Divemedic

Practice Pearls

I have done previous posts on firefighting, brain injuries, and other things seen in my various lines of work. Response to these insights into how the sausage is made have been generally positive, so I figured I would toss out another one.

Ever since Florida legalized medical marijuana, those of us who work in the emergency department have seen an alarming uptick in people coming in with complaints of nonstop vomiting. If you ask, they will usually admit to you that they smoke marijuana. Those who won’t admit it always show it on toxicology screens.

The syndrome that is responsible for this is Cannabinoid Hyperemesis Syndrome, or CHS. This is a fairly new thing that has been becoming more and more of a thing since the legalization of marijuana has gained steam across the country.

How is it spotted?

It is reported in people who are frequent (more than once per week) users of cannabis for a year or more. The signs are pretty easy to spot:

  • The victims make a loud, very characteristic retching sound
  • Vomiting as often as 6 to 10 times per hour
  • History of frequent marijuana use within the past 24 hours and over the past year or more
  • Symptoms do not respond well to standard antiemetics (Zofran, Reglan, Compazine)
  • The person will seek out and even crave hot baths and showers for temporary relief, but as soon as the shower is over, the vomiting starts back up again
  • The symptoms ARE well controlled with psychoactive medications like Haldol
  • They will also admit that they have been having lower abdominal pain/cramps for weeks before they began vomiting.

CHS is often misdiagnosed as Cyclic Vomiting Syndrome, but note that CHS patients when questioned will tell you that they seek out hot water baths and/or showers for temporary relief of symptoms. CVS patients don’t get relief from hot bathing and showering.

Whenever I get a patient who complains of frequent bouts of vomiting, I always administer 8mg of Zofran (I have standing orders that I can give that to anyone over the age of 16 without asking the doctor) and order a urine drug screen. If the Zofran doesn’t work, I can be fairly sure that CHS is what we are looking at.

Then I ask them what they do to relieve their symptoms. They will always tell you that while they are in a hot bath or shower, they stop vomiting. Once we know for sure that they are cannabis users, I ask the doctor for an order for Haldol. I usually get it.

At the same time, we need to make sure that the frequent vomiting hasn’t been causing any mischief , so we will also do a CBC, a Comprehensive Metabolic Panel, and will also give them a liter of normal saline and possibly 2 grams of Magnesium sulfate. Expect to see elevated WBC counts in patients who have been vomiting for a while. Absent other signs of infection, this is an inflammatory response to the vomiting.

Depending on other factors found in the initial assessment, an abdominal CT with contrast, or even a head CT without contrast will also be ordered.

Prevalance

Since people are frequently dishonest about marijuana use, its impossible to know for sure, but among people who DO admit to frequent use of cannabis, between 35 and 45 percent report frequent vomiting. This is in line with my personal experience- nearly two thirds of those who come in with vomiting complaints test positive for weed, as opposed to about ten percent of general teen and adult patients.

No one is exactly sure what causes CHS. It is believed that, although cannabis calms the vomiting center in the hypothalamus, it also irritates the enteric nervous system. That theory also explains why hot bathing seems to give temporary relief, as the hypothalamus also controls body temperature.

The patients that I talk to admit to anything from “just one joint at night before I go to bed to help me sleep” all the way to “all day, every day. As many as 15 joints per day.” With edibles, I have had people say that they eat as many as 6 to 10 edible gummies per day. That’s a lot of weed.

Treatment

To stop them from vomiting, the administration of 5 mg of Haldol usually does the trick and will stop the vomiting for a few hours. Antiemetics, including Zofran and Reglan don’t work very well or at all. Even with Haldol, the next time they use, the vomiting will start right back up again. The only way to stop the vomiting on a permanent basis is for them to stop using cannabis. Within a day or two, the vomiting will stop.

The problem is that people who use marijuana don’t believe you and will continue to do so. You will see them again in a week or two. Rinse, repeat. There is also a myth that you can’t overdose on weed. We are finding out that this is not true. The more weed, the higher your odds of seeing me with your CHS. Left untreated, constant vomiting can be fatal by causing lethal electrolyte imbalances. The severe retching that comes with it can cause issues like a Mallory-Weiss tear.

*I have also heard that rubbing capsaicin cream on the abdomen provides the same temporary relief as hot showers, but I have no personal data or experience on that. I would assume that long term use of this method will become less and less effective over time.

By Divemedic, ago

Good

Colorado has proposed SB25-003, a law which would ban the manufacture, distribution, transfer, sale, and purchase of any semiautomatic firearm that has a detachable magazine, with the exception of .22 rimfire. First offense would be a misdemeanor, second offense a felony.

Exempt from this law is the government, colleges, and armed security guards that work for companies operating armored vehicles.

It also appears to establish a requirement to have a firearms license with required training that expires every 5 years and must be taught by a sheriff department approved instructor.

I hope this passes. This is so blatantly unconstitutional that there is no way it makes it through the courts.

By Divemedic, ago

Identity Theft

I have been the victim of identity theft a couple of times. A year ago, someone opened an online bank account using my information. I am sure that information had been obtained through one of the many data breaches that have happened in recent years. This episode was easy to clear up. Just call the bank in question, tell them that it was fraudulent, and it’s a done deal. Identity theft is so common nowadays, it’s become routine.

That wasn’t always the case. About 25 years ago, I was the victim of identity theft. I had just divorced my first wife and I needed a car, seeing as how she had gotten most everything in the divorce. I went to a small used car dealer, and it turns out that they were a bit, shall we say, shady. The finance manager had a scam going- he would file finance paperwork for several cars using the information of customers and by cutting and pasting their signatures onto multiple sales contracts. He would then take the checks for the car sales that had never actually happened. Since the dealer hadn’t sold those cars, they never missed the checks. He was also making money on the side by selling people’s financial information.

You can complain to the credit reporting agencies, but their investigations are a joke. In the end, it took me about two years to clear my name.

I solved it by becoming a pro se litigant. I sued several collection agencies and one fairly largish bank- SunTrust. I wasn’t greedy about it. Each entity I sued, I settled out of court for a few hundred dollars and for removing the credit line from my record. The Suntrust people were vindictive. They reported the “forgiven” loan to the IRS as income, and I wound up having to pay the IRS about 8 thousand dollars in taxes on the income when they subsequently audited me. I tried telling the IRS that my identity had been stolen, but back then it was such a new crime that they didn’t believe me.

Years later, SunTrust and their lawyers turned out to be just as shady and I wound up suing them half a dozen times with the mortgage scandal that caused my bankruptcy. It’s why I won’t do business with Truist to this day, that being the bank that SunTrust morphed into.

By Divemedic, ago

They Are Bums, not Unhoused

Florida requires counties to ban “camping” in areas that are not specifically designated for camping. Volusia has become the latest county to do so. The city of Orlando has arrested 25 people for this so far, which tells me that the law is going largely unenforced. I can drive through downtown Orlando and find 25 people violating this law in less than an hour.

The left hates it, complaining about how cruel it is:

While the ordinance cites the importance of protecting the “health, safety, welfare, quality of life, and aesthetics” of communities, per the state law, it makes no mention of any obligation to assist individuals or connect them to resources before applying enforcement measures.

Note that what the bleeding hearts fail to mention is that, while there is nothing in the law requiring that local governments assist these bums, there is also nothing in the law that prohibits helping them, either. It’s almost as if the left won’t do anything unless the law tells them to.

Still, I don’t care. I have a lot of experience dealing with the “unhoused” people that the left loves so much. They aren’t average people who fell on hard times. Overwhelmingly, these people have two problems:

  • Mental health issues
  • Drug addiction

We got rid of the mental hospitals, so now they live on the street. Bring back mental institutions and the problem is largely solved.

You will note that the homeless population DOESN’T include illegal immigrants. They are staying downtown at the Ritz.

By Divemedic, ago

Mindless

Here is what the left has to say about Europe, Russia, and Ukraine:

1. Europe Calls Putin’s Bluff

  • Macron and Scholz, backed by Poland, the Baltics, and Finland, make a historic decision: “Withdraw from Ukraine or we’re moving in.”
  • European forces begin massing in Poland, Finland, the Baltics, and Romania—fully armed, fully mobilized.
  • Putin shits his pants. But, of course, he threatens nukes, because that’s the only card he has left.
  • Europe responds: “Our nukes are locked and loaded, motherfucker.”
  • France and the UK together have around 500+ modern nuclear warheads, and their delivery systems outmatch Russia’s aging Soviet-era bullshit.
  • Reality check: Russia’s nukes? Aging, unstable, and probably not even fully functional. Meanwhile, Europe’s nukes are modern, precise, and READY.
  • Before Russia could even launch a full-scale attack, Moscow, St. Petersburg, and every major Russian military hub could be vaporized.

2. Putin Realizes He’s Cornered

  • Unlike dealing with the U.S., Putin suddenly faces an enemy that doesn’t give a fuck about “red lines.”
  • He tries to call China. China says: “Nah, we’re good.”
  • He turns to his generals. Some of them start looking for an escape plan.

3. What Happens in the U.S.?

  • MAGA Still Thinks It’s a ‘Liberal Hoax’
  • MAGA will believe whatever Trump tells them, and Trump will say: “Europe is acting reckless. We need to stay out of this. Russia’s not our problem.”
  • Fox News and right-wing media will blame Europe and call it a “deep state” NATO conspiracy.
  • Some MAGA morons will actually cheer for Putin.
  • The Military and Security Establishment Lose Their Shit
  • The Pentagon, CIA, and U.S. Generals will PANIC.
  • Because if Europe goes in and wins, it proves that they never needed the U.S. in the first place.
  • Europe goes in and nukes start flying
  • The U.S. gets dragged into WWIII no matter what Trump says.
  • Wall Street and the Economy Freak the Fuck Out
  • Markets CRASH.
  • Oil prices SKYROCKET.
  • The dollar tanks because nobody trusts the U.S. anymore.
  • Europe starts looking at China for financial stability.
  • The American Public Finally Wakes Up
  • Millions of Americans will realize that their country has become a joke on the global stage.
  • Anti-Trump protests erupt.
  • Independents and moderates start turning against him, realizing they’ve been gaslit by his “America First” bullshit.

So that is what the leftists who are analyzing this think is going to happen- they believe that Russian nuclear weapons are not going to work, and that Europe is going to win any nuclear war that happens, and once it is over, the US military and US people will turn on Trump and depose him. They are delusional.

By Divemedic, ago