Damn. Under Trump the White House Medical Unit was a pill-mill. Thousands of ambien & provigil per month.

Worse, for a clinic that doesn’t typically do procedures w/ moderate sedation they sure are they ordering prodigious quantities of morphine, fentanyl, versed, & ketamine…? Honestly, this reminds me of Norman Ohler’s Blitzed.

It’s October - hockey season - so let’s talk about a hockey/pulmonary case:

A previously healthy 17yo presents with dyspnea, frothy sputum, & orthopnea that began after playing hockey.

In the ED he is tachycardic, tachypneic, mildly hypoxic. He has crackles bilaterally.

Dx?
1/ Before we get to the diagnosis, Inhalation of which of the following could explain his symptoms?

2/

Lots of inane comments from Elon/Rohan bros that vaccines don’t prevent disease.

Let’s debunk these claims:
1. Polio - vaccine introduced 1957
ourworldindata.org/grapher/report…

2. Measles - vaccine introduced 1963
ourworldindata.org/grapher/measle… 3. Tetanus - vaccine 1938
cdc.gov/vaccines/pubs/…

4. Diphtheria
researchgate.net/publication/32…

The long awaited #COVIDOUT RCT is now in @TheLancet:
- high risk adults randomized to either metformin (MET), ivermectin (IVM), fluvoxamine (FLV) or placebo.
- MET reduced the risk of long COVID (6.3% vs 10.4%; NNT = 24)
- no benefit with IVM or FLV

thelancet.com/journals/lanin…
1/ COVID-OUT was a large blinded multicenter RCT looking at repurposed oral meds.

The primary outcome was severe COVID; this was one of the *MANY* negative RCTs of ivermectin. (See 🧵👇)

The current study is a planned secondary analysis, looking at the incidence of long COVID.
2/

https://twitter.com/nickmmark/status/1560272414323249152

Pulmonary teaching case: you are called to the bedside of a 60yo man who was admitted for pneumonia a week ago. You were called because “he coughed and now his chest is PULSATING!”

This is what you see at the site of a previously removed chest drain:

What’s the diagnosis?
1/ twitter.com/i/web/status/1… This is Empyema necessitans (EN):

EN is a rare complication of an infected pleural effusion where purulent fluid “escapes” the pleura and erodes into the chest wall, causing an extrapleural fluid collection that communicates with the pleural space.

From @Radiopaedia:
2/ twitter.com/i/web/status/1…

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/ 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/

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/

https://twitter.com/khibbert_md/status/1661365076178206720

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/ 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/

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… 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/

Here’s a fun medical puzzle: what does this antidote (Sugammadex) have in common with this cleaning product (Febreze)?

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

2/
Sugammadex Febreze

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/

https://twitter.com/SRAnesthesiaICU/status/1646227897596641313

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/

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/

The usual anti-vax suspects are talking about a paper “proving masks raise CO2 to harmful levels.”

Well I read it and it’s a bunch of non clinical wackos who used the wrong equipment to accidentally measure end tidal CO2.

A debunking 🧵

1/ Before we get to the paper with it’s very flawed methods & conclusions, let’s talk about the authors.
2/

In 2021, Stella Immanuel wrote over 69,000 prescriptions for hydroxychloroquine & almost 32,000 prescriptions for ivermectin.

This continued in 2022, with 30,996 prescriptions for hydroxychloroquine & 16,085 for ivermectin.

Why don’t medical boards act?
medpagetoday.com/special-report… To put this another way 69k / 365 = 189 Rx per day

Even if she worked 12 hours every day, that’s 14 Rx per hour. Or one every 4 minutes.

There is simply no way she could have taken a history, reviewed medications/allergies & adequately counseled about the risks/benefits.

2/

Like all quacks, the FLCCC’s claims about their miracle cures get ever bigger with time.

Now, despite a glut of negative RCTs in COVID, they claim that ivermectin cures influenza & RSV.

Anything to keep the snake oil gravy train running.

washingtonpost.com/health/2023/02… Fact check: Marik was fired (he claims he resigned) from EVMS in late 2021. With no institution willing to hire him, he was *unable* to renew his university limited license. His license to practice medicine expired in 2022.

https://twitter.com/nickmmark/status/1543030193517826049?s=46&t=weYnJSt_eJyKUF36dt6MoA

Here’s a critical care puzzle & illustrates some important cardiopulmonary physiology:

These two pictures were taken just an hour apart. What intervention was done in between that changed the respiratory pattern? (Red box)

Multiple choice & answers in the 🧵.

1/ The intervention was:

2/

A man comes to the ICU after uncomplicated cardiac surgery. He is hypertensive and a nicardipine infusion is started. 10 minutes later he becomes hypoxemic. A chest radiograph is obtained.

What happened?

1/ Here's some followup: an intervention was performed & hypoxemia resolved. These two CXR are taken 15 minutes apart.

What was done?

2/

Pre: Post:

Here's a physiology case that *everyone* who touches a ventilator needs to understand:

A 60 yo woman is intubated for hypoxemia from multifocal pneumonia.
She has a SpO2 of 89% on PEEP +12 and 100% FiO2.
PEEP is increased to +16 & her SpO2 drops to 80%!

What happened?

1/ Before we get into the answer, let's make it interesting with some multiple choice.

Which mechanism(s) could cause worsening hypoxemia with increasing PEEP?

2/

Important ICU teaching case:
A woman with AL amyloidosis presents with hemorrhagic shock from a GI bleed. HR 130, BP 80s/40s, Hb 4.5. She’s been receiving CyBorD-Dara chemotherapy up until 1 month ago.

What crucial fact do you need to remember when ordering blood transfusions? The answer is that daratumumab (an anti-CD38 monoclonal) interferes with antibody screening & crossmatch!

In order to understand *why* this occurs we need to step back and review how blood is tested for compatibility.

Buckle up for a🧵! Let’s get our Coombs on, indirectly.
2/

This is incremental.

During my undergrad @BrownUniversity I remember when researchers did this in *humans*: A man with quadriplegia controlled a computer or robotic limb using a brain-machine interface. It was on the cover of @Nature. That was in 2006.

brown.edu/Administration…

https://twitter.com/NYTHealth/status/1600134063460962305

More hilarious is in a “groundbreaking paper” ostensibly written by Elon & published in the Journal of Internet Medical Research, they claim it’s “plausible a person may someday control a digital mouse” w/ this technology.

Ignoring the fact that it was accomplished >15 yrs ago!

Here’s an ECG with a pathognomonic finding that everyone ought to know, especially at this time of year. Explanation: this is an example of Osborn Waves seen in a person whose core temp was 28°C.

Osborn waves are positive deflections that occur at the J point. They are seen in hypothermia (T usually <32C) and typically more pronounced at lower temperatures.