1/ Serious End-of-Life 🧵

…He told her, “Never give up on me because I’ll keep fighting to live.” What does it mean when a person valiantly asks this of a spouse & then illness leads to #transplant, #infection, and eventually #life support that doesn’t help?
2/ First I just listened to her heartache and saw their immense love. “I made a #promise, Doctor.” My personal commitment became to help this couple uphold that promise, yet medical options had long since run out & failed him. I asked her to come into the hall.
3/ Always go out outside a pt’s room to discuss anything you don’t want the patient to hear, even when he is in a dense coma. Assume dying pts hear everything said & respect their dignity as your number one goal in all interactions. Here is what I said…
4/ “You made a promise and you have kept it. You as a couple are an inspiration to me. You told me your marriage was a sacrament and what I see is two people living that out in the most beautiful of ways. What you & I need to do now is face the truth of where he is in his life.”
5/ I listened and asked her more questions about her thinking. I let her unspool as she wished…
6/ Then I replied: “He asked you never to give up, and you didn’t. He did NOT ask you to deny the truth and to use technology even if it had failed to help him. That is what has become very clear in the past several days.”
7/ I listened some more. Then…
8/ “We all hope to get clear messages in life about our most important decisions. It’s so helpful how clear this message has become. A blood pH below 7 that drops further, despite all our best efforts, makes it easy to understand that we must not deny what is happening.”
9/ “What I want to do is help you finish keeping your promise: Never to give up on him. Today that means staying faithfully at his side as he is dying. You can make courageous and benevolent decisions. You will not leave him, and we will not leave you or him. We are together.”
And so it goes. “Never give up” does NOT mean to keep machines going. It means to see life through to its natural end, which in this case was peaceful and right. We must help each other face the truth of where each person is…upholding service, love, and covenant.

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More from @WesElyMD

30 Jun
1/🧵🎥 Hepato-Jugular Reflux (HJR)?
Neck Veins tell us a lot about how much fluid people have in their body. Look at this video & you’ll learn a trick doctors use that tips us off about blood volume! (Movie w perm)
#medtwitter #nursetwitter #TipsForNewDocs #TipsForNewInterns
2/ My patient had kidney failure & too much fluid, making him short of breath. I press down over his liver & watch his neck veins pop up (or not). When they do, it correlates w high pressures in the heart from too much blood volume.

3/ Another way of seeing this is the CXR (see pic). This simple measurement from a vein to an artery called the Vascular Pedicle Width (VPW) also tells me the heart pressures are too high. His VPW is 84 mm and > 70 is way too much. So he needs to pee a LOT!
Read 5 tweets
29 Jun
1/🧵What do CONDOMS have to do with the #COVID Vaccine?
The Pelzman Effect is currently threatening societal safety.

What is it & why is it important? Let’s unpack.
#MedTwitter #Pandemic
2/ The #vaccine, heralded as a panacea to the pandemic, risks further weakening adherence to other safety measures like social distancing & masks 😷. When people respond to safety measures with a compensatory ⬆️ in risky behavior, it’s called the “Peltzman Effect.”
3/ Example: medications allowing HIV preexposure prophylaxis (PrEP) dramatically lessened risk for HIV transmission AND were associated with decreased use of condoms, higher numbers of sexual partners, & more STDs. 😤
Read 11 tweets
28 Jun
1/ 🧵🎥 Chronic Pain

#Pain comes in all shapes & sizes. Let’s explore how we process pain. Watch & Listen to what Anderson Cooper tells Stephen Colbert about #grief and #suffering: “You can’t have happiness without having loss and suffering.”
2/ My lucid & kind patient (pic w written perm) uses scalding water as a coping mechanism for abdominal pain from pancreatitis. He wants to share his rationale.

#MedTwitter #ChronicPain #nurse
3/ Before I share what he told me, I first want to make my mindset as his #physician clear: My first job is to believe in him. Then to understand him. Then to devise a plan to help him.
Read 13 tweets
21 Jun
1/🧵How do we overcome #vaccination hesitancy?
#COVID19 ICU pts & #LongCOVID survivors tell me they wanted to get #Vaccinated but had immense pressure from family/friends NOT to…All but 1 said, “I should have protected myself & stayed safe.”

What’s our best approach? Read👇
2/ A significant portion of Skilled Nursing Facility (SNF) Staff remain #unvaccinated. Early data: bit.ly/3gOdSLi. Reasons include mistrust of govt & big pharma, potential side effects, and racism. Staff’s close contact w pts makes it essential to study their reasoning.
3/ N=193 staff from 63 Skilled Nursing Facilities (SNFs) were studied. The best way to overcome misinformation on #Vaccination from social media is to model specific scenarios & prepare positive approaches, NOT guilt or shaming. Let’s look at specifics…

Read 9 tweets
21 Jun
1/ Imatinib for #COVID19: @TheLancet

This study of N=385 ICU pts tested a Tyrosine-Kinase Inhibitor vs. Plac for 9 days. It’s important because it did NOT decrease ventilator or oxygen needs BUT reduced death at 28 days. What does this mean?


2/ This study is technically “negative” because it didn’t hit the primary endpoint scientists “guessed” ahead of time as best choice to see if the drug works in #COVID: time to stopping ventilation & O2. Importantly, we sometimes GUESS WRONG! Next let’s look at other endpoints!
3/ This drug stops lung & blood vessel membranes from going haywire. It did not have safety problems & decreased DEATHS by ~50%, TIME on VENT by 5 days, length of ICU stay a WEEK, #delirium by 5%. These are huge improvements that I would want if I had #COVID. ( Fig 2, Tab 2/3)
Read 6 tweets
16 Jun
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
Read 7 tweets

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