Nick Mark MD Profile picture
Dec 25, 2021 32 tweets 9 min read Read on X
Doing a coding refresher while my kids were watching a movie, resulted in an epic crossover: Home Alone ICD10

First the title. 3 options:
Z62.29 Other upbringing away from parents
Z60.2 Problems related to living alone
T76.02XA Child neglect or abandonment, initial encounter
1/
The movies opens with household chaos. The protagonist (Kevin) is bullied by his older Brother “Buzz”.

Don’t worry there’s not one but two ICD10 codes for this:
1️⃣Y07.41 Sibling, perpetrator of maltreatment
2️⃣F93.9 Childhood emotional disorder, unspecified
2/
Kevin fears that Fuller (played by his real life brother Kieran) will wet the bed.

You can code this concern from Fuller’s perspective or from Kevin’s:
1️⃣N39.44 Nocturnal enuresis
2️⃣W55. contact with urine of unspecified mammal

3/
Buzz further torments his little brother by eating all his plain cheese pizza. This backfires on Buzz leading to:
🍕R63.2 Excessive eating
🤮R11.10 Vomiting, unspecified

4/
Kevin retaliates against buzz leading to
🥊 Z62.891 Sibling rivalry

(Eagle eyed fans will note that Kevins passport/ticket get accidentally thrown out with the milk stained napkins; this kinda explains how his terrible parents forget him)

5/
In the resulting fracas, Fuller gets smooshed by a chair causing:
👃S09.92 Unspecified injury of nose
(don’t worry he turns out OK, just watch Succession)

6/
The next morning:
F51.12 Insufficient sleep syndrome
Z63.79 Other stressful life events affecting family and household
7/
After rushing to the airport and boarding a flight to Paris, the family realizes they made a terrible mistake:

Z62.0 Inadequate parental supervision and control
F48.8 Psychogenic Syncope
8/
Z63.1: Problems in relationship with in-laws
Meanwhile
Z63.6 absence of family member due to disappearance
Skipping ahead to act 5, Kevin has to defend his house from the Wet Bandits. This entails:
🏠 F02ZBFZ Environmental, Home and Work Barriers Assessment
👨‍🔧Y93.D: Activities involved arts and handcrafts
🔨Z99.89: Dependence on enabling machines and devices, not elsewhere classified.
X95.01XA Assault by airgun discharge, initial encounter
S39.94XA Unspecified injury of external genitals, initial encounter
X95.01XD Assault by airgun 
discharge, subsequent encounter
W00.1 Fall from stairs and steps due to ice and snow 
W00.2XXA Other fall from one level to another due to ice and snow, initial encounter
T45.4X3 Poisoning by iron and its compounds, assault
W92.x18 Exposure to excessive heat of man-made origin, initial encounter, Contact with hot metals
X97 Assault by smoke, fire and flames
L64.8 Other androgenic alopecia
W45.0 Nail entering through skin
S91.331A Puncture wound without foreign body, right foot, initial encounter
Brief aside from grievous bodily injury GIFs to repeat what my dad said to me after we saw Home Alone in theaters: “you know not to try any of this at home right?”
J30.89 Allergic rhinitis due to feathers
Z18.81 Retained glass fragments
R46.1: Bizarre personal appearance
W30 fall involving recreational machinery
T65.6X3A Toxic effect of paints and dyes, not elsewhere classified, assault, initial encounter
T65.6X3D Toxic effect of paints and dyes, not elsewhere classified, assault, subsequent encounter
T63.303A Toxic effect of unspecified spider venom, assault, initial encounter
F40.210 Arachnophobia
W22.8 Striking against object, wall 
Y30.XXXA Falling, jumping or pushed from a high place, undetermined intent, initial encounter
Just when you think Kevin has messed up and been caught, he’s saved by his neighbor Ulysses S Grant:

Z59.2 Discord with neighbors
W27.8 Contact with other non- powered hand tool
Y35 Legal intervention
Z63.71 Stress on family due to return of family
And of course:
S03.02 Dislocation of tooth
Anyway, if you are still here I hope you enjoyed the ICD10 version of Home Alone.

This ought to have been worth 1.0 CME credit

I’m open to suggestions for next years movie

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More from @nickmmark

Oct 13
#HurricaneHelene damaged the factory responsible for manufacturing over 60% of all IV fluids used in the US, leading to a major national shortage.

As clinicians what can we do to about the #IVFluidShortage and how can we prevent this crisis from happening again?

A thread 🧵
1/ Image
There are many things we can do as clinicians to improve ICU care & reduce IVF use.

1️⃣Don't order Maintenance IV Fluid!
Almost no patient actually needs continuous IV fluids.
Most either need resuscitation (e.g. boluses) or can take fluid other ways (PO, feeding tube, TPN).
2/
Frequently if someone is NPO overnight for a procedure, MIVF are ordered.
This is wrong for two reasons.
We are all NPO while asleep & don't need salt water infusions!
We should be letting people drink clears up to TWO HOURS before surgery, per ASA.

3/ pubs.asahq.org/anesthesiology…Image
Read 16 tweets
Oct 1
New favorite physiology paper: Central Venous Pressure in Space.

So much space & cardio physiology to unpack here including:
- effects of posture, 3g shuttle launch, & microgravity on CVP
- change in the relationship between filling pressure (CVP) & LV size
- Guyton curves!
1/

Image
Image
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To measure CVP in space they needed two things:
📼 an instrument/recorder that could accurately measure pressure despite g-force, vibration, & changes in pressure. They built & tested one!
🧑‍🚀👩‍🚀👨‍🚀 an astronaut willing to fly into space with a central line! 3 volunteered!
2/
Image
Image
The night before launch they placed a 4Fr central line in the median cubital vein & advanced under fluoro.

🚀The astronauts wore the data recorder under their flight suit during launch.

🌍The collected data from launch up to 48 hrs in orbit.
3/
Image
Image
Read 16 tweets
Jul 16
The media silence on this is deafening.

Did he have a head CT? What did it show?
Did he have stitches? Tetanus shot?

The NYT ran nonstop stories about Biden’s health after the debate but can’t be bothered to report on the health of someone who was literally shot in the head?
To the people in the replies who say it’s impossible because of “HIPPA”
1. I assume you mean HIPAA
2. A normal presidential candidate would allow his doctors to release the info. This is exactly what happened when Reagan survived an assassination attempt.
washingtonpost.com/obituaries/202…
My advice to journalists is to lookup tangential gunshot wounds (TGSW).

Ask questions like:
- what imaging has he had?
- what cognitive assessments?
- has he seen a neurosurgeon or neurologist?
- he’s previously had symptoms like slurred speech, abnormal gait - are these worse?
Read 4 tweets
Jun 30
You've probably heard "don't give lactated ringers because it raises lactate"

This statement is ~98% false, but there's one crucial practice-changing fact that you need to know.

A 🧵 all about lactic acid and lactated ringers!
1/
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First off, we should ackowledge the obvious: Lactated ringers does in fact contain lactate... 28 mEq/L in fact

BUT there's one little detail to remember:
Lactate ≠ Lactic acid

When we measure "lactate" we care about the ACID (H+) which lowers pH & causes organ dysfunction
2/ Image
But the correlation between pH & lactate is really bad!

Look at this analysis of lactate vs pH in 171 ICU patients.

There is a *weak* correlation in people with arterial lactate > 5, but even w/ lactate =10, pH ranged from 7.5 to 7.05. Quite a spread!

3/ ncbi.nlm.nih.gov/pmc/articles/P…
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Read 10 tweets
Jun 13
If you intubate you need to read the #PREOXI trial!
-n=1301 people requiring intubation in ED/ ICU were randomized to preoxygenation with oxygen mask vs non-invasive ventilation (NIV)
-NIV HALVED the risk of hypoxemia: 9 vs 18%
-NIV reduced mortality: 0.2% vs 1.1%

#CCR24
🧵
1/

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Hypoxemia (SpO2 <85%) occurs in 10-20% of ED & ICU intubations.

1-2% of intubations performed in ED/ICU result in cardiac arrest!

This is an exceptionally dangerous procedure and preoxygenation is essential to keep patients safe.

But what’s the *BEST* way to preoxygenate?
2/
Most people use a non-rebreather oxygen mask, but because of its loose fit it often delivers much less than 100% FiO2.

NIV (“BiPAP”) delivers a higher FiO2 because of its tight fit. It also delivers PEEP & achieves a higher mean airway pressure which is theoretically helpful!
3/
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Read 15 tweets
Jun 12
Results from #PROTECTION presented #CCR24 & published @NEJM.
- DB RCT of amino acid infusion vs placebo in n=3511 people undergoing cardiac surgery w/ bypass.
- Reduced incidence of AKI (26.9% vs 31.7% NNT=20) & need for RRT (1.4% vs 1.9% NNT=200)

Potential game changer!

🧵
1/
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I work in a busy CVICU & I often see AKI following cardiac surgery.

Despite risk stratification & hemodynamic optimization, AKI remains one of the most common complications after cardiac surgery with bypass.

Even a modest reduction in AKI/CRRT would be great for my patients.
2/ From Nature reviews nephrology  https://www.nature.com/articles/nrneph.2017.119
During cardiac surgery w/ bypass, renal blood flow (RBF) is reduced dramatically. This causes injury, especially in susceptible individuals.

But what if we could use physiology to protect the kidneys?

Renal blood vessels dilate after a high protein meal increasing RBF & GFR!
3/ https://www.jtcvs.org/article/S0022-5223(18)33243-4/fulltext
Read 11 tweets

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