In the Intensive Care Unit we're used to taking care of sick patients.

We do it all day, every day. So why is #COVIDー19 any different?

It’s the silence and the volume.

THREAD 1/5
Sure, there are sounds in the ICU.

The donning and doffing of PPE like rustling leaves. The muffled chirp of a ventilator alarming behind shut doors.

But there’s less chatter amongst the staff now. No families. No lingering in the doorway of a patient on the mend.

2/5
And the silence spreads as more and more sick patients come.

Like a tidal wave slowly cresting, a volume of patients beyond that which any of us have ever seen. 

More ventilators. More drips. More silence.

3/5
ICU beds are scarce. One opens up but it’s claimed within minutes and soon filled.

Filled by grandmothers and grandfathers and sisters and brothers and sons and daughters and mothers and fathers.

Many in shock, confused, in multi-system organ failure. All severely hypoxic.

4/5
But we know more patients are coming.

Thanksgiving happened. And Christmas and New Years will happen. And bars and restaurants and play dates and dinners with friends.

Outside the ICU, outside the hospital, there’s so little silence.

Not nearly enough silence. 

5/5
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More from @AvrahamCooperMD

14 Nov
1/13
Why does cilantro taste and smell so delicious to some people but like soap (or worse) to others?

Personally, I love cilantro. 🌿

Some folks can't even be around it. 🧼

Why?

#tweetorial #medtwitter
2/
The disagreement about cilantro - whether it is delicious or disgusting - is nothing new.

Pliny, the 1st century Roman naturalist, referred to it as having "cooling and refreshing properties". 

bit.ly/3ebhtRC
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Conversely, John Gerard, a 16th century herbalist, called cilantro (aka coriander leaf) a "stinking herb with venomous quality".

His French contemporary, Olivier de Serres, said it "smells like stinkbugs". 

Are we even talking about the same plant?

online.ucpress.edu/gastronomica/a…
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27 Oct
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Why doesn't daptomycin treat pneumonia?

The answer also explains why dapto raises serum CK levels.

#medtwitter #tweetorial
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First let's establish that daptomycin (bactericidal against gram positives) lacks efficacy in treating lung infections.

⚡️ In this study with mouse lungs, daptomycin didn't reliably kill strep pneumo or MRSA, even at high doses of the drug.

pubmed.ncbi.nlm.nih.gov/15898002/
3/
What about lung infections in humans?

Compared to ceftriaxone,  daptomycin had lower cure rates for treatment of community acquired pneumonia (CAP).

pubmed.ncbi.nlm.nih.gov/18444848/
Read 14 tweets
3 Oct
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What is the mechanism of brain freeze?

Why do some people (myself included) get piercing headaches when eating cold food or drinks while others are totally unaffected?

#medtwitter #tweetorial
2/
Brain freeze, formally known as cold stimulus headache, actually has a diagnostic classification:

Transient frontal, temporal, or occipital headaches caused by passage of cold liquids or food over the palate and posterior oropharynx.

pubmed.ncbi.nlm.nih.gov/29368949/
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The first question that I had was how common is susceptibility to brain freeze?

I asked #medtwitter what percentage experience it and 82% said they do.

Read 19 tweets
12 Sep
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Ever wonder why eosinophils vanish from the blood after exposure to steroids?

I assumed that steroids somehow destroy them and that is why they disappear.

But there's a lot more going on.

#tweetorial #medtwitter
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First let's review eosinophil biology.

Eosinophils are granulocytic white blood cells that develop in the bone marrow and reside primarily in tissues.

They have a multitude of physiologic functions, from parasite defense to immuno-regulation.

pubmed.ncbi.nlm.nih.gov/31977298/
3/
In the 1970s the effects of steroids on blood eosinophil levels were first studied.

🔑 Prednisone led to marked declines in peripheral eosinophil counts within 4 hours.

(bonus: the senior author on this paper was Dr. Anthony Fauci!)

pubmed.ncbi.nlm.nih.gov/313411/
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28 Aug
1/
Why does albuterol induce a lactic acidosis when given in high doses?

This can occur even as patients with severe asthma exacerbations are improving in every other way.

#medtwitter #tweetorial
2/
The first observation that β₂ agonists could produce lactic acidosis came in the early 1980s.

Terbutaline (a β₂ agonist like albuterol) was given as a tocolytic to 6 women in preterm labor. Their serum lactate levels rose within a few hours.

pubmed.ncbi.nlm.nih.gov/7315890/
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By 1985, the first case report of lactic acidosis from inhaled β₂ agonist therapy for status asthmaticus was published.

The patient's acidemia persisted despite normalization of PCO₂, and a new anion gap emerged.

💥Her lactate level was 7.

pubmed.ncbi.nlm.nih.gov/4033719/
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8 Aug
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Why can furosemide improve dyspnea/pulmonary edema from acute congestive heart failure within minutes of administration?

The answer does not involve diuresis.

#medtwitter #tweetorial Image
2/
Furosemide (aka Lasix) was introduced as a loop diuretic in 1964.

It was soon observed that treatment of pulmonary edema w/ furosemide led to rapid improvement in dyspnea, sometimes before diuresis.

The mechanism of this effect was unknown.

ncbi.nlm.nih.gov/pmc/articles/P… Image
3/
The first clue as to why came in a subsequent study in 1973.

It was noted that left ventricular (LV) filling pressures ⬇️ within 5 minutes of administering furosemide to patients w/ heart failure.

pubmed.ncbi.nlm.nih.gov/4697939/ Image
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