Andrew Stolbach, MD, MPH
@toxicologist12
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Toxicologist. Emergency doctor. Teaching and learning about poisoning and overdose. Living in Baltimore City. @acmtmedtox Board of Directors @HopkinsMedicine
Baltimore
Joined September 2010
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Pinned Tweet
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Me:
You don’t need to tip your head back when you have a nosebleed
10 yo daughter:
My friends’s sister gets a lot of nosebleeds and she says that you should
Me:
I’m a doctor
10 yo:
Do you specialize in nosebleeds?
Me: [wtf]
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In medical school, they never teach you what to do when pizza delivery man arrives in ER waiting room with $200 of pizza ordered by a patient for an ER waiting room “pizza party.”
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When I was a medical student, another med student asked, “Why are we admitting this guy to psychiatry for hearing voices? Everyone hears voices all the time.”
I think about this a lot.
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Dermatologists hate the sun.
Pediatricians hate trampolines.
ENTs hate Q-tips.
What is the mortal enemy of other specialties?
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Patients, if your nurse:
-introduces herself as your doctor
-uses the word “doctor” before her name
-has ID badge with MD or DO after her name
-wears white coat
-uses word “doctor” to describe herself one more time before leaving room
She’s not your nurse.
She’s your doctor.
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If you have a nosebleed:
1: Pinch both nostrils together firmly (just enough to stop bleeding)
2: Keep your head neutral or slightly forward
3: Hold CONSTANTLY for 5 minutes. (No peaking)
4: It hasn’t been 5 minutes yet.
5: If that didn’t work, back to 1
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YOU CAN'T CATCH A COLD FROM GOING OUTSIDE IN THE COLD.
YOU CAN'T CATCH A COLD FROM GETTING YOUR HEAD WET.
YOU CAN'T CATCH A COLD FROM BEING COLD.
YOU CATCH A COLD FROM A VIRUS.
(Wash your hands.)
Sincerely,
Doctors
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I have two speeds of responding to your email:
1) Within 7 seconds
2) Never
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A graduating resident borrowed my pen on shift yesterday and didn’t return it. I’m so proud. She is ready to be an attending. I have nothing left to teach her.
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Guy at gym: Do you do keto?
Me: Yes, my body makes ketones when ATP demand cannot be met by readily available carbohydrate and my NAD/NADH ratio shifts to favor production of ketone bodies.
Guy at gym:
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If you’re not on blood thinners, the above method almost always works. If you can’t stop it after 2 solid 5-minute tries, keep it pinched and call for medical help.
(And yes, even though I’ll never convince my kids, I am an expert 😂)
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14 yo: What is an “IV lounge?”
Me: People pay for intravenous fluids
14 yo: Can’t they just drink water?
Me: Yes
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Snowblower safety from your neighborhood ER doctor:
NEVER try to unjam a snowblower with your hand.
Even if it is turned off!
The jammed blade may be under tension and have an extra turn left in it.
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(Ugh excuse the peaking/peeking typo. I’m not a spelling expert)
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When resident says:
“Our intoxicated patient urinated in the sink”
I hear:
“Patient ambulating independently”
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My fellow attendings:
When a medical student tells you they are excited about the specialty they have chosen, the only acceptable thing to say is, “Great choice!”
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To work in a hospital, one thing you have to learn:
How to grab ringing phone from pocket of someone doing a procedure in a way that it’s clear that you’re not trying to grope them.
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Spin instructor:
That burning in your legs is lactic acidosis!
Me [struggling for breath]: Actually lactate <gasp> and pyruvate <gasp> have similar pka. The <gasp> condition <gasp> is better <gasp> described as <gasp> hyperlactatemia <gasp> with <gasp> acidosis.
Everyone else:
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ER Doctors:
We must use the highest level of available scientific evidence to guide our practice.
Also ER Doctors:
Omg it’s Friday the 13th and tonight will be crazy.
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No one, in 15+ my years working in the ER, has ever told me they came to the ER because it's Monday.
And yet, Monday is always the busiest day in every ER, all throughout the country. There are 25-50% more ER visits on Monday than on Sunday.
People are fascinating.
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Young resident just said the troponin elevation was “mid”
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Me: Is the patient using any drugs?
Trainee: No. They are incarcerated.
Oh, my sweet summer child.
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I’m seeing ads for drinks with “no booze” that intoxicate you with the active ingredient 1,3 butanediol.
Reminder: 1,3 butanediol is, from a chemistry standpoint, an *alcohol*. (A diol because it has 2 -OH groups.)
This is “booze” by another name.
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Medical student:
The patient has an oxygen requirement.
My Brain:
Don’t say it.
Don’t say it.
Don’t say it.
Don’t say it.
Don’t say it.
Don’t say it.
Don’t say it.
Don’t say it.
Don’t say it.
Me:
Actually, everyone has an oxygen requirement.
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Dear Patients,
Taking care of you is an honor and a privilege.
Also, please don’t talk when the stethoscope is touching you.
Thanks,
Me
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4th-year resident, after presenting plan for patient:
“But I’m just a resident, what do you think we should do?”
Me:
“I literally found out about this disease the same day as you.”
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Me: So, what’s going on?
New Patient: I was hoping you could tell me.
Me: I mean, what brought you to the ER today?
New Patient: The ambulance.
Me:
New Patient:
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I just realized that that the name “Moderna” comes from “mRNA.”
Just wanted you all to know I’m the last to figure it out.
Carry on.
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Me: What brought you to the hospital?
Patient: The ambulance.
Me: Ok. Let me ask you this way: How do you feel?
Patient: With my fingers.
Me: You win this round.
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Me:
I think he has Guillain-Barrè
Neurologist:
I think you mean to say “Guillain-Barré”
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Differential diagnosis:
1. fishhook
2. in
3. the
4. eye
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I will die on this hill:
High blood pressure didn’t cause your headache.
Your headache raised your blood pressure.
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Child development question:
At what age can kids properly close a box of cereal?
20 years?
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The best part about pediatrics is the kids who say “heartbeep.”
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Other toxicologists are going to hate me for telling you this secret, but nothing will happen if you eat this packet.
That doesn't mean you should eat it.
(Seriously, don't eat it.)
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Question:
What is the craziest thing you see in the ER?
Answer:
We live in the richest country in the world *ever* and we don’t provide universal basic health care.
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When a pharmacist accept a job at a hospital, they surrender their prior identity and their name changes to
“Pharmacy”
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Me:
[Explains laboratory tests to patient in detail.]
Do you have any questions?
Patient:
Are teeth bones?
Me:
I don’t think so.
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Fentanyl doesn't easily aerosolize, even when we want it to!
I just reviewed two papers where it was nebulized in regular form and then a special lipid encapsulated form.
Bioavailability was a paltry 10-15%.
You won't accidentally inhale fentanyl by being adjacent to it.
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Before wearing your festive Halloween outfit to work in the ER, ask yourself:
Is this what you want to be wearing when you tell someone their family member died?
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Flashback to my 2nd year of medical school:
I asked the attending, “What’s the differential diagnosis?” and he responded, “You tell me.”
[But I was literally asking for the definition of the term “differential diagnosis”]
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Medical student:
Do you ever get used to that smell?
Me:
What smell?
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Can you get high from nutmeg?
Yes*
*(Most people don’t describe the high as very pleasant and it lasts waaaay longer than you want it to)
A short nutmeg hallucination thread...
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My mom says I was a “colicky” baby until the pediatrician prescribed Donnatal (phenobarbital and belladonna).
I think about this a lot.
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I use my liver and kidneys to detoxify my blood. It’s free.
Missed yesterday's
#webinar
on the importance of
#detoxification
, and which foods and
#supplements
can do the trick? It's available in our online archives now:
#Chiropractic
#detox
#nutrition
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Ask your patient,
"What were you hoping we could do for you today?"
For those cases when you take a history and still aren't sure why they came to the hospital, the answer may be illuminating. (Basically, a really nice way of asking, "Why are you here?")
#TipsForNewDocs
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I am a toxicologist with nothing to sell you.
My medical advice: Exercise, avoid tobacco, eat veggies, and don't panic over trace chemicals in your food.
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If your hospital coworker tells you that you have “big muscles,” they are about to ask for help lifting/moving a patient.
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Condiments drawer in the staff break room at a major Baltimore hospital.
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You know you are having a good ER shift when your Apple Watch asks if you are working out.
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Guaifenesin has entered the chat
People are mad over phenylephrine being sold when it does virtually nothing, just wait until they find out about Docusate 😂
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Attention patients and families:
I’m sorry your IV is making that beeping sound.
I could press a button to silence it for (maybe) 7 seconds, but I have no idea how to actually solve the problem.
The nurse is the only person smart enough to fix it.
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Why does the patient‘s history seem to change from triage to resident to attending?
Because the history isn’t static; it’s a story patients discover as they tell it.
Each retelling is new draft of the story.
-
@JBaruchMD
, at HumanisEM Speaker Series
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I can’t say too much (patient confidentiality) but we had a busy shift last night at the Winterfell Emergency Department.
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Just got my 2020-21 flu shot.
This vintage has subtle H1N1 notes with hints of Hong Kong H3N2 and a long B/Washington/02/2019 finish.
Great value for the price.
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When our ED clinical pharmacist asks, “Do you think we should start X?” the answer is always “Yes, I do think that.”
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The tragic lesson here is that it’s risky to use sedative drugs when you’re in water, especially when you are alone.
Matthew Perry died from the acute effects of the drug ketamine, according to the results of an autopsy on the 54-year-old “Friends” actor.
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I signed in/out on the log, drank some water, and pulled myself together.
My score was fine, I graduated, got my first choice for residency, and lived happily ever after.
Anyway, I hope this story is inspirational to vomiters everywhere.
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I have seen a lot, but never an improvised sleep mask like the one this nurse made for her patient.
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My resident just said “Hashtag review of systems” in his patient presentation, in case you’re wondering about medical education in the era of social media.
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Right before you go under anesthesia for your surgery, remember that everyone else in the room is wearing pants they got out of a vending machine.
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Bummer. One applicant used this space to share a YouTube video showing him being shot into a lake using a giant catapult he built himself.
We ranked him to match.
Disappointed to confirm that the AAMC has removed the “Hobbies & Interests” field from the 2024 ERAS application. It might seem trivial, but that small field had value, and it’s going to make interviews less interesting and personal.
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Me:
You have something called "Lupus Anticoagulant", which means your blood is more likely to clot. And you don't have Lupus.
Patient:
That name makes no sense.
Me:
That name makes no sense.
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Looks like chlorine-
Greenish yellow
Heavier than air.
Expect bad lung injury, pulmonary edema
Crane drops tank with poisonous gas in Jordan's Aqaba port; at least 10 dead, 251 injured
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Orthopedics note recommends "aggressive elevation."
That's the most ortho thing ever.
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Am I the only one that excitedly tells patients when we share a birthday?
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My USMLE Step 2 🤮story:
I felt a stomach bug coming on the night before exam, but didn’t reschedule because I wanted to get it over with.
Midway through exam, I felt clammy, nauseated, and then sudden urge to vomit.
No time to raise my hand, sign out, get the bathroom key.
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Resident: How do you know the patient doesn’t have hypertensive urgency?
Me: Because there is no such thing as hypertensive urgency.
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What my dog thinks about your poison prevention rules.
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Patient told the med student that he hadn’t taken methamphetamine but the 3 people with him in the room had.
(The patient was alone.)
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Overrated- Lactate
Underrated- Respiratory rate
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We knew that St. John’s Wort induces CYP3A4, decreasing cyclosporine levels, possibly causing transplant organ rejection. Now it appears CBD can cause toxic levels from another transplant drug. Ask your transplant patients (and all patients) about “alternative medicine” products!
Fascinating report just out in
@amjtransplant
:
CBD increases tacrolimus concentrations **3-fold**, most likely via CYP3A4 inhibition.
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The US COVID-19 death toll surpassed 9/11 and will unfortunately continue to multiply. After the 2001 tragedy, we changed our foreign policy, spent trillions, and created a new cabinet-level agency.
Are we willing to invest and make bold choices to prevent the next pandemic?
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Winter pitfall: We had to cut the down jacket off of a trauma victim and there were feathers everywhere. It was like we were performing a resuscitation in a snow globe.
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If you don’t see me tweet for a few days it usually means I owe someone an email and I’m afraid they’re on this website.
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“Vital signs stable” is a completely acceptable way to describe vital signs that don’t require an intervention.
🙋♂️ What’s your unpopular opinion in medicine that will get you in this position?
#MedTwitter
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Roses are red
Methylene blue
Is reduced to leucomethylene blue, which reduces dysfunctional methemoglobin ferric iron back to ferrous state and sorry I'm a toxicologist not a poet and nature doesn’t have to rhyme to be beautiful
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The choice isn’t whether to get the vaccine or not to get the vaccine.
The choice is whether to get the vaccine or to get the virus.
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@DrEricBall
Now I need to know why they chose that shape.
All the others are readily identifiable symbols and have at least one plane of symmetry.
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My advice: put a sprinkle of nutmeg on your eggnog.
Try a dash on your coffee (with cinnamon.)
Don't use nutmeg as a hallucinogen.
Love,
A neighborhood toxicologist who cares
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Common “alcohol” is ethanol. Ethanol is 2 carbons and 1 -OH group.
Butanediol is 4 carbons and 2 -OH groups.
In general, the longer the carbon chain, the more intoxicating the alcohol.
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Toxicologist here.
You can't have both:
1) "Superhuman strength"
2) "Dying from fentanyl overdose"
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I love medical students because they ask,
"Why do we do it this way?"
and then I wonder,
"Why do we do it this way?"
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“Lactic acidosis” is incorrect because conversion of glucose to lactate is not acidifying and the increased proton production responsible for metabolic acidosis in hyperlactatemia results from ATP hydrolysis without ability to consume protons in oxidative phosphorylation
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My wife is running late for dinner tonight because of a meeting with the Director of CDC. That’s badass.
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Essential oils get their name because they are the “essence” or “extract” of various plant products.
Essential oils are not essential for your body, or even proven to help in any way.
They smell nice.
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I made a chart summarizing emergency medicine career options a few years ago. It still holds up.
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“The heart has no bones.”
That’s what the cardiologist said to me before asking an orthopedic question.
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As a toxicologist, emergency doctor, and parent, I am more worried about my kids being hurt by a backyard trampoline than by Roundup (glyphosate).
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Tingling of the fingers is a sign of hyperventilation and anxiety, not fentanyl.
Officers found a broken pill inside the car and one of them started to feel sick, numb and tingling in the fingers and hands.
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Myth:
It’s dangerous to fall asleep after a head injury, because you may not wake up.
Truth:
Sleeping isn’t harmful after a head injury. (And may help!)
If your injury was bad enough that you need serial neuro exams, you belong in a hospital.
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Elderly female patient points to single male resident on rounds.
“He is the handsomest of all of you.”
[The rest of us sheepishly nod.]
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I haven’t read the whole AHRQ paper, but I’m immediately suspicious when non-ER people opine on what doctors shouldn't have missed in the ER.
We’ve all seen plenty of cases where vague presentations become clear with time and the benefit of hindsight.
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