5:30 pm.

3rd year of medical school.

Internal medicine clerkship.

Medically “routine” evening discharge.

The patient happened to be homeless.

Tasks my resident gave me to do: make sure the patient had their prescriptions, a place to stay and a way to get there.
First I headed straight to the hospital pharmacy before they closed and picked up the scripts.

Then a taxi voucher from the nurses station.

Quick Google search and printed off 3 shelter options.

All of it went in a bag that we gave to the patient.
The whole thing took maybe 15 minutes.

I can still remember the look on her face when we gave her the bag.

Like she’d been seen and heard and cared about for the first time in a long while.
She was still chronically ill and homeless.

But she had medicine, a place to stay and a way to get there.

And that meant the world.

Students: never underestimate the impact that your small gestures can have on patient’s dignity, comfort and quality of life.

#MedTwitter

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More from @AvrahamCooperMD

11 Apr
1/ 🧵

Why can propofol infusion at high doses cause Propofol-related Infusion Syndrome (PRIS)?

To understand why we have to revisit the old adage of supply and demand.

#Tweetorial #MedTwitter
2/
Propofol is a sedative-hypnotic developed in the 1970s.

PRIS was first described in the late 1980s when several children had cardiovascular collapse and severe bradyarrythmias while on propofol.

🔑They all had received extended, high-dose infusions.

ncbi.nlm.nih.gov/pmc/articles/P…
3/
Subsequent case descriptions found that patients who developed PRIS also had:

❤️Severe rhabdomyolysis and diffuse skeletal and cardiac muscular necrosis
❤️Hypertriglyceridemia
❤️Lactic acidosis
❤️Multiorgan failure

Kids seem to be more susceptible.

pubmed.ncbi.nlm.nih.gov/10759487/
Read 18 tweets
7 Mar
1/🧵
Why does catamenial pneumothorax (pneumothorax that recurs with menstruation) almost always occur on the right side?

Why doesn't it affect both sides of the chest equally?

#medtwitter #tweetorial
2/
Catamenial pneumothorax was first described in 1958.

A woman presented w/ 12 episodes of right-sided pneumothorax over 1 year, recurring monthly w/ menstruation.

Thoracotomy revealed thoracic endometriosis.

pubmed.ncbi.nlm.nih.gov/13598643/
3/
Endometriosis = extra-uterine implantation of endometrial tissue

Mechanisms include:

💡Retrograde menstruation ➡️ abdominopelvic spread
💡Blood/lymph-borne deposition
💡Metaplasia

🔑Retrograde menstruation is considered the predominant mechanism.

ncbi.nlm.nih.gov/pmc/articles/P…
Read 18 tweets
24 Jan
1/15
Why can cefepime cause neurological toxicity?

And why is renal failure the main risk factor for this complication?

The answer requires us to learn about cefepime's structure and why it unexpectedly binds to a certain CNS receptor.

#MedTwitter #Tweetorial
2/
Let's establish a few facts about cefepime:

🔺4th generation cephalosporin antibiotic
🔺Excretion = exclusively in the urine (mostly as unchanged drug)
🔺Readily crosses the blood-brain barrier (so it easily accesses the brain)

pubmed.ncbi.nlm.nih.gov/7785999/
3/
The first report of cefepime neurotoxicity was in 1999.

A patient w/ renal failure received high doses of cefepime and then developed encephalopathy, tremors, myoclonic jerks, and tonic-clonic seizures.

✅All symptoms resolved after hemodialysis.

pubmed.ncbi.nlm.nih.gov/10489256/
Read 15 tweets
3 Jan
1/14
Why do muscles grow in size after weightlifting or other types of resistance training?

The answer is both more straightforward and more complicated than I realized.

Let’s get “swol”...

#Tweetorial #MedTwitter
2/
First, a review of skeletal muscle physiology:

The fundamental unit of muscular contraction is the sarcomere, made up of actin and myosin proteins.

Myosin slides along actin in an ATP-dependent fashion, shortening the sarcomere, inducing contraction.

pubmed.ncbi.nlm.nih.gov/11331913/
3/
Sarcomeres line up in parallel and are bunched into myofibrils.

Myofibrils pack together to make muscle fibers, which comprise skeletal muscle.

ncbi.nlm.nih.gov/pmc/articles/P…
Read 14 tweets
13 Dec 20
1/17
Why do patients with advanced heart failure often develop the Cheyne-Stokes breathing pattern?

To understand this phenomenon we'll have to explore circulatory flow time and the concept of loop gain.

And no this tracing isn't Torsades de Pointes 😉

#tweetorial #medtwitter
2/
What exactly is Cheyne-Stokes respiration (CSR)?

💡This respiratory pattern is characterized by tachypnea and hyperpnea (aka deep breathing) alternating with periods of apnea.

The pattern then repeats cyclically.

pubmed.ncbi.nlm.nih.gov/10228116/
3/
Let's start w/ some history.

CSR was actually first described by the Hippocratic authors (400 BCE).

Observing the illness of a man named Philiscus, it was noted that "his respiration [was] like that of a person recollecting himself, rare and large".

classics.mit.edu/Hippocrates/ep…
Read 18 tweets
3 Dec 20
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
Read 6 tweets

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