iiinova — where your digital self keeps evolving

Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 13/04/2025

It’s the person I sometimes think I am, but in reality I try to have positive energy at every patient encounter

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 13/04/2025

I love it lol - also it’s exactly what I wear on shift 😍

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Reposted by Joshua Niforatos, MD, MTS

Justin Morgenstern @first10em.bsky.social · 12/02/2025

CJEM debate: clinical decision rules–thinking beyond the algorithm link.springer.com/article/10.1... We need to think deeply about how we use decision rules in medicine Thank you so much @emlitofnote.bsky.social @lwestafer.bsky.social @reverendofdoubt.bsky.social for joining me in this debate

link.springer.com

CJEM debate: clinical decision rules–thinking beyond the algorithm - Canadian Journal of Emergency Medicine

Canadian Journal of Emergency Medicine -

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 31/03/2025

for the oncologists out there: which types of presumed new cancer diagnoses (non-liquid tumors) found in the ED require expedited inpatient work-ups vs outpatient referrals? i.e.: time from diagnosis to therapy is critical?

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 04/02/2025

Apparently the fad of using propensity matching is switching to the new fad of target trial emulation, regardless of the quality of data.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 04/02/2025

The fact that this paper got so much press despite its profound limitations and really not adding anything to the literature is more of a testament of how physicians have no research background or ability to interpret the academic literature pubmed.ncbi.nlm.nih.gov/39173173/

pubmed.ncbi.nlm.nih.gov

Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients - PubMed

Rationale: Uncertainty remains regarding the risks associated with single-dose use of etomidate. Objectives: To assess the use of etomidate in critically ill patients and compare o...

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Reposted by Joshua Niforatos, MD, MTS

Deandre.King2.0 @doctororbust.bsky.social · 30/01/2025

When EM has to absorb all of the social failings of society it’s going to lead to long wait times.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 30/01/2025

I’m 100% convinced that until hospital reimbursement is tied to ED boarding times, no meaningful changes will occur.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 30/01/2025

It ain’t easy… :( www.cbsnews.com/baltimore/ne...

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 15/01/2025

Whenever I hear "tox/metabolic etiology,"... you should be able to identify the toxidrome or metabolic derangement causing [insert X] condition...

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 08/01/2025

A total of 2.5 hours of shoveling my driveway over the last two days and my entire body hurts

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 03/01/2025

I wish someone would’ve told me as a medical student and as a resent that working your @$$ off for years with dozens and dozens of first author publications (study design, data analysis, writing, presentations) means nothing at the early career level … I would’ve done things differently.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 01/01/2025

the authors do mention important limitations, especially how acute/emergent some of the diagnoses might actually be; regardless, worth a read

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 01/01/2025

This editorial by J. Broder on imaging utilization in the ED is the best piece I've ever read on the topic: when there are no CDRs for abdominal pain, no time to see patients, unreliable exam findings, high rates of (+) imaging, expectations of "zero miss culture" pubmed.ncbi.nlm.nih.gov/39487590/

media.tenor.com

a man standing in a parking lot with the words " what the hell am i supposed to do " above him

ALT: a man standing in a parking lot with the words " what the hell am i supposed to do " above him

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 01/01/2025

New paper from Johns Hopkins (radiology/EM) questioning the use of "age over 65" for C spine imaging in trauma patients Of 9455 CTs performed in pts ≥ 65, 192 (2.0%) fractures were identified (113 females); 28 (0.30%) were in asymptomatic pts pubmed.ncbi.nlm.nih.gov/38940447/#:~...

pubmed.ncbi.nlm.nih.gov

Is older age an appropriate criterion alone for ordering cervical spine computed tomography after trauma - PubMed

Cervical spine fractures in posttrauma patients ≥ 65 years are uncommon, with the lowest incidence in those 65 to 70 years old. Excluding asymptomatic individuals aged 65-70 from routine CSCT presents...

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 25/12/2024

Oh for sure!!! Decent literature showing practice variation across numerous specialties I think looking at low value admissions is a very worthwhile endeavor — and every ED doc knows at their shop who the people are that admit and scan everyone :)

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

But I think that’s not the point because admissions are to reduce morbidity and mortality, and that’s hard to study.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

I think the elephant in the room if we’re going to say that all these admits don’t change morality is… what is the point then of GIM / hospital medicine?

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

I guess the thing that needs to be addressed is why did over 80% require greater than 24 hour stay? But that’s the point- the question is one of indication, not mortality. The former is harder to study but is what the relevant question is. Very few things influence mortality in medicine.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

I think this study has a lot of issues and likely doesn’t capture the SDoH involved with caring for patients in a VA ED, at least based on my experience. Also the admit rate of 41.2% or CP, SOB, Abd pain tells me something isn’t being captured.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

That’s not the central question. The central question is: By how much does the propensity to admit patients vary across physicians within a given emergency department (ED). And there are many reasons for admission, many that improve morbidity and not mortality

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

the other question is: were admissions indicated? mortality is very rare event and not the sole or even the reason for admission. For patient's DC'd w/in 24h, what was the ED census that day? Was their boarding? Sometimes when there's ED boarding, admissions are necessary if inpatient has beds.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

If you publish a JAMA IM paper and make these conclusions, you at least need to do it correctly from a research perspective if the goal is to ascertain "provider practice variation".

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Reposted by Joshua Niforatos, MD, MTS

Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

This concerns me. A 2015 paper showed that < 50% of VA ED physicians were board certified EM physicians... I did a quick skim of the paper, and they did not break it down by IM vs EM, unless I missed it... which is a HUGE problem for this paper.... pubmed.ncbi.nlm.nih.gov/25936477/

pubmed.ncbi.nlm.nih.gov

Emergency medicine in the Veterans Health Administration-results from a nationwide survey - PubMed

Veterans Health Administration emergency physicians have primarily clinical responsibilities, and less than half have formal emergency medicine board certification. Despite most VHA EDs having univers...

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

pubmed.ncbi.nlm.nih.gov

Emergency medicine in the Veterans Health Administration-results from a nationwide survey - PubMed

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

I think the idea that admissions are to solely reduce mortality doesn’t make any sense tbh…. sure, sometimes an admission may do that. The real question is: was the admission indicated or not indicated. Haven’t read the paper yet but… did it stratify by IM and EM docs in the ED?

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 24/12/2024

Did you stratify by EM and IM physicians too? Lots of IM docs work in the VA ED. Mostly curious if there was a difference.

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Reposted by Joshua Niforatos, MD, MTS

Jonathan Howard @joho.bsky.social · 11/12/2024

Part of being anti-RFK Jr. is calling out doctors who spread pro-RFK Jr. propaganda. If you partner with and/or support these doctors in any way, you are enabling RFK Jr no matter what you say about him yourself. Sorry.

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Reposted by Joshua Niforatos, MD, MTS

Peter Morley ♿️ @petermorley.bsky.social · 14/12/2024

Never underestimate the POWER of a Vaccine Scientist. If RFK Jr. is voted DOWN for head of HHS (and he should NOT be confirmed), it's not because of Congress, it will be because people like Dr. Peter Hotez spoke out.🙏💜

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Reposted by Joshua Niforatos, MD, MTS

Nick Mark, MD @nickmark.bsky.social · 09/12/2024

#ADAPTtrial released & the results are interesting… Compared to SOC, Procalcitonin guided antibiotics in sepsis resulted in: - FEWER antibiotic days: 10.7 vs 9.8 (p=0.01) BUT - HIGHER 28 day mortality: 19.4% vs 20.9% (p=0.02) though this did not meet the pre-specified non-inferiority margin 🤔 1/

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Reposted by Joshua Niforatos, MD, MTS

CJ Ciaramella @cjciaramella.bsky.social · 08/12/2024

NYPD officials say a massive, citywide hunt for overtime pay is underway.

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 08/12/2024

EAST guidelines for ED thoracotomy were written in 2015. WTA (West) guidelines were just updated in 2024 and are presented below: Adult emergency resuscitative thoracotomy: A Western Trauma Association clinical decisions algorithm journals.lww.com/jtrauma/full...

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Reposted by Joshua Niforatos, MD, MTS

Austin Slaughter @austinslaughter.bsky.social · 05/12/2024

No, it's not. Musk and Ramaswamy wrote an op-ed saying they wanted to cut all programs with expired authorizations. That includes the programs in Rattner's list. www.cbsnews.com/news/musk-ra...

cbsnews.com

Musk and Ramaswamy say DOGE will target $500 billion in spending. Here's where they say they'll cut.

Billionaires Elon Musk and Vivek Ramaswamy say the Department of Government Efficiency has targets in mind for cost cutting.

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Reposted by Joshua Niforatos, MD, MTS

Ed @notdred.bsky.social · 05/12/2024

Eliminating the NIH is a particularly rich idea coming from a biotech billionaire whose companies literally specialize in scooping up other people’s inventions to commercialize them, good luck with that strategy Vivek

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Corrie Chumpitazi MD MS @pedisedationdoc.bsky.social · 03/12/2024

Monumental day for a bluesky debut with the opening of our new Pediatric Emergency Department #DukeChildren’s #PEM #pediatricreadiness

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Joshua Niforatos, MD, MTS @reverendofdoubt.bsky.social · 04/12/2024

Doctors commit their lives to improving the health of others, but who’s helping us improve our financial and career well-being? Enter Offcall, a new platform redefining what it means to care for physicians. I’m thrilled to participate in this and encourage you to sign up! www.offcall.com

offcall.com

Offcall: Elevating transparency, empowering physicians.

Our mission is to dramatically reverse burnout by improving the wealth and wellbeing of physicians.

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Reposted by Joshua Niforatos, MD, MTS

Graham Walker, MD @drgrahamwalker.com · 04/12/2024

So I'm finally allowed to tell you about what I've been working on for the past year: It's called Offcall. It's built by physicians for physicians, and we're starting with one of the biggest problems we've heard amongst physicians: salary and workplace transparency.

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