1/ 🎥🧵 How do we test someone for #delirium in #COVID19 or any ICU? When someone won’t engage it can be a huge red-flag for “quiet” delirium, which predicts 3X ⬆️ #DEATH by 6 mo & acquired #dementia. Watch this movie of me testing pt #1 for delirium.

#MedTwitter #NurseTwitter
2/ What does this mean? He starts out OK but then can’t follow my command to squeeze only on the letter A. Instead, he squeezes when I say the word “squeeze” & doesn’t relax his grip or vary it on different letters. This is inattention & a cardinal feature of #Delirium.
3/ 🎥 Contrast Pt 1 with this Pt 2 video of me doing the same test. This person had delirium on earlier days & is now improving. He gets 8/10 correct responses, which means he’s attentive and not delirious any more. This day he walked & talked for the 1st time!

#Recovery #nurse
4/ Here’s a CIBS team member testing another pt (pic w perm). Delirium is not about hallucinations & delusions. Inability to pay attention is the cardinal feature. Pt #1 couldn’t follow my simple command because he was secretly septic & inattention was his 🧠 burglar alarm!
5/ For this test, we recite a letter string (eg, CASABLANCA) & ask the pt to squeeze only on “A” & not on other letters. 8 of 10 correct responses is “attention.” We validated the CAM-ICU in JAMA 2001. It’s now translated in >35 languages & used 🌎 over.

Drowsiness…we just published a meta-analysis of 21 studies (N>50,000 pts) showing reduced arousal had a 6X ⬆️ hospital death rate. This can be the canary in the coal mine for #delirium, which we miss to our pts’ peril 😖!


#MedTwitter #NurseTwitter
It may seem hard to believe that such a simple test can predict such important clinical outcomes($ cost, LOS, death, dementia), yet it’s been shown consistently over & over in trials. For non-ICU pts, the 4AT by @A_MacLullich a fabulous bedside clinical tool for #Delirium.

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More from @WesElyMD

14 Jun
1/🧵 🎥
This week I met an extraordinary #COVID19 survivor who lost both hands, both feet & the tip of her tongue. @ccquad was featured on BBC as WINNER of the Queen’s MBE (Member of British Empire) award. Listen to her #Wisdom & teaching point on #Vaccination.

2/ @ccquad reached out to my #COVID patient, Autumn, who is now also losing her hands + feet & keeps asking me to share her story so all can learn. She went completely deaf as part of her viral sepsis & blood clotting. Her hearing is back & she’s getting koala prosthetics…🎥
3/ Watching these 2 powerful women meet and share their drive & passion is a major gift to me. They define #resilience. Rebooting life & finding the best way forward regardless of obstacles. Here is what Autumn told @ccquad… “I live freely. I live one day at a time…” Image
Read 6 tweets
14 Jun
1/🧵 I’d like to think as a medical community that we have changed & no longer discharge people w/out appropriate follow-up, but just last week I met a #COVID19 survivor who was discharged from the ICU simply to follow up w his primary care physician.

#LongCOVID #PICS #A2FBundle
2/ He couldn’t return to his job, was fired & had no income for his family. That resulted in him not having enough money for medications, gas, or bills. He missed his doctor’s appointment, his electricity was turned off, so he is unable to apply online for disability. 😤
3/ The cycle continues. I usually see these pts when they get septic again & end up back in my ICU on life support.
Read 4 tweets
7 Jun
1/🧵#SEPSIS is URGENT. Here it was caught way too late! Sepsis is marked by WBCs (White Blood Cells) either too high OR too low. If someone’s WBC drops from 14k to 6k to 3k WITHOUT antibiotics, that’s a total catastrophe & usually means death is closing in.👇

2/ So hypothetically (& I’m changing details to make this situation unrecognizable to the real patient my comment is based on)…if a month after a knee replacement someone comes in complaining of NEW knee pain and no fever…

#COVID19 #nursetwitter #TipsForNewDocs #nurse
3/ …with a WBC count of 14,000, scans & xrays not showing an abscess, an infected prosthetic joint is still my #1 Dx unless there is a completely obvious other cause of infection. Said another way, this is sepsis due to an infected knee until proven otherwise.
Read 10 tweets
7 Jun
1/🧵An Epiphany: #delirium treated w touch & eye contact, day by day...his mom cried, “He won’t let us help him shake this damned disease.” Finally his mind cleared. “What matters to you? How can I help?” Slowly, surely, he asked, “Doc, can you help me stop drinking?”💔
2/ #GroundZero. What a privilege it is to witness someone enter a long-awaited epiphany that opens the door to so much recovery. Unfortunately, in my early years as a doc, I thought, “Well, this isn’t critical care, so I’ll move on & let someone else take over.”

#shame on me
3/ But what is a doctor for?

1. To reduce human suffering & heal people where they are.
2. Plus the Latin root is “docere,” teacher.

It’s a dual vocation: healer + teacher. Because of the “Law of the Gift,” I know that the more I give, the more I receive, so…

Read 7 tweets
2 Jun
1/ 🧵Wisdom in Medicine
What’s going on here? And why it’s key in #COVID19
It’s quite simple: we finally had the #wisdom to ask Mr. D the right question! He and his wife encouraged us to use this picture to teach what we learned.
#PalliativeCare #MedTwitter #NurseTwitter
2/ What we learned was to switch the preposition!
Mr. D was a pre-#COVID patient. On this day, he was taken off the vent after a MONTH. The incessant mantra had been, “What’s the matter WITH Mr. D?” He was surprised when we asked, “What matters TO you, Mr. D?”
3/ He has a tracheostomy, as you can see. We insert this airway through the neck to improve #comfort when someone is on a vent well beyond 10 days. He’s more comfortable because he no longer has a tube in his mouth. We used a program called the #A2Fbundle to reduce his #delirium.
Read 13 tweets
1 Jun
1/🧵 AGEISM: Never be discouraged by age AND don’t judge others by age. Chronological age is a bogus constraint in life. I read today of some great examples of iconic people who did crazy cool things after 7 decades of life. See these & realize age is NOT a limitation...
2/ 👏 Major late-life #winners: 👏

#NelsonMandela, president of SA at 75 y/o
#Michelangelo started on St. Peter’s at 72
#GrandmaMoses folk artist sold her 1st painting at 90!
#ArthurMuir just scaled Mt Everest 🏔 at 75 (pic)
#JohnGlenn went into space at 77 y/o!
3/ Bonus 😀: German athlete Johanna Quaas at 86 y/o is the world’s oldest gymnast at age 86. She’s a retired P.E. teacher & started in this sport at age 56.

#NoLimits 🧠

Read 7 tweets

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