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Nick Mark MD Profile picture
@nickmmark
May 24 • 6 tweets • 4 min read Twitter logo Read on Twitter
ATS’ Leadership are in a Kobiyashi Maru situation with #ConferenceGate
- one one hand, they signed a terrible contract and stand to lose a ton of money if they pull out of Orlando
- the other hand, they risk having no one show up & alienating most of their members
#ATSSafe4All
1/
People are angry. Seeing how many green ribbons there are at ATS, it’s dawning on ATS’ leadership that they screwed up big time.

They wonder: Will these people boycott Orlando 3 times in the next decade? Will they keep paying dues? Is this an existential threat to the org?
2/
The easiest move for the EC is to do nothing and (try to) pass the buck: If ATS implodes in 10 years after three disastrously unattended Orlando conferences will anyone remember whose fault it was?

By then EC members will have moved on to other things. Will we remember them?
3/ ImageImageImage
But remember, the Koboyashi Maru is a test of character. How do candidates face a no-win situation?

Passing the buck & leaving others to deal w/ the inevitable consequences of their decisions isn’t leadership. It fails the test.

Lead with moral conviction not
spreadsheets.
3/
ATS’ Executive Committee should lead by example:

ATS should make it clear they won’t ever hold conferences in places with unjust laws. If NAACP issues travel advisories for FL, the EC shouldn’t be going there.

Lead by setting a moral example. People will remember that.
4/
Finally remember that there is no such thing as a no-win scenario.

ATS could fight to get out of the onerous & expensive escape clauses.

ATS could raise money to cover the losses. Solicit donations from members. Hold two smaller ATS conferences/year.

Change the rules & win!
5/

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More from @nickmmark

Nick Mark MD Profile picture
May 25
Interesting RCT in @NEJM about platelet transfusions prior to CVC placement in people w/ thrombocytopenia (Plt 10-50k):
- higher rate of grade 2-4 bleeding w/o Plt transfusion: 11.9% vs 4.9%
- difference driven by much more bleeding w/ subclavian lines
nejm.org/doi/full/10.10…
1/ Image
This trial enrolled n=338 hospitalized people in 🇳🇱 with platelets between 10-50k, INR <1.5 (changed to 3.0). 57% were heme/onc patients & 43% were ICU patients.

Median Plt count was 30k

Most were getting a CVC for chemoTx. (Most weren’t exactly your “typical” ICU patient.)
2/ ImageImage
Importantly they placed the CVC within 1 hour or randomization. This means they probably didn’t transfuse then place a line, more like placed a line while transfusing.

(IMO this difference matters in situations where platelets are dysfunctional, like uremia)
3/ Image
Read 7 tweets
Nick Mark MD Profile picture
May 14
You've probably heard that Bicarbonate has to turn into CO2 to raise the pH. “Don’t give bicarb if you can’t increase ventilation.”

But how much CO2 is there in an amp of sodium bicarbonate?

A bicarb 🧵
1/ Image
Sodium bicarbonate raises the pH by binding H+ ions and turning into CO2 and water.

For my fellow 🧪 nerds, I’ll write:

HCO3 (aq) + H+ (aq) --> CO2 (g) + H2O (l)

2/ Image
This means that - just like adding alka-seltzer to water - when we give sodium bicarbonate we liberate CO2 & raise the pH!

In fact the major ingredient in Alka-Selzer is sodium bicarb!

(Also can we agree that this is the creepiest mascot ever?)


3/
Read 10 tweets
Nick Mark MD Profile picture
May 13
Real shitty explanation by @atscommunity about where they plan to hold future conferences.

TL/DR: On one hand they had to consider safety & inclusion, on the other hand ATS’ sterling “reputation in the meetings industry.” They prioritized the latter.

news.thoracic.org/community/pres… ImageImage
I’m disappointed that they have prioritized profit over the concerns of members.

Frankly, I would have been willing to pay higher dues, higher conference fees, legal fees, etc if the financial concerns had been raised transparently.

Instead they decided unilaterally.
2/
A few more points to respond to:

“Who knows what the policy will be in 10 years?”

This is textbook passing the buck, a major problem in organizations with annual rotating leadership.

We ought to elect leaders who are willing to make hard decisive choices.
3/ Image
Read 7 tweets
Nick Mark MD Profile picture
Apr 15
Here’s a fun medical puzzle: what does this antidote (Sugammadex) have in common with this cleaning product (Febreze)?

1/ ImageImage
The answer is the chemical structures for both are cyclodextrins!

2/
 Sugammadex Febreze ImageImage
Cyclodextrins are rings of glucose molecules linked together by α-1,4 glycosidic bonds.

Depending on the size, these ring can trap other molecules inside it.

For example, a 7 glucose (beta) cyclodextrin called Febreze can trap small odor molecules & neutralize smells.
3/ ImageImage
Read 5 tweets
Nick Mark MD Profile picture
Apr 13
This is an important & thought provoking meta-analysis about the potential harms of propofol.

I think this should (& almost certainly will) inspire important future studies.

But it won’t change my practice in the ICU quite yet. Here’s a 🧵 about why.
1/
First, this finding was driven by OR mortality, particularly in cardiac surgery patients.

ICU mortality was non-significant. (p=0.5). Additionally this is an unadjusted p-value, so if we correct for multiple comparisons it’s even more insignificant.

2/ Image
The OR and the ICU are different places & propofol is used differently: higher doses & boluses are frequent in the OR whereas low doses with daily interruptions are common in the ICU.

In short, I don’t think it’s reasonable to extrapolate an OR finding onto an ICU population.
3/
Read 9 tweets
Nick Mark MD Profile picture
Apr 2
Much has been made of the declining life expectancy in the US.

The reality is regional. Think of the US as two countries:

Some blue counties with increasing life-expectancy better than 🇯🇵 (84) & many red counties with plummeting life expectancy worse than 🇷🇺 (71).
1/
Compare the narrow variation between prefectures in Japan (range 82-84) with the wide variation among US states (range 71-81).

🇺🇸 cdc.gov/nchs/pressroom…

🇯🇵 en.wikipedia.org/wiki/List_of_J…

2/
It’s not that the “US healthcare system is bad” it’s more that access to healthcare varies wildly.

The latent confounder is poverty. This is illustrated by this @FinancialTimes comparison of life expectancy in the 🇺🇸 & 🇬🇧:
3/
Read 12 tweets

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