Discover and read the best of Twitter Threads about #PICS

Most recents (24)

🧵1/ Here’s your “Big Picture” of COVID & Long COVID for 2022

See my new Figure👇 summarizing #COVID19 Management & Outcomes

Two years in & we have splendid choices.

Stay in peaceful waters of prevention (green) or risk treacherous cliffs of #LongCOVID & Death (red & black)…
2/ Knowledge is Power, and our knowledge has grown dramatically.

Let’s take a look at where we were just 2 years ago - even though it seems like 20 yrs ago.

April 2020: our approach & understanding of COVID looked like this👇.

We didn’t even know about #LongCOVID yet 🤯
3/ Remember, with #LongCOVID, your brain & heart are at stake.

@JohnsHopkinsSPH reports on emerging data: “COVID doesn’t discriminate when it comes to heart problems.”

Anyone affected may develop clots, arrhythmias & strokes >1 yr later.

Link &🧵below
bit.ly/3KzYcbp
Read 23 tweets
Ok. As promised, here is a super-🧵 on cognition and #LongCovid. This will be a combination of published material and things that we have observed in-clinic. This is not intended to be definitive nor epidemiological and so it is highly likely that your personal experience (1/n)
may deviate significantly. This is about my reading and experience of cognition and #LongCovid but from what I have seen shared in the comments of my tweet yesterday, it seems that much of this may apply to other infection-associated chronic illnesses (h/t @microbeminded2) (2/n)
such as #MECFS, #Lyme and #dysautonomia/#POTS to name a few. Let’s start out with naming. I try not to use the term “brain fog” because I don’t think it conveys the seriousness. People with LC are experiencing cognitive dysfunction that often results in cognitive impairment (3/n)
Read 25 tweets
1/🧵 You have a COVID ICU patient on benzos who doesn’t respond to needle injection of local anesthetic do to sedatives.
 
What depth of sedation do you consider this? (it was a CME question just now)
2/ The answer is GENERAL ANESTHESIA, which of course makes sense.

If a person is so deep that he/she doesn’t respond to getting stuck by a needle and the pain of lidocaine injection, that is general!

Why am I writing about this?
3/ Anyone working in the ICU this past few years of #COVID #PANDEMIC is seeing this depth of sedation on a regular basis.

We had almost gotten rid of this by 2019. Then COVID undid progress.

People now think this is normal for some reason.

It is NOT normal.

It is not OK.
Read 9 tweets
1/🧵🎥 “It’s a very bad disease. It can be overcome.”
 
My #COVID patient tearfully speaks of his BIG DECISION on the ventilator.

This soldier & leukemia survivor made it through 3 weeks on a ventilator. How?
 
Video shown w his permission “to help others find hope, Doc.”
#Hope
2/ This immunocompromised man was in massive viral septic shock from COVID.

Huge doses of vasopressors.

Gargantuan levels of O2 & vent pressure to save his life.

Lungs, Kidneys, Heart and Brain all failed.
3/ His wife was there with him daily.

We put up pictures of his kids and pets.

We talked to him about the things he loved every day (even when sedated and seemingly unable to hear us).

Somewhere in all of that, he made a silent decision…
Read 8 tweets
1/🧵 Why is COVID hospitalization like 2X sticks of dynamite 🧨?
 
A thread on the ICU portion… #PICS + #LongCOVID.
 
Prevent this w 3 steps:
📌Avoid #COVID by Vax & Mask
📌Avoid severe COVID by Paxlovid & Monoclonal Ab
📌👇 read here about PICS & how to reduce injury in the ICU
2/ Here’s what you must know if you get too sick & land in an ICU.

History Lesson 📝
In the past, too many decisions in #CriticalCare were guided by fear. We oversedated patients for too long out of worry they might self-extubate & pull off restraints.

That’s happening again 🤮
3/ We kept patients immobilized due to an overly conservative approach to fall prevention that precluded us from attempting to walk them early. We kept families away from patients, treating loved ones as visitors rather than members of the healing plan.

That’s happening again.
Read 10 tweets
1/🧵 Seeing Differently in #COVID ICU Care 👁

The world tells me “stuff” & “freedom ” bring happiness, yet neither suffice or satisfy.

If I reject chances to serve my suffering patients, I am left bereft.

Merciful care brings healing & provides joy all around.

What is #Mercy?
2/ My working definition of mercy is my willingness to dive into the chaos of another person’s life & provide lifting & healing.

Often as an ICU physician I do the former but not the latter.

That is, I dive into their #chaos without admitting I don’t know what’s right for them.
3/…but without performing actions that lead to lifting and healing of my patient’s spirit & mind, what I’m doing is dispensing false mercy.

eg, If in #COVID, I make the lungs 🫁 my whole goal, sedate & depersonalize someone for too long, I beget new diseases.

#PICS #LongCovid
Read 5 tweets
1/🧵 How do #COVID patients suffer after the ICU?
 
This new @JAMA_current study of 246 Dutch pts shows that 3 out of 4 people had physical problems 1 YEAR LATER plus 1 in 4 have #brainfog, depression & anxiety.
 
What do we call this?

#LongCOVID #PICS
 
bit.ly/3o4djkT
2/ The paper is also discussed in @Medscape👇: “Our study shows what an impact ICU admission has on former #COVID19 pts. Even after 1 year, half are tired or experience lack of the energy to fully resume their work," says author Marieke Zegers, PhD
 
wb.md/33U9DeF
3/ I searched this paper for well-known terms like post-intensive care syndrome #PICS, #LongCOVID & even “post-acute sequelae of COVID”#PASC
 
NADA. Zip. Zilch.

Why weren’t these names mentioned? At the very least, these pts’ disabilities are DEFINITELY PICS & underestimated btw
Read 9 tweets
1/🧵Important = Brain Injury in #COVID💥
 
📍N=251 hospitalized COVID pts had biomarkers of neurodegeneration (dying brain cells).

📍Previously healthy COVID pts had ⬆️er levels than Alzheimer’s pts!

How do we understand this?
Hint: #Vaccinate yourself

bit.ly/3frTcbB
2/ These elevated brain biomarkers indicate disease to different types of brain cells (eg, astrocytes, glial cells, neurons) in COVID patients. These were early unvaccinated pandemic patients. Vaccinated people will be less prone. WHY?
3/ There isn’t a ton of brain invasion by COVID. We think most of the 🧠 injury is INDIRECT. Meaning downstream injury from 1. upstream inflammation 2. blood clotting & 3. heavy sedation causing #delirium, which we proved to be a #dementia risk factor!

bit.ly/3qCaOrQ
Read 7 tweets
1/🧵🎥 A young mom suffering #COVID. Her husband is scared.

We need to prevent serious long-term complications. Her new normal will likely include PTSD, Dementia, Depression & severe physical disability. (shown w Perm)

Not so “mild” ➡️ Do you want this?

#vaccinate
#LongCOVID
2/ what you need to know about ICUs, #PICS and #LongCOVID prevention:

I wrote this @thedailybeast piece👇 to help empower you as patients & families. It’ll tell you what you need to know & ask your team for amid the chaos and confusion.

There’s more…

bit.ly/3DhC6Xe
3/ This patient on 100% O2 and high-dose propofol & fentanyl did not need both agents. When able, we try to avoid prop & benzos. We stopped Prop, continued Fentanyl & added dexmedetomidine because it’s shorter acting & won’t build up so much in her brain.

This is the #A2Fbundle.
Read 7 tweets
1/🧵 Brain + Body damage in #COVID & Critical Illness
 
Sepsis -bacterial, viral, fungal- can cause rapid-onset #dementia. Finishing this test should be easy at her age but Millions of brain cells are damaged!

Protect yourself & others: #Vaxx + #Mask

H/T @trishla_17 for helping
2/ Our brain depends on a delicate balance of blood flow, nutrients & oxygen. When someone gets critically ill w #Covid or from other causes, that balance is dramatically disrupted. Small blood clots, dropping oxygen levels cause 🧠 damage.

bit.ly/36K5F65
3/ It’s odd to me that people don’t see severe COVID as a form of VIRAL SEPSIS. Sepsis is when infection of any kind causes your organs to begin to fail – lungs, brain, heart, kidneys.  It’s EXACTLY what we see day-in day-out in the COVID ICU.
 
bit.ly/3eM8pUx
Read 6 tweets
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/🧵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/🧵🎥 Hard-Won #Wisdom from the wife of a #LongCovid patient >140 days into hospitalization.

You need to hear her 2 messages:
1. “What I can tell you is I’ve never given up #hope. To make it to tomorrow, we have to make it through today first.”

HUMILITY ❤️‍🩹 IS HER MEDICINE
2/ When things are acute, like in this video of her husband when he was 1st in the ICU, we tend to think our task list is all technological. I’m guilty of this. And I’ve caused ⬆️ suffering because of my tunnel vision.

3/🎥 Point #2 from my pts wife:
“He’s not gonna get better next week or next month. #COVID takes a LONG time. Our lives are forever changed. Expect setbacks & be your loved one’s advocate!”

NOW she & he are convinced of the importance of #Vaccination & masking. Learn from them!
Read 15 tweets
1/🧵🎥 The #COVID19 ICU: an Insider’s look behind the curtain of our conversations with patients.
 
From my vantage point, there are TWO ROADS. Whether we meet depends on which one is chosen…see this video and read a real patient conversation👇

2/ Two Roads:

1. Get a #vaccine & >99% you won’t have me as your doctor.

2. Don’t get a vaccine & #DeltaVariant’s SUPER-VELCRO Spike Protein gets to decide your fate.
3/ If you don’t get a vaccine and then go to #DisneyWorld or the mall, & get #Delta infection (as multiple people in my life did recently)…

THIS is the conversation we may have…
Read 12 tweets
1/ How do Children Suffer after ICU?

Today the mom of a 4 y/o boy who is in 📚#EveryDeepDrawnBreath wrote me & said to share this pic (w his twin). The family’s story can help us understand life after #CriticalIllness:

“Dr. Wes, we are 2 years out & he’s got a new limp!”
WHY?
2/ Mom writes: “Many appointments later we have learned that either his septic shock, ECMO, or the strokes caused damage to his growth plates. His left leg & foot are shorter than his right leg & right foot.”

This feature of pediatric #PICS will also affect sick #COVID19 kids.
3/ She goes on… “The doc at the children's hospital who we see said any of these 3 conditions can cause this to happen and our son had all three (strokes, septic shock, ECMO).”
Read 9 tweets
1/🧵 #LongCovid: Lumper vs Splitter terminology

🎥👇This man is suffering a form of longCovid wrought by complications of his ICU illness. He’s a clear example of the most severe form of #longCovid, also known as #PICS, for “post intensive care syndrome”…

@Dr2NisreenAlwan
2/ There are vastly different ways Covid will affect people over future months & years. Do we split those into multiple diseases or lump them into 1 big syndrome (w subgroups) to grab millions of people & help grow advocacy & gain footing?
3/ #PICS is mainly encompassed by cognitive difficulties, an acquired dementia called ADRD (#Alzheimers Disease & Related-Dementias), as well as #PTSD and depression PLUS profound muscle and nerve disease called ICU-AW (ICU Acquired Weakness).
Read 5 tweets
🎥 “If everyone knew THIS was #COVID, we’d get >80% #Vaccination.”

This video shows TYPICAL long-term ICU #COVID19. My patient & family want to share this to help you & your loved ones avoid #LongCOVID

PROTECT YOURSELF today w the #VACCINE.

#MedTwitter #NurseTwitter
The experiences of ICU survival & #PICS written about by @MichaelRosenYes are extremely accurate and moving. I often think about him when I’m at the bedside w patients like 🎥 depicts.

bit.ly/3ATQtkz

#resilience #LongCOVID #poem
The strongest voice by far in the UK for advocacy of our #LongCOVID patients is @Dr2NisreenAlwan. I hope this video will complement her great #PublicHealth Service. TY Dr. Alwan.
Read 3 tweets
1/🧵 I’d like to think as a medical community that we have changed & no longer discharge people w/out appropriate follow-up, but just last week I met a #COVID19 survivor who was discharged from the ICU simply to follow up w his primary care physician.

#LongCOVID #PICS #A2FBundle
2/ He couldn’t return to his job, was fired & had no income for his family. That resulted in him not having enough money for medications, gas, or bills. He missed his doctor’s appointment, his electricity was turned off, so he is unable to apply online for disability. 😤
3/ The cycle continues. I usually see these pts when they get septic again & end up back in my ICU on life support.
Read 4 tweets
1/🧵 AGEISM: Never be discouraged by age AND don’t judge others by age. Chronological age is a bogus constraint in life. I read today of some great examples of iconic people who did crazy cool things after 7 decades of life. See these & realize age is NOT a limitation...
#MedEd
2/ 👏 Major late-life #winners: 👏

#NelsonMandela, president of SA at 75 y/o
#Michelangelo started on St. Peter’s at 72
#GrandmaMoses folk artist sold her 1st painting at 90!
#ArthurMuir just scaled Mt Everest 🏔 at 75 (pic)
#JohnGlenn went into space at 77 y/o!
3/ Bonus 😀: German athlete Johanna Quaas at 86 y/o is the world’s oldest gymnast at age 86. She’s a retired P.E. teacher & started in this sport at age 56.

#NoLimits 🧠

bit.ly/3i5wclf
Read 7 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/🧵This figure from CHEST on early tracheostomy in #COVID19 pts is helpful for 2 reasons: it points out different ways of care. Read the BLUE circles clockwise & then switch to OUTER RED ARROWS clockwise again. Clear and True.

bit.ly/3w3DXfc

#medtwitter #nursetwitter Image
2/ The #COVID pt with ARDS + Sepsis on a ventilator is TOO often subjected to TONS of sedation, which adds brain injury, immobilization & development of physical disability. NEW DISEASES added to the original problem. We call this Post-Intensive Care Syndrome #PICS. Image
3/ Early tracheostomy around day 10 can help (not always!) as outlined in the RED ARROWS. The goal is to lessen the added injury by waking people up, getting them out of bed and early mobilization plus talking with family. This is done via the #A2Fbundle. @SCCM Image
Read 4 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

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