WesElyMD Profile picture
Sep 12 11 tweets 6 min read
1/🧵🎥 How do “Dominoes of life” fall in critical illness⁉️

A pt arrives awake & talking but vomiting. In just 8 hrs he nearly dies of sepsis 🤯

Lung & kidney failure, heart attack, coma.

How can this happen & can we save him?

This🧵can help us understand the “arc of illness”
2/ His disease is Ascending Cholangitis

A gall stone lands in his common bile duct

📍Pain & vomiting
📍He’s admitted to the ICU
📍GI performs an ERCP to place a stent, bypass the stone, drain pus & control the source of sepsis
📍Add fluids & antibiotics
📍But he gets worse
Why?
3/ We bypassed the septic source (stone) & drain the pus, but dominoes were already falling.

Bacteria had gotten into his blood.

Too much inflammation & capillary blood clotting occurred, just like in COVID.

What happens when “cellular” dominoes start to fall uncontrollably?
4/ Our bodies can’t work well without blood & O2.

His BP dropped (shock) & didn’t perfuse his vital organs, so his heart, lungs, kidneys, brain went down.

CXR👇shows a catheter in his heart to measure pressures.

NOTE: Not everyone so sick needs a ventilator (no ET tube on CXR)
5/ We found his “WEDGE PRESSURE” initially to be >20mm Hg, which is very high & indicated his shock was not purely septic.

Indeed, his Troponin peaked at a whopping 77.

A heart cath showed clean coronaries.

This was a stress-induced heart attack, not blocked arteries.
6/ Here is a good one-pager to learn about the Swan Ganz Catheter and right heart catheterization.

It’ll tell you what different measurements mean.

In his case, we used norepinephrine, vasopressin, sedation with dexmedetomidine & a little fentanyl.
7/ While he was in multi-organ dysfunction…

☑️ Our focus on the #A2Fbundle kept #humanism at the forefront of our game plan
☑️ Awake/alert, light sedation, mobilizing, family
☑️ We kept his daughter at the bedside
☑️ She helped him through a 48-hour period of #delirium
8/ Sepsis care today is very different than 20 yrs ago.

We improved it but then COVID brought antiquated practices like deep sedation & immobilization.

This man’s family advocated for him. Please do the same for your loved ones.

ICU Liberation data:
bit.ly/3elkHq2
9/Follow Up: He’s doing well, but #Recovery from Sepsis can take years.

He’s suffering from #PICS & 2 weeks later can’t walk yet.

He’ll attend support groups & get cognitive & physical rehab in his “new normal.”

Long COVID pts need similar programs‼️

bit.ly/3DhC6Xe
10/Pro-Tip quiz question:

My patient presented with Reynold’s Pentad. What is that?👇

#MedTwitter #MedicalResidency #medstudenttwitter
12/fin
Spiritual Rounds - 2 weeks following ICU discharge, I went to find my patient recovering ❤️‍🩹 from his sepsis.

He taught me all about the power of acceptance & being spiritually grounded. What a beautiful man. I thought I’d help him, but he helped me way more as usual.

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More from @WesElyMD

Sep 13
1/🧵 Land Mines in Long COVID - @BostonGlobe

Alex was training for 2024 Olympic Trials 🥇

That dream exploded 💣
 
New #LongCOVID science
📌Viral reservoirs at 1 year
📌Cardiac edema at 1 year
📌Dementia at 2 years
📌Hijacked mitochondria

ScreenShot👇
bit.ly/3U77u4r Image
2/ It’s one thing to concede that Long COVID exists as a societal problem for those w vulnerabilities like advanced age, pre-existing health conditions, or nearly dying in ICU.

What about nationally ranked D-1 long-distance runners⁉️

Paywall so read 🧵
bit.ly/3U77u4r Image
3/ Alex Schell is 21 & based his life decisions on making the 2024 Olympic trials.
 
“Not only can I not run due to #LongCOVID, I’ve also lost everything I hoped for. Who I envisioned myself to be is a past idea. It’s a monumental loss.” (story w perm)
 
What causes LongCOVID? Image
Read 22 tweets
Sep 6
1/🧵 Beauty in the Now…

While normally Greg doesn’t #worry, in this case, he succumbed to fear of change.

He was screaming and Crying in Fear - see tweet below.

How did he get through it?
What did he teach me?

#NothingDownAboutIt #DownRightPerfect #UpSyndrome #Tribe321
2/ Greg held his head in his hands and trembled with worry.

We were disrupting his usual Saturday of watching “I Love Lucy.”

Think Rain Man type of dependence on routine &
that’s Greg.

So when Kim and I took him to the mountains, it totally messed him up.

What happened?

#T21
3/ At first Greg got angry with us for taking him on this trip.

I mean, REALLY angry.

And we know that #ANGER is just one letter away from #DANGER.

He was heading in a dangerous path of rejecting something that could be healing & good in his life.

#TheLuckyFew #FindYourTribe
Read 7 tweets
Aug 30
1/🧵 Paxlovid in Omicron⁉️
 
🔸Large study of 4k treated pts vs. 105k not on Pax
🔸Robust 80% ⬇️ in death prevention in elderly
🔸Hospitalization 70% lower if >65 y/o
🔸No help in young?

Why will I keep using in young & old patients?

Read next tweet…
 
bit.ly/3PRbbId
2/ This retrospective observational cohort in @NEJM only showed statistical benefit in patients 65 & older.

Does that mean Paxlovid does not work in the young during #omicron times?

I don’t think so.

Here are reasons why I will keep using the drug in young patients as well…
3/ Subgroup analysis of studies are mainly meant for hypothesis generation.

Usually in clinical trials there are not qualitative differences in how a medication works by age cut off.

There can be, but it’s unusual.

Original Paxlovid data showed efficacy across age.
Read 5 tweets
Aug 25
1/🧵 The Haunting Brain Science of Long COVID 🧠

@washingtonpost Aug 25

📍Brain shrinking
📍Corona ghosts
📍Autoimmunity
📍Clinical clusters

“The good news is that in some pts #LongCovid #BrainFog may not be permanent.”

Link👇 but paywall so see 🧵

wapo.st/3wvPBlF
2/ Mild Covid is biologically dangerous long after initial viral infection.

81 mild COVID pts:

Study revealed:
✔️Astrocytes (🧠 support cells for neurons) get infected
✔️Neurotransmitters are altered
✔️Neurons die indirectly
✔️Then we lose brain power

bit.ly/3pcqbFV
3/ Epidemiology💥

Long COVID is tightening its grip on society.
 
We’re still losing >600 people a day to death from COVID in US alone

Over 100,000 new infections per day (Johns Hopkins data).
 
This is an epic global 🌍#PublicHealth catastrophe.

wb.md/3SKjGrh
Read 28 tweets
Aug 22
1/🧵Mild Traumatic Brain Injury (TBI) isn’t “Mild” 🧠
 
Our daughter fell off a high diving board headfirst to cement years ago. Though she had 2 cracks through her foramen magnum, her GCS was 15 & CT had no bleeding.
 
“She’s OK,” they said.
 
Wrong answer 😔

#TrackTBI Data…
2/ Mild TBI isn’t mild at all. Lives & entire families are uprooted.
 
Over half of these N=991 patients with GCS of 15 & negative head CT scan reported incomplete recovery at 6 months.
 
90% w incomplete recovery were unable to return to preinjury life.
 
bit.ly/3pxd4ze
3/ Medicine & Trauma are only now waking up to the realities of this “invisible” yet devastating injury.
 
I’d been trained in all modern #CriticalCare & you’d think I would know better.

But I didn’t.
 
bit.ly/3R0enCt
Read 4 tweets
Aug 10
1/🧵 Is MonkeyPox airborne?

I’m not an ID specialist, but evidence from this often cited 2001 @Nature study does NOT speak to usual #MPX exposure.

The Methods describe high dose, highly lethal variant. This is more like being sprayed w viral fluid.

go.nature.com/3vMCbkP
2/ Is MPX airborne?

This 🧵 is to alert readers that methods of studies are critical to analyze. These authors set up an experiment that was designed to be as HIGHLY infectious as possible w a dose & delivery highly unlike what we see in society. They even got rectal lesions.
3/ There’s no doubt that respiratory secretions from prolonged close physical contact (kissing) are a way to transmit monkeypox. That is NOT the type of droplet transfer across multiple feet of physical separation we have to worry about.
Read 4 tweets

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