Interesting experience at the dentist, with #zentensivist and #healthpolicy lessons.

Had a cleaning a couple weeks ago, she said I had a small cavity worth filling. I went back today to do that.

1/5
She pokes around, makes eyebrows, says let me go look at that X-ray again.

Pokes around some more, pauses for a moment.

“Let’s just leave it alone and watch it.”

2/
I’m de facto happy but also curious about the reasoning. She explains. It makes sense (but not quite enough for me to relate it here).

On my way out I ask her if there’s a billing code for her careful consideration.

Nope. You only get paid if you do stuff.

3/
Imagine the conscious + subconscious influences here:

To face potential embarrassment of having made someone come in “for nothing.”

To forgo payment for time you’ve already spent/dedicated.

When the judgment call is borderline, these things make a difference.

4/
And yet she stays her hand/drill.

Feel inspired to always be so thoughtful in my own clinical decisions.

And also disappointed as ever in what is considered a worthwhile service in “fee-for-service.“

5/5

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More from @sargsyanz

7 Dec 20
As you turned the corner on the second flight of stairs, you felt your breath pull a little deeper, the next one come a little earlier. Your heart said 👋🏼, bounding softly in your neck.

Ten seconds down the hall, all that faded. You were back to mulling some thought.

1/
But hold on. Let’s pause for a minute and retrace the steps.

A lot happened before the extra breath and the tug in your neck caught your attention.

And it’s all so damn cool.

2/
At the foot of the stairs, anticipation of exertion 🔔 and the stretch of muscle fibers 🦵🏽sent a signal to the sympathetic nervous system: start the car.

3/
Read 13 tweets
27 Nov 20
I’m fascinated by the question raised in this great blog post (read first).

“Always address the abnormal vital signs first”

I’m gonna think through some physiologic uncertainties and hope that @smithECGBlog @JSawallaGusehMD @MKIttlesonMD @BCMHeart can help me.

Thread 1/
I’ve always thought of severe hypertension as a cause of increased myocardial oxygen demand. Which makes sense for the SBP (afterload, wall stress)... it’s what the LV is contracting against.

2/
But what role does the DBP play?

Not much of one as far as the LV’s workload far as I can think...

But diastole is when coronary perfusion happens. Applying Ohm’s law in that vascular bed,

DBP - LVEDP = coronary blood flow (CBF) x coronary vascular resistance (CVR).

3/
Read 7 tweets
11 Nov 20
Folks always confuse 1:1,000 vs. 1:10,000 epinephrine, when you're supposed to use which, what the dosing is, etc

Here's what helps me remember/teach.

Thread 1/9 Image
There's two main indications for epi - code blue and anaphylaxis.

1. Code blue is a 1mg IV dose of 1:10,000 epi

2. Anaphylaxis is 0.3mg IM dose of 1:1,000 epi

Shouldn't be that hard to remember... but it is.

2/
There's the route, the dose, and the concentration.

The route is easiest. Think of epi being pushed IV during a code. Think of the epipen people jab into their thigh muscle for anaphylaxis.

1. Code – IV

2. Anaphylaxis - IM

Great, moving on.

3/
Read 9 tweets
1 Oct 20
Descriptive terms are great.

Take “calcific uremic arteriopathy.”

Arteriopathy. There’s a problem with arteries, so you might guess manifestations may be ischemic/necrotic.

1/6
Calcific...

Calcium deposits in the arteriolar walls, usually of the skin, causing fibrosis, thrombosis, obstruction.

Uremic...

This usually happens in the setting of kidney disease and a high calcium-phosphate product, though it’s complicated.

PMID 29719190

2/
Ischemic skin hurts, and necrotic tissues get infected. It’s a very bad disease.

The original (and still most commonly used) name, calciphylaxis, doesn’t tell as much of a story. Where did it come from?

3/
Read 6 tweets
15 Sep 20
+1 for organization/structure as foundation of effective communication.

Learners often struggle with shifting expectations. And teachers sometimes associated highly structured presentations with wordy ones. So I want to emphasize:

Organized does not mean wordy.

1/6
Example: here is a organized and efficient yet thorough presentation. < 1 minute. < 3 tweets.

“Ms J is our lady with HF and DM here with pyelo.

This morning back pain is better, dysuria’s gone. Didn’t sleep well from noise.

Tmax 99.7, BP around 150s, other VS normal...”
“...Looks more comfy, oriented. JV 10cm, lungs clear. CVA less tender.

White count 10 from 16. Chem 7 totally normal. Sugars were 180, 203, 144, 130. Urine with E.coli, sensies pending.

Right now she’s on ceftriaxone, lisinopril, metop, Lantus + prandial, senna, prn APAP...”
Read 6 tweets
10 Sep 20
I agree; there’s a theme there to be explored.

We have a tendency to overcorrect, to gravitate to extremes.

And to get overemotional or snarky when advocating for what we think are best clinical practices.

I’m guilty too. But I think there are downsides.

1/8
First, our own practice & quality of care suffer when we think in extremes and absolutes.

Second, we can communicate oversimplified or wrong messages to learners who don’t have the same contextual knowledge.

Some examples of such misunderstandings...

2/
#NeverFOBT 😡, people say.

What about CRC screening?

What about this stool, which might be blood or food pigment? Or the self-evacuated black stool of a patient who’s on iron or pepto, and is tachy today?

I’d Guaiac that, and change management if overtly + vs -.

3/ Image
Read 8 tweets

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