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Nick Mark MD Profile picture
@nickmmark
Mar 21, 2020 • 3 tweets • 2 min read • Read on X
Brilliant. I think this idea really has legs. If we can move the vent controls outside the room we can check/adjust ventilators without consuming PPE. Combine this with moving IV pumps to the hall and we may reduce ICU PPE consumption by 50%. #innovation #covid4MDs
Calling all #RespiratoryTherapist For which ventilators is it possible to separate the control unit from the ventilator? What type of extension cable is needed? Let’s #crowdsource these extensions. This is an effective low tech way to conserve PPE and save lives. #covid4MDs
Looks like this is the connector we need. Anyone know if these are widely available? Image

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More from @nickmmark

Nick Mark MD Profile picture
Jan 27
Damn. Under Trump the White House Medical Unit was a pill-mill. Thousands of ambien & provigil per month.

Worse, for a clinic that doesn’t typically do procedures w/ moderate sedation they sure are they ordering prodigious quantities of morphine, fentanyl, versed, & ketamine…? Image
Honestly, this reminds me of Norman Ohler’s Blitzed.
The AG report was largely concerned with the enormous cost of prescribing these non-genetic meds.

It’s worth pointing out that dispensing prescription meds without documentation is malpractice. In the case of controlled substances it’s also likely a crime.
Read 8 tweets
Nick Mark MD Profile picture
Oct 28, 2023
It’s October - hockey season - so let’s talk about a hockey/pulmonary case:

A previously healthy 17yo presents with dyspnea, frothy sputum, & orthopnea that began after playing hockey.

In the ED he is tachycardic, tachypneic, mildly hypoxic. He has crackles bilaterally.

Dx?
1/ Image
Before we get to the diagnosis, Inhalation of which of the following could explain his symptoms?

2/
The answer is ZAMBONI DISEASE!

Poorly maintained combustion engines produce carbon monoxide (CO), nitrogen oxides (NO₂), & other volatile organic compounds.

These compounds are heavier than air.

To avoiding melting the ice, there is often minimal ventilation in ice rinks.
3/
Read 10 tweets
Nick Mark MD Profile picture
Jun 19, 2023
Lots of inane comments from Elon/Rohan bros that vaccines don’t prevent disease.

Let’s debunk these claims:
1. Polio - vaccine introduced 1957
ourworldindata.org/grapher/report…

2. Measles - vaccine introduced 1963
ourworldindata.org/grapher/measle… ImageImage
3. Tetanus - vaccine 1938
cdc.gov/vaccines/pubs/…

4. Diphtheria
researchgate.net/publication/32… ImageImage
5. Hepatitis A - 1996
cdc.gov/mmwr/volumes/6…

6. Hepatitis B - 1982
cdc.gov/mmwr/volumes/6… ImageImage
Read 6 tweets
Nick Mark MD Profile picture
Jun 8, 2023
The long awaited #COVIDOUT RCT is now in @TheLancet:
- high risk adults randomized to either metformin (MET), ivermectin (IVM), fluvoxamine (FLV) or placebo.
- MET reduced the risk of long COVID (6.3% vs 10.4%; NNT = 24)
- no benefit with IVM or FLV

thelancet.com/journals/lanin…
1/ ImageImageImageImage
COVID-OUT was a large blinded multicenter RCT looking at repurposed oral meds.

The primary outcome was severe COVID; this was one of the *MANY* negative RCTs of ivermectin. (See 🧵👇)

The current study is a planned secondary analysis, looking at the incidence of long COVID.
2/
COVID-OUT was a factorial design enabling efficient evaluation of multiple oral medications in various combinations.

After diagnosis, subjects received meds by next day mail. They were followed up to 300 days (10 months).

Diagnosis of long COVID was made by a synonym survey
3/ ImageImageImage
Read 9 tweets
Nick Mark MD Profile picture
May 28, 2023
Pulmonary teaching case: you are called to the bedside of a 60yo man who was admitted for pneumonia a week ago. You were called because “he coughed and now his chest is PULSATING!”

This is what you see at the site of a previously removed chest drain:

What’s the diagnosis?
1/ twitter.com/i/web/status/1…
This is Empyema necessitans (EN):

EN is a rare complication of an infected pleural effusion where purulent fluid “escapes” the pleura and erodes into the chest wall, causing an extrapleural fluid collection that communicates with the pleural space.

From @Radiopaedia:
2/ twitter.com/i/web/status/1…
Because Empyema necessitans communicates with the pleural space, fluid can move back & forth with respiration, as seen here:

With inspiration, negative intra-thoracic pressure pulls the fluid into the chest. With expiration, positive intra-thoracic pressure pushes fluid out.
3/ twitter.com/i/web/status/1…
Read 7 tweets
Nick Mark MD Profile picture
May 25, 2023
Interesting RCT in @NEJM about platelet transfusions prior to CVC placement in people w/ thrombocytopenia (Plt 10-50k):
- higher rate of grade 2-4 bleeding w/o Plt transfusion: 11.9% vs 4.9%
- difference driven by much more bleeding w/ subclavian lines
nejm.org/doi/full/10.10…
1/ Image
This trial enrolled n=338 hospitalized people in 🇳🇱 with platelets between 10-50k, INR <1.5 (changed to 3.0). 57% were heme/onc patients & 43% were ICU patients.

Median Plt count was 30k

Most were getting a CVC for chemoTx. (Most weren’t exactly your “typical” ICU patient.)
2/ ImageImage
Importantly they placed the CVC within 1 hour or randomization. This means they probably didn’t transfuse then place a line, more like placed a line while transfusing.

(IMO this difference matters in situations where platelets are dysfunctional, like uremia)
3/ Image
Read 7 tweets

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