Discover and read the best of Twitter Threads about #Delirium

Most recents (24)

1/🧵For months I’ve been grappling with what seemed like a real gap in conversations about #LongCOVID.

Here in @STATnews, I introduce you to 30 references & 3 #COVID survivors – Ray, Pam, and Carolyn – who taught me a lot. I hope you think so, too…

bit.ly/2Zb9S2J
2/ "I feel like I'm getting the silent treatment & it's killing me," #LongCOVID pt Pamela Bishop confided in me about her months-long interactions as she tried to get answers about a strange array of symptoms that have plagued her since recovering from #Covid19.

Pam then & now…
3/ Up to1 in 3 COVID survivors report experiencing #longCovid symptoms 3 to 6 months later. Their stories give me an extreme case of déjà vu because this is playing out similarly to the problem of long-term survivorship after non-COVID critical illness.
 
bit.ly/3vzcIdn
Read 26 tweets
1/🧵 Dozens of #Ivermectin lawsuits now filed trying to FORCE doctors to give a worm & parasite drug to people infected with a VIRUS!

If you saw a movie with this tag-line, you’d say, “That is so stupid.” And yet…read on…
 
bit.ly/2Z6QJ1o
2/ There has been a mix of results in state courts. Some judges have refused to order hospitals to give ivermectin. Others HAVE ordered medical providers to give the medication, despite concerns it could be harmful.
3/ NY State Supreme Court Judge Porzio wrote: “This court will not require a doctor to be placed in a potentially unethical position committing medical malpractice by administering a medication for an unapproved, alleged off-label purpose.”
Read 9 tweets
1/🧵 Billing for #LongCOVID💰

It Matters!

What does it mean that docs can now bill using ICD-10 code U09.9 “Post COVID-19 condition, unspecified”effective October 1, 2021?

Let me explain a tad bit why this is so key.

bit.ly/2ZLOHE5
2/ I fully believe in #LongCOVID, and patients must be validated as the experts of their own narrative. BUT, absence of a billing code sent a terrible message to clinicians & pts.

This legitimizes the #PublicHealth catastrophe & facilitates pts being HEARD & SEEN 👁.
3/ Docs “believe” better when they can charge for testing & get pts covered, too. This also allows databases to track & analyze epidemiology of #LongCOVID. That means research can be carried out to answer questions, improve care & prepare for future pandemics. Read an anecdote👇
Read 7 tweets
1/🧵ROADMAP: What should you know before someone you ❤️ lands in the ICU? @TheDailyBeast
 
I whittle down IMPORTANT PEARLS & pro-tips about how to approach acute #COVID19 and non-COVID care to avoid life-changing disabilities later.
👇

bit.ly/3oRVZRt
2/ #COVID pts return home after cutting-edge medical care but many survivors are now living with massive & likely life-long disabilities that include dementia, PTSD, depression & major weakness from muscle and nerve disease. #PICS #LongCOVID

3/ These two entities, #LongCOVID and #PICS, have many overlapping forms of suffering that must be acknowledged by healthcare professionals and loved one for survivors to feel validated & heard. People throughout society in all our communities will benefit.
Read 21 tweets
1/🧵 People ask me, “What’s the main purpose of treating #COVID ICU pts with the #A2Fbundle? (a daily safety checklist of ⬇️ sedation & ⬆️ mobilization). It’s to prevent #PICS related dementia, PTSD, depression & reduce suffering in #LongCOVID.

HOW? What is the philosophy?
2/ For patients it’s about magnifying their #dignity and self-worth by liberating them sooner from us (our treatments that put them through a depersonalization chamber). For HCWs, it’s about purity of service, avoiding hypocrisy, and better self-sacrifice for our patients.
3/ Waking people up and walking them w family at their side in PPE (even inside a room if #COVID+) allows them to feel alive again. Repersonalized! Human. Seen. Drives away #delirium & #brainfog. Wouldn’t you want this?
Read 8 tweets
1/🧵💥 NEW COVID THERAPY SAVES LIVES

Adding baricitinib to steroids will save 1,000s of hospitalized #COVID pts. Our @LancetRespirMed COV-Barrier study is FREE.

I explain👇why it’s such a great #Pandemic discovery story: a new way to ⬇️ COVID19 deaths.

bit.ly/3DE8Co8
2/ Early in COVID, computers predicted “Berry” (for Bari-citinib), an FDA-approved medication for rheumatoid arthritis, could be repurposed to stop SARS-CoV-2 from killing us. Now we proved it! Why did the computers think it would work?

bit.ly/3t244CR
3/ Bari has antiviral mechanism but mainly we thought it would work by interfering with the intense inflammation the virus 🦠 causes, which is what leads to so much lung, heart, blood vessel, & brain damage (#delirium).

bit.ly/3jsgCjN
Read 15 tweets
1/🧵 The main question I wake up wanting to answer every day as a physician in the #COVID “I see you!” is this:

“How can I help people recover fully so that their dignity is upheld…so that the unique pricelessness…(read on)

Podcast: bit.ly/3gLnCa0

#ListenDNA
2/ of every human being who comes into my care is such that they feel fully human, fully respected, and that they don’t think they lost part of themselves in the process of critical illness.”

Yet #LongCovid pts are telling me they’ve lost themselves.
3/ my colleague #delirium neuro @doctorShawniqua is haunted by this too. She’s trying to find out what exactly happens to the neurons & synapses in the brain of critical illness survivors so that we can manage people more safely during and after illness.
Read 4 tweets
1/🧵🎥 “Doc, TIME is BROKEN.” ⏰ #BRAINFOG in #COVID19 is something like this stuttering second-hand on a hospital room clock with a low battery. Imagine if your brain stuttered like this! This video was taken by an ICU survivor who told me how the clock contributed to #Delirium.
2/ Now our @CIBScenter ICU survivor @SGFesquire sees how the clock not only contributed to his delirium but symbolized his brokenness & need of healing (pic w perm). Brain Fog presents as delirium when 1st sick & as cognitive impairment (memory + mental slowness) in #LongCOVID.
3/fin
Ongoing Brain Dysfunction = major suffering. Let’s be patient with #LongHaulers. They look normal & are silenced like #MECFS pts. Patients, seek help. We will help you “unbreak time.” We do this through cognitive rehabilitation tools. #recovery

bit.ly/3y8vaJt
Read 3 tweets
1/🧵🎥 MAJOR TIPS about #Liver Disease
 
Why do we ask pts to “hold up traffic”? When people get severe liver disease, “asterixis” is a finding on exam we often see.

What does it mean?
 
#MedTwitter #NurseTwitter #TipsforNewDocs #Addiction
2/ Asterixis indicates that toxins like ammonia have built up in the body because the scarred liver no longer filters them out. The brain cells no long function normally (#Delirium or Hepatic #Encephalopathy) & can no longer control muscle movements like posture!
3/ These same toxin cause vessels to dilate and develop problems with blood flow in the skin and lungs. A skin finding is called “spiders.” They look like a multi-legged spider, right? It’s a tip-off.
Read 9 tweets
Tijdens een delier heeft de patiënt last van acute verwardheid. De patiënt kan deze waanbeelden niet van echt onderscheiden. Gisteren hoorde ik op de nazorgpoli hoe echt deze ideeën blijven voor de patient, zelfs tot lang na ontslag #ICUpdate #NietVanEchtTeOnderscheiden ⤵️
Want na haar ontslag uit het revalidatiecentrum, inmiddels al weer twee weken thuis, belde ze haar vriendin om te vragen hoe het nu gaat en of ze het allemaal redt. Haar vriendin antwoordde met goed, maar waarom zou ze zich niet redden?
Mijn patiënt vertelde haar dat ze het een mooie dienst had gevonden en dat haar man (van de vriendin die ze dus belde) er heel vredig had bijgelegen. En dat ze het fijn had gevonden dat ze van de verpleging even de IC af had gemogen om de dienst bij te wonen.
Read 5 tweets
1/ Imatinib for #COVID19: @TheLancet

This study of N=385 ICU pts tested a Tyrosine-Kinase Inhibitor vs. Plac for 9 days. It’s important because it did NOT decrease ventilator or oxygen needs BUT reduced death at 28 days. What does this mean?

bit.ly/3gFJELG

#MedTwitter
2/ This study is technically “negative” because it didn’t hit the primary endpoint scientists “guessed” ahead of time as best choice to see if the drug works in #COVID: time to stopping ventilation & O2. Importantly, we sometimes GUESS WRONG! Next let’s look at other endpoints!
3/ This drug stops lung & blood vessel membranes from going haywire. It did not have safety problems & decreased DEATHS by ~50%, TIME on VENT by 5 days, length of ICU stay a WEEK, #delirium by 5%. These are huge improvements that I would want if I had #COVID. ( Fig 2, Tab 2/3)
Read 6 tweets
1/ 🎥🧵 How do we test someone for #delirium in #COVID19 or any ICU? When someone won’t engage it can be a huge red-flag for “quiet” delirium, which predicts 3X ⬆️ #DEATH by 6 mo & acquired #dementia. Watch this movie of me testing pt #1 for delirium.

#MedTwitter #NurseTwitter
2/ What does this mean? He starts out OK but then can’t follow my command to squeeze only on the letter A. Instead, he squeezes when I say the word “squeeze” & doesn’t relax his grip or vary it on different letters. This is inattention & a cardinal feature of #Delirium.
3/ 🎥 Contrast Pt 1 with this Pt 2 video of me doing the same test. This person had delirium on earlier days & is now improving. He gets 8/10 correct responses, which means he’s attentive and not delirious any more. This day he walked & talked for the 1st time!

#Recovery #nurse
Read 7 tweets
1/🧵An Epiphany: #delirium treated w touch & eye contact, day by day...his mom cried, “He won’t let us help him shake this damned disease.” Finally his mind cleared. “What matters to you? How can I help?” Slowly, surely, he asked, “Doc, can you help me stop drinking?”💔
#Recovery
2/ #GroundZero. What a privilege it is to witness someone enter a long-awaited epiphany that opens the door to so much recovery. Unfortunately, in my early years as a doc, I thought, “Well, this isn’t critical care, so I’ll move on & let someone else take over.”

#shame on me
3/ But what is a doctor for?

1. To reduce human suffering & heal people where they are.
2. Plus the Latin root is “docere,” teacher.

It’s a dual vocation: healer + teacher. Because of the “Law of the Gift,” I know that the more I give, the more I receive, so…

#TipsForNewDocs
Read 7 tweets
1/ 🧵Wisdom in Medicine
 
What’s going on here? And why it’s key in #COVID19
 
It’s quite simple: we finally had the #wisdom to ask Mr. D the right question! He and his wife encouraged us to use this picture to teach what we learned.
 
#PalliativeCare #MedTwitter #NurseTwitter
2/ What we learned was to switch the preposition!
 
Mr. D was a pre-#COVID patient. On this day, he was taken off the vent after a MONTH. The incessant mantra had been, “What’s the matter WITH Mr. D?” He was surprised when we asked, “What matters TO you, Mr. D?”
3/ He has a tracheostomy, as you can see. We insert this airway through the neck to improve #comfort when someone is on a vent well beyond 10 days. He’s more comfortable because he no longer has a tube in his mouth. We used a program called the #A2Fbundle to reduce his #delirium.
Read 13 tweets
1/🧵The Nightmare of #COVID19 & #LongCOVID
 
Im a doctor who is now spending more & more time daily caring for #LongHaulers (pts w LongCOVID). I just got a TINY dose of what it must feel like to be unheard and unseen…AND I want to apologize to you.
 
#MedTwitter #NurseTwitter
2/ I just keep hearing you say, “Doc, why doesn’t anyone believe me? My friends look at me and think I’m fine, even as I feel further and further adrift. I’m not myself and I can’t tell if I ever will be again. #COVID has ruined my life.”
3/ Yesterday as my plan landed, my phone vibrated. It was the wife of a former ICU #COVID pt, now trached & living on a vent in an LTAC, asking how she can get his new docs to understand & carefully manage her husband’s ongoing #LongCOVID & Post-Intensive Care Syndrome (#PICS).
Read 13 tweets
1/ 🧵 What is “Brain Fog” in #COVID19: discussion, papers & pts
 Brain Fog is a non-medical term but it works since it’s what pts describe. Whether in a ward, ICU on a vent, or months later as a #LongHauler w #LongCOVID, they are “in a fog.”

bit.ly/3vMZ2ui

#medtwitter
2/ Medically this is #Delirium acutely and #Dementia chronically + various forms of neuropsychological impairment coupled with #depression and #PTSD.
 
Our paper: go.nature.com/3nU9ZYm
3/ Scientifically, it’s millions of neurons sick, dying or dead. This is depersonalizing & devastating. Fig A shows MRI 3 mos after ICU in pt w/out delirium vs B shows ICU pt w #Delirium. Duration of delirium predicted loss of 🧠 tissue.

Our MRI study - bit.ly/3uxAqFQ
Read 13 tweets
1/ #Sleep & #Dementia: @NatureComms
 
Study of ~8,000 people followed for 25 years! Look at the figures. Sleeping <7 hrs per night chronically increases risk of dementia by 30%.  Get your sleep!

go.nature.com/3tjRxJB

#MedTwitter #MedEd #Geriatrics
2/ Sleep and Dementia Risk: @nytimes

@PamBelluck wrote a great article on this NatureComm paper showing heightened risk of #dementia for “short-sleepers,” defined as <7 hrs of sleep a night.

nyti.ms/3h7KZeV

#Aging #Delirium
3/ What’s the Mechanism?

Our brain’s “trash” clearance (like the body’s Lymphatic system but by brain’s “glial” cells & called Glymphatics) kicks into ⬆️ gear in sleep. So less sleep is like your waste management system going on strike. Kapische??

REF: bit.ly/3eQxtte
Read 5 tweets
1/ 🧵A picture is worth 1,000 words 👁 #COVID19:

This 🎥 shows a clear example of what can happen to a person’s body w #COVID. His wife asked me to show it on twitter & urges everyone to get #vaccinate

(w/ consent of pt & wife)

#MedTwitter #NurseTwitter #CriticalCare
2/ You’ll notice his eyes are swollen shut. (Written perm to show). This is not fluid. It’s AIR from inside his chest leaking out his lungs 🫁 through muscles & skin to his neck & into his face. He is AWAKE & communicating but had ICU #delirium earlier.

#MedStudentTwitter #Nurse
3/ Look at his chest CT. See the “L” lungs w #Covid pneumonia/#ARDS & also AIR leaking out under his skin. Now go back to 1st tweet & watch 🎥 again. This is called “barotrauma” & happens when the 🫁s get too stiff and pop. Difficult situation. We’re hoping he can heal!

#MedEd
Read 5 tweets
1/ Do data support pt trial off sedation for “SAT” when pt is comfortable on current dose? Yes
 
Shared w permission:
“Dr. Ely, yesterday our ICU #nurses went over #A2Fbundle in Epic for implementation. Do you recommend SAT at RASS Goal of RASS -1 to +1?
#medtwitter #criticalcare
2/ Excellent #Nurse added:

“We are currently not doing SAT (Spontaneous Awakening Trial) but keeping pt’s RASS -1 to +1.  Just want to make sure we are interpreting #A2Fbundle correctly.”
 
#TipsForNewDocs
#medstudenttwitter #COVID19 #pandemic
3/ my Answers:

Great questions. I don’t think +1 (anxiety) is ever a good goal but 0 to -1 is a 👍 default target RASS if we acknowledge there are times when sedation target should acceptably be set as deep as -3/-4 in bad #ARDS or -5 transiently when pt requires paralytics.
Read 8 tweets
1/ Scientific Discovery: time & patience
 
Be patient in science. 25 yrs ago, I & others felt we were harming ICU patients by deep sedation & immobility. Our goal: PROVE IT & change culture in #criticalcare.
 
How did we start?

#medtwitter #A2Fbundle #nursetwitter
2/ Scientific Discovery: takes time

There weren’t tools 😤Reluctantly, I had to go “backwards” to validate CAM-ICU & RASS (@JAMA_current X3). A DECADE later we produced studies lightening sedation (MENDS/ABC trials JAMA/@TheLancet). Be patient!

#academictwitter #ScienceTwitter
3/ Scientific Discovery: patience
 
Give yourself space to be creative! Science takes time & Data must lead you. All our 1st grants & papers were rejected for 5 YEARS. NIH said: #Delirium in ICU is not a viable topic or a “thing.” Go away. Persistence paid off for patient safety.
Read 5 tweets
Here is the #PedsICU #BestOf2020 collection.
Jointly chosen by
@Dr_Hari_Krishna @sgdambrauskas and myself
Pubmed collection 40 articles: bit.ly/pedsicubestof2…
Infographic (clickable PDF) in English: bit.ly/bestof2020eng
Spanish: bit.ly/bestof2020esp
#PedsCICU #NeuroPICU
This will be a bilingual tweetorial in Spanish/English!
Infographics are available in both languages in Tweet #1

El hilo será en Español/Inglés. El resumen infográfico está disponible en los dos idiomas en el primer Tweet
1/What are the outcomes that matter to children, to families and to #researchers/clinicians? @ericka_fink et al & @PostPICU_PALISI investigators identified COS using a delphi process. @CritCareMed bit.ly/381cfq8. Developmental and functional outcomes were important.
Read 44 tweets
#Tweetorial
Llegó colección de lo #Mejor2020 en #PedsICU &
@Dr_Hari_Krishna 🇬🇧@MiguelrrMD 🇪🇸 @sgdambrauskas 🇺🇾

Pubmed: bit.ly/pedsicubestof2…
Versión infográfico español: bit.ly/bestof2020esp
Version inglés: bit.ly/bestof2020eng

#SoMe4MV #neuroPICU #delirium #PedsCICU
English #BestOf2020
The #Bestof2020 #PedsICU pubmed collection will also be available in the FREE #PICCHub app (sponsored by @PICSociety) as the latest monthly #PICUJournalwatch collection:
Download links: Android: play.google.com/store/apps/det…
iOS: apps.apple.com/gb/app/picchub…
3/ La FUNCIÓN como nuevo paradigma
@ericka_fink et al POST #PedsICU investigators & @PALISInet hicieron consenso Delphi
Qué es lo importante como resultados al alta #PedsICU?

En @CritCareMed lo que encontraron con precioso infogràfico
bit.ly/381cfq8
#PedsICU #PICSp
Read 42 tweets
Green Urine: #NEJM
 
....will be seen in #COVID – Why? Massive use of Propofol. While Green Urine is Benign, effects of prolonged over-sedation & immobilization ++ #DELIRIUM are not 😤 Wake them up & get out of bed. Start w/SAT…#A2Fbundle & #PICS

#medtwitter #nursetwitter
1/ re: SATs to avoid over-sedation in #COVID19 pts, Thx @phanton_icu for Protocol Blindness caution & @Nitkjain reminder “Easier said than done.” I’ve been pondering your comments all day & think them ripe for further conversation on #A2Fbundle

#medtwitter #pulmcc #nursetwitter
2/ Remember, protocols like #A2Fbundle are guides & not “1-shoe-fits-all pts.” Correct, we must deviate when needed. However, these 6 principles (ABCDEF) are derived from 35 NEJM, JAMA, Lancet papers +400 others & now >25,000 pts of data. Not chump change.
bit.ly/2JwVA4E
Read 10 tweets
1/ ICU #diaries for Good #Death:
 
Especially at EOL, ICU #Diary is part of #A2Fbundle. My pt w/ home-hospice told me details recorded in #ICU by #nurse allowed her to decipher cryptic #delirium memories she was struggling with.

bit.ly/36DOtk3

#medtwitter #meded
2/ Then she told me of hours spent reading big-hearted comments others had written in her ICU diary, making her realize how much her life meant to others. It was a priceless gift to her at a critical juncture in what had a time of deep poverty in her life. #PalliativeCare
3/ ICU Diaries give family members at bedside a practical way of helping w/ loved one’s care & can help channel their worries in a focused way.
#criticalcare #pulmcc
Read 7 tweets

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