I often teach the a few core principles of what makes ICU decision making different from treating what appears to be similar problems on the med-surg floors. Here are a few principles I emphasize, in no particular order...🧵 1. Think pressors, not fluids.
💊On the floor, low BP ➡️ IVF bolus. But in ICU, patients, physiology, monitoring are all different. Short term peripheral pressors are generally safe, but repeated IVF can be harmful. If the pt already rec'd IVF, think pressors.

Thank you all SO MUCH! I ran the Boston Marathon!! ALL of your support carried me through one of the hardest, most joyful, most exhilarating experiences of my life. I ran to support mental health... 🧵 Mental health hits close to home for all of us. I had the great privilege of running in honor of my uncle, Nagendra Prasad- Babu Uncle, who lived with me through much of my childhood. You'll see his name on my singlet- it gave me a huge boost when I heard the crowds cheering him!

Thinking about the acute care experience of caring for patients w self harm / attempted suicide. What is it like when you care for someone immediately after a 'medically serious suicide attempt' ?
- how do you think you can help them?
- how does caring for them impact you? - >700k people die by suicide every year: 1 person every 40s. 1.3% of deaths worldwide in 2019
- Occurs at all stages of life; 4th cause of death in 15-29 years of age
- People w a 'medically serious' attempt are more likely to die by suicide in the future
https://t.co/1cNFUiBu66bmcpsychiatry.biomedcentral.com/articles/10.11…

In 1 week, I'll be at the starting line for the Boston Marathon. I hope I will already be across the finish line for my goal to raise $20k for mental health. I am working in the ICU this week and seeing the profound impacts of mental illness everywhere I look... People with severe anxiety from one of the scariest things we experience- not being able to breathe-- and living like that every hour of every day. The devastating impact of substance abuse- especially alcohol and opiates.

I had the chance to give a talk on the Quintuple Aim and a vision for the future of quality. I'm sharing some of the highlights from my talk, "QUALITY: AIMING FOR THE FUTURE" 🎯 🧵 I open with the original Institute of Medicine (now @theNAMedicine Domains of Quality- hopefully old news by now!
Crossing the Quality Chasm, A New Health System for the 21st Century. https://t.co/efTIF3Xs3h https://t.co/OqoaBaOj5pahrq.gov/talkingquality…
psqh.com/analysis/impro…

Twitter allowed us to create something different in medicine. I think it's special for these reasons:
🔸Transparency
🔸Content
🔸Flattened hierarchies
🔸Low barrier to entry
🔸Voice
Here's what I mean... 🔸Transparency = public accountability. Less locker room talk. Patients & the public hear us & engage, generally raising the bar for the conversation, bringing in diverse perspectives, and forcing some degree of professionalism. Unlike what we see in some closed groups on FB.

Possibly my most important 🧵 & a big announcement(!)

Please read & share.

In 2020, I was on the front lines of the pandemic in Boston- it was a bad time, the worst in my life... I saw a lot of people die and far more suffer worse than any of us ever should. One day, I was invited to speak about our experience in the ICU to my local center for Community Mental Health. I remember thinking, wow, I feel like a hypocrite...

Recently had the chance to be the *very first person* to teach a student how to write a note(!) Sharing a few of my teaching points on crafting the critically important ✨ONE-LINER✨ here for beginners! This is medicine focused & I apply it to both my inpt & outpt notes.🧵 Why is a "one liner" important? This brief problem representation in the chart helps me remember important medical details & communicate clearly when I have 16 other patients on the list. A well crafted one-liner helps everyone & these concepts apply to oral presentations too!

It is just past 7 as I shuffle into the work room and toss my bag down. You're already huddled in front of your monitor, keys clicking away on today's notes. You're always here earlier, always stay later. It makes this even harder. I try to think of the right words. I never know what to say. But if there's one thing I've learned since meeting you, it is always better to say something. We've seen too many people who never got their second chance.

"Hey, I'm so sorry. I heard about yesterday."

It's six AM. I'm still in bed and my eyes are barely open. I reach for my phone. I check my email. Last night's sign out just arrived. I scan last the names I don't recognize, looking for one in particular... 🧵 I admitted you just hours before, just a few days into your symptoms. You got sicker fast. I remember you insisted that intubation 'wasn't within your wishes' to every clinician before me. I wasn't so sure...

Does every admitted patient need a code status discussion? @AvrahamCooperMD and I propose a more individualized & patient centered approach. The current 'checkbox' practice leads to superficial discussions & inaccurate code status determinations.
sciencedirect.com/science/articl… Both @AvrahamCooperMD & I have thought about this quite a bit since we were interns. I still remember residents asking me after I presented an H&P for a low acuity admit, "did you remember to ask code status?" not because it was clinically relevant, but because it was a To Do ✅

I had the chance to speak about individual well-being strategies... I opened by saying it's like asking a patient coming in with gunshot wounds if they've had their colonoscopy yet. It is a hard subject to talk about... 🧵#CHEST2021

https://twitter.com/gretchemaben/status/1449786069411586050

I started with what I think of as 🚩🚩🚩 when I hear about wellbeing. Especially during covid. Especially in the ICU. See this thread for more! #CHEST2021

https://twitter.com/laxswamy/status/1449203321718427648?t=RLO6uy0CBEL52S8AZ4WaWQ&s=19

"I've had someone die in every one of these rooms." - ICU nurse

Some things will never be the same... 🧵 Before COVID, we all had our bad days and nights, the kinds of traumatic moments that left a stain long after the details faded. Every time I walked past one of those rooms I felt a little sick- even years later. Some of the things we see are just that bad.

You've seen it: a floridly agitated patient, moaning or screaming non-stop, heard across the entire unit.
My approach to:
- maintain dignity, humanity, safety
- not let it interfere with the care of other patients
- not let it get to you, but not being dead inside
🧵 I see how shocked visitors/med students are when they see a patient like this, yet ICU staff is so used to it that we can ignore it- a necessity in order to care for other patients. As a med student, I would not have been able to filter it out... (maybe that isn't a bad thing)

Highlights from an ICU delirium talk I give to the residents, please share your thoughts & feedback! Image credit: deliriumcarenetwork.com/art.html Delirium: An acute change in attention, awareness and cognition caused by a medical condition that cannot be better explained by a pre- existing neurocognitive disorder. Often reversible.

Drugs don’t work to treat it... but they can precipitate it.

I love working in the ICU. So much of what we do is just trying to reduce the harm we inflict keeping people alive long enough to either get better or not. The harm is immense despite that ... 🧵

cw: icu trauma

https://twitter.com/drjessigold/status/1359851087436644353

ICU patients, more than most any other, lose autonomy. Most icu patients can't make decisions about anything- either you're sedated or too confused or otherwise incapacitated. Imagine having no say in whether a needle goes in your body.

More hospital strain is unsurprisingly a/w worse outcomes. As mentioned, a lot goes into the occupancy of beds suitable for mechanical ventilation: the bed/room and equipment- one MV bed is not always like another (are you in a converted unit)? but especially...STAFFING!🧵

https://twitter.com/juliaoftoronto/status/1349360038595489792

In ideal circumstances, a sick ICU patient on a ventilator has a dedicated ICU nurse focused only on their care and a multidisciplinary team- a doctor, respiratory therapist, pharmacist, all seeing more patients but not so many that they can't give attention as needed...

"Mechanical Ventilation Supply and Options for the COVID-19 Pandemic" in @AnnalsATS

Here are some of our key takeaways... a #COVID19 🧵to assist in planning for the next surge.

atsjournals.org/doi/abs/10.151… We faced intense strain from #COVID19 in Boston, an incredibly well resourced city.

The Hawaiian islands have about 250 ICU beds & 500 ventilators for a population of about 1.4m.

Haiti, with 11m people, can provide MV to <100 people.

#COVID19 can create a crisis anywhere.

i mean, this is gonna be great. #CHEST2020 These cases are great, and the vent sim is really top notch. here is a takeaway slide re: elevated peak pressures #CHEST2020

And you thought we were done talking about burnout!

WINTER IS COMING #CHEST2020 @niven_alex @md_ritwick @susan_corbridge and Curtis Sessler! #COVID19 'reminded me a lot of my prior deployments as a military physician' - @niven_alex

This feels more accurate than the usual military analogies - deployed _as a clinician_ #CHEST2020

Well, a crying child slowed me down, but better late than never. Excited to see @RanaAwdish @WesElyMD @hopealuko @BrendaPun

Rana: "Wanting the patients to be comforted and having almost nothing to do that except for the medications..." #COVID19 #chest2020 'are coma and deep sedation just markers of severe ARDS?'
@WesElyMD - absolutely NOT- they are independent!
#chest2020 #COVID19