Zaven Sargsyan
@sargsyanz
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Carvajal
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• 57304 Tweets
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FELIX ON JEWEL BOX
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[Random loose mRNA lying around in a deltoid]
Nobody:
Ribosome: let me go ahead and transcribe this
Macrophage: Yo, check out this cool spike I found
T-cell: wtf is that? Get rid of it. Where’s Bob?
B-cell: yes?
T-cell: If it ever shows up here again...
B-cell: yes mam
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… it means they care more about getting things right for you than living in some pretend world where they supposedly know everything
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Just saw a group of OBGYNs power walking to the OR, and I thought wow, what they do is amazing. And then I saw a mother walking with her infant and I thought wow, what a cute baby. And then I saw 6 more pregnant women, and I thought wow, this is the 3rd floor not the 2nd floor.
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Dear medical students, I was recently in the car of another attending physician, and I found all your pens.
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An autopsy is a test and has false negatives like any other test.
The pre-test probability that George Floyd died from a 200+ pound force applied to the airways and vessels of his neck for many minutes is pretty much 100%.
No test can move that needle.
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Ultrasound: “no evidence of cholecystitis”
Op report: “gangrenous cholecystitis with extremely friable tissue. Purulent drainage with manipulation of gallbladder.”
I've seen this many times.
Thread
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What’s wrong with this ABG attempt?
Thread. On one of the most common pitfalls when doing vascular punctures and other bedside medicine procedures.
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First day PGY-1
Me: [orders 30 mEq potassium cause level is 3.7]
RN: we don't do 30, we do 20 or 40
Me: oh wow thanks, does it only come in 20s?
RN: no it comes in 10s
Me:
RN:
Me: cool, I'll change it to 20, thanks!
#TipsForNewDocs
: choose laminar flow over turbulent
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What’s a stronger regimen of furosemide, 40 daily or 20 bid?
I ask this question often on rounds. The answer: it depends.
Understanding what it depends ON is really helpful for dosing decisions.
Let’s explore.
#tweetorial
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Escape room for physicians where you have to…
- Turn off (and on) the bed alarm
- Boost a patient in bed
- Pull tray table over the bed
- Troubleshoot a beeping infusion pump
- Silence and adjust alarm parameters on patient monitor
- Disconnect tube from an IV
What else?
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The longer you wait, the harder it is:
- washing egg yolk off a plate
- washing oatmeal off a plate
- writing a discharge summary
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Code blue: as the code runner, do you walk or jog?
I have a Russian friend who’s read a lot of Tolstoy. Once I asked him if he ever runs to codes. He said-
“A general should never run. In peacetime, it looks foolish. In wartime, it induces panic.”
1/2
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This came in a toy doctor kit, and I can’t figure out what it is. Please help.
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I’m a big fan of cancel culture if the UA has no leukocytes
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The left iliac vein has to cross under the right iliac artery in all of us, and is subject to relative compression/stasis. Thus, even in systemic causes of edema, the left leg often swells first, stays slightly more swollen, and comes down last during diuresis.
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Understanding this joke is the only use of organic chemistry to a doctor.
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“Warfarin… that’s weird… why warfarin?” - resident
We’ve come a long way. Thank you apixaban.
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When the creatinine was around 2.5 for a long time and has been “improving” to 1.5 over the last year, it’s not the GFR increasing, it’s muscle mass being lost.
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Once I asked a fellow academic hospitalist how work was going and he said “you know, acute on chronic,” and I think that’s a good way to put it.
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Folks always confuse 1:1,000 vs. 1:10,000 epinephrine, when you're supposed to use which, what the dosing is, etc
Here's what helps me remember/teach.
Thread 1/9
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Guy who drinks came in confused with sodium of 116.
Received 2 liters NS downstairs.
Repeat BMP is pending.
Medicine team waiting for the result:
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The “hyperkalemia box” mnemonic.
Taught to me by
@DonaldStader
, reminded by
@EM_RESUS
.
Note: some oversimplification involved.. sequential progression does not always occur or correlate with serum levels.
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ACE inhibitors and ARBs are not “nephrotoxins.”
They improve renal blood flow.
But they reduce GFR, and impair potassium elimination.
Which is why we might hold them in [severe and/or worsening] AKI.
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Saw a creatinine this morning.
Hold the dose!
Hold the dose!
Hold dose.
Hodos.
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The respiratory rate is recorded as 18.
❗️𝗢𝗳𝗳𝗶𝗰𝗶𝗮𝗹 𝘀𝗼𝘂𝗿𝗰𝗲𝘀 𝗵𝗮𝘃𝗲 𝗱𝗲𝘁𝗲𝗿𝗺𝗶𝗻𝗲𝗱 𝗱𝗶𝗳𝗳𝗲𝗿𝗲𝗻𝘁𝗹𝘆
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Just need a single button that prescribes all the diabetes paraphernalia (glucometer, lancets, strips, alcohol swabs etc) without 30 clicks.
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I’ve never had a viral tweet but I have had a couple of mycobacterial tweets
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If we never stop saying "formerly known as Wegener's," it will always be known as Wegener's.
It's granulomatosis with polyangiitis. Period.
Ready... set... done.
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My favorite exam finding in hospitalized patients: “Multiple family members at bedside.”
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How I first learned it:
Past medical history:
- HTN
- CAD
- Localized RCC
Past surgical history:
- CABG 2007
- Cholecystectomy 2009
- L Nephrectomy 2011
How I've adjusted it:
PMH/PSH:
- HTN
- CAD s/p CABG 2007
- Localized RCC s/p L nephrectomy 2011
- Cholecystectomy 2009
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On your last day on an inpatient team, make rounds before leaving to tell each patient that
- you won’t be there tomorrow
- your oncoming counterpart (that you’re gonna talk to tonight) will take good care of them
- that you’ll be thinking of them and wishing them well
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Does pancakeopenia mean there’s a deficiency of pancake, or a deficiency of all cakes
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It’s also nice to not be breathless when you get there.
On other hand, some hospitals are expansive, and a lot can happen (or not happen) in a minute.
My compromise: jog with a calm face, breathing deeply. Slow to a walk when approaching the unit.
2/2
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CT angiograms are great for some things... but sometimes you need a conventional angiogram.
Polyarteritis nodosa.
From PMID 22704357
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You know how trimethoprim-sulfamethoxazole can cause hyperkalemia?
And remember triamterene, the potassium-sparing diuretic that acts on the ENaC channel?
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Many medicine procedures involve (1) pushing a needle into a fluid-filled space, (2) advancing a plastic catheter over the needle into the space, (3) pulling the needle out, and (4) leaving the catheter in either for drainage or infusion.
Things often go wrong at (2).
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Learning cardiology on OBGYN. 🧵for students.
On my labor & delivery rotation, every patient I saw had a systolic murmur over the pulmonic valve area.
Why?
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You can have iron deficiency anemia (case and air pods both depleted)
You can have iron deficiency without anemia (case empty, air pods full)
And you can have anemia without iron deficiency (please don’t refer to GI)
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US hospitals employ many Sitters - people who sit in the rooms of patients with delirium to keep them safe.
We should also employ many Walkers - people who motivate and assist patients (without specialized physical therapy needs) in staying mobile - and thus safe.
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Penicillin, 1940: cures sepsis, saves lives
Penicillin, 2020: hangs out with syphilis and under ‘allergies’
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Spleen: nobody understands or cares about me
Thymus: 🙄 cry me a river
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It must be easy practicing medicine in the Ohio River Valley, where people only get one disease.
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Working at night can be hard physically, so I’m gonna pump myself and you up by highlighting the upsides:
- the hospital is quiet and peaceful
- there’s less clerical work
- often more time to talk to patients, think, read
- more snacks and music than during day
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In 2020, “call patient’s family” should be part of our daily checklist for every hospitaized patient.
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Dear chemotherapy,
The abbreviation CTX is mine. You’re chemo. That’s pretty good. You don’t need CTX. I’m CTX.
Sincerely,
Ceftriaxone
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IgE. Keeps us from being eaten by worms. Can also kill you in 90 seconds. Respect.
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Myxedema coma would be more easily recognized if we renamed it sleepy hypoglycothermotensive hypothyroidism
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What potential “easy fixes” in the EHR would save time and headaches for clinicians (especially new ones) and their patients?
I’ll start: the fact that something called an “iron panel” does not include a ferritin.
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During intern orientation, I shared some advice: “an extra hour of sleep is better than anything on Netflix.” I didn’t say HBO.
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When I’m rounding in the hospital I usually hit 10,000 steps during the workday and I’m pretty sure 9,000 of those are walking in random directions before I figure out where I actually need to be going
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Why do some people treat B12 deficiency with oral B12 even if the problem is poor absorption?
Is this a good idea? Is it a paradox? Let’s reconcile,
@tonybrue
#tweetorial
style.
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@DGlaucomflecken
I’ve heard reading in a foreign language helps you fall asleep too, so I keep a stack of ophtho notes by my bedside table
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Poor haptoglobin, people never care about it when it's there but when it's gone suddenly everyone's all peripheral smear this and schistocytes that
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The serum creatinine level is a concentration, amount per volume.
If you quickly expand plasma volume by 20%, the Cr will decrease by ~20%, saying nothing of GFR.
Same goes for ALT, WBC, CRP, and other values that we trend and sometimes overinterpret small fluctuations of.
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A slide on infectious organisms that can be seen on peripheral smear.
Sensitivity may not be adequate but generally increases with severity. On the other hand, a positive finding may be specific/diagnostic much earlier than alternative dx methods.
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Q: what did the person with this ECG say to the interventional cardiologist?
A: thank you from the bottom of my heart
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A white blood cell count without a differential is like if your basic metabolic panel just said 292 as the sum of all the numbers.
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When a patient suddenly insists on leaving against our advice, we get worked up.
We beg them to reconsider. We worry about their health.
Often it's too late. A made-up mind is hard to change.
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I was taught, and continue to hear it taught, that the history of present illness (HPI) should be crafted to "convince the listener/reader of your suspected diagnosis."
I think this framing is problematic...
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Most medical students have fainted or almost fainted their first time watching a surgery or suturing or making a nervous presentation.
It’s vasovagal syncope. It’s common and some folks are prone to it. Anxiety. Anger. Seeing blood or needles. A big meal.
Not a big deal.
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Telling clinicians not to use copy-paste in notes is like abstinence-only sex education.
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Prophylaxis tips, medical floor:
- Constipation: use anything but docusate
- Ulcer ppx: almost never indicated
- DVT: if using drug, don’t use pneumatic compression, and use LMWH unless GFR<30
- Delirium and deconditioning: help pts hear, see, talk, walk, eat, and sleep
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If a patient with pancreatitis is getting 5 liters of fluid and making 5 liters of urine, they don’t need 5 liters of fluid.
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Ok, I’m generally up for whatever and happy to roll my sleeves up… but I don’t have this many sleeves.
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“He failed anticoagulation” Didn’t anticoagulation fail him? “X-ray with poor inspiratory effort.” But she’s intubated and sedated... Collecting other examples of blame, wired into in our language, that we should unwire.
@adamcifu
#WordsMatter
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Eosinophils matter:
Inspired by yesterday’s
@CPSolvers
case + last week’s NEJM case, reprising this thread with 5 more real case examples of this take-home point:
In acute presentations, eosinophilia is often a pivot point: it dramatically shifts/narrows the ddx.
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Medical student learning about nursemaid’s elbow for the first time: “geez why would you yank a kid by the arm that hard?”
15 years later: kid decides to protest and go limp in the middle of crossing the street. (thankfully radial head stayed in place)
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The physical exam sucks because I can’t palpate the retroperitoneum
Ultrasound sucks cause I can’t diagnose a stroke with it
CTs and MRIs suck, they didn’t help me with a rash
History sucks cause sometimes patients are altered
I practice medicine with my head in the sand
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Amount of time it takes to properly teach hyponatremia: 120 minutes
Amount of time it takes to properly teach hypernatremia: 150 seconds
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Anatomy quiz: why does this pan feel twice as heavy when I hold it sideways?
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Love this pearl. This venodilatory effect of IV loop diuretics is prostaglandin-mediated and negated/prevented by NSAIDs... as if you didn't have enough reason to avoid NSAIDs in patients with heart failure.
Did you know? IV furosemide reduces preload within minutes (venodilation), long before its diuretic effects kick in. Don't hesitate to give it in acutely symptomatic ADHF!
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The presence of a Foley catheter belongs on a problem list.
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