we need to talk about a really painful topic - deaths of essential workers & what we can do to prevent them. this discussion is often framed in terms of physicians or healthcare workers, but it applies to *all* essential workers (grocery store clerks, janitors, etc). (1/5)
with COVID there is a natural tendency towards denialism. bad things happened in China and Italy, but they won't happen here. this leads us to behave in a reactive, rather than pro-active fashion. we end behind the virus, struggling to catch up. (2/5)
it is increasingly clear that many essential workers will become infected and die. this site catalogues a shocking number of healthcare workers who have died so far. prompt action is needed to prevent this list from growing further (3/5) medscape.com/viewarticle/92…
more & better PPE is the most important intervention needed. unfortunately, the reality is that this problem cannot be fixed overnight. maximal effort is needed on this front, but shortages are still likely to occur (4/5) #GetMePPE
another intervention which needs to be immediately considered is identifying high-risk people and minimizing their exposure. this may not be feasible during disease surges, but it should be pursued to the extent possible. (5/5)
(pre-print: bit.ly/2RF4Kgn)
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how to place a consult: you MUST understand the five stages of consultant grief.
once you can understand this painful and natural process, requesting consults will make a LOT more sense
buckle up, it can be a little rough…
🧵 1/6…
stage 1: denial
- You dont need a consult.
- You called the wrong service.
- 18 years old? consult pediatrics
- I’m not actually on call now
- Everything’s fine, just walk it off…
stage 2: anger
- you should have consulted us earlier/later
- you should have checked this test before calling us
- you’re a terrible doctor/student/human being
this is much better than MINDS (which contained ~90% hypoactive), but probably still not ideal.
(at this point, does anyone actually think that haloperidol helps with hypoactive delirium ??)
other than dilution of the patient population by patients with hypoactive delirium (who are unlikely to benefit & might conceivably be harmed by over-sedation), the methodology seems pretty solid.
I think it's time for a difficult discussion, folks.
Let's talk about CSF lactate 🫣
CSF lactate has been shown to be *superior* to traditional CSF studies in sorting out viral vs. bacterial meningitis in several studies & meta-analyses...
a subset of patients with viral meningitis will initially have a *neutrophilic* pleocytosis.
this can lead to unnecessary admissions & antibiotics
some patients are subjected to repeat LPs 😩
a low CSF lactate could avoid all of this, allowing patients to go home from the ED
CSF lactate measurement is recommended in guidelines from the United Kingdom, Europe, and France.
(it's not recommended in the ID society of America guidelines, but they're from *2004* and require revisions)