they would not fill their Rx Adderall as they were not seen in person *by the MD/DO* on the Rx within the last year. Big picture speaking, I understand the hesitation, since the online pill-mill shops are getting to be worse and worse. But this patient is in our (fairly strict, in my estimation) Controlled Substance prescription program, with a signed contract. We prescribe”

“Hello everyone Last post: https://www.reddit.com/r/AskVet/s/A05h0NXv3P We consulted with a specialist on soft tissues. He was very kind and lifted our mood. He is very experienced with these kind of surgeries. She had another ultrasound. The left kidney looks done, it even looks like a bladder. The stone is in left ureter. We don't know if the stone blocked the way or the kidney lost its function long before. Tomorrow she will undergo a contrast enhanced CT scan under anesthesia. We have thr”

True Cardiogenic shock, I have seen over 35.000

“There are people who chart because the hospital says so and there are those who chart because they've been disposed. Youll have to pick which side to follow. Ive been disposed far too many time. I dont chart at the times management says I should chart, I chart when I did it. If I start my night with a hard assignment or out of ratio, why would I not want that reflected in my times? Its perfectly ok to chart that you were not able to do something because of a higher priority.”

“Oh wow really, I didnt know it was unusual. I'm in england tho. A lot of our palliative patients even have syringe drivers at home delivering sub cut meds. Ive even known severe hyperemesis pts have sub cut antiemetic”

“There doesn’t seem to be a lot of good advice on this and we know that refusal forms hold little weight in lawsuits. When patients are refusing the appropriate care how are we handling this? submitted by /u/WolverineSeparate568 [link] [comments]”

“I’m a PGY-2 resident in a specialty not related to cardiology and have a friend with a-fib who lives in another country. The a-fib has been very well managed by flecainide by their cardiologist there but they have run into shortages and are unable to get the meds any longer. Chat gpt says it’s technically legal to prescribe it to them in the US and then have someone else pick it up for them and bring it to them (they are unable to travel to the US). But I’m hesitant about this.. Has anyone had e”

“You can call poison control and they can probably give you the most accurate information and hopefully give you some reassurance. 1-800-222-1222”

“Thats an interesting option I had no idea this was a thing!”

“I think it also could have been avoided if the CUSTODIAL MEDICAL FACILITY had a basic medication like GLUCAGON. This is at minimum, manslaughter.”

“Could maybe alo be a pulmonary embolism. You get the sense of impending doom with it too.”

Christ

“I had a patient on three pressors: vaso, epi, and maxed out on quad strength levo (32 mg/250 mL). The family had also changed the code status to DNR/DNE. From the beginning of my shift to the end, her BP was averaging 70s–80s systolic over 30s–40s diastolic. Considering how hemodynamically unstable the patient was, the intensivist placed a Do Not Turn order. For context, this was a bariatric pt (about 170 kg) on a low-air-loss bariatric bed. Her skin was severely edematous and weeping. I tried t”

“i mean at least the cup is labeled, that's more than what we get from half of admitted patients”

“Patient comes in asking for a B12 injection for energy. How do you go about this situation? I typically check a level first and if low will recommend oral supplementation. I typically don’t administer the shot unless they have pernicious anemia or GI conditions that affect absorption (I.e. IBD, celiac, gastric surgery) submitted by /u/MasterChief_117_ [link] [comments]”

“Medication boluses through the pump (ie propofol, midaz, ketamine) do not have scanning functionality in cerner.”

“Just wanted to vent and see if anyone else is dealing with this. I’m a clinician at an outpatient clinic in Southern California. My clinic has a regular lower level of care outpatient program and an FSP (full service partnership) program for those with higher needs (both case management and therapy). Our fiscal year started in July and DMH (Department of Mental Health) has rolled out a level of care system called LOCUS (that was created in response to prop 1). It’s an assessment you complete whi”

“No a patient had a intermittent bolus and im used to continuous with a flush. I didnt know how to set up the intermittent. There was a way- but I still dont know lol”

“Has anyone ever increased the rate of an EPOCH infusion? Apparently, the pump malfunctioned, and the patient didn’t receive any of the dose for approximately 6 hours. submitted by /u/vegan-zombie [link] [comments]”

“Hey guys, I wanted to share a med error I made earlier at work. 😭 I had a patient who needed a heparin infusion. A PTT was taken beforehand, and the heparin bolus followed by the infusion was started by another RN before the patient was handed over to me. When the first PTT result came back, I honestly wasn’t thinking and ended up titrating the heparin based on that result. I also had a colleague co-sign with me, and we both agreed with the adjustment. About an hour later, it hit me that I had”

“What and why A same turn collision produces a question the clinician has no way to answer. C3, dev 7f8f1bd. The clinician types It was 500 mg — no, 875 mg. and the reply is: I heard two values for strength: 500 mg and 875 mg — which should I write? Got it. Still need: strength and manufacturer/compounder. The affordances on screen at that moment, read off the DOM ( runs/gate probes/7f8f1bd/probe.txt , screenshot 03 collision.png ): There is no chip for 500 mg and none for 875 mg. Prod1Strength e”

Should be using LR anyway

“Anyone been able to get hep C tx covered for a patient? Both GI and I have been hitting a wall with coverage for this patient, and it's my first time trying to do it so I don't know if his insurance is shit or if it's just the way it is. Tried glecapravir/pibrentasvir and epclusa and both denied. They say patient has to be cirrhotic or in need of transplant, which is ridiculous. submitted by /u/april5115 [link] [comments]”

“Preface: I’m a paramedic trying to get my flight medic and I work with Flight Medics in a critical care IFT job. Another crew had a pediatric DKA patient with BGL around 580 and on insulin with K+ around 6. The patient was only on insulin and transfer was initiated. (We have no POC testing for K+ btw). Anyways, the BGL dropped about 200 in 40ish minutes. They called and receiving physician said to stop the insulin and they just started NS at like 120ml/hr ish. They did not start hypertonic as th”

“My 12 years old boy has new findings of elevated ALT and was put on Denamarin for 30 days and repeat labs are higher. My vet suggested an abdominal ultrasound but I would like to know what I expect the prognosis to be. AST 356>448 (30 days later). AST was 90 on the most recent lab. Previously ALT was normal. No symptoms beside some increased thirst. Bilirubin normal, ggt normal, alk phos normal. I was concern with a cushing vs chronic hepatitis but obviously it could be a lot. I just wanted t”

“I know there are many questions about SDT (edit: show don't tell) already on the sub but I wasn't able to find something regarding my specific question. I know the consensus is to not follow rules blindly but with snd i am never sure to what extent it needs to be followed. What I thought was the rule that shouldn't be broken is to not write what cannot be known to the audience when watching the movie. Here's a specific example from TWBB: DANIEL is working again in a large field w”

“I work in the 3 top peds cardiac icu in the US and honestly we don’t even listen to PALS algorithms. I honestly think those guidelines are more useful for less sick patients”

“I’m gonna be honest I think something was lost in translation here, while I get people are trying to grasp at what you’re saying, that’s actually how medication errors occur. And it’s going to confuse you more if we’re guessing wrong. What we need to know is what the order was, so administer 2mg? Or administer 0.2mg Then we need to know how the drug was supplied, was it 2mg/ml or 10mg/ml. Then we need to know what the dilution was for, did they want 0.2/ml? And why, dilution isn’t common with a”

“A nurse had IVF infusing at 150ml/hr and regular insulin drip infusing at 2 units/hr. The nurse accidentally switched up the lines. Entire bag of insulin infused in less than an hour.”

“Gotcha. My hospital doesn’t have an “early warning sepsis” alert, seems like maybe that’s just anyone with a high WBC but I hadn’t seen it. They had told her to follow up with PCP if she was still concerned after she said her provider wasn’t handling her care well. Instead of furthering things and setting up an appointment with someone in their system they sent her home. The clinic with the provider who did her surgery delayed sending her abx ointment to the pharmacy and they suck in general. I”

“Exactly! Only when in the ICU 🤣or running pressors in ER hahah. If I had to do q15 on all my sepsis alert patients I would never get anything else done”

“Right. Which is why I was confused when they triggered protocol and did a 1000mL bolus. Our ED docs are hesitant to even do a 500mL bolus for anything unless hypotensive.”

“Epic seems to ask me via pop up ads if I’d like to initiate SIRS protocol constantly on patients that are no where near sepsis. It seems to be as sensitive as like HR above 100 and/or temp above seemingly 99, even before labs result. A nurse probably just hit “yes” to the pop up asking if they would like to initiate SIRS protocol or something.”

Yeah q15 is pretty excessive.

“Is doing a partial sepsis protocol normal in the ER or is a complete protocol always required? When do you guys usually trigger sepsis protocol and when do you not? I’m an ICU nurse but have zero experience in ER when it comes to how you guys make decisions to discharge or admit if not all signs of sepsis are there. My hospital protocol requires Lactic, Cultures, Abx, 500-1500mL bolus, and q15 vitals. I’ve actually wondered this recently but now am more curious as it involves my friend who went”

“I don’t know too much about Zosyn and EBV to say anything much but my question is, what’s the risk vs. Benefit of giving zosyn to such patients? Because it would have passed the pharmacists’s check right? There’s a ton of interactions between medications that people take daily and if the pharmacists avoid dispensing them together just due to “potential risk” people would not be able to take medications for all the conditions they have and would have to pick and choose. If there’s a risk for rash”

“Never felt so powerless in ICU than with really sick COVID patients. Best I could do was titrate O2 by a couple of points and watch them deteriorate as you said. Give them steroids, give them antibiotics, wash them, oral care, reposition and feed them. On the other hand, they were "easy" to look after because there wasn't much to be done. Truly ill MOF patients are way busier.”

“I have an 80 year old male who I recently admitted to home health. He has been through the constant cycle of SNF to HH to OP. He originally didn't want HH after his most recent SNF stay because he feels like he doesn't think home health makes him stronger and he is ready for outpatient already (even though he did fall during the SOC and I had to catch him). Pmh includes chronic SCI with sacral involvement, incontinence of B/B, CHF, TYPE II DM, alcoholic cirrhosis, asthma. Walks with a ro”

“I need to work out a diet prescription for a pt with AOCKD. The protein restriction is difficult enough to work with, but I managed. I have *no idea* how I'm meant to meet the increased CHO requirement with his fluid restriction. If I use the guideline of "output + 500 to 750ml", his fluid allowance is 1250ml, but he's receiving 1000ml IV fluids. I thought I could give him more sugar with fruit juice or something, but that's not an option now. I'm stumped. Any advice? N”

“As a new grad ER nurse, I've been taught to administer antibiotics for sepsis one at a time, and give the fastest running infusion first. I wanted to come online and see if this was truly best practice? submitted by /u/HurryObjective3375 [link] [comments]”

“Received an outside calcium score fax from a cardiology NP that said, "Liver mass - notify PCP". No phone call, no nurse message, no contact other than document faxed that thankfully ended up in my box. Am I insane for this really upsetting me? In my opinion, this is lazy, dangerous medicine. No provider is above picking up the phone and calling me over something like this. I rarely do this, but I called the patient and said, "I don't care how much you like this provider, we&#”

“Hi everyone. I have a family member who has been living with a very serious gastrointestinal illness for the past few years. He has been in and out of the hospital and received a number of treatments, but nothing has really been working for him. Recently he has spent months continuously in the hospital. Although he has a great team of doctors around him, they seem genuinely baffled by why nothing has worked to restore some of his health, and they told us he's in the 1% of non-responders. I l”

This is a situation where ultrasound is super helpful.

“Nashville and med errors…again submitted by /u/cpweisbrod [link] [comments]”

“The best analogy I have for watching nursing titrate morphine for dyspnea according to some dumb slow protocol is it's like someone actively drowning while you just stand there and watch. I intervened once and ordered nursing to skip one of the titration steps to get to a higher morphine infusion rate/bolus dosing sooner, and I'm glad I did. My patient kept having really forceful agonal gasps even after we skipped the hour of titration it would have required. I wish I had intervened a li”

“Only time I see this actually being a concern is when I have people that just aren't healing anymore and are already leaking from every venipuncture and third spacing terribly. Then at that point youve got bigger fish to fry”

“Devil's in the details. How long ago did the AC IV get taken out? What needs to run? If you flush the hand/forearm IV hard, do you have any leakage at the old IV site? I had an ED admit come up with levo at 30 and vaso at 0.04 running into a forearm vein that was leaking right out of an AC IV site they had just taken out... He wasn't getting the pressor and it was all going straight to his arm. So in that situation, no good. But if it's just fluids, the old IV came out yesterday, and”

“I’m at a Pedi CCU and was about to say the same. I know some kids post-Fontan or post-op where their goal is just greater than 70% or 75-85% still and they are straight chilling for years”

“She’s the sweetest - diagnosed with colangiohepatitis at 1 yr upon routine bloodwork for spay (asymptomatic).Has been on immunosuppressive therapy- mycophenolate q 12hrs since 7/24/26 (Vomitting/diarrhea and Hasn’t taken food or water in 48 hours. ER vet visit yesterday with xray imaging - discharged with vitals WNL. Xray of chest/abdomen revealed “nothing”. Still lethargic today. Regular vet saw ER report, called, I reported has not taken food or water. Advised to return to ER. Returned to ER -”

Could be back ordered meds.

“I’m hoping some PACU nurses can give me their perspective on how this type of situation is generally handled at their facilities. I’m not asking for a diagnosis, medical advice, or whether anyone did anything wrong. I already have my treating physicians for that. I recently obtained my complete hospital record after an unexpected postoperative complication, and reading the PACU documentation made me curious about normal PACU-to-floor practices. I had a two-level C5-C6/C6-C7 cervical disc replace”

“I have a patient who is 12 weeks out from radial head replacement and LCL repair but I feel like we have hit a wall with ROM. She is stuck at ~20 extension lag. If I really crank I can maybe get 15 but I don’t see the point to cause her severe pain for such a short term improvement in ROM. Elbow extension over pressure just leads to compensation at the shoulder so it’s hard to stabilize Is there something I’m missing? Is it just a slow heal? Im doing prox and distal radioulnar mobs, humeroulnar”

“I'm a nurse, and a lot of the standard order sets for our patients come with a set of default parameters around when to notify the provider that I typically sort of ignore because I assume that clogging up your inbox with a bunch of messages every time there's a vital sign or blood sugar check thats slightly abnormal but asymptomatic, unchanged, or not clinically urgent seems annoying and distracting, and I feel fairly confident i exercise good judgement when it comes to VS notification.”

“If you have a medication on your formulary but it requires PA, is the pt able to see the clinical criteria used to determine approval? In the past I thought an individual reviewed it with their "medical judgement" but my understanding now is there is written clinical guidelines used. Are pts able (and more importantly, legally entitled) to see this prior to submitting a PA (or receiving a denial)? The PA process takes time with back and forth and it would be nice to have the clinical i”