nick pulmcrit
@pulmtoilet
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Dad/Husband | Current #PCCM MedStar Baltimore | Former Chief Fellow @medstarwhc | Former Chief Resident @mcmc_imres | ABG miser | #Philly
The Trenches
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One of my cofellows was killed in a tragic and senseless act of violence. The ID/ccm world lost a hero yesterday.
We are heartbroken to learn of the sudden passing of Dr. Rakesh (Rick) Patel. He served his residency here, had completed a fellowship in Infectious Diseases, and was currently training as a Critical Care fellow. Dr. Patel will be greatly missed.
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I’ll save you the reading time :
Hypotensive:: too unstable for scope
Not hypotensive: outpatient scope
“Establish peripheral access, transfuse pRBCs, don’t call after 9pm”
JAMA Clinical Guidelines Synopsis summarizes the 2023
@AmCollegeGastro
guidelines on management of patients with acute lower gastrointestinal bleeding.
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There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
There is no such thing as maintenance fluids
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can someone please explain to me what is so magical about ABGs? Patient short of breath , "wow we should check an ABG" whyyyyyyyyyyyyyyyyyyyyyyyyy
STOP. CHECKING. ABGs
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Disclaimer:: I am not a surgeon, but did have to do an emergency cric on a patient with massive hematemesis, a soiled bloody airway, who was coding. I've played this out in my mind mentally so many time and made the decision to cut before I hit the door. MY practical experience:
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Following case has been altered but is based on real events:
I was called to the patient’s bedside for episode of SVT and hypotension. Our patient was admitted recently with acute renal failure and cardiogenic shock.
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Your patient is in shock. Are you titrating pressors based on art line or cuff? Pretty big discrepancy so you need to make a good case
@IM_Crit_
@msiuba
@PulmCrit
@PulmPEEPs
@EMNerd_
@emily_fri
@heart_lung
@ThinkingCC
@icmteaching
@AZviman
@nickmmark
@CriticalCareNow
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🚨🚨🚨🚨another edition of
#fromthetrenches
🚨🚨🚨🚨
Recent case of mine —> clinical details altered for anonymity
59 year old male presents to ED with SOB. Family states was at home at fell in bathroom. Hx of HTN/DM. Unsure of meds or compliance to therapy. Arrival BP 79/42 😱😱
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@PulmCrit
85 year old patient
“Patients only eating 25% meals”
“What’s the diet order?”
“Carb conscious low sodium”
“Please get the patient ice cream stat”
What exactly are we accomplishing with these strict diet orders in elderly frail patients besides torture
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Please: antipsychotics 👏should 👏not👏be 👏used 👏in 👏the👏ICU👏solely👏for👏sleep👏
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Pt found down in shock. Brought to ED and Intubated, worked way from a little Levo to a ton of Levo very quickly. Get to bedside, gotta figure out what’s going on. Find this little bugger—This is why echo ☝️
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78 yr old bad sys HF (ef 20%, also RV dysfunction with baseline TAPSE 1.0) in shock also has pneumonia (clinically and microbiologically)
These are recs: “Please start gentle hydration as patient looks clinically dry and has sepsis”
Takes me 15seconds to KNOW he isn’t
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S/p cardiac arrest. Tough subcostal views, other views unobtainable. Think we get the point 😱😱😱😱
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When trouble shooting the ventilator always look from wall to patient. This much debris in the circuit could lead to auto trigger !
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Hoping to have
#medtwitter
amplify this message so his death does not go Unnoticed in our community
@DGlaucomflecken
@MDaware
@GoodishIntent
@RyanMarino
@WesElyMD
@DrSandman11
@chungk1031
@gradydoctor
@GovLarryHogan
@MurielBowser
@Bob_Wachter
@Surgeon_General
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Hi , pulm/ccm here
NEVER use a blood gas for a decision to intubate, arterial or venous
If the pCO2 on a VENOUS blood gas is NORMAL or 42 or 44 you can exclude CO2 retention, but if there is COPD or hypotension or the use of pressors, we are in trouble using a venous blood gas for pCO2 of 50 or 55 to decide to intubate
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@EricTopol
@imperialcollege
We really need to be careful with the “no evidence” statement. I’m old enough to remember when there was no evidence that : covid spread person to person, that steroids didn’t help, that toci didn’t help, that covid wasn’t airborne, that we were immune after 2 doses
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10 abgs for the chronic hypercapnic patient who is obtunded and just needs the NIPPV optimized but do one LP for undifferentiated AMS and everyone loses their minds
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This is precisely the reason why prvc is the singular worst mode of ventilation
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IV diuresis in severe pre-capillary
#PulmonaryHypertension
&
#RightHeartFailure
- effects on Renal fxn & BP
From
#TempleMade
@TempleIM
&
@TempleCards
alum
🙌🏽
@LyanaLabrada
@PForfiaPHDOC
CarlosRomero AhmedSadek
@DBelardoMD
YasminRaza
🔗
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“Dad, what’s 30cc/kg?”
“I don’t know son. We don’t blindly follow recommendations based on weak outdated non-physiologic evidence whose major citation is just the previous committees guidelines”
#hocuspocus
#perfusionpressure
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This is an amazing thread on pneumonia. But please god don’t do a 7% saline neb for an induced sputum. Hypertonic nebs INDUCE bronchspasm, decrease fev1, and aren’t patient centered or evidence based
Sputum cultures - underdone. Make efforts to get them and get them early. Think induced sputum in the ED with 7% hypertonic saline.
Neg cultures have value. If no MRSA/PsA grow, they're not there.
Viral options and multiplex PCR ($$$) highlighted below.
#SHEASpring2024
6/
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Another edition of
#fromthetrenches
(courtesy of
@IM_Crit_
) :
:details changed:
59year old male PMH severe pulm htn comes to the hospital with increasing sob, edema. Admitted, developed shock, and was diuresed but eventually needed CRRT for AKI and volume removal.
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Tales from the
#trenches
The sepsis paradigm that’s preached as dogma is fundamentally flawed.
TLDR:
My personal biggest hits on the “oh shit-o-meter” with sepsis is:
1.Hypothermia🥶
2.Lactic+sepsis+”normal BP” (so called cryptic shock)
3.⬇️low white count
4.Bandemia 🩹
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Dear pediatricians, ED ped docs, adult ED docs who are ready to care for pediatric patients, PICU docs, peds nurses, everything pediatrics related
Thank you.
From a dad
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@DGlaucomflecken
I want to thank Bill for approaching all these attendings with the blindest of courage
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Thank you everyone! Rick was a great guy, a dedicated doc, and a staunch support for the residents at
@IMMWHC
.
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Time for Another
#FROMTHETRENCHES
. Recent case of mine. (Details altered for anonymity).
60 year old female with PMH of HTN comes to the ED with complaint of RLE pain. States that she had recent fall and her RLE is now swollen and very painful. Triage BP is 79/42!!!!
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@grahamwalker
@joerogan
you said you’re interested in the truth. This thread has a lot of truth in it. Why don’t you bring on an actual expert.
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Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
Dexmedetomidine does NOT treat behavioral disorders.
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Tales from the
#trenches
:
Overwhelming sepsis, aki, younger patient with not much comorbids, maybe diabetes or liver dysfunction?
It’s group A strep with toxic shock til proven otherwise
Add anti toxin, get aggressive: steroids, IVIG
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Lessons: “looking dry/wet” are non-sensical terms that I don’t accept as an assessment, all hemodynamic decisions in decompensated pulm htn should be based on some echocardiographic imaging data (pocus or formal echo), las art line variation does not equal hypovolemia
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Our residency is experiencing a heart breaking loss with the unexpected death of PGY2 resident, Ainsley Pratt. An absolute paragon of patient advocacy, I was very lucky to work with her in the MICU and witness first hand what happens when the doc gives 120% everyday.
#RIP
We are heartbroken with the loss of our dear friend and beloved resident, Ainsley Pratt. We will remember her for her unwavering courage, vivacious energy and unbeatable wit. Our thoughts and prayers are with her family and friends.
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Maybe it’s because I’m older now but as the usual last person to talk with the patient I ask such basic questions. None are really medical. I like to ask
1. Why did you come to the hospital? — the art of the chief complaint is really lost
2. What do you do?
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Them: “patient was in respiratory distress so we got an ABG”
Me: “
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I didn't match. Found my way into a transitional year then went to IM then chief resident now chief fellow about to graduate. important lesson learned--->
"a smooth sea never made a skilled sailor"
#conditionedforchaos
@FewWillHunt
#MATCH2023
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@DanMunro
@nurse_jaqwellen
Dan, I’ll take an average salary of your wise choosing if you wipe away my medical school debt 370k and I only work 40 hours a week and I’m free of litigation for errors, we’ll chalk it up to spillage—deal?
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Cardiac output is always the sacrificial lamb on the alter of making the rate 120 instead of 135 in acute medical illness and I will never understand it
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Can we just take a time out and really appreciate what
@CritCareReviews
has done since being founded? Provide a newsletter with the most up to date evidence, guidelines, podcasts, and now hosting a meeting for many pivotal CC trials-all from a FOAM mindset. Inspiring for us all!
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Often missed point is that the LV ef could be very high (70%) but the LVOT VTI could be veryyyyyyy lowwwwwww (<10)
the uninitiated would give fluid b/c the LV hyperdynamic but the secret🥤is 160lasix
Throw EF in the 🗑️ during acute illness
@msiuba
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Night nurse after saying all night that we should intubate the patient and at 630am the icu resident saying “let’s intubate”
@TheBlondeRN
@nurse_jaqwellen
@nursekelsey
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@NoobieMatt
Meanwhile I’m sitting here like damn he really went all out for this sim session.
Old attending surgeon said train them well cuz one day you’ll be the one looking up at them for help
Hope you’re feelin better !!
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We’re in a different time in the pandemic, but I’ll never forget those midnight conversations in my own mind with Intuabted patients and myself when I see their phone on the table and just wonder what messages they’d either wake up to or messages of love that were never seen
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@TriageNurseMD
The pandemic has taught me that young people without a lot of comorbids can tolerate a wildly low pulse ox.
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Wild night lysing massive PE with
@EMNerd_
!
Remember kids, it’s not hypoxia that kills patients it’s hemodynamic collapse!
#respecttheRV
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Teaching points:
1. Echo first always
2. Valvular disasters are an important consideration in acute resp distress/shock
3. Need to dx early so can get patient to place with appropriate therapies if needed
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the decision to cric is harder than the procedure itself. Can confirm
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@DocMcCafferty
For what it’s worth, loss of sense of smell/taste tied to lower risk of resp failure in retrospective studies. Take care!
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@sbABetterLeader
I’m going to sleep soon. Better put in my nightly IV and start my 75cc/hr of LR
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Still surprised me that there’s a subset that believes POCUS does not change outcomes or contribute to diagnosis
Won’t change me view that echo is ☝️
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Kudos to the
@emcrit
team for the mantra of Scalpel-finger-bougie because thats what I thought in my mind the whole it.
These are obviously high risk, low frequency procedures but in all honestly, its not as complicated as you think.
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In short, tamponade is a clinical diagnosis that requires rapid assessment and treatment. This patient underwent pericardiocentesis and shock was resolving
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@kidney_boy
I force my students and residents to leave early—why? They’ll have plenty of time for the masochism, sometimes it’s unavoidable. Stayed late plenty of times intubating patients, putting in lines, calling families, running codes. Can only do it so long before the dread comes
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Friends, let’s be honest. None of us knows anything about inhalers.
If you prescribe inhalers(IM, EM, FM, Peds), you need to listen to this episode
Shout to the inhaler 🐐
@AmberMartirosov
for giving her perspective and expertise to guide this discussion
There are many inhaler devices available and selecting the right device for your patient can be overwhelming. Listen today on selecting the proper inhaler, how to ensure proper inhaler technique and hear about great resources for you and your patients
🔗
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@nursekelsey
Some people on this feed may be surprised to find out you go without water quite often for 8-12 hours at a time. It’s called sleep and somehow, maybe magic, they still work. Keep fighting!
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If there’s a disagreement whether sepsis was present or not, who would you believe?
Crit care
1778
ID
962
Surgery
95
Other/it’s always present
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My threshold is incredibly low for high dose thiamine. It’s hard to think of a downside
nutritional deficiency + any clinical feature of wernicke (ataxia, confusion, nystagmus, or opthalmoplegia) = high dose thiamine 😛
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@drgregkelly
I prefer to have the mitigation measures in place until we’re really certain we can control the outbreaks cuz it just feels like we’re still at its mercy and can’t prevent any wave from happening. The next few months should be a barometer for that.
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@jmugele
Thanks in advance for probably not being a dick about it—Im sure the team and patient needed your help.
#seeonedoone
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After I place a chest tube for pneumothorax, I place the chest tube to
water seal
665
suction -10
163
suction -20
714
comments/controversy
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Friends, "Sepsis", whatever that means, is truly the great masquerader.
This seemingly easy diagnosis lulls you into a sense of calm: fluids, antibiotics, lactate.
All the while, your patient with tamponade dies
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@eemoin
Akin to extubation failure or rate of self extubation. Self extubation is the best kind of sbt is what I always say
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to those asking why-->fluids should have an indication attached to them. Patients being NPO or not taking oral is not the best use for them. I would argue if a patient is NPO for a certain period of time-->nutrition, lyte repletion should be done via NG tube not 75ccD5 half nml
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Unlike Mg or potassium(2 hour run time), IV phos repletion takes 6 hours. If you can use the gut, use it !
3/ Moving on to our good friend phosphorus…We can think of hypophosphatemia in 4 🪣s:
Decreased intake🍴
Renal losses 🫘
GI losses 💩
Transcellular shifts ↔️
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Levaquin gets a bad rep and for good reason probably. But, can we just have a moment of appreciation for this med that treat pseudomonas, is oral, is bio available AND can treat your patients co-infectious partner, stenotrophomonas.
🫡 levofloxacin
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📢📢Midweek vent rounds !📢📢
You’re called to see a patient on MV for resp failure. Unclear etiology, no PMH because patient avoided care until he came in dyspneic and hypoxic. Pt appears intermittently agitated on the vent, team requesting more sedation
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And no I do not have anesthesia, trauma, ENT, or gen surg in house at one of my shops.
In the trenches, its the intensivist vs the airway.
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@ecalhoun21
So much this.also for in house subspecialties for me. Oh you aren’t “impressed” cardiology? Great meet me bedside and explain
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Please note this is why patients on tube feeds in the icu should be managed with rapid acting q4 or regular acting q6 along with whatever basal insulin is needed. Great work. Add this to your FASTHUGS BID tweetorial
@emily_fri
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Happy to be an official 🐥 🐥🐥🐥!
We are excited to welcome
@pulmtoilet
as our newest Associate Editor to
@PulmPEEPs
Dr. Ghionni is faculty at MedStar Baltimore and was a former Chief Fellow
@MedStarWHC
Welcome to the team 🙌
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@emily_fri
@EM_RESUS
Agree w/new pulm attending. I’d add that there could be effusion -> pleura looks thickened which makes me think trapped lung, prob long standing process since patient isn’t Intuabted and has compensated so all this is chronic
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@jmugele
Hot take: I feel like you can exchange "COVID" with any upper respiratory complaint and you'd get the same answer if the patient went to an urgent care.
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👉👉👉 my take on an often encountered and consulted entity— the Solitary Pulmonary Nodule—any one can start the work up before referring over to your friendly neighborhood pulmonologist!!!
Releasing soon—the multiple nodule infographic!
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@rubin_allergy
@DGlaucomflecken
I just want a xarelto pen. Apparently the pen will Influence my prescribing habits because I am a mindless drone
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Sometimes the most aggressive choice is do aggressively reasses, aggressively be at the bedside, and aggressively do nothing as opposed to doing something for the sake of doing something. Sometimes no action is the best action. But ALWAYS BE AT THE BEDSIDE
#MedTwitter
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What we should remember is “sepsis” by definition is not an oxygen DELIVERY issue; it’s an oxygen utilization issue —
Sure some patients could use fluid but remember that’s NOT the issue in sepsis
1. Get source control
2. Antibiotics early and the right ones
3. Do no harm
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What happens is that someone usually starts IV fluids for this reason (NPO) and they are maintained for days and days and you wind up with fluid overload, edema, and congestion esp in the frail medical patients (among other issues). If you got a GUT, USE IT!
@msiuba
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🚨🚨🚨hyponatremia and AKI in a heart failure patient, if the patient is clinically dry (whatever that means), I will give IVF at a rate of :
100cc/hr /24 hrs
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"gentle hydration"😒😒
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Small bolus
514
IVF ru crazyyyyyy??!!
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Another day, another way PRVC is convincing me its perhaps the most dangerous mode of ventilation
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As the kids say, TLDR:
Every patient with asthma should be on
ICS at every level of control and during exacerbation.
Amazing episode and infographic !!!
1/ 🚨 NEW
#BeyondJournalClub
with
@NEJMGroup
: Asthma Management & the Mandala Trial 🫁
Rescue inhalers for adult pts w/ asthma should include an ICS + SABA/LABA*
*unless the pt is very well controlled
🎧:
🖥️:
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@eemoin
“Pt self extubated and is now on room air”
It’s amazing how much group are uncomfortable with diagnostic uncertainty like anything we do in medicine is infallible.
In residency, we had reverse case—>thought was uti—> AMS persisted—>turned out to be HSV encephalitis
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Dear IM friends, learn how to put in PIVs. Learn down to do it quickly as well.
Anything you’re going to give to a patient is likely going through an IV and without access you can’t doctor
#EJallDay
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@SMacMillanMD
@ogi_gajic
@chungk1031
Literally just happened to me. Patient is tachypneic but nothing else vital sign wise. Says to me “I feel like I’m going to die” before I could say it’ll be ok; she codes
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BUT, I remember
#echo
first☝️☝️So, on bedside, there’s wildly diffuse B lines. Ok consistent with my CXR
Now cardiac
I’m no expert, but that looks weird?
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@EM_RESUS
Thanks Sam! I think I’ve seen what u mean before—3 things favor clot though: I found a left femoral vein DVT, clot in the RA/RV and PE on CT scan!
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@GoodishIntent
Quick to judge the OSH but often forget that community hospitals are resource poor because health care in America is completely lopsided
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What’s the most tedious ICU procedure and why is it suturing a radial A-Line
#CRITCARE
#MedTwitter
#PROCEDURETWITTER
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Well, thats it for me for
#CHEST2022
. It was a whirlwind few days with some great talks by some amazing faculty. Really enjoyed meeting some of the twitterverse IRL. Definitely looking forward to continuing to have shared learning experiences that this platform affords us!
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My daughter is awake and therefore I am awake. I cruise
#medtwitter
in order to keep myself in the loop but inevitably always seem to find
@DrLeanaWen
‘s belligerent commentary, and attached are her views published in
@washingtonpost
that she wants us to read. So I did—a 🧵
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I love how we’ve been gaslit into thinking that some how iv fluids cures this incredibly complex pathobiological state
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