I’m going to tag this as a little tutorial for @MichaelYeadon3 who keeps saying that there’s no problem from the suppliers of medical ‘gasses’

Most hospitals in the U.K. run their O2 supply from a Vacuum Insulated Evaporator (VIE)

frca.co.uk/article.aspx?a…

1/n

https://twitter.com/shaunlintern/status/1347166201064075264

This VIE is essentially a large thermos flask/ vacuum insulated cylinder at -180C
O2 is supplied from (typically) BOC in liquid form; when required, allowed to evaporate into gas, & supplied to hospital outlets.

Most hospitals have a VIE big enough to meet their needs

2/n

This may sound gruesome to many

But last night, I read the ‘drowning rats experiment’

Rats were put in water. They normally swim well. So the surprise was they seemed to drown quickly. Then the researcher reflected: perhaps there was an imponderable here.

If you think there’s no solution, fight or flight is not an option. So you give up.

Anyone else irritated by the fact that the useful but dull stuff seems to get very little attention

New ICU Trainees want to know about how to manage refractory hypoxia, ventilator settings for asthma

Not relevant for anyone that’s not going to make icu a career

1/n What almost every Dr working in hospital needs to know about is

Types of O2 delivery devices, limitations, variable vs fixed performance

In the last year, I’ve kept some numbers, and 86% had never heard of Peak Inspiratory Flow Rate. Which is not their fault, obv

2/n

I saw him first on my evening rounds.
A tall, strong man around 60, He’d just come back from major bowel surgery

An epidural top-up helped with pain, and put a smile on his face, and his wife’s

They were very pleased at the lack of a colostomy too

Thread...

1/n Around 2AM, he went wild.

Trying to pull out lines, hit nurses, run away

Screaming we were going to catch him, kill him and he wanted to go home

He was a danger to himself- was on strong medication to keep his blood pressure up, and had lines and drains

2/n

Today I’m going to talk about something uncomfortable

Do you have friends or colleagues who don’t have children?

Here’s some things not to say

Thread...

1/n When are you going to start a family?

We are a family... and it’s none of your business

Family ≠ children

2/n

This is my day of being horrified

Having lived out of India for ~15 years, I had no idea this wasn’t crime fiction

But it seems it’s true!

Read on about ‘Narco-Analysis’ and role of Drs in judicial process

1/n The World Medical Association says Drs should not be involved in judicial executions

This is probably why we see so many reports of execution by injection going wrong in 🇺🇸

2/

I have to disagree here...

There’s levels of research involvement

1. Being able to read papers, stay up to date, critique papers, and apply evidence to practice.

If you can’t do this to a reasonable (not great) level, you’re unlikely to be a great clinician.

1/4

https://twitter.com/vishnuvy/status/1286496041559154694

Level 2: involved in a research group. Recruit patients, collect data: smaller number of clinicians at this level. Must be encouraged and given credit.

This is frontline of clinical research!

2/4

One of the things that has struck me in the last few days

I’ve noticed a lot of misinformation on SoMe around EoL decision making, and especially DNACPR

So I thought I’d look.

@RCoANews : have this amazing patient focused page:
rcoa.ac.uk/patient-inform…
1/ Where you can find so much information about risks of anaes and how an anaes is delivered.

Lots of leaflets, information videos etc

Take this for instance

But nothing around DNAR/EoL
2/

People talking about #BLM

Including Bollywood celebrities

@priyankachopra

Playing both sides?

Advert for fairness cream?

1/ ‘Fairness creams’ are a huge business in India

A range of Bollywood celebrities have been endorsing them for years.

Suddenly, lots of them want to demonstrate political correctness. And had black squares on Insta!

Seriously?

2/

I am a jobbing intensivist.

I know nothing of politics

But I have questions for @BorisJohnson

If ‘following your instincts’ is the law, why did

1/ 1. My colleagues and I have to have end of life discussions with patients’ families over the phone rather than face to face.

2. Why did nearly 50% of U.K. ICUs prohibit all visiting? Others only allowed visiting at end of life

2/

Just had another masterclass in @ICNARC report interpretation by @ActuaryByDay

As I was reading the report, I noticed a couple of things too

Reports here

icnarc.org/Our-Audit/Audi…

Both national, and regional network reports available on this page
1/

https://twitter.com/ActuaryByDay/status/1264109818312372228

One of the things that’s apparent when you read the report is the distribution of the disease with social deprivation- the bottom 2 quintiles nationally have nearly 50% of ICU patients

@ActuaryByDay has analysed this, and ethnicity in his thread

2/

The lockdown has been eased...

#COVID19 case numbers and mortality are coming down

But the crisis isn’t over. There will be second wave

We have an opportunity here to help save lives

#AllWeAskIsWearAMask

@PriyamvadaGopal @trishgreenhalgh There’s been some controversy around masks.

Some national health authorities recommend them. Others don’t.

But there is an interesting graphic here demonstrating countries where people regularly wear masks have lower incidence of #COVID19

So here’s the #Conga

Well done for celebrating

While most ICUs in the country are working on a #NoVisitors policy

colleagues and I are having end of life discussions on the phone

My organisation are relying on medical students and retired consultants to talk to families

https://twitter.com/MerseyHack/status/1258758842680254465

While 20% of my colleagues are off with #COVID

While most ICU beds in the country (including surge capacity) are full of COVID patients

Most cancer surgery is still cancelled

Do you fucking realise you’re placing all of us in jeopardy? Risks to staff, risks to patients

This week’s @ICNARC report throws out interesting facts!

@ActuaryByDay has done his excellent weekly analysis

But as I was reading the report, a few things did jump out at me

So here’s a short thread. Numbers:

Why did we need this massive effort of expanding ICU capacity?

As you can see here, we have seen more patients with #COVID19 admitted to ICUs nationally, than the total number of viral pneumonias (mainly flu) in 3 years

There have been excellent summaries of the @ICNARC report today by @ActuaryByDay and @Gas_Craic

I would urge colleagues to read them!

https://twitter.com/ActuaryByDay/status/1251463674369314819

I’d just like to make a couple of additional points

Our overall mortality still remains ~50%.

But nearly 65% in invasively ventilated patients.

The rates of people requiring renal support are very high at 1:4

Was on ICU nights over the weekend

With

1 anaes consultant
1 Vascular surgeon
1 Thoracic surgery registrar
2 anaes registrars
1 ICU registrar
3 ICU SHOs

11 ICU nurses
24 non icu nurses

Walked an average of 17000 steps each night

The team spirit was AMAZING!

#Covid_19 1/4 I was stunned at how the team blended.
Vascular surgeon + ICU Reg combining their skills : technical + senior consultant skills to make very sensible decisions

Theatre nurses looking after patients, ICU nurses stepping up to supervising

Thoracic registrar taking referrals 2/4

An instructive read...

We’ve been lulled into a false sense of security by Clapping for the NHS, free pizza, chicken balti and fried chicken.

But read this.

ukmedicaldecisionlawblog.co.uk/rss-feed/119-c…

About limitations of treatment, distributive justice, and conflicting GMC guidance.

1/4 We would do well to remember that there will be a legal reckoning after this crisis.

Everything we do... especially declining admission, and withholding/ withdrawing treatment needs extensive documenting. And second opinions.

2/4

Lots of news coming about new ventilators being developed

This leaves me with some apprehension

Let’s think about ventilators...

(thread) 1/n It’s not very difficult or high tech to make a ventilator that is a basic ‘bag squeezer’ or a minute volume divider

They’re typically time cycled, flow generators, and work best in a mandatory mode

This is why we kept patients deep and often paralysed 30 years ago 2/n

Over the last few months, I’ve been asked by a few overseas colleagues why UK surgeons are addressed as Mr once they become Members or Fellows of the @RCSnews @RCSEd or @rcpsglasgow

And discovered many surgeons didn’t know either!

Here’s a short explanation (thread) 1/x If you have read the Hippocratic oath, you’ll remember the bit where it says
‘I will not use the knife...’
2/x