1/🧵 Giving & Receiving Advice:

My medical advice is not infallible. Maybe I’m wrong and maybe my patient knows it? Maybe that’s one reason she/he is non-compliant. Even if I am right, it might not be the time in that person‘s life to hear the message.

#selfcare #medtwitter
2/ A pt may seem to be listening & carefully taking it all in. But later that morning she/he may leave against medical advice (AMA). What are we to think when we give our best #advice and others don’t take it? Especially in the medical field?
#tipsfornewinterns #tipsfornewdocs
3/ First of all, of course, unsolicited advice is #criticism. Especially when I’m not with a patient, I try to resist all urges to give unsolicited advice.
4/ At the bedside things are quite different. We are there, all of us in medicine, to treat our patients’ immediate problems and help them steer toward success in the future.
5/ And whenever someone refuses our advice either through general noncompliance or through something more overt like leaving AMA, it may frustrate us. Should it?
6/ Have I erroneously judged a person for leaving AMA or subconsciously thought something negative about their character? 😔
7/ It is common to judge other people’s outsides using our insides. Meaning I don’t know how that person is suffering. I don’t know the power of a substance-use disorder in their lives controlling their thinking and preventing them from doing “the next right thing.”
8/ “Sir, all you have to do is the next right thing.” That's what I told my patient on rounds when he was lying there shaking from drug withdrawal, scared & unsure of how his life was going to go next.

#emotionalhealth #Recovery
9/ It might be better for him to hit rock bottom and so maybe leaving AMA is actually going to help him more in the long run. None of this is for me to understand, and it is certainly not for me to judge.
10/ Of course, I worry that his leaving will land him on the street in a more dangerous circumstance and that maybe he won’t live to be readmitted next time. I think he would have done better had he stayed and received our care. But I don’t know this.
11/ Most importantly, I must remain small and a person of service to the patient and never her or his judge. Never placing the patient as the butt of the joke or even a negative nod of my head as if everyone should listen to me. NOPE.
In this example, addiction ruled the day. I can’t possibly understand what he’s going through, but I can focus on my ability to empathize with his pain and suffering. That’s what I’m left with. How about you?
#medtwitter #nursetwitter #tipsforolddocs
This paper by @RanaAwdish fits this 🧵perfectly…blurb…

“When patients believe they lack control, sense deficiency in self-confidence, or experience repeated authoritarianism, their helplessness can lead to passivity, neglect, loneliness & depression.


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More from @WesElyMD

7 Jul
1/🧵 Addiction is a family disease:

Drinking three 8-packs of Budweiser Nitro Gold daily for 10 yrs takes its toll on the entire family. I told my patient, “All you have to do is the next right thing.” Then…

#MedTwitter #Nurse
2/ His family was very upset when his “next right thing” was to check out against medical advice. I shared a quote from @MalibuMelB (M. Beattie): “Others don’t know what’s best for us. We do not know what’s best for others. Our main job is to determine what’s best for ourselves.”
3/ Terminology: Addiction vs. Substance-Use Disorder…there are many things people can be addicted to besides “substances.” Addictions to things like exercise, love, money, control of others, etc. For this🧵, I am referring to addiction broadly…and how it robs people of joy.
Read 7 tweets
6 Jul
1/🧵Wake-Up to how #SLEEP flushes waste from your brain 🧠 @JAMA_current
I may get more done when I 💤 less, but I lose the long-game! #Evolution dictated that we gain an advantage by spending 1/3rd of our lives asleep.

I’ll tell you WHY? bit.ly/3qPgzAA

2/ Why do we sleep? Brain rest? To process bad decisions or incomplete conversations? Maybe. But the coolest reason is removal of #amyloid & #tau proteins that cause #dementia. Our #glymphatic system does this most efficiently during deep sleep.
3/ Have I mentioned that I’m fascinated by the glymphatic system? It’s the lymph system for our #brain & serves as the “garbage” removal program to keep our #neurons healthy. Wanna know more?
Read 12 tweets
5 Jul
1/🧵COVAX was created to get #COVID19 #Vaccine to ALL countries. Hailed as a “heroic effort to transcend limits of human ingenuity,” it fell short globally because we “rich countries behaved worse than anyone’s worst nightmare.” @TheLancet
2/ At COVAX’s pledging summit, it finally secured US $8B ask for procurement & delivery of #vaccines for 92 eligible low-middle-income countries (LMICs) this year. But even with full financing, the COVAX roll-out is moving too slowly compared to high-income countries.
3/ “Today, ten countries have administered 75% of all COVID-19 vaccines, but, in poor countries, health workers and people with underlying conditions cannot access them. This is not only manifestly unjust, it is also self-defeating”, UN secretary general António Guterres said.
Read 7 tweets
5 Jul
1/🧵Human Error in Decision Making and Judgment:
For those who loved @NobelPrize Laureate’s book Thinking Fast & Slow, there is a new Kahneman book called Noise reviewed @TheLancet. It’s worthy of a bit of commentary…


#MedTwitter #ScienceTwitter
2/In statistics, #NOISE refers to random scatter, ie, variations in our judgment that are NOT caused by individual judgment. #BIAS on the other hand is systematic deviation in judgment.
@nataliexdean @EpiEllie @f2harrell – teach us more & did you read Kahneman’s book yet?
3/ Kahneman himself (see quote in @TheLancet review👆) acknowledges that this book is somewhat data-o-penic. We need much more knowledge about “noise”…it’s a limitation in science at this point. In Medicine, he claims #Psychiatry is an extreme noise factory…@APAPsychiatric
Read 5 tweets
1 Jul
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…
Read 10 tweets
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

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