Tim Astles

@cliffreid Could be. Would be interesting to hear if does appear to be more successful.

@TimAstles Thanks. I wonder if milrinone would be any different.

Has anybody here used milrinone for life threatening asthma refractory to standard therapies? Keen to hear about experience with it

If you missed out on that ST anaesthetics job and need to fill 6-12 months, come and work with us on Aintree ICU: careers.liverpoolft.nhs.uk/current-vacanc…

@markpalexander @andymoz78 What is the advantage to consumers of this pricing structure? Who decides that it’s the mode we should use?

Your fuel bill is everything to do with natural gas and little to do with renewables and net zero. The right wing fluffers promoting this talking point tie you into higher fuel bills and its straight out of Putin's playbook. Here's how.

@goldstone_tony @nhs_pensions Am I right to think the TRS doesn’t contain the figures you need to calculate your pension pot growth for Annual Allowance purposes?

1/ So @nhs_pensions were meant to update TRS overnight to 23-24 which *SHOULD* show post rollback service for those affected by McCloud... so far so good on the front screen

@docib @richardbody @smithECGBlog Genuine question… as testing becomes more sensitive/widespread, is there now over treatment? Are there groups which wouldn’t have been captured in previous studies? Is it right to extrapolate evidence for these patients?

Isn’t Myocardial Infarction defined as a ‘rise and/or fall of troponin’ and therefore it’s not possible to overdiagnose? @richardbody @smithECGBlog

If you missed out on that precious anaesthesia ST job and are looking for a post to build your portfolio, come and work at the busiest ICU in the region in a big major trauma centre. Weekly teaching, research and QI opportunities, SPA time, and me. careers.liverpoolft.nhs.uk/current-vacanc…

@armyemdoc Whilst you’re right that we should avoid nonsense mantras like this, it must be remembered that intubation is not a fix for asthma. They’re not an easy group to ventilate as it’s pathology where exhilation is the problem and intubation turns this into an entirely passive process.

"NeVeR iNtUbAtE aN AsThMaTiC" Unfortunately, this nonsense is still talked about in EM, as if intubating a patient with an asthma attack is a failure. Here's a few key things to know: -The majority of asthma-deaths occur prehospital. This is where high-quality care needs to start. -Most in-hospital asthma deaths occur peri-intubation. Don't wait until you have 🗑 conditions to make the decision. pubmed.ncbi.nlm.nih.gov/24040898/ #emergency #emergencymedicine #foam #foamed #foamcc #army #armymedicine #armyemdoc #meded #icu #criticalcare #airway #prehospital #medic #ems #paramedic #asthma #medx #medtwitter #medairway #airwaytwitter

@jdrwilcox @BCIS_uk Looks like a very valuable audit with some really powerful data. What are the inclusion criteria for being entered into the audit? Who gives the NSTEMI label - local team or PCI centre?

Just on this, for those out there without access to the wonderful resource of @BCIS_uk audit data, here are some slides testing what I felt - that saying you wait a week for your NSTEMI PCI is a bit hefty...

@jdrwilcox @VirtueOfNothing @rbauld @mmamas1973 @BCIS_uk Our experience is it’s either immediate or delayed until patient is ward/outpatient level. If relatively short ITU stay then that’s ok but if long stay then that 72 hours is distant memory! Would be really interesting to know “delayed” timings for ITU NSTEMI patients nationally.

@VirtueOfNothing @TimAstles @rbauld @mmamas1973 @BCIS_uk I’ve worked in Devon and London, DGH and tertiary, in places with and without PCI. It’s very variable, in both time and place. A week at the longest of my experience. Let me just delve the @BCIS_uk database (later today, if I can get my login working)…

Interesting new evidence summary for OHCA management from the AHA, specifically looking at post-ROSC interventions. How many UK centres have the facilities to offer this sort of state-of-the-art management? #postcodelottery 📖 ahajournals.org/doi/10.1161/CI…

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk I am however now working out transfer times from Liverpool to Surrey for when we need 2nd opinions!!

@TimAstles @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk The delay sometimes is the perceived time it takes to get ICU pts in and out of lab IME. If you can stent two NSTEMIs from the ward in the time it takes to prove an ICU pt doesn’t have a culprit lesion, we often choose (rightly or wrongly) the greater over the individual good.

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk Like much in medicine, it’s all psychology! Nobody comes to work seeking to do the wrong thing. These are complex decisions which trail data doesn’t nearly give us answers for.

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk Think this is where we often feel ITU patients miss out. I’ve no doubt they would be getting a cath if service available in our hospital without risks of transfer having to be considered.

@TimAstles @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk For NSTEMIs - ischaemic ecgs, new regional wall motion issues, bigger trops - the evidence is clear. Urgent cath +/- PCI - 24-72hrs the aim in 🇬🇧, but 🇪🇺 and trials much quicker. Any longer delay, worth asking (perhaps with an 🤨 IRL) why… any shock/instability, straight➡️lab.

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk Equal measures fascinating & frustrating most of the time!!

@TimAstles @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk With all things ICU, there’s always room for debate - it’s what makes your specialty fascinating (and not a little frustrating at times I imagine).

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk I take your point but a system where the patient only gets the treatment they need after multiple layers of referral/argument/pressure is by definition not a great system. Human nature means we all make different decisions based on whether pt is in front of us or at end of phone.

@TimAstles @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk If you’ve got a recalcitrant cardiology team as your reason for not transferring for PCI (and honestly, have you ever had definitive push back if a consultant discusses with their opposite number?), then I’d probably take the patient to stop you thrombolysing them.

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk Accept that the group I see in an ITU setting are a small minority of the workload of a Cardiology service and have additional logistic complexities which will factor into decision making.

@jdrwilcox @rbauld @VirtueOfNothing @mmamas1973 @BCIS_uk Other area where there seems to be a big gulf between guidelines & reality is the delayed coronary intervention. Many studies will describe immediate vs 48/72 hour but our experience if often if patients don’t have immediate PCI then their intervention is delayed for weeks.

@rbauld @jdrwilcox @VirtueOfNothing Interesting/depressing/reassuring to see that many regions in the UK have similar issues with emergent PCI access. Out of interest, are many people thrombolysing this group of “persistent shock but too unstable to transfer” patients?

@jdrwilcox @VirtueOfNothing Repeatedly that good “ED/ICU bundles” are what these patients need. Yet, I’m then berated for managing cardiogenic shock pharmacologically because of “myocardial oxygen demand” or “you’ve induced vasospasm”. They can’t have it both ways. If we wouldn’t accept an unconscious /

@TeleFootball @Carra23 @HACKETTREF It does seem slightly odd that the infraction was offside. Seems to suggest that obstructing a defender would have been fine if done from an onside position.

'Liverpool should feel aggrieved – two key Carabao Cup final decisions went against them' ✍️ @HACKETTREF #TelegraphFootball | #CHELIV | #CarabaoCupFinal