iiinova — where your digital self keeps evolving

Josh Trebach, MD @jtrebach.bsky.social · 22/09/2026

don’t make fun of neurologists until you walk a myelin their shoes

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Josh Trebach, MD @jtrebach.bsky.social · 06/09/2026

sadly this is not the worst cpr i have seen

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Josh Trebach, MD @jtrebach.bsky.social · 01/09/2026

didn’t think I needed to say this but epipens do not contain beta blockers and this home brew “allergy kit” is not a substitute for an actual epipen

Post that says: AN EMT taught me a secret many years ago.
An epipen is medicine that includes both types of beta blockers designed for rapid release.
You can make your own allergy kit at home.
Take Benadryl, and Pepcid AC with a glass of water that has had a small amount of Epson salt dissolved.
This cocktail works just as well as an epipen and costs almost nothing.

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Josh Trebach, MD @jtrebach.bsky.social · 24/08/2026

As an ER doctor I hate these e-bikes… Please wear a helmet Don’t drink alcohol and e-bike Don’t carry a baby while riding an e-bike Don’t e-bike after taking your blood thinners and reminiscing about your last hip fracture

Graph titled Estimated e-bike injuries treated in U.S. emergency rooms, 2020-2025
National estimates extrapolated from the CPSC NEISS hospital sample.

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Josh Trebach, MD @jtrebach.bsky.social · 17/07/2026

Reposting this thread now that people are studying for tox boards and other tests!!! Good luck :)

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Josh Trebach, MD @jtrebach.bsky.social · 26/06/2026

I’m worried about ur methodology

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Josh Trebach, MD @jtrebach.bsky.social · 26/06/2026

stop telling yourself you deserve a sensitive man you deserve a sensitive AND specific man

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Josh Trebach, MD @jtrebach.bsky.social · 14/06/2026

If the human body was an amusement park would the nephron or the semicircular canals be a better rollercoaster

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Josh Trebach, MD @jtrebach.bsky.social · 02/06/2026

friendly reminder that sometimes your patient isn’t “confused” or “altered” or “demented” they literally just need their hearing aids

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Josh Trebach, MD @jtrebach.bsky.social · 27/04/2026

currently in the phase of my life where all my shirts need texture

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Josh Trebach, MD @jtrebach.bsky.social · 21/04/2026

one time in med school I asked a doctor for feedback and he told me that I was stapling the patient lists together with the staple in the incorrect orientation and that a diagonal staple was not appropriate and it needed to be a horizontal staple so I laughed but he did not laugh

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Josh Trebach, MD @jtrebach.bsky.social · 08/04/2026

one time in med school we learned about a disease that gives you silver stools and I was like “woah I wonder what that looks like” so I googled it and idk what I was expecting

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Josh Trebach, MD @jtrebach.bsky.social · 20/03/2026

Thank you I like to think it was a graceful tumble

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Josh Trebach, MD @jtrebach.bsky.social · 20/03/2026

we joke in the ER that “chief complaints come in threes” so after two people came in after slipping/falling on ice i was like “okay who’s next” but a third never came in anyways i got off shift, walked to my car, and i

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Josh Trebach, MD @jtrebach.bsky.social · 03/03/2026

*be me in airport* me: person: hi Dr Trebach me: oh hey (who is this person? are they a patient? a student? why can’t I remember? Omg I’ve been thinking too long now it’s getting uncomfo—) person: u dropped this *hands me my hospital badge that says Dr Trebach*

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Josh Trebach, MD @jtrebach.bsky.social · 11/02/2026

it kind of sucks that you can randomly dislocate your jaw from yawning and then you have to go to the ER so we can pop it back into place

Skull drawing showing anterior dislocation of mandible

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Josh Trebach, MD @jtrebach.bsky.social · 23/01/2026

got a space heater and I was like “omg it’s so cute its saying hi to us!!” and my husband was like “no u doofus that is the power setting” 🙃

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Josh Trebach, MD @jtrebach.bsky.social · 17/01/2026

nothing will betray you faster than the front shirt pocket of hospital scrubs one lean forward and your pens and dignity end up on the floor

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Josh Trebach, MD @jtrebach.bsky.social · 09/01/2026

ER doc here. I’ve seen patients walk out during heart attacks and other life-threatening emergencies because no one could feed their pets at home. Imagine the lives saved if free emergency pet care existed.

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

I'll wrap this up here so I don't keep rambling--thanks for reading everyone. If you are concerned about yourself/someone, please call 911/go to the nearest hospital (pls do not dm/email me asking for medical advice).

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

(cont.) Good supportive care is key. Acute withdrawal from the opioids should be managed the same way you would normally manage opioid withdrawal (ie, meds like buprenorphine). Medetomidine withdrawal may require introduction of alpha 2 agonists like clonidine to help manage.

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

HOW DO CLINICIANS TREAT WITHDRAWAL FROM OPIOID/MEDETOMIDINE? I recommend consulting with tox/poison center/addiction medicine. There's good data on opioid withdrawal treatment, but medetomidine withdrawal has less data and would benefit from expert involvement (see next tweet)

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

CAN YOU WITHDRAW FROM BOTH OPIOIDS & MEDETOMIDINE? People can withdraw from opioids which can be incredibly awful to go through. One can withdraw from medetomidine as well and experience effects like tachycardia and encephalopathy. Going through both withdrawals would be awful

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

TREATMENT FOR OPIOID/MEDETOMIDINE TOXICITY? For clinicians, treatment = supportive (protect airway, address hypotension with fluids & pressors if needed, etc), give naloxone if concern for opioid toxidrome present/respiratory depression. Calling poison control/tox is recommended

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

WHAT HAPPENS WHEN SOMEONE USES OPIOIDS + MEDETOMIDINE? Medetomidine = sedation, bradycardias, hypotension. Some data show hallucinations. Opioids = sedation, bradycardias, hypotension, and life-threatening respiratory depression. Together these are a dangerous combination

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

CAN YOU TEST SOMEONE FOR MEDETOMIDINE? Yeah you can do testing to look for medetomidine/metabolite of medetomidine but it’s certainly not a routine test that is quickly done. Usually it would be a test that a hospital would have to send out to specific lab.

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

WOULD SOMEONE KNOW IF THEIR OPIOIDS HAS MEDETOMIDINE IN IT? There’s no data (to my knowledge) that says medetomidine has a certain taste/smell/appearance. People may feel their normal opioid hit them harder (or cause hallucinations?) and it may lead to a new withdrawal state

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

WHY IS MEDETOMIDINE IN THE ILLICIT OPIOID SUPPLY? Not entirely clear, but possibly bc it can be used to mimic sedative effects of opioids (e.g., fentanyl) while reducing cost for suppliers. There's also market/cost factors $$$$$. Also its high potency may make it appealing

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

SO DOES THE LEVOMEDETOMIDINE DO ANYTHING? Short version: eh Long version: the data we have shows that it doesn’t seem to be cause any effects in dogs/rats at decent dosing; however, there may be some human cell/receptor interactions in some data (PMID 9584224)?

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

WAIT ISN’T DEXMEDETOMIDINE A HUMAN DRUG? Ya there’s a drug called Precedex (dexmedetomidine) that is used in humans for sedation. It does not contain levomedetomidine.

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

WHAT IS MEDETOMIDINE? Medetomidine is a veterinary anesthetic medication. It’s composed of two different types of molecules called enantiomers: dexmedetomidine and levomedetomidine. The dexmedetomidine is the active component and is an alpha 2 adrenergic agonist.

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Josh Trebach, MD @jtrebach.bsky.social · 15/12/2025

Hi, medical toxicologist/ER doctor here 👋 here’s what you need to know about medetomidine in the illicit opioid supply

New York Times headline: A Powerful New Drug Is Creating a 'Withdrawal Crisis' in Philadelphia
Medetomidine, a veterinary sedative, mixed into fentanyl has sent thousands to hospitals, not only for overdose but for life-threatening withdrawal. It is spreading to other cities.

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Josh Trebach, MD @jtrebach.bsky.social · 07/11/2025

one time I was driving home and I saw a small crowd around someone who looked dead so I pulled my car over and checked for a pulse and then started cpr on the sidewalk and while I was doing cpr a bystander tried to STEAL MY CAR KEYS

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Josh Trebach, MD @jtrebach.bsky.social · 03/11/2025

nurse: doctor josh can you please tell my son that he shouldn’t eat too much candy me: ugh yeah one time I ate so much sour candy that my tongue started peeling it was soooo painful nurse: oh wow how old were you me: …….yesterday

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Josh Trebach, MD @jtrebach.bsky.social · 27/10/2025

one time in college I took an exam thinking “wow this is way harder than I expected” and the professor walked by and gasped because she’d given me (AND ONLY ME??) an exam from a different course. Every hard exam since I was like IS IT HAPPENING AGAIN? IT CAN’T HAPPEN TWICE RIGHT?

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Josh Trebach, MD @jtrebach.bsky.social · 22/10/2025

people named barb are so lucky because they can be like “my name is short for phenobarbital” and no one can argue with them

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Josh Trebach, MD @jtrebach.bsky.social · 18/10/2025

didn’t think this needed to be said but please don’t put urine in your eyes

Social media post where someone is describing putting urine in their eyes and then having their eyes get red and have pus

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Josh Trebach, MD @jtrebach.bsky.social · 16/10/2025

I became an attending and work somewhere else now!! My mysterious cookie benefactor did not follow me hehe

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Josh Trebach, MD @jtrebach.bsky.social · 16/10/2025

when I was a resident, a mysterious ER nurse used to leave a cookie on my desk after I did a good job with a sick patient. Years later, no cookies appear…but after every resuscitation I still crave one….a Pavlovian echo of a kindness that never quite left me 🍪

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Josh Trebach, MD @jtrebach.bsky.social · 02/10/2025

*be me in med school* me: ok remember these 3 words—book, cat, potato. I’ll ask again in 5 min to test your memory patient: ok *5min later* patient: book, cat…uhhh…what was the third one? me: ……. patient: did u forget too me: …………yeah

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Josh Trebach, MD @jtrebach.bsky.social · 01/10/2025

just Bucket (orange) and Pebble (grey) being gamer kitties

Orange cat and grey cat on top of Simpsons arcade cabinet

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Josh Trebach, MD @jtrebach.bsky.social · 23/09/2025

Happy birthday omgggggg!!!! 🎉

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Josh Trebach, MD @jtrebach.bsky.social · 21/09/2025

*me working in pediatrics ER* kid: do u play video games kid’s dad: he’s a doctor of course he doesn’t play video games me:

Marge looking concerned and then Marge covering her mouth while smiling

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