Proud parent moment - behold my 10.7x10.8x7.9cm liver haemangioma (fresh, and after fixation and slicing in pathology).

My squishy liver baby was delivered by hand assisted laparoscopic surgery, I am still in hospital and recovering well.

I have named it Haggis.

Clinical Indication: History of endometriosis

IMPRESSION:

Again noted is T2 hypointense thickening involving the uterine body, uterine ligaments, and uterosacral ligaments. These findings can be seen in deep pelvic endometriosis in appropriate clinical setting.

Again noted is a bicornuate uterus.

Middle compartment:

Torus uterinus (Uterine body): Plaque-like thickening involving the posterior right horn is again noted (series 5 image 30), slightly less conspicuous compared to prior.

Plaque-like T2 hypointense thickening involving the left uterine horn is also suggested, stable.

Fallopian tube: Normal

Uterine ligaments: T2 hypointense thickening is noted

Posterior compartment:

Uterosacral ligaments: Mild T2 hypointense thickening, left greater than right

Rectovaginal septum: Normal

Anterior rectal wall: Mild tethering is noted (series 5 image 22)

This image in axial view shows the rectal tethering the best, but does not clearly show the bicornuate uterus situation. I was referred for this repeat MRI after recurring painful bowel movements and abdominal pain 10 months post op from my first endometriosis surgery.

Was going through my pictures and found my family members imaging from 5-6 years ago. For context, I was a resident at the time. They called me with a sense of impending doom, so I told them to go to the ER.

• EKG showed minor ischemic changes and troponin was just a bit elevated.
• Got a heart catheterization that showed a subtotal occluded left main with relatively preserved coronaries otherwise. Definitely a butt clenching cath to look at. I was quite surprised his ECG did not look worse. They placed a balloon pump then got a 2-vessel bypass a day later.
• Did well post-operatively until they got acutely short of breath, hypotensive, and hypoxic in front of me. I thought they had a failed/thrombosed graft. At the ER, they quickly recognized RV failure and found a massive pulmonary embolism. The PE team was getting ready for a thrombectomy, but they unfortunately did not survive.

Just thought I'd share some bread and butter medical problems that should make anybody in healthcare get scared.

So, I'm a long time user of the same medicine and for the first time noticed that some pills in my pack look sketchy. The packaging, blister and everything looks perfect, but some of the pills have correct, but irregular imprinting. You can see in the picture for on pill it's way off, for one it's a bit off. The whole pack is like this.

Is this a quality issue and should be reported? I'm in Germany btw...

Extensive multifocal and confluent T1 hypointense plaque-like/nodular tissue throughout the peritoneal and mesenteric compartments, associated with marked bowel crowding, tethering, and multiple loculated cystic spaces.

Easy to miss these spots and mark them off as normal stool or gas but upon further cross sectional analysis of more imaging including a CT scan from a year prior shows these same signal voids.

35F over 10 years patient complained of deep burning hip pain, followed by ER visit in 2023 after sharp abdominal pain on left side. Diagnostic laparoscopy was finally done where endometriosis was found and ablation was done to treat some of the lesions.

2026 New surgical team findings: endometriosis in cul de sac and possible endometrioma on right ovary. Treatment was full hysterectomy and excision of endometriosis. Uterus sent to pathology.

HazMat-ish scene, you're the first arriving unit. You do it by the book: establish command, size-up, staging, callouts.

Working command for ten minutes. Then fire arrives. The battalion chief doesn't check in with you, just starts running the scene. Two questions.

Formally, by ICS rules: who is in command at this exact moment, and what has to happen for that to change? And practically: how does this actually go down in your system?

Fire, EMS, police turf stories welcome. We all have one. Breakdown tonight in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

A below-knee amputation, formally a transtibial amputation, removes the leg below the knee joint while preserving the knee itself. Keeping the knee matters a lot for the patient: walking with a prosthesis is far easier and less energy-demanding than after an above-knee amputation.

The most common indications are severe trauma, peripheral vascular disease (often with diabetes), infection that can't be controlled, and congenital limb deformities.

How it's done (details vary between surgeons, but the general sequence is similar):

Under anaesthesia, a curved or straight incision is made around the leg below the knee, and the surgeon dissects through skin, subcutaneous tissue and muscle to expose the tibia. The muscles are divided and retracted to get clear access to the bone.

The tibia is then cut with a saw – that's the step in this clip, with a metal shield protecting the soft tissues from the blade. The goal is a smooth, even bone end. Depending on the technique, the fibula is usually divided as well (typically a little shorter than the tibia), though some surgeons leave it in place to add stability to the stump.

The major vessels are ligated to control bleeding. The nerves are pulled down gently, cut and allowed to retract into the soft tissue, so the cut ends don't sit at the tip of the stump – an important step for reducing neuroma formation and residual limb pain.

Finally, muscle and skin are closed over the bone end to create a well-padded stump. The skin flaps (classically a long posterior flap, since the calf has a better blood supply) are planned before the first incision to make sure the bone is properly covered and to reduce the risk of wound complications.

Rehabilitation and prosthetic fitting follow, and that's where the patient gets their mobility back.

Follow-up to the earthquake post, since half the thread brought up JumpSTART. Here's where it earns its keep. 20-patient MCI. You get to a 7-year-old girl, not breathing. You reposition the airway and she starts breathing on her own, 26/min. Carotid pulse present, no radial. Doesn't follow commands, withdraws from pain. Tag her. And walk me through it, decision point by decision point, because this kid sits exactly on the lines where people go wrong in both directions. Some of you are about to black tag her. Some of you are about to call her yellow. Both camps, show your work.

Bonus: name the step in JumpSTART that doesn't exist in adult START at all, and why it's there.

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

(sorry if this has already been posted recently or if anything is wrong) Pediatric neurosurgeon Dr. Paul Grabb was astonished to discover a tiny foot growing inside the brain of three-day-old Sam Esquibel. It was initially thought to be either a teratoma (a congenital brain tumor composed of foreign tissue such as muscle, hair, or teeth) or a fetus-in-fetus, a developmental anomaly in which one fetal twin begins to form inside the other. Teratomas are rare congenital brain tumors, but finding one in such a complex shape (a foot) was unprecedented. The foot was discovered and surgically removed in 2008. The procedure was a success, and it was treated like any other teratoma.

This one is together with lock jaw right? Or is lock jaw just another name instead of like a Hallmark symptom?

16 cm left renal tumor. Open radical nephrectomy

Car hit at highway speed, everyone else walking around. Your patient is 5, properly restrained in a booster, awake and scared. Tachypneic, SpO2 89% on room air, visible bruising over the left chest, clearly increased work of breathing.

You auscultate: breath sounds equal and normal bilaterally. Chest wall stable, no crepitus, nothing to suggest broken ribs.

So, thread questions. What's your working diagnosis? Is the absence of rib fractures in this kid reassuring or the opposite? And there's one common ALS intervention you want to be stingy with on this call. Which one, and why?

Breakdown tomorrow in the comments.

Case adapted from the EMS Mastery (NREMT prep) question bank.

This patient's history includes:

▪️ Extensive oncologic resection
▪️ Tumor recurrence
▪️ Prior radiotherapy
▪️ A complex oro-orbital fistula
▪️ A major cardiac event managed with coronary stenting
▪️ Four previous free-flap reconstructions

Any one of these would make reconstruction harder. All of them together leave the surgeon working with distorted anatomy, scarred and irradiated tissue, recipient vessels that may be compromised, and far fewer options after four free flaps have already been used.

The next stage will depend on careful planning, a well-chosen recipient vessel, and a strategy that restores both function and appearance.

Case by @drbmoodie

35-year-old man, four years of progressive memory loss and cognitive decline, now needs round-the-clock care. Mini-Mental score is poor. No focal neurological deficits, gait is normal, nothing vascular on the workup.

Two more things from his chart. His face: flat nasal bridge, prominent epicanthal folds. And from his childhood: surgery on his duodenum as an infant.

Three questions for the thread: what's the underlying condition, why is he demented at 35 when this disease usually waits decades longer, and what will his cortex look like under the microscope?

The duodenal surgery is not a red herring. It's the second clue.

Case adapted from the USMLE Mastery (Step 1 prep) question bank.

Mass casualty, resources are what you carry. Four patients in front of you:

Patient W, young adult. Walking around, minor abrasions, sprained ankle, asking if he can help.

Patient X, adult. Conscious, compound fracture of the forearm, bleeding heavily.

Patient Y, a kid. Semi-conscious, severe respiratory distress, possible spinal injury.

Patient Z, elderly. Unconscious, multiple fractures, not breathing.

Tag all four. And before you give anyone the black one: what has to happen first? There's a step people skip under pressure, and it changes the tag. If you've worked a real MCI, how did the triage decisions sit with you afterward?

That part never makes it into the textbooks.

Case adapted from the EMS Mastery (NREMT prep) question bank.

Very premature babies lose heat crazy fast. They have almost no fat, their skin is super thin, and they're wet right after delivery, so every minute on the resus table counts. Hypothermia in that first hour is linked to worse outcomes, and in places without good warmers or incubators it's a real problem.

One of the simplest fixes is a plain polyethylene bag (basically a food-grade zip bag). For babies born before about 32 weeks, you skip drying the body and slide them straight in from the neck down. The head stays out and gets a hat. You can still ventilate, place lines and watch the chest through the plastic, like in the photo.

It works because the bag stops evaporation, which is how a wet newborn loses most of its heat. Babies wrapped this way arrive in the NICU noticeably warmer and hypothermia is a lot less common. It's in the resuscitation guidelines now. Nobody has really proven it lowers mortality, though, and you do have to keep checking the temperature so they don't overheat under the warmer.

It costs pretty much nothing and makes a real difference.