Discover and read the best of Twitter Threads about #tipsfornewdocs

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#TipsForNewDocs #medicalpoetry

Hi, BP

Hello my old friend, uncontrolled BP
Seems like every night on call, you call for me
Why a normal systolic goes to 203
Could be hospital medicine's biggest mystery.

95, dementia, in with hip fracture,
Usually a calm sedentary character
BP 190, but see the empty bowel chart
Amlodipine 5 won't help them to start

82, not frail, post laparotomy
Nobody's realised that she can't pee
Bladder distended, wasn't percussed
Amlodipine 5 is simply the worst

Read 7 tweets
Do you manage the renal impact of #covid19 on general wards?

My summarised recommendations on;
✅ Volume status
✅ ACEi
✅ Transplant & dialysis patients

taken from @RenalAssoc, #eraedta, #nephjc & @UpToDate

= lots of relevant info in 8 tweets👇

#medtwitter #covid4mds

✅ Many potential factors;
✔️hypovolaemia due to fever / GI symptoms
✔️sepsis & cytokine release
✔️rhabdo, even without myalgia; check CK!
✔️direct viral tubule invasion?
✅ Low grade proteinuria & haematuria common
✅ Don’t miss ‘usual’ post-renal AKI; bladder scan +- US
Volume status

Assessment not easy at best of times!

Balance of maintaining volume to prevent AKI & avoiding hypervolaemia which impairs oxygenation in ARDS

🟠 UK Renal Assoc - “target euvolaemia”

🟠 Uptodate - “fluid goals conservative as per ARDS criteria” but individualise
Read 10 tweets
Hyperkalaemia treatment

KDIGO have just published their conference conclusions on managing acute #hyperkalaemia so I run through some learning points, some criticisms and the bits I’m not sure about as a renal reg.

#medtwitter #nephpearls #meded
Before we start - why do we care?

Because hyperkalaemia associates with a large increase in risk of death in the next 24 hours.

☠️ mortality not necessarily caused by the hyperkalaemia itself, but can indicate that something bad is happening…
So, the KDIGO conference paper.

Firstly, no one can even agree on the definition of hyperK. What’s up with the Swiss? 4.5mmol/l as the upper limit of normal? Compare this with some values used in research papers.....!
Read 14 tweets
Bit of a different #tweetorial today, on:


- TIPS for the PRIMARY TEAM calling the consult.

Caveat: Some examples are a little #dermconsult specific, but can be extrapolated to others!

#medthread #dermtwitter #medtwitter #meded #FOAMEd #tipsfornewdocs
As both a #dermatologist & a #hospitalist, I have the pleasure of being on both ends of the #consult game.

So, your team has decided to call a consult, and you are the intern or student who has been tasked with contacting the team. Don't be nervous! Try these tips!👇👇👇
First of all:

1)Have a consult question

Asking a consultant to see a pt w/o a ? is like having a pt see you w/o a chief complaint! The ? helps the consultant frame the note in a way that is most helpful for you & your team. Otherwise, I'm guessing at what you want to know.
Read 11 tweets
Last week twitter was unexpectedly keen for renal registrar on-call tips, so here’s round 2️⃣ of kidney #tipsfornewdocs covering iv fluids, AKI, “renal screen” bloods, immunosuppression, electrolytes, DKA in ESKD, peritoneal dialysis, proteinuria, meds & ⬆️BP (thread)
Iv fluids; Renal #tipsfornewdocs 2️⃣ 1/15

✅ 1L 5% dextrose 12 hourly = 50g glucose = 55 skittles. Not same as feeding patient.
✅ “iv fluid for AKI plus furosemide to keep it off their chest” isn’t a thing - commit to goal of wetter or drier.
(specialist use only eg. ⬆️Ca, ⬆️K)
AKI; Renal #tipsfornewdocs 2️⃣ 2/15

✅ In AKI anticipate accumulating meds (eg opiates,insulin) & ⬇️dose before complications
✅ Seeing unobstructed AKI pt, BP/K/pH fine but becoming oligoanuric at 1am despite euvolaemia? It’s OK to watch + wait. Trial by drowning not obligatory.
Read 17 tweets
To celebrate 1 yr of taking referrals as the renal registrar on-call, it’s time for some kidney-themed #tipsfornewdocs covering high K, AKI, “nephrotoxins”, medications, iv contrast, hypertension, & caring for kidney transplant & dialysis patients. #nephpearls (thread)
⬆️K - Renal #tipsfornewdocs 1/18

✅ Insulin-dextrose is not benign (⬇️BM risk) & does not get rid of K (only hides it), therefore rather than give round after round do phone us for help!
✅ Repeat ECG, re-bolus calcium gluconate if persistent changes
✅ Salbutamol dose = 10-20mg
⬆️K - Renal #tipsfornewdocs 2/18

✅ Get a bicarb level (correct acidaemia to help ⬇️K)
✅ No one who can’t name 3 side-effects of bicarb should decide to give bicarb (not a bad rule for any drug!)
✅ Review NSAIDs, ACEi, A2RBs, spironactone, beta-blockers, trimethoprim, diet
Read 20 tweets
Some patients are sick enough to die. They may pull through. They might not.
Say 'sick enough to die' to pt & family. Not 'serious.' Not 'critical.' Not 'unstable.' Name death as a possibility, & plan good #eol care in parallel with current treatment plan.
If your patient is sick enough to die, get support from your seniors &/or pall care team.
Patients who see the pall care team are not obliged to die.
Pall care can help you with parallel planning, support pt/family/staff (you!), in ER, wards or ICU.
A common complaint from families when patient dies is 'we didn't realise s/he might die!'
They are told about sepsis/low oxygen sats/hypotension/poor blood supply to vital organ(s) but this doesn't communicate 'sick enough to die.'
Use your D-words.
Read 5 tweets
Every summer my heart is heavy with memories of a time when I even came close to leaving #medicine-when career & motherhood collided and I didn’t ask for help.

I want to share that story in case it helps even 1 person.(Thread) #medtwitter #meded #womeninmedicine #TipsForNewDocs
I share this now because July is full of #tipsfornewdocs but August comes & we all get swallowed up in the hustle & bustle of heavy clinical loads- when orientation ends and the real work begins.
I had just finished #pediatric residency and started #anesthesia residency with a 6 month old baby. Orientation was over & we were deployed to do our first cases in the OR without an attending always in the room with us.
Read 19 tweets
Follow up a proportion of the patients you see on call - see what happened, see if you made the right call, get feedback if you can. This how you learn.

Dealing with uncertainty - simple tasks may give you pause. We're happy to help, but do try to use BNF, hospital guidelines, oxford handbook to see if you can find the answer before asking your senior.
Dealing with uncertainty pt 2.
Sometimes you just don't know what is wrong with the patient. Take the basic alphabetical approach to assessment and then ask for help.
Read 14 tweets
Hey #tipsfornewdocs #medtwitter folks! I wanted to review side effects of immune checkpoint inhibitors (ICIs) for a non-#oncology audience. Immune-related adverse events (irAEs) present across all medicine specialties so we are all in this together. 1/x
The most common ICIs are against PD-1 (e.g. nivolumab, pembrolizumab) and PD-L1 (e.g. atezolizumab, durvalumab). I use a blanket term “PD-1” throughout. Anti-CTLA-4 (ipilimumab) is a distant second; often in combo or directly after PD-1 in #melanoma #lung #kidney cancers. 2/x
They have led to pharma riches and Nobel Prizes and lots of TV commercials because they work really well for some patients. People with advanced #melanoma, #lcsm etc who used to live ~1 year now can hope to live for several years or more. 3/x
Read 17 tweets
#Tweetorial vs. #UnsolicitedAdviceThread
🤔"What I wish I knew"🤔
#tipsfornewdocs #2wk

I was asked to do a wonderful Q&A during @umnmedresidency's first intern academic 1/2 day

Complied all tips👇

(💪work @Kay_L_Ingraham, @VigneshWP, @PendlKM) with co-panel (@jenwong101)
Before we begin.

Aside from trying to coax you to try twitter for #FOAMed #MedEd ...

Please know👉🏽not every tip will work for every person. Find what works for you!

Don't be overwhelmed
👉 Focus on something new each week or month!
** Audience ?s **

🗝️ Step 3 😱?👉focus on patient care unless you are taking w/in 3 months, just get signed up (it'll be OK)

🗝️ Research?👉focus on patient care and being a wonderful doctor (till spring @ earliest)

🗝️ Reading?👉read to care for your patient's illness

Read 18 tweets
Two oral💊 antibiotics can be used for Pseudomonas aeruginosa👾: Ciprofloxacin (usually preferred) & levofloxacin. Typically, go with the high dose (750mg/dose).
Beta-lactamase inhibitors (clavulanate,sulbactam,tazobactam) broaden activity spectrum of penicillins for MSSA, anaerobes, & more Gram-negatives (not pseudomonas). Sulbactam can be used for its activity against Acinetobacter baumannii. Clav cause > GI side effects
Aminoglycosides active against several MDR Gram -ve but prefer combination (one exception: UTI). Used as adjunctive agent for Gram +ve as it does not penetrate cell wall to act on protein synthesis except when cell wall is opened by cell wall inhibitors (BL/vanco)
Read 13 tweets
Hello #MedTwitter! Inspired by @tony_breu, this is a tweetorial on feeding tube indications, a technique for placement, and how to read the post film. Credit goes to Dr. @AvoArtinyanMD who taught me this technique @BCM_Surgery! @RASACS #FOAMed #Tweetorial @BehindTheKnife
The above is an image from a patient who I placed a tube on, and is being shared with the consent of (and actually at the request of) that patient. She endured 4 unsuccessful placement attempts, but was gracious enough to let me try when I came on to cover overnight-
- a reminder of the incredible courage and resilience of our patients. Which is another tip- whenever you are feeling run down slogging through the endless 80+ hr weeks, just think of your patients. No matter how bad your day is, they are enduring far worse, and deserve your best
Read 23 tweets
With a crop of new interns hitting the wards tomorrow, here are ten (somewhat random) #TipsForNewDocs with a focus on drugs. Feel free to suggest others.

Thread —>
1. Most patients who report a penicillin allergy don’t actually have one. Rather than blanket avoidance, use the history to guide your approach.… by @ericashenoy, @EricMacyMD et al.
2. Not sure why the creatinine is up? Consider drug-induced AIN, and PPIs in particular because of how widely used they are. The presentation is bland and easily missed.…
Read 14 tweets
An ode to #MedEve, and with huge thanks to @karanpdesai for apparently coining the term.
Care to join me for some summer reflections and musings? 1/x
@karanpdesai today is also my birthday, so it coincides with the end of the academic year annually
(I was also born in a teaching hospital, and grew up being told stories of the change over, so I was aware there was something special about 6/30-7/1 before I even chose to enter medicine 2/x
@karanpdesai I tend to be moody, broody, reflective before my birthday each year, which in years past has been magnified by trying to wrap up the end of the academic year, settle out FTE (ie actually work a true 1.0 not more...).
it's been "blamed" on my zodiac sign... 🤷‍♀️ 3/x
Read 13 tweets
History & Physical #tipsfornewdocs

- Where are you from? is a good thing to ask somewhere near the beginning

- When was the last time you felt like your normal self? can help you establish chronology

- Who is your family doctor?
- “I’m going to tell you what I know and you let me know what I’ve missed” can be helpful for the patient who is tired of telling their story over and over

- Ditto for “As far as your medical problems, I know you have XY and Z. Am I missing anything?”
Don’t forget to ask details about PMH

- COPD ➡️ home O2? Prior hospitalizations/intubations?
- CAD ➡️ stents?
- DM ➡️ a1c? Insulin?
- Valve ➡️ type? A/c?
- Coumadin ➡️ dose?
- CHF ➡️ AICD?
- Cancer ➡️ last chemo?

And on and on, etc.
Read 16 tweets
Practice guessing everything:
- what will the troponin be
- how many days in the hospital
- what’s the next CBC
- peptic ulcer or gastric cancer
- lives or dies
This makes you an active participant in the result.

Instead of 7 or 10 it becomes I’m right or I’m wrong.
In time you’ll create a virtual version of each patient in your mind. Some will be destroyed by the truth and facts as they develop.
Read 17 tweets
My approach to family meetings in the ICU & some #TipsForNewDocs I've learned along the way. Here is my approach - - my favorite part is the mandatory interpreter!
Set the stage: invite the right people (HCP, RN), consider ambiance & setup, have a plan w objectives but manage your own expectations! It's work to you, but life & death to the family.

Sometimes the patient's room itself is the best location, esp if they can participate!
✨The Jargonese Interpreter ✨
Empower someone to interrupt you & ask for clarifications before the meeting. "Can you explain what you mean by ventilation?"

We use way more jargon than we think, and the family may not ask for nearly as much translation as is needed.
Read 16 tweets
Thread: Tell me about the good times (#residency)
1/Obviously, so many threads about the tough times in training. Neg experiences, disrespect, fatigue, depression. I began to wonder if I had imagined having a great residency experience. How could mine have been so different?
2/I wouldn't put it past me to have amnesia about the whole thing. So I texted some of my co-residents? Was I seeing things thru rose-colored goggles? Nope-they all said "Great time and Hard Work." Which is what I recall. With so many new interns preparing to start....
3/ Can you share with me some of the good times you remember? Because we surely don't want them all to start a new experience expecting doom and gloom. #MedTwitter #Twitternist #ProudToBeGIM #TipsForNewDocs
Read 8 tweets
1/15 As promised, here is a summary of my presentation from today about “Using Your Phone for Lifelong Learning”

As a note, these slides are all hyperlinked instead of referenced and can be seen in full in the previous tweet.
2/15 We started with our objectives for today. While the topic is huge, we focused on three things that have been instrumental in my education. Twitter, podcasts, and the Human Diagnosis Project.
3/15 I argued that these tools are not only useful, but also necessary! Medical knowledge is increasing too quickly for us to keep up, and using all our technology gives us an advantage at staying up to date.

Read 16 tweets
1/n #Tweetorial: As an Assistant PD for @OHSUIMRes focused on scholarship, #medtwitter, & #hcsm (health care social media), I’m often guide residents and colleagues on how to best use Twitter for academics, networking, learning, etc...
2/n recently, while welcoming newbies (esp students) and “onboarding” them to #medtwitter & #hcsm, I was asked to put together advice for IM applicants on how to best use social media during application/interview season. I think this advice is applicable beyond IM, too.
3/n First, tell me about yourself:
Read 28 tweets
Been thinking a bit about what I’ve learnt in the two years since I qualified as a doctor & what (hopefully, helpful and honest) advice I’d give to brand new medics on the cusp of a career in the NHS - a thread #TipsForNewDocs
1. Being a doctor is the best job in the world. Some days it will feel like the worst, but 95% of the time it’s the best and most rewarding career. I adore the NHS. Be proud of yourself, you’ve worked damn hard to get here.
2. Remembering to say “thank you” on a busy ward at 2pm can earn you a cup of tea at 4am. A sincere “thank you” with eye contact might even get you a cup of tea *and* some magical NHS biscuits on your night shift (the holy grail is NHS toast). Nurses are all-seeing superheroes.
Read 22 tweets
Here’s my small contribution to #TipsForNewDocs - ready? YOU DON’T NEED ANY TIPS. IGNORE THIS THREAD. YOU ARE AMAZING! Remember why you’re here and stay true to yourself. You’ll get the hang of it in no time. And if not, reach out to a friend. #sorrynotsorry #tipoverload
Allow me to explain why you should ignore #TipsForNewDocs, or at least set it aside for now (and I mean no offense to the originators, it’s full of really GREAT tips). Seems to me that this thread attempts to address, and ameliorate, the anxiety caused by 2/x
the transition from student doctor to doctor in training (really not that big a jump if you stop to think about it). But it does so with the unintended consequence of contributing to burnout via imposter syndrome and reinforcing a sense of helplessness. 3/x
Read 9 tweets
In these days at the end of June 22 years ago I began to formulate my internship mantra:

Remove unnecessary motion.

Anything you do must move you towards the goal of completion. You don't "read the patient's old medical record." You "write a summary of the patient's past medical history." Always active, never passive.
When you read a paper or an online summary, seek the answer you are looking for and nothing more, e.g. if you give steroids for alcoholic hepatitis, how long is the course?
When you find the answer, stop reading.
Read 5 tweets

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