Answer: Ethylene Glycol poisoning

🔑send out confirmatory test comes back days later, long after damage is done

Kidneys will fail, patient will die if you don't make treatment decisions now.

How do you do this?

A tale of "3 gaps"... 🧵

1/11

https://twitter.com/CoryRohlfsen/status/1892685127962022076

Without an obvious history of ingestion, the first clue is a high anion gap (AG) metabolic acidosis

"MUDPILES" is the broad ddx

- METHANOL
- uremia
- dka
- PROPYLENE GLYCOL
- inh
- lactic acidosis
- ETHYLENE GLYCOL
- salicylate

But there are 2 more gaps in this case...

2/11

What is the one skillset that matters more than any as a #doctor, #leader, or #teacher?

A 🧵on #AdaptiveExpertise for anyone who seeks to master their craft

Hint: it's more than adaptability

@johnbeshears @YihanYangMD @MarenGube @Midwest_MedPeds @mpusic @erhall1 @LRinMD

1/ In Oct 2022, a new home run (HR) king was crowned.

Aaron Judge made history with 62 HRs in a single season.

But what can we possibly learn from this future hall of famer in other domains of expertise?

2/

()mlb.com

The science of learning is the science of neuroplasticity.

After years of evolution, humans broke through.

Follow this 🧵 to learn how to optimize performance & learning…

#MedEd #Learning #Whitematter

@ShreyaTrivediMD @SatyaPatelMD @mendesthiagob @DxRxEdu @rabihmgeha

1/ Ever wonder why horses are born with the ability to walk while human babies can’t do anything but eat and poop for months?

The answer is horses (like most mammals) come pre-myelinated.

Their motor and sensory circuits are hard-wired in the womb.

2/

#MedTwitter

We glorify hypothesis-driven reasoning & #problemsolving.

But in doing so, we neglect our biggest contribution to medicine.

After nearly despairing over how #AI will soon replace us, I realized it just ain’t so.

Here’s why.. a 🧵on “situated cognition”

@hdx

1/ AI will outperform average docs in info RICH environments.

It will process higher volumes of data with greater speed & superior (tireless) aptitude.

But only a fraction of diagnoses come to light in this domain.

Most diagnoses spring forth from information DESERTS.

2/

To err is human.

Our judgments are flawed.
Our decision making is under constant assault.

But there is something we can do about it.

Read this 🧵to learn how “Decision Hygiene” can improve your judgment

@SatyaPatelMD @PrathitKulkarni @DxRxEdu @rabihmgeha @goodmra1 #IDTwitter Did you know judges are more likely to give out lenient sentences the Monday after their favorite football team wins?

Docs are more likely to prescribe opiates at 4pm appts, especially if scheduled on a Friday.

Surgeons have worse outcomes on their bday!

Why is this?

1/15

“They want more autonomy”

Timeless feedback given to every clinician educator in the first 5-10 years of their career.

Why is it so hard? Any solutions?

Read this 🧵 to learn how to let go without putting patients at risk.

#MedEd #ClinicianEducator #Autonomy #Kolbs #ZPD

1/ I was confident going into my driver’s ed test as a teenager.

After all, I'd been driving thru busy intersections, merging on highways, & parallel parking for 6+ mos.

But as I stepped on the gas to skirt across oncoming traffic, the car STALLED.

2/22

Heya #MedEd,

What do these 3 things have in common?

- Intern presentations (e.g. med student day off)
- Inverted SOAP – “APSO”
- Inheriting a pt w/ organ-based documentation

Answer: an opportunity to INVEST in your interns and here’s why...

@medrants @rabihmgeha

🧵
1/8 All 3 of the above scenarios encourage interns to leave their comfort zone to do more than simply “explain the data” or “propose a plan.”

This opportunity adds the DESIRABLE difficulty of letting them “say what they think is going on” & most importantly, explain “why?”

2/8

As I wrap up my 5th year of #primarycare practice, I can't help but reflect on the TEN "sparks" trainees may miss out on during residency that make this work so rewarding.

A 🧵of #gratitude...

@CLOSLER @primarycarechat @InduPartha @adamcifu @gabrieldane @GIMaPreceptor

0/11 1) Spending the majority of time in an office visit talking about kids, grandkids, sports, golf league, and fears for the future.

Very few people get to be a sounding board in the lives of others.

Knowing when to test (vs) when not to test is the hallmark of a seasoned clinician.

But how to you teach this?

Follow this 🧵 to help your trainees navigate uncertainty.

#MedTwitter #FOAM #diagnosticreasoning

@medrants @AdamRodmanMD @EmilyAbdoler @DxRxEdu @rabihmgeha

1/17 The art & science of #diagnosticreasoning is still in its infancy but we now at least have a shared language to navigate the unknown and have meaningful conversations.

2/17

Votes are in... this is a GREAT example of COLLIDER bias which I will explain in this 🧵

I agree with the votes that A fib is NOT an independent harbinger of CAD (in general).

That said, we can't ignore the possibility of CAD either.

Here's why... 👇

1/15

https://twitter.com/CoryRohlfsen/status/1643122265624805377

Let's start by defining "CAD-AF" (having both CAD and Afib)...

There are 2 types:

1) MI (ischemia) => A fib
(increased risk of mortality in CAD-AF!!!)

2) A fib later found to have CAD
(more likely correlation than causation... is it clinically relevant?)

2/15

#HospitalMedicine 101

What is difference between "failure to thrive" , "frailty" , and "malnutrition" in adults?

Follow the thread 👇for some🧠food

@BrownJHM FRAILTY is a loss of physiological reserve (usually from deconditioning, aging, cancer, a prolonged ICU stay, or loss of function after a stroke).

Pre-conditioning, re-conditioning, or assistive devices may optimize some function but most causes are not so easily reversible.

The 3 most powerful (& liberating) words a #clinicianeducator can use…

“..I don’t know”

Most junior #MedEd faculty will be tempted to avoid them b/c of #impostersyndrome.

I went far too long resisting them but now am free. Don’t make the same mistake I did.

Here’s why…👇 Saying “I don’t know” will…

-Normalize gaps in knowledge – “we can’t know it all” (say it with me 👏)
-Flatten the hierarchy to increase psychological safety
-Increase the collective curiosity on the team to increase dialogue and stimulate learning

and...

Imagine, explore, and discover your SUPER POWER as a clinical educator in Health Educators and Academic Leaders (HEAL) - a GME pathway to clinical educator excellence!

unmc.edu/intmed/educati…

Applications due Monday (3/20) 😀 "One of you in this room will be the next best [ ... ]"

Such a fun way to start HEAL orientation each year!

Fill in the blank below 👇

10 things a #primarycaredoctor should know about Celiac Disease:

Dive with me into some #diagnosticexcellence and #managementreasoning !

acpinternist.org/archives/2023/… 1)1% of US population has Celiac Disease (CD). It’s underdiagnosed.

It will see you, but will you see it?

Remember: an atypical presentation of a common disease is more common than a typical presentation of a rare disease.

Be on the lookout!