Discover and read the best of Twitter Threads about #pulmcc

Most recents (24)

Dr. Cook begins her #CCC50 Lifetime Achievement Award talk with reflection on her own 1st presentation ever as an #ICU fellow- at an @SCCM Congress! She was struck by the interprofessional group of attendees.(Thread)

#NationalWomenPhysiciansDay #WomenInMedicine #clinicalresearch
Her first lesson learned to impart to us.


An early senior researcher said to her early in career:
"I just don't think research is in your future"

Imagine what #CriticalCare world would have lost if she had listened.

#CCC50 #pulmcc #PedsICU
Dr. Cook: Sometimes dialogue is more important than consensus. You have the TRUST YOUR GUT. #CCC50

You're not growing until you're changing. Defining moments for bravery may come along when you least expect them. Be brave. #WomensPhysicianDay #PedsICU #pulmcc #ICU
Read 14 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.
Read 10 tweets
Coming up in a few minutes! Catch @SMHollenberg @ammo_uw @KristinBurkart3 @davidschulman and David Bowton duke it out in Pardon the Interruption, an @ESPN-style “discussion” of #pulmcc at #CHEST2020
Unsurprising the women and crushing the boys on the first question. (And no one gets out of the ICU without steroids, so I agree with @KristinBurkart3 and @Ammo_uw!) #CHEST2020
David Bowton @SMHollenberg getting crushed in this contest (and deservedly so for continuing to promote therapeutic hypothermia!). #CHEST2020
Read 4 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.

#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
1/ When I play the #criticalcare movie 🎥 of me as an intern or resident back in my head, I see myself as much too robotic 🤖 with my patients, as if plugging in kitchen appliances.

#medtwitter #meded #tipsfornewdocs #medstudenttwitter #nurse #pulmcc #COVID19
2/ The nurse would slip a Foley catheter up his urethra into his bladder. I’d go to the stockroom to get all the materials to slide a plastic endotracheal tube down his trachea to become command-central for his breathing on the ventilator.
3/ Next, I’d methodically place a Swan-Ganz catheter by serial insertion of a needle first, then a wire through the needle, next a dilator over the wire, and finally the catheter itself down into his great vessels and heart. And start the ‘pressors.
Read 6 tweets
1/ There are clinically relevant differences between #COVID19 #Sepsis & typical bacterial sepsis, but they are Quantitative rather than Qualitative. That is, all clinicians have seen them before in other sepsis pts before this #virus 🦠 infected its 1st human.

#medtwitter #meded
2/ Quantitative septic findings are more commonly part of daily care for #COVID patients than we have been used eg, near total loss of the tracheobronchial tree’s muco-ciliary escalator due to destruction of ciliated respiratory epithelium.

#pulmcc #tipsfornewdocs #criticalcare
3/ Classically in #Influenza pneumonia/sepsis, this predisposes to subsequent superinfection from bacteria like Staph & Strep. In #COVID, we are always on the ready to begin antibiotics to cover such complications of what initially was a pure viral infection.

Read 8 tweets
1/ Most indicative of my ignorance as a young ICU doc in 1990 was my off-service note for a 28 year old w/ PROFOUND post-ARDS #PICS: “However, amazingly enough, she still manifests only single organ damage (lungs) w/ good renal, GI, & CV fxn.”
#medtwitter #pulmcc #TipsForNewDocs Image
2/fin #longhaulcovid

Apparently, neither her brain nor neuromuscular system were on my 🧠radar, because both organ systems were newly, severely, & permanently diseased as I penned that statement. Beware now in #COVID
#medstudenttwitter #dementia #TipsForNewDocs #tipsforolddocs
By the way, of course, I showed that note 📝 and use this patient’s example with written permission from her son who wants others to learn from the experience of his mother.
Read 3 tweets
1/ Vaccine Hope in #COVID19: JAMA

Mechanism & Facts -
After #COVID, only 1/3 have Ab w low spike Pr titers & viral neutralizing. Given variability in Dz severity, this is expected. Highest Ag burden & Ab titers seen in severe disease.

#medtwitter #meded Image
2/ Vaccine Hope in #COVID19: JAMA

SARS-CoV-2–specific CD4+ and CD8+ memory T cells are also generated across asymptomatic to severe disease that express antiviral cytokines, control viral replication & should prevent recurrent severe infections.

#tipsfornewdocs #pulmcc Image
3/ Vaccine Hope in #COVID19: JAMA

Abs to #SARS-CoV-2 spike protein show there may be 10X more SARS-CoV-2 infections than reported cases (=40-50 million or 15% of US population) to date. 

#tipsforolddocs #criticalcare
Read 4 tweets
1/ Women in #CriticalCare: #Anesthesia/CC

Four EXPERT MD mentees in our CIBS Center (clockwise top left): Heidi Smith (R01 funded for Mini-MENDS), @kimberlyrengel (studies prehabilitation), @christinahayhu2 (pain after ICU) & Tina Boncyk (FAER awardee).
#medtwitter #heforshe Image
2/ Women in #CriticalCare: Biostatistics

“Stats-magicians” bring truth from darkness to light at CIBS Center. Our EXPERT is Dr. Rameela Raman (e.g. MIND-USA NEJM). Dr. Ayumi Shintani & @jent103 did stats for CAM-ICU, MENDS & ABC trials & BRAIN-ICU NEJM.

#biostats #epidemiology Image
3/ Women in #CriticalCare: #Surgery

Dr. @MinaFaye = bada$$ #surgeon runs CIBS weekly ICU Support Group w @CLG_PhD & 2 major studies: ISOLATE-ICU (COVID isolation on pts & families), RETURN III (VA Merit RCT of Cog-Rehab post ICU). All this & new mom of Milo James!

#heforshe Image
Read 5 tweets
1/ Women in Critical Care:

👍 Just recorded #ISICEM roundtable w @frubulotta @ElisabethWaele @FlaviaSepsis & Dr. Juffermans. 🎥 🍿 on Sept 16th.

Let’s eliminate prejudice based on gender, sexual pref & color. Here is a Baker’s Dozen of Women ICU Leaders!

#heforshe #medtwitter Image
2/ The first woman leader in Critical Care I discussed was Dr. Christina Jones from UK. She is a Biochemist, Nurse, Masters Social Work, PhD in Psychotherapy.

👊Mother of ICU Support Groups & ICU Diaries. As an expert, she shaped our field!

#sccm #esicm #pulmcc #ICUrehap Image
3/ 2nd world leader in Crit Care presented was Dr. Deborah Cook, from McMaster Univ in Canada. Seminal trials in Ulcer Proph, Bioethics, CCCTG trials, and now edifying us about how to provide healing in the dying process through her 3-Wishes Project.
#endoflife #palliativecare Image
Read 8 tweets
1/ CXR Rounds ⏰ #26:
Mediastinum refresher!

See anatomy below. Look at CXR. What compartment is this lesion in?What is the differential dx of lesions in this space?

#tipsfornewdocs #medstudenttwitter #medtwitter #pulmcc ImageImageImage
2/ CXR Rounds ⏰ #26:
CXR on tweet #1 was Adenoid Cystic cancer in MIDDLE + POST MEDIASTINUM. 

You can’t distinguish those two compartments easily on CXR so they go together for Diff Dx! See these other masses below in the same space. What are they?
#radiology #tipsforolddocs ImageImageImageImage
3/ CXR Rounds #26:
First, what is the Diff Dx of lesions in Mid/Post Mediastinum?
Answer: Bronchogenic Cysts. Infxn – Mediastinitis. Neoplasia – goiter, cancer, lymphoma, mets, esophageal CA. CV – Aortic Aneurysms. Traumatic Hemorrhage. Hiatial Hernia
Read 4 tweets
1/ #Sedation & #Delirium in #COVID19:

The cornerstone of best sedation practice in #COVID is not a specific drug. It’s about lightening whatever you use to allow the brain to take over again as captain of the body’s ship.

#medtwitter #tipsfornewdocs #medstudenttwitter #pulmcc Image
2/ Personally, & this is a share of my own weakness, it makes a huge difference when my patient is awake & not sedated. Awake patients immediately become humans with real lives beyond the ICU.

#meded #sccm Image
3/ The outer shell of patients changes in my mind’s eye when they are lying in a drug-induced coma - the person becomes disembodied. I am blind to the person, who doesn’t seem to be with her own body. I know this is a defect in my own abilities as a physician.

#tipsforolddocs Image
Read 5 tweets
Brain 🧠 #COVID19: “F__k Covid”

Am I right?! 😅

To help us teach others causes of #Delirium in our pts & reduce suffering & #PICS, I made these two slides. Use today. Spread the word!

#MedTwitter #MedEd #TipsForNewDocs #A2Fbundle #pulmcc ImageImage
Also if anyone is offended by the F-Covid mnemonic please accept my apology. The original I taught in rounds this week was VOC-DIF but my residents quickly suggested I rearrange the letters. TRUE STORY!! 🤣

#MedTwitter #TipsForNewDocs #laughter #pulmcc
Inventors of F-COVID MNEMONIC:

To give credit where credit is due, Alex Wiles @AlexWilesTweets & John Laurenzano were the two #Vanderbilt #medicine residents who rearranged the letters to “fix” this mnemonic! Thanks guys 😘 ImageImage
Read 3 tweets
1/ Mechanism: Lung + Brain Injury in #COVID19:
In the ICU w/ #COVID we are dealing w/ SEPSIS & ARDS…most of what goes wrong in the human body when it’s infected with SARS-CoV-2 virus is mediated by…

read on...
#medtwitter #medstudenttwitter #pulmcc #tipsfornewdocs #meded
2/ Injury from SARS-CoV-2 virus is mediated by how much swelling (inflammation) and blood flow abnormalities (clotting and bleeding) occur, it’s wise to review what we know about SEPSIS, ARDS, & the BRAIN.
3/ Lung pathology affect parallel disturbances in the brain (& liver) via endotoxin, TNF, hypoxemia, shock & coagulopathy, metabolic derangements, & medical therapy such as the mechanical ventilator itself & sedatives & analgesics.
Read 8 tweets
Happy birthday @SCCMPresident! Look forward to hearing your very timely plenary address @SCCMMW

#SCCMSoMe #SCCMMWC20 #pulmcc #PedsICU #COVID19
Nice #COVID19 timeline schematic from @SCCMPresident @sccmmw #SCCMSoMe
Read 14 tweets
1/ ICU Rounds ⏰: QUESTION for YOU 👇

An #overdose patient admitted to #ISeeYou (deliberate misspelling) is now safe for transfer to floor. Do you bless triage decision & move on to your next pt? Or is there more to your job this morning?

#MedTwitter #tipsfornewdocs #pulmcc Image
2/fin ICU Rounds:

You have 1 shot in helping this person before his transfer. Was medical tx enough or should it include you 🪑down to listen...To prove it’s an “I SEE 👀 YOU”? How do you know there’s not more you can do unless you sit down &👂?

#medicalstudenttwitter #meded Image
P.S. Often rounds are too busy and we have to keep moving. So I jot down 🖊 a ‘to do’ item on my patient list: “go back” ✅
Read 3 tweets
Face Shields & #Covid19: JAMA

20% workers infected when wearing mask @ ~6000 home visits 🆚

0% infected when wearing face shield @ >18,000 home visits to 118,000! Badass!

#medtwitter #meded #pandemic #pulmcc #medstudenttwitter #tipsfornewdocs ImageImage
I really am stunned at how great these masks work. Three times the visits, huge scale, and virtually complete protection out in the field yielding real world #COVID-era safety. So cool. It’s all about the mouth, nose AND EYES 👀!!!

Think 🤔 Wards & Nursing Homes!

#MedTwitter Image
Oops...I meant FACE SHIELDS!! - it’s more than just the 😷
Read 3 tweets
1/ Patient-Physician Relationship: TEN POINTS
As a student & in training, I was told to keep a professional distance from patients, that getting to know them too well would backfire & cause stress if they should die.

#medtwitter #meded #medstudenttwitter #tipsfornewdocs #pulmcc Image
2/ Patient-Physician Relationship: Young Doc vs. Older Doc thoughts…

I heard these warnings & often people mistakenly, in my opinion, used Osler’s advice in his Aequanimitas address as a basis for this ‘sage’ counsel. This meant my patients were victims of my “standoffishness.”
3/ Patient-Physician Relationship: Young Doc vs. Older Doc thoughts…

Later, once I sensed something missing in my service to my patients as their physician, I went back to what I’d learned reading Martin Buber & his brilliant “I-thou” (think “I-you”) treatise on relationships.
Read 10 tweets
1/ Today I was asked by #ATS forum: “Are antipsychotics ever indicated for #delirium in ICU patients?”

My reply: “YES, to control hyperactive delirium symptoms to avoid respiratory suppression...👀 example...

#MedTwitter #MedEd #MedStudentTwitter #pulmcc #TipsForNewDocs
2/ HYPERACTIVE DELIRIUM & antipsychotics

Answer cont: For example, in a patient with CHF or COPD who needs BIPAP to avoid intubation but has marginal BP and HR so perhaps can’t tolerate an alpha-2 agonist. In such patients, antipsychotics might be just the right medication...
3/ HYPERACTIVE DELIRIUM & antipsychotics

Answer help patient get over claustrophobia of CPAP mask. This approach is fine as long AS LONG AS we know we are NOT reducing delirium, rather converting positive sympt of anxiety/delirium into calm toleration of resp support.
Read 5 tweets
1/ ICU QUIZ ⏰:

Our #COVID19 pt last night had worsening ARDS & shock. Hx of kidney failure on dialysis. Started on pressors. Eventually ended up w 3 ways of checking BP. See image.

Question: Why would pressures be so different?

#TipsForNewDocs #MedTwitter #MedStudentTwitter Image
2/fin ICU QUIZ ⏰:

ANSWER: nurse pointed out A-line #1 not correlating w cuff pressure #3. #1 was in wrist below upper arm A-V fistula (steal phenomenon likely falsely lowered BP). So #2 A-Line placed in other wrist = correct BP. Weaning pressors & encouraging prognostically!
Do other #pulmcc docs or #ICU #nurses have other examples of reasons for getting falsely high or low BP readings you can share? Teach us! This was a great pick up.
Read 3 tweets
1/ Families #COVID19: @washingtonpost

With COVID our ICUs fell backwards in time. Consolidation of power within the medical team. Lack of visitation. It’s suppression of healing and it’s wrong.
Op-Ed Link:
#medtwitter #pulmcc #meded @WesElyMD
2/ How do we bring patients and families (safely) into the very foreign world of the ICU with humility, integrity and purpose? How do we share the space?
#patientexp #MedTwitter
3/ Episteme – a principled system of knowledge; scientific knowledge. How can we truly share what we know without family presence? How do we learn what they know?
Read 9 tweets
World 🌎 Brain Death Project – JAMA

We have WAY too much variation in use of DNC criteria for #braindeath.

Standardization must be improved. This publication is SO IMPORTANT & will reduce confusion as seen w Jahi McMath.

#medtwitter #pulmcc Image
AUDIO Highlights re: Brain 🧠 Death 📝

1. JAMA paper is a building block towards consensus & minimum standards.
2. International multidisciplinary effort can help others adopt criteria.

3. LISTEN👂to excellent interview w authors:
Apnea Test - this is a major research question addressed in the paper. What is the right PaCO2? There is arbitrariness around the criteria of >60, but it’s widely accepted and future work must study more.
Read 3 tweets

1. What disease is this? (hint: pt is less sick than 👀 on CXR)
2. What famous CXR sign is shown by these 3 arrows on both?

#MedTwitter #MedStudentTwitter #pulmcc #TipsForNewDocs ImageImage

1. Sarcoidosis
2. This is the famous “123 sign” of sarcoid. Paratracheal + right + left hilar adenopathy.
Quiz - In Sarcoid, what is seen on the biopsy and how do you define it?

Answer: Noncaseating granulomas which are a collection of histiocytes surrounded by a rim of lymphocytes

#TipsForNewDocs #MedStudentTwitter
Read 3 tweets

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