WesElyMD Profile picture
20 May, 13 tweets, 6 min read
1/🧵#COVID19 Compassion

Our patient wants to live 3 days to see his grandson graduate. He has #COVID19 pneumonia & is extremely short of breath. He’s chosen NOT to go on a ventilator & is on 100% O2 HiFlow Canula. He’s afraid of tight-fitting a bipap mask.

2/ The intern said, “I never saw a patient whose respiratory rate was twice his oxygen saturation!” Yep, last night his O2 sats dropped to 30% and he was breathing 60 times a minute! By morning he was 85% sat and RR was 28. Better but tenuous.

#TipsForNewDocs #MedStudentTwitter
3/ All of this raises some complicated ethical + treatment questions that I’d like to cover. We addressed this on rounds several times this week & at times it got a bit heated. His #nurse said she noticed herself flushed, mad, and heart rate >130…why?
4/ We have #nurses present their patient on rounds, and she was anticipating we’d disagree with her ideas. #Nurses deserve autonomy and respect. We use the #A2Fbundle format & it takes them ~60 sec. This is well worth trying if you’re aren’t currently rounding like this.
5/ So his nurse compassionately told us that he had great urine output and was on all the right meds, but he was still getting worse, more anxious & out of breath. A Facetime visit w his #family, who are quarantined w #COVID, lifted his spirits a ton. Before that…
6/ Before visiting with his family, he was giving up completely, but now he said, “PLEASE keep me alive to see him graduate! This is worth everything to me.”💥 Family proved better than any anti-depressant. This is the essence of #A2Fbundle & humanism: 👁 the full person.
7/ the 🕰 is ticking: it’s not what’s the matter WITH the patient, but what matters TO him. He told us his immediate goals. 1. Reduce my suffering in whatever way possible. 2. I want to stay alive until graduation. But medical care is maxed out, right?

8/ Treatment Care vs. Comfort Care:

Remember to treat the patient not the numbers. His nurse asked for morphine to ⬇️ his “air hunger.” Early in COVID, she’d been told “no” unless the patient had been converted to full “comfort care.” Is that a hard & fast rule? No.
9/ Narcotics (eg, morphine) dampen the perception of shortness of breath. We give 1-4 mg Morphine every several hours when pts are at end-of-life to keep them comfortable, reduce suffering, and allow death to come peacefully. It is kind, dignified, and humane. What about now?
10/ Such care is not done w intent to end life. We are removing pain and suffering. The principle of “double effect” states that it is ethically sound because any unintended shortening of life that occurs by respiratory suppression from the morphine was not the primary intent.
11/ The Dilemma: Although he doesn’t want heroic measures like CPR, he is still getting lots of active COVID therapies and wants to live long enough to experience his grandson’s graduation in 72 hours over zoom. So can we invoke #PalliativeCare? Yes!
12/ His nurse had the right call. His air hunger had to be mitigated. We prescribed low dose morphine & I felt the nurse idea was right, caring, loving, and smart! We have a primary obligation to reduce his suffering. Period. But we can do that AND help him get to Graduation.
She also asked for an antipsychotic or dexmedetomidine to calm him without suppressing breathing. This combination of morphine plus dex was excellent. He kept breathing & was calm w/out nearly as much suffering. Each day, we will titrate to accomplish his stated goals.

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More from @WesElyMD

17 May
1/🧵This figure from CHEST on early tracheostomy in #COVID19 pts is helpful for 2 reasons: it points out different ways of care. Read the BLUE circles clockwise & then switch to OUTER RED ARROWS clockwise again. Clear and True.


#medtwitter #nursetwitter Image
2/ The #COVID pt with ARDS + Sepsis on a ventilator is TOO often subjected to TONS of sedation, which adds brain injury, immobilization & development of physical disability. NEW DISEASES added to the original problem. We call this Post-Intensive Care Syndrome #PICS. Image
3/ Early tracheostomy around day 10 can help (not always!) as outlined in the RED ARROWS. The goal is to lessen the added injury by waking people up, getting them out of bed and early mobilization plus talking with family. This is done via the #A2Fbundle. @SCCM Image
Read 4 tweets
13 May
1/ 🧵 Mentor-Mentee topic: MEANWHILES
Mentees often tell me they feel stuck in time with no progress in achieving their goals. This is a Meanwhile. As humans, we want to get through meanwhiles, but they are important times of growth. Don’t rush meanwhiles!

Some thoughts…
2/ When I was in college, a mentor taught me about the 3 major types of meanwhiles.

1. Uneventful Occurrence.
2. Unknowing.
3. Not Yet.

Don’t let fear drive you past the riches of these meanwhiles!

Let’s break them down…
3/ Meanwhiles of Uneventful Occurrence:
Tedium is not just OK. It’s necessary. Ordinary times are preparation for fruit to come. Let the grace of your routine establish sustainable balance in your life…one day at a time…in this we grow.
Read 8 tweets
12 May
1/ Steroids in #COVID19?🧵

N=428. In 1 study we go from
1. statistically significant ⬆️ Deaths w steroids
2. to no difference by adjusting
3. to statistically significant ⬇️ Deaths by subgroup phenotyping of inflammation…

All in the same study? Let’s unpack this...
2/ Chen et al built on a 2014 @LancetRM study by Dr. Calfee of 1,022 pts, showing that sick people on a ventilator w ARDS (think #COVID19) are of 2 types, 1 of which is Hyperinflammatory (storm of inflammation) who might benefit from drugs like steroids.

3/ First Chen tried to overcome the biases associated with their observational data & showed that some observational methods (eg, multivariable regression including baseline SOI) can give the exact wrong answer (HR 1.97) because it does not include temporal biases.
Read 7 tweets
11 May
1/ #COVID19’s “Long Loneliness” was exacerbated by our flawed decision to separate pts from family at just the time they needed each other most. @doctor_oxford has captured the sorrow & pleads for us to come to our senses.
#medtwitter #PalliativeCare
2/ @doctor_oxford ✍🏻: “NHS did its best, but too many were isolated when they needed connxn most, leaving a legacy of deep trauma.” No doubt we dropped them “into Hades.” It was done w benevolent intent but in fear. PPE works & we must adjust visitation humanely.

3/ One daughter who lost her dad said, “Even when they told us they were going to withdraw Dad’s life support, no one from the hospital offered us the chance to come in or suggested a video call or a phone call.” This is flat out wrong at every level & we know it.
Read 4 tweets
10 May
1/ Typewriters & Stethoscopes:

Ann Patchett wrote a tantalizing @NewYorker piece on, among other things, tools of the trade. Reflecting on her cherished Hermes 3000 typewriter, my 🧠 wandered to the stethoscope. She ✍🏻


@ParnassusBooks1 @MedBookClub1
2/ “I didn’t need the glasses or silver, things that represented who I thought I’d become but never did, & I didn’t need dolls, which represented who I’d been & no longer was. The typewriter, on the other hand, represented both the person I had wanted to be & the person I am...” Image
3/ “Finding the typewriter was like finding the axe I’d used to chop the wood to build the house I lived in. It had been my essential tool. After all it had given me, didn’t it deserve something better than to sit on a shelf?”

#docswhoread #nurseswhoread
Read 11 tweets
10 May
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
Read 13 tweets

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