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Nick Mark MD

@nickmmark

Jan 7, 2022 • 11 tweets • 7 min read • Read on X

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https://twitter.com/nickmmark/status/1479340577854398466

As someone who has dedicated a lot of time to studying and making #dataviz, let me explain why I dislike this NYT COVID graphic so much.

1/

https://twitter.com/nickmmark/status/1479340577854398466

It’s not that it’s a spiral - one of my favorite types of graphs is the Condegram spiral. (Named after Mark Conde)

It’s used in astronomy/meteorology to show changes the Earths magnetic fields (Kp index) & is used to visualize space weather.

2/

Another awesome spiral graph - and one of the best examples of #dataviz ever IMO - is the Rose plots by Florence Nightingale.

These 1858 plots show the causes of mortality in Crimean war & make a compelling case that for improving conditions (particularly shelter in winter).
3/

I also really like circular or spiral dendrograms. Take a look at this beautiful 🌀 graphic showing the evolution/domestication of yeast.

4/

So if I like 🌀graphics so much why do I viscerally dislike this NYT COVID spiral?
5/

The beauty of Nightingale & Conde’s spirals is they show *granular* data. You can clearly see the sudden changes in deaths or solar activity.

The NYT graphic *averages* the data - this makes it look smooth but it also makes the surges in cases more subtle & harder to see.
6/

Another problem is how the NYT graphic plots cases: above & below the spiral.

Compare to the Condegram, which only goes above the spiral.

Humans are better at perceiving height than width. Just look at these two lines of identical length. Which case is easier to discern?
7/

To illustrate this point: Compare the NYT COVID spiral to the same data presented linearly.

Is it obvious that the green🟩line is more than twice as wide as the blue 🟦 line?
8/

Bottom line: this plot from the NYT distorts the data through unnecessary smoothing & plotting on both the inside & outside of the spiral. This has the effect of making it hard to see the true increase in cases. A missed #dataviz opportunity.

9/9

As a bonus - here are few more of my favorite spiral #dataviz:

A 1850 plot by William Farr showing a (spurious) relationship between temperature & cholera cases in London. Correlation doesn't equal causation but it's still a compelling spiral graphic.

Not a spiral but another of my all time favorite ID dataviz examples: a plot showing polio cases in the US from 1931 to 1955.

Look how it combines granular data from each state/each week, along with monthly averages, and a heatmap for emphasis. 😍

journals.plos.org/plosbiology/ar…

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More from @nickmmark

Nick Mark MD

@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/

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…

Read 16 tweets

Nick Mark MD

@nickmmark

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/

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/

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/

Read 16 tweets

Nick Mark MD

@nickmmark

Jul 16

https://twitter.com/matt4va/status/1813202802337779731

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?

https://twitter.com/matt4va/status/1813202802337779731

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

Nick Mark MD

@nickmmark

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/

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/

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…

Read 10 tweets

Nick Mark MD

@nickmmark

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/

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/

Read 15 tweets

Nick Mark MD

@nickmmark

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/

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/

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/

Read 11 tweets

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