Peter Sherren
@PBSherren
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Intensive care medicine and anaesthesia consultant specialising in ECMO/cardiac/prehospital care. Love coffee and all things automotive. @GSTT_ICU @EHAAT_
London
Joined May 2009
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Pinned Tweet
With the number of COVID-19 critical care admissions in the UK rising again, clinicians may find our narrative review on 'COVID-19-related organ dysfunction and management strategies on the intensive care unit' of interest
@BJAJournals
@GSTT_ICU
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Please stay at home as COVID-19 is running amok in London and it really is getting desperately bad. No long, eloquent and well referenced tweet I'm afraid, just the reflections of a busy and tired ICU consultant. Worst that I've seen it in my 20 odd years by a cataclysmic margin
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Quite a few actually Eljay. Some in their twenties/thirties previously fit and well now fighting for their life on ECMO/lung bypass on the intensive care, none vaccinated. Not sure if this is quite what you were after but all the best. Best wishes Peter, Intensive Care Consultant
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I suspect there is a difference in opinion because Tony is a football coach that visited a hospital once (for meeting and a hot drink in Costa I believe) and I'm a consultant in Intensive Care Medicine who has worked as doctor in the NHS for 18 years 🤷♂️
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New ECMO retrieval ambulance and trolley up and running, shame about the weather!
@GSTT_ICU
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The priority for patients haemorrhaging to death is to stop the bleeding, not develop a bigger blood bank over the next 5-10 years. This NHS workforce plan is just another Tory smokescreen to avoid talking about the real issues. We need to talk about pay, conditions and retention
“It will represent… the largest expansion in training and workforce in NHS history”
PM Rishi Sunak says his NHS workforce plan, to be announced later this week, will ensure the NHS has the right number of doctors and nurses
#BBCLauraK
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Only once points 1-5 have been fully addressed should your institution every consider discussing any form of resilience, mindfulness, wellness or yoga sessions with employees
End of 🧵
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Pre-resilience training checklist:
1. Our staff are appropriately paid?
2. There is no sustained overworking?
3. Humane rest facilities & oncall rooms available?
4. Hot food & refreshments available 24/7?
5. We currently have a well staffed, safe & supportive working environment?
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So far this year we've had 40+ COVID patients require ECMO/lung bypass at
@GSTT_ICU
. These are the sickest patients across ICUs in the UK with an average age of 46. So far we've not had a single double vaccinated patient on ECMO. Vaccinations matter even if you're young/healthy
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I suggest a moratorium on the use of the words wellbeing, resilience or free yoga until the government/NHSe sort out working conditions, hours and pay for the entire workforce
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'My consultant, who has never seen the patient, says they should be for everything...'
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Standard LUCAS position versus ~5cm lower and slightly off centre, ETCO2 increased 2kPa. Are we even getting the essentials right every time during cardiac arrest? Increasing need for precision rather than algorithmic medicine
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Don't trust peripheral arterial lines in critically ill patients on high dose inopressors
#oldiebutgoodie
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Absolutely fascinated by my little girl who will normally only sleep on her back or side but as soon as her first virus arrives you can't keep her from self-proning! Amazing how long science can take to catch up with what a seven month old intuitively knows
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We're two NHS consultants oncall 24/7 this weekend for the NHS. To allow this, we need my wife's Indian parents to look after our two beautiful dual-heritage girls. Currently deciding if it's safe for these two retired NHS GPs to travel to London, sad state of affairs
#RacistsOut
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In my last few decades working in the NHS I've not seen a single medical professional with a lanyard/exemption certificate for not wearing a facemask. I'm curious as to what is so different about the general population on the tube this morning 🤔.
#Oncallmusings
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Whilst the peak may be coming soon, sadly we still have almost 200patients in our critical care. 84% have respiratory failure because of COVID-19 (not a coincidental admission or false positive). We've never had >90patients in our ICU's history, this isn't 'just a bad flu season'
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Sadly seeing increasing misinformation on COVID vaccine related deaths. While there're very rare serious adverse reactions to the vaccine (VITT etc) & deaths, as a consultant in one of the busiest ICUs in the UK I've not had to directly care for a vaccine related death myself 1/3
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Disgusting behaviour. If only they could see the death and destruction that COVID-19 is wreaking behind those walls and across the NHS. Having just finished 72hrs oncall for ECMO
@GSTT_ICU
, where we're being stretched like never before, I find such selfish acts soul-destroying 😥
Worked the late A&E SHO shift on NYE and came out to this. Hundreds of maskless, drunk people in huge groups shouting "Covid is a hoax", literally outside the building where hundreds are sick and dying. Why do people still not realise the seriousness of this pandemic?
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Full text of our article on 'Systemic complications of traumatic brain injury' now available
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'Predictors of post-intubation hypotension in trauma following prehospital emergency anaesthesia: multi-centre observational study'
One of the largest trauma PHEA datasets published, fantastic collaboration between
@EastAngliAirAmb
@Magpas_Charity
@EHAAT_
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Interhospital severe respiratory failure retrieval utilising Sedaconda for volatile anaesthesia delivery and scavenging with Flur Absorb. Avoiding need for ECMO
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So sad to watch again. A witnessed collapse in a young athlete with a 'seizure' is a cardiac arrest until proven otherwise
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A few things I find rather grating when discussing PHEM/HEMS/enhanced care teams:
1. Tenuous military comparisons
2. Frequent use of heroism or 'heroic intervention'
3. Any use of the phrase 'adrenaline rush'
As professional/essential services we need to move on
#mondaywhinge
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Refining our eCPR grab bag. Pack 1 and pack 2 layout. Down to a single dilator 16/26f for the arterial and venous cannulae respectively.
@GSTT_ICU
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Apologies POCUS/echo rant! It's a brilliant skill to have just don't forget to be a doctor, know your pathogenesis/DDx and management strategies. Knowing Kumar&Clark inside out may not be as cool as wielding an US probe but remember an accredited fool with a tool is still a fool
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I enjoy Twitter but is it possible that when you look at conference speakers/committee members etc that they're disproportionately populated by prominent Twitter medical professionals? Are more skilled/experienced clinicians overlooked due to the lack of social media presence?
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Really important paper. Cardiac arrest commonly presents with seizure-like activity given abrupt loss of cerebral perfusion. 'The seizure preceded the arrest' default not only delays CPR but it sadly often clouds the triage decision on cardiac vs neuro centre in shockable OOHCA
Third year
@UWMedicine
student
@maddyschwarz
published her analysis in Resuscitation showing that patients in
#OHCA
presenting with seizure-like activity see delays in cardiac arrest recognition and bystander CPR.
#UWashEMS
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Compete sepsis six and refer to ICU
Lactate from an athlete after a 1200m time trial... If this was recorded in a hospital they'd already be writing the death certificate!
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Busy year for the
@GSTT_ICU
ECMO service. Many exhausted staff but hopefully the outcomes will provide some solace. Proud to be part of such a fantastic team.
- 990 referrals
- 178 ecmo runs
- Peak numbers Apr 2020 & Jan 2021
- Peak of 20pts on ecmo
Slides courtesy of
@Luigi_ICM
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New airway trollies&checklists looking good. 4yr journey: Initial audit→SOP development→Airway course→embedding into practice
@chrislockie79
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ICU referral from the dermatology consultant covering the med reg's bleep during the junior doctor strikes
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Not really sure how I feel about this. To be honest I'd rather people just obeyed lockdown measures, followed public health advice and got vaccinated. However, I could get onboard with 'booing the government' every Thursday at 8pm, just a thought
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Things I like to see in the medical plan for a longterm ventilated ICU patient:
- Cold Guinness on mouth swabs as requested.
- Trip outside to get some sun.
- England match on iplayer.
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Bill Gates and I set up a deal a while ago, plus I get a bonus for every 100 vaccinations I deliver. In addition, I've been given lifelong free access to the 5g network. Some really silver linings to this pandemic buisness
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Many of my colleagues & I are very concerned about the growing momentum for CPAP use in COVID-19. Patient's lungs are already primed with a significant viral pneumonitis/hyperinflammatory state, adding swinging transpulmonary pressures/P-SILI into the mix is a recipe for disaster
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Flu A with superadded toxin producing organisms is really hitting hard this year. Being young and fit isn't necessarily enough, get your flu vaccination. Some oncalls remind you just how precious and short life can be
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New eCPR guidelines at
@GSTT_ICU
going live. Plenty of work still to be undertaken but exciting times ahead
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Patient remained conscious throughout 2hours of LUCAS delivered CPR and ultimately involved in the decision to terminate efforts.
A case study of CPR-induced consc. in which the pt indicated agreement to stopping their own resuscitation...
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Annual change day
@ehaatClinical
. Number of SOP revisions and new equipment being introduced. Considered iterative evolution of our critical care delivery. New kit/monitoring only introduced as part of pt-centred bundles of care. Fantastic work by the team! Exciting times ahead..
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Young patient presents to local district general hospital with reduced GCS, cardiovascular/electrical instability and temperature 38C.
DDx and management?
Historical case
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Huge privilege for both Neal and I to take on these roles. Lucky to be part of such a fantastic team at
@EHAAT_
and we look forward to helping guide the service onwards to great things. Really exciting times ahead! Thank you for all the kind comments from colleagues and friends
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Thanks for all the supportive messages, lovely to see the conspiracy theorists are such a minority. Unfortunately, I must go now & focus on what's really important in life as I've have neglected my TikTok videos for too long, sorry I mean be with my family prior to 96hours oncall
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In addition, on our Extracorporeal Membrane Oxygenation (ECMO) unit over 80% of COVID-19 patients are under the age of 50. These are the sickest COVID-19 cases where a ventilator/lifesupport machine isn't sufficient to sustain life. This doesn't affect 'just the elderly and sick'
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Today in theatres all operations were completed, we all had a proper lunch break, finished slightly early & everyone was happy! Bizarrely I almost felt guilty that we hadn't been 'productive' enough. Medicine warps your idea of what's acceptable/normal
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Great open acess article by a UK group on tracheostomy/laryngectomy management. Includes algorithms we use locally
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Massive PE with McConnell's sign presented in extremis to local hospital on high dose inopressors & brief IHCA → no response to tPA → mobile pVA-ECMO → retrieval → thrombectomy x2 → reperfusion injury/DIC/pulmonary haemorrhage → VAV-ECMO → Recovery after 12days hybrid ECLS
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ECMO referral 24hrs post blunt polytrauma. SpO2 70s on Fio2 1, NA >1mcg/kg/min, AVP 0.04, ~10u prbc/products, lactate 8 and brief cardiac arrest/adrenaline boluses. Panscan: APC3# with haematoma but no active extravasation, ICDx2 lungs up and abdo/head ok. Plan?
Historical case
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New critical clinical case passport for
@EHAAT_
. Great way to ensure 'clinical currency' in high risk procedures is maintained beyond the sign off process by the whole team.
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It's ok boys you clapped for the NHS during COVID, you don't need to worry about pesky things like paying nurses & allied health professionals a fair wage. Tory track record on NHS pay over the last 10years is appalling.
@BorisJohnson
@MattHancock
should be ashamed of themselves
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Conversely, I've had to deal with large numbers of direct COVID deaths. Importantly, of the 26,550 patients admitted to ICUs with COVID in the UK since the 1st September the mean/average age is 58.9 years old. 37.5% of these patients died (ICNARC data) 2/3
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James Dyson did not supply a single working ventilator to the NHS, not one!
@BorisJohnson
, sadly there is no doubt you will continue offering favours and tax breaks to your Eton/Oxford chums and the rich but please don't insult our intelligence while doing so, sleaze is sleaze
"If you think there is anything remotely dodgy or rum or sleazy about trying to secure more ventilators at a time of a national pandemic... I think you're out of your mind," says Boris Johnson
The PM defends his text messages to James Dyson about tax
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Exciting times for
@ehaatClinical
with our new Prehospital Care Course. Fantastic 6-day course covering all aspects of prehospital critical care. Well done to
@BurrellLisa
&
@gareth_grier
for bringing together such a comprehensive program & expert faculty. Looking forward to it!!
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Brilliant European open access guideline on the diagnosis and management of hyponatraemia
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Miserable day to be out but our shiny new Volvo is making up for it!
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Extracranial complications of TBI, the often neglected component of TBI management. Figure from our upcoming review
http://t.co/vGKIvPcYab
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Final PDF now available: 'Development of SOP&checklist for RSI in the critically ill'
#FOAMed
http://t.co/1HWh6zws3w
http://t.co/uj89GqI3d1
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So these stats don't align with the narrative of 'they're all elderly or medically unwell'. Such elderly/frail patients with significant comorbidities/health issues are unlikely to benefit from intensive care & hence if deteriorate will sadly die on the medical ward not ICU 3/3
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Only just getting round to fully reading the NCEPOD report Time Matters on out-of-hospital cardiac arrest care in the UK. Fantastic resource for those interested in OOHCA management.
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Fantastic
@EHAAT_
Clinical Governance Day on the 'The Bleeding Patient'. Talks from Gareth Davies, Laura Green,
@karimbrohi
and more! Sign up at for the 4th October using the link below:
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And deaths are only part of the problem, bed occupancy and the impact on other essential non-COVID work (heart and cancer services) is hugely important too
48553 cases today. 100 more patients in ICU with covid19 than 5days ago. No one talking about covid length of stay so I will.
Median ICU stay:-
Heart/major cancer surgery 1-2d
Covid (not ventilated) 5d
Covid (ventilated) 20d
Covid (kidney support) 32d
Do the maths
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Despite greater experience, ICU capacity and access to EBM therapies, the current invasive ventilation mortality for COVID-19 in the UK is 64.6% versus 47.6% in the first wave. Is anyone else a little bit concerned about the reasons behind this?
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An absolutely brilliant bit of work to generate evidence based thromboelastometry algorithms to guide transfusions in trauma induced coagulopathy! Well done to all involved.
@J_Stensballe
@karimbrohi
at al
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It's incredible how many of these 'false positives' are critically ill & dying, so strange but thanks for educating me. Who would have thought all those years of training, experience & exams would be such a waste, instead I could have just come to twitter/google to get the truth
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There are survivors out there in the PEA group with eCPR. A more recent case we had below where most of the 'physiological STOP criteria' were present. Question is where do you set the bar, too many bordeline cases=poorer survival, too good survival might=missed opportunities 🤷♂️
Going back to our case,
NSE 167 --> 55
EEG : low amplitude
Then, EEG reactive on day 8, GCS E3M6 remifentanil held, - obeys command. So all the parameters are pointing to negative outcome. This is after ECPR at 80 mins
#UKECPR23
@MLSCourse
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Poster now up
@EuroELSO
and abstracts available in Perfusion. One of the largest single centre studies looking at ECMO use in major trauma. 33 patients with limited bleeding complications and 88% survival to discharge despite mobile initiation and high mean ISS/prevalence of TBI
📣 The
#EuroELSO2024
special edition of Perfusion Journal including all conference manuscripts & accepted abstracts is now available, free open access! Enjoy
#FOAMcc
#FOAMecmo
🔓
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Understandably it's all getting a bit serious at work at the moment but if you can tolerate a bit of swearing here is something to lighten the mood!
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Nice algorithm for applying pelvic binder. HT
@LeechCaroline
for highlighting FPHC statement
http://t.co/hAVcpqrd0l
http://t.co/Cl97QVZnlE
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This is real amateur hour stuff! A true professional bosher would leave the lights off and intubate in the car with NVGs
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Probably time to reflect on your political approach when the president of the Australian Medical Association openly mocks you. Such Tory bully boy tactics only accelerate the staffing crisis/mass exodus to Australia. This isn't the way to deal with highly trained professionals
Looking forward to working with many ex-NHS colleagues next year!
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Still my favourite review of cardiac arrest management post cardiothoracic surgery.Need to think beyond standard ALS
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In addition to the loss of senior clinicans due to early retirement, the loss of good will is going to be huge! Particularly poor timing given the NHS needs them to work additional hrs to clear an enormous backlog of work. Unbelievably short sighted or deliberately destructive?🤔
BREAKING:
#2021budget
@RishiSunak
announces freeze to indexation of LTA - freezing it at current levels.
Ignoring the warning from
@TheBMA
this *will* have a devastating effect on the NHS with doctors pushed into early retirement or working less
@JosephineCumbo
@HSJnews
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Last medic 1 shift done.Sad to be moving on but it was a privilege to be part of such an exceptional team
@LDNairamb
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Two very important papers on OOHCA management just released:
- Time Matters: NCEPOD review of in-hospital care provided following an OOHCA
- Association between admission to a cardiac arrest centre & survival to hospital discharge
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Absolutely pathetic opportunistic grifter, I'm embarrassed that we share/shared the same profession. Such strong opinions on COVID-19 deaths from an individual who hasn't got a licence to practise and doesn't work in the NHS anymore 🤔
@ClareCraigPath
announces the Covid Death Audit which will investigate EVERY official UK Covid death.
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Love it! "
@VPIMedic
: Anesthesia rez showed up to trauma alert prepared. Too good not to share
#FOAMed
http://t.co/V6zDCahDB5"
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Recent visit to Harefield Hospital with
@EHAAT_
. Fantastic reception in the cardiac cath labs by an experienced multidisciplinary team as always! 👌
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There should be laws against tweeting post oncall much like drink driving, until then, is anyone else tired of reading COVID-19 publications on critical care issues written by previously well published experts that have cared for minimal or no critically ill coronavirus patients?
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Interesting review of 22 patients with near fatal asthma requiring ECMO at
@GSTT_ICU
in 5yrs. All survived and a high rate of fungal/viral isolates. Increasingly of the opinion that young asthma patients just shouldn't be dying from asthma exacerbations
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Fantastic eCPR education half day for the South Thames ED regional training day. Lots learning for the participants and MDT faculty, great opportunity to refine process/kit for this challenging group of patients. Drowning/hypothermic cases challenging decision making
@GSTT_ICU
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Hi Russell haven't you heard that all these people dying of severe respiratory failure with chest Xray changes and +ve COVID-19 PCR are actually just false positives or dying with COVID not because of it? I'm finding such rhetoric very comforting during these difficult times.....
I’m really really really really really really sick of this disease now...
Seeing people gasping for breath.
Trying to explain over the phone in the middle of the night just how unwell a relative is.
Doing it over and over and over again all day every day.
It feels endless.
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Great lecture by
@robfenwick
on the
@theEXITProject
, so many important take home messages. Number 10 is critical from a patient perspective, too easily overlooked on a busy incident.
@Aeromed2023
@EHAAT_
#aeromed2023
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My daughter never fails to bring a smile to my face despite whatever is going on in the outside world
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I'm increasingly worried about an endemic COVID-19 related brain injury that is as yet undefined. COVID idiōticus is heralded by a few of pathognomonic phrases:
'It's a conspiracy'
'Only effects old people'
'It's no worse than the flu'
'They died with COVID not because of it'
1/2
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A few golden rules when dealing with severe respiratory failure patients:
1. ARDS is not a diagnosis
2. ARDS is not a diagnosis
3. ARDS is not a diagnosis
'Subtypes' improve at variable rates because they have a different primary diagnosis
Rapidly improving
#ARDS
(riARDS), a new and important clinical subtype of ARDS.
#journalCHEST
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Interractive PDF of
@GSTT_ICU
intubation checklist. Easy to use from your mobile. Great work
@jakobdudziak
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Both scientists would have failed the FRCA miserably with their graph legibility....
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Brilliant 2017 consensus update on cardiac arrest management post CT surgery from EACTS/Society of thoracic surgeons
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8.4% Na bicarbonate tonicity equivalent to 5.8% HTS. 85ml of 8.4% can reduce ICP & increase serum sodium by 1.6mmol
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Great open access paper from Minnesota on their advanced resus strategy for refractory VF/VT
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Nice video on the HINTS exam for distinguishing posterior circulatory events from peripheral causes
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Abstract submitted to
@EuroELSO
, should hopefully encourage some healthy debate on ideal pathways. Not too many spoilers but very good outcomes in 33 patients despite high ISSs and mobile ecmo initiation. Always worth referring major trauma cases even with TBI/multisystem trauma
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