1/🧵 An exacerbating factor in #LongCOVID is the “Quality of Life (QOL) Gap”🧵👇

…when a person’s expectations about QOL are at odds w their reality.
 
“Covid was over & Long COVID hit my brain, heart & GI.”
 
Let me unpack a study of ICU survivors…
bit.ly/3vp0AMl

https://twitter.com/WesElyMD/status/1498272732609490948

2/ Read the thread I attached to the first tweet.

From the cancer literature, we learned about the QOL Gap.

If people appropriately prepare for their “ACTUAL” QOL, there’s a narrow gap and all is well.

If not, #Depression & #Despair too often set in.

🧵1/ Here’s your “Big Picture” of COVID & Long COVID for 2022

See my new Figure👇 summarizing #COVID19 Management & Outcomes

Two years in & we have splendid choices.

Stay in peaceful waters of prevention (green) or risk treacherous cliffs of #LongCOVID & Death (red & black)… 2/ Knowledge is Power, and our knowledge has grown dramatically.

Let’s take a look at where we were just 2 years ago - even though it seems like 20 yrs ago.

April 2020: our approach & understanding of COVID looked like this👇.

We didn’t even know about #LongCOVID yet 🤯

1/🧵 What does it mean to be human?

How do I magnify human dignity?

I face this daily as we have dying ICU patients.

Recently 2 young men w #COVID, both progressive lung failure, chose not to be put on a ventilator.

Both young & fearful they wouldn’t survive if put on vent… 2/ I kept turning up HiFlow & Bipap. At one point each asked,

“What treatment is NEXT, Doc?”

Knowing I’d exhausted our solutions, I looked up again into each man’s eyes.

Honesty is the only way...

“Sir, your disease pushed beyond our tools. There’s no ‘next.’ No cure.”

1/🧵 Does Alcohol shrink the brain?
 
Yes, all liquor can hurt our brains if we drink too much. The disease of Alcoholism, which is NOT the fault of the person afflicted, causes brain injury slowly over time.
 
A picture is worth 1,000 words. Look below at a diseased brain… 2/ Gray on this CT scan indicates actual brain tissue.

Do you see the black areas pointed out here by RED arrows?

These are called sulci (grooves).

This <40 year old person has VERY large grooves that show the amount of brain tissue as we would see in someone >80 w dementia.

1/🧵 I DARE YOU 👍

When we’re busy, relationships become I-It & should be “I-Thou”

How can we fix it?

I asked him 4 Questions:

What’s your favorite song, hobby, food, pet’s name?

Do this for 1 WEEK. How does it change the way you SEE & CARE for others?

Read on…(pic w perm) 2/ Hecame to our ICU service over night after his spinal fusion.

He would only be w us a short time & would then be gone. So why dive deeply into his history??

Because he’s an ENTIRE PERSON.

So every minute with him is a gift. What did I learn?

1/🧵 You have a COVID ICU patient on benzos who doesn’t respond to needle injection of local anesthetic do to sedatives.
 
What depth of sedation do you consider this? (it was a CME question just now) 2/ The answer is GENERAL ANESTHESIA, which of course makes sense.

If a person is so deep that he/she doesn’t respond to getting stuck by a needle and the pain of lidocaine injection, that is general!

Why am I writing about this?

1/🧵 A personal story of misjudgment as a physician.
 
Years ago, when I was a young doctor, I had a patient in the ICU on a ventilator who was doing so poorly, day after day, that I was certain he was going to die.

I confidently told the family he was going to die. 2/ The family members all gathered and were extremely distraught. They listened and trusted me.
 
But I was wrong.

#PalliativeCare #EndofLife

1/🧵 #LongCovid is REAL & up to 23,000,000 ARE (not “may be”👇) suffering.

Yesterday, @POTUS announced expanded funding.

Becerra told reporters Tuesday. "Millions of Americans may be ⁉️struggling with lingering health effects…”

nbcnews.to/3ramyS3 2/ As part of its efforts, the White House said in a statement that Biden will push to accelerate a $1.5 billion study started last year by the National Institutes of Health to follow 40,000 individuals with and without long Covid to try to better understand the condition.

1/🧵 Race & Medicine - #COVID

Dark-skinned people who get #COVID, or any disease lowering O2 levels, are more likely vs whites to suffer undetected hypoxemia (missed ⬇️ O2 levels).

Pulse oximeters are affected by skin color & read falsely high in Blacks.

Does it matter? 2/ It matters because undetected hypoxemia tripled the odds of DEATH 💀
 
This study of >128k measurements from 26,000 pts confirmed these inaccuracies that we’ve known about for 30 years.

Black, Asian & Am Indians were all included. #Disparity
 
bit.ly/3KaNAAj

1/🧵Serious question:
Is it ok to CLAMP OFF blood vessels to a human brain to stop cell function & get organs for transplant?

A new procedure does this to ensure no blood reaches a person’s 🧠 as surgeons take organs from freshly ‘dead’ bodies. Discuss.

bit.ly/3tEZhtl 2/ We all want to relieve the suffering when people are dying of failing kidneys, lungs, hearts.

Transplant can be a great solution.

As a transplant physician myself, I directed lung transplantation at #Vanderbilt.

I worry this new approach is a breech of the dead donor rule.

1/🧵 True Medicine #LongCOVID
 
In #COVID & beyond, TRUE medicine, which is to say true healing ❤️‍🩹,  adapts itself to each suffering patient.
 
It’s the opposite of #gaslighting someone because her disease doesn't “fit” our model when she (eg) fails POTS criteria.

Instead… 2/ Our healing must have the character of MERCY, which means we #doctors & #nurses will bend our love to fit the shape of each suffering patient.

Only then can we lift her up.

It may means admitting we don't know what to do now other than listen more.

#Medtwitter #NurseTwitter

1/🧵 Wanna learn from a 61-year love affair? ❤️

They met at a drive-in burger joint in Memphis. Elvis blaring.

He peered into a car of 6 teenage girls & saw her.

💭 “That’s the most beautiful girl I’ve ever seen.”

They’ve been madly in love ever since.

(Pics & story w perm) 2/ Pain feeds pain, but love & gratefulness starve pain…

Mr. M came into the ICU w sepsis & shortness of breath.

We placed him on life support to help reduce his suffering. The disease proved too much.

Fortunately, sadness & despair took a back seat to what happened next…

1/🧵🎥 “It’s a very bad disease. It can be overcome.”
 
My #COVID patient tearfully speaks of his BIG DECISION on the ventilator.

This soldier & leukemia survivor made it through 3 weeks on a ventilator. How?
 
Video shown w his permission “to help others find hope, Doc.”
#Hope 2/ This immunocompromised man was in massive viral septic shock from COVID.

Huge doses of vasopressors.

Gargantuan levels of O2 & vent pressure to save his life.

Lungs, Kidneys, Heart and Brain all failed.

1/🧵 Let’s learn about Ace inh-induced angioedema
 
His lips & tongue swelled up hours after taking a blood pressure med he’d been on 10 years - lisinopril.

📍What’s the treatment?
📍Is it an allergy?
📍What’s a common thought error?

(Pic w Perm - trigger warning tweets 2 & 4) 2/ Angioedema is potentially life-threatening
 
It’s very scary to see the tongue & lips swelling up so much and the airway compromised.

The patients are watched in the ICU so that intubation and even tracheostomy can occur emergently if required.

What’s the Dz Mechanism?

1/🧵 Let’s talk Long COVID:

I’m grouping several important & interesting articles about the reality of #LongCOVID.

By studying brain fluid, viral persistence & MRIs, we’re building our understanding of the “how” & “why” of this devastating malady.

A train is coming, read on… 2/ Cerebrospinal Fluid Offers Clues to #BrainFog

Most pts w new “thinking problems” after mild #COVID had abnormalities in fluid from lumbar punctures (image); controls did not.

Delayed #LongCOVID was common in younger people who thought they were safe.

bit.ly/3pS0JWN

1/🧵 A sister & two brothers were born into a wonderful family. They led an exciting life. 4 months ago, 2 of them died young of #COVID, unprotected. The surviving sibling decided to get Vaxxed but stopped after 1 shot & is now on ventilator (CT scan) w COVID pneumonia. Read on… 2/ A teaching Point: This CT scan shows “holes” in his lung (red lines above & arrows👇) surrounded by white pneumonia.

The holes are previously damaged lung from smoking.

Millions in society, victims of misinformation, remain unprotected & the vaccine could save their lives.

1/🧵 WAKE UP - #COVID is a Ball & Chain for heart disease & stroke.
 
This 154,000 pt study & others solidify COVID as a PREDICTOR of a variety of CardioVascular Dzs.
 
Translation: #LongCOVID pts suffer heart attacks, strokes & much more.
 
#Vaccinate!
 
go.nature.com/3pxKjmi 2/ SHOCKER: Amazing work scientifically. Every med student is taught to gauge Cardiovascular risk history: Smoking, Obesity, HTN, Cholesterol, Family History…

Add COVID to the list. Solid data from @NatureMedicine of US Veterans used >11M contemporary + historical controls!

1/🧵 Are you happy?

My brother w #DownSyndrome is teaching me tons of life lessons.

In medicine & in life, I make big decisions based on guesstimates of other’s Quality of Life #QOL.

I often GET IT WRONG!
 
What do adults w #disability teach me about TRUTH?

Can I learn? 2/🎥 How do we “calculate” someone’s #QOL?
 
#Confession: I get it all wrong when I impose MY judgment onto THEIR life.
 
Greg, my 57 y/o brother-in-law with Down Syndrome, has a better QOL than I do.

Why?

Digest this…read on…
 
#DownSyndromeLove

1/🧵 Paul Farmer has died.

It is so heartbreaking 💔. Let us collectively mourn his passing - one of the greatest #PublicHealth figures in the history of Medicine.

His @PIH is a tribute to a kinder gentler way to love each other.

More…

https://twitter.com/PIH/status/1495806101769670658

2/ Dr. Farmer started his vocation of #SocialJustice by serving the beautiful people of Haiti, the world’s 1st Black republic. He looked in their eyes & saw their needs…HIV, malaria, Tb, hunger, poverty, neglect.

In response he took action…

(paintings below by my daughter)

1/🧵 Why is COVID hospitalization like 2X sticks of dynamite 🧨?
 
A thread on the ICU portion… #PICS + #LongCOVID.
 
Prevent this w 3 steps:
📌Avoid #COVID by Vax & Mask
📌Avoid severe COVID by Paxlovid & Monoclonal Ab
📌👇 read here about PICS & how to reduce injury in the ICU 2/ Here’s what you must know if you get too sick & land in an ICU.

History Lesson 📝
In the past, too many decisions in #CriticalCare were guided by fear. We oversedated patients for too long out of worry they might self-extubate & pull off restraints.

That’s happening again 🤮

1/🧵 Seeing Differently in #COVID ICU Care 👁

The world tells me “stuff” & “freedom ” bring happiness, yet neither suffice or satisfy.

If I reject chances to serve my suffering patients, I am left bereft.

Merciful care brings healing & provides joy all around.

What is #Mercy? 2/ My working definition of mercy is my willingness to dive into the chaos of another person’s life & provide lifting & healing.

Often as an ICU physician I do the former but not the latter.

That is, I dive into their #chaos without admitting I don’t know what’s right for them.