WesElyMD Profile picture
10 May, 13 tweets, 10 min read
1/ 🧵 What is “Brain Fog” in #COVID19: discussion, papers & pts
 Brain Fog is a non-medical term but it works since it’s what pts describe. Whether in a ward, ICU on a vent, or months later as a #LongHauler w #LongCOVID, they are “in a fog.”


2/ Medically this is #Delirium acutely and #Dementia chronically + various forms of neuropsychological impairment coupled with #depression and #PTSD.
Our paper: go.nature.com/3nU9ZYm
3/ Scientifically, it’s millions of neurons sick, dying or dead. This is depersonalizing & devastating. Fig A shows MRI 3 mos after ICU in pt w/out delirium vs B shows ICU pt w #Delirium. Duration of delirium predicted loss of 🧠 tissue.

Our MRI study - bit.ly/3uxAqFQ
4/ Most brain 🧠 loss following #CriticalCare time is from our frontal lobes & hippocampus, which causes problems with executive function & memory problems. See this previously normal person’s new inability to draw the figure months into recovery.

Paper: bit.ly/3o0l6PA
5/ In #COVID this goes by terms like PACS & PICS (post-acute #COVID syndrome & post-intensive care syndrome). These “worst case” pts are part of the spectrum of brain fog we see in #LongCovid.
6/ One of the #COVID19 pts in @doctor_oxford’s book Breathtaking about @NHS & the #Pandemic is Ken Wood. 2 wks into his ICU experience she writes: “From the moment he was sedated & placed on a ventilator…
7/ @doctor_oxford continues… “Ken has inhabited a lurid world of visions, nightmares, and hallucinatory horror. His brain is running amok.” This #Delirium is caused by the #COVID virus plus other things shown on my F-COVID slide below.
8/ We studied >2,000 #COVID pts & found they suffered ~2 WEEKS of coma/delirium, an epidemic within our pandemic. @LancetRespirMed published our COVID-D study: overuse of benzodiazepines and underuse of family were the main culprits – BOTH modifiable!
8/ This severe acute brain fog is sometimes very harsh. Last week I was rounding in the afternoon with a stellar PA, Ann Marie Harrington at @VUMCLung (pic shown with her permission), and our intubated, delirious patient erupted in his bed, trying to jump out…
9/ Ms. Harrington and I didn’t even have PPE on other than our N95s and goggles. Reflexively and courageously, she bolted into the room and pushed him back down in the bed. There we held him until #nursehero could help calm him.
10/ I am sure that his #COVID19 brain fog made him think we were trying to hurt him or even kill him, when we were there to protect him. The PA bravely did something loving for him that was (we later learned) perceived as unloving. How often that happens in life.
11/ We must face hard truths about #LongCovid in the months & years of recovery ahead. Ask @Dr2NisreenAlwan - ongoing brain fog, which shifts from delirium early & into a dementia-like illness later, is fraught w landmines for family, care givers, and most of all…patients.
#LongCovid brain fog will require patience, hard work, cognitive rehabilitation, rest, counseling, adjustment to a new normal. Anticipating a new #qualityoflife will help bridge the gap between former self & new self, hopefully increasing acceptance & serenity. Get ready!

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More from @WesElyMD

6 May
1/ #Sleep & #Dementia: @NatureComms
Study of ~8,000 people followed for 25 years! Look at the figures. Sleeping <7 hrs per night chronically increases risk of dementia by 30%.  Get your sleep!


#MedTwitter #MedEd #Geriatrics
2/ Sleep and Dementia Risk: @nytimes

@PamBelluck wrote a great article on this NatureComm paper showing heightened risk of #dementia for “short-sleepers,” defined as <7 hrs of sleep a night.


#Aging #Delirium
3/ What’s the Mechanism?

Our brain’s “trash” clearance (like the body’s Lymphatic system but by brain’s “glial” cells & called Glymphatics) kicks into ⬆️ gear in sleep. So less sleep is like your waste management system going on strike. Kapische??

REF: bit.ly/3eQxtte
Read 5 tweets
3 May
1/ 🧵A picture is worth 1,000 words 👁 #COVID19:

This 🎥 shows a clear example of what can happen to a person’s body w #COVID. His wife asked me to show it on twitter & urges everyone to get #vaccinate

(w/ consent of pt & wife)

#MedTwitter #NurseTwitter #CriticalCare
2/ You’ll notice his eyes are swollen shut. (Written perm to show). This is not fluid. It’s AIR from inside his chest leaking out his lungs 🫁 through muscles & skin to his neck & into his face. He is AWAKE & communicating but had ICU #delirium earlier.

#MedStudentTwitter #Nurse
3/ Look at his chest CT. See the “L” lungs w #Covid pneumonia/#ARDS & also AIR leaking out under his skin. Now go back to 1st tweet & watch 🎥 again. This is called “barotrauma” & happens when the 🫁s get too stiff and pop. Difficult situation. We’re hoping he can heal!

Read 5 tweets
29 Apr
1/ End of Life in #COVID19...
yesterday I was removing life support from a patient, according to his wishes as stated by his wife, to convert the goals of care to comfort measures only. I took some time in the room alone with him & considered...
@pallipulm #palliativecare
2/ just for a moment all the very difficult & also excellent things that happened in my own life that no one else understood. Then I looked at my patient & realized he had just as many highs & lows that only he knew. Here was an infinite treasure of a person...
#MedTwitter #Nurse
3/ and the actions I was about to take would allow his life to come to a peaceful natural end. I committed to do everything I could for him to make sure he didn’t suffer as he sauntered out of life. What a privilege & honor to be allowed to enter into the miracle of him...
Read 7 tweets
28 Apr
Extra-Bad Blood🩸Vessel Dz in #COVID19:

1. Immunogenic HITT (heparin-ind thrombocytopenia & thrombosis) NOT from heparin but #Covid itself. Bilateral arterial clots.

2. TSS (toxic shock synd) + #COVID - nightmarish clotting in legs/arms = like burns

#MedTwitter #Nurse #Vaxx
1/ Since others asked, our diagnosis of “spontaneous immunogenic HITT” was made by positive HIT ELISA (an immunoassay) showing the presence of anti-PF4 IgG antibodies even though he had not been (past or present) on heparin. This in setting of #COVID19.
2/ He also had an abnormal functional assay of platelet-activating capacity of PF4/heparin-Ab complexes, though there are slight differences in results of his assay vs. typical HIT. He now has 2 problems (#COVID & HIT) causing potentially life-threatening arterial thrombosis.
Read 4 tweets
19 Apr
1/ #Mentorship 🧵

This woman is my #mentor (pic w perm). Joan W Bennett. She’s in @theNASciences as geneticist & mycologist. Today we are at the Parthenon in Nashville TN where after 35 YEARS, she still provides me council…


#MedTwitter #Sciencetwitter
2/ Dr. Bennett taught me that mentorship is not a job w an endpoint. She assumed this role IN my life FOR life. Today we talked as much about parenting as science. We are in each other’s front row. This is the depth of a true mentor-mentee relationship.
#MedEd @theNAMedicine
3/ Like any relationship, there must be chemistry & connection. If you don’t have that w a “mentor,” maybe you have the wrong person. Build a relationship not a business arrangement. It’s also NOT just a trajectory to promotion. #Mentorship is “whole” person care & development.
Read 11 tweets
14 Mar
1/ Do data support pt trial off sedation for “SAT” when pt is comfortable on current dose? Yes
Shared w permission:
“Dr. Ely, yesterday our ICU #nurses went over #A2Fbundle in Epic for implementation. Do you recommend SAT at RASS Goal of RASS -1 to +1?
#medtwitter #criticalcare
2/ Excellent #Nurse added:

“We are currently not doing SAT (Spontaneous Awakening Trial) but keeping pt’s RASS -1 to +1.  Just want to make sure we are interpreting #A2Fbundle correctly.”
#medstudenttwitter #COVID19 #pandemic
3/ my Answers:

Great questions. I don’t think +1 (anxiety) is ever a good goal but 0 to -1 is a 👍 default target RASS if we acknowledge there are times when sedation target should acceptably be set as deep as -3/-4 in bad #ARDS or -5 transiently when pt requires paralytics.
Read 8 tweets

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