Andy Deitchman

@PulmCrit @nickmmark Do you have access to Sugammadex outside of the OR? We don’t.

@nickmmark agree. the whole roc-vs-succ debate in status epilepticus predates sugammadex. I’ve always been a roc fan here, but now that we have sugammadex that clinches the debate. 1st priority = airway control without killing the patient. Then give sugammadex and get back neuro exam.

Weird medical decision making in the final episode of the Pitt 1. Using diazepam instead of lorazepam in status epilepticus. The latter is probably superior. Probably should have used more mag too. 2. They delayed intubation until she was clearly in status. I get waiting a minute to see if the mag works but giving multiple second line meds before deciding to take the airway is not a great move imho. 3. This is the big one. Using succinylcholine to intubate a seizing woman with eclampsia —> major risk for provoking hyperkalemia and cardiac arrest, which is exactly what happened! The rationale was “we need a neuro exam after”. Dude first of all you are gonna use an EEG to titrate anti-seizure meds (they showed this). Second you can just reverse roccuronium with suggamadex. That’s way more reliable than *hoping* the dangerous drug you gave wears off (in a patient with renal and liver injury no less)! 4. I could quibble about transfusions too. Rapid infusing blood when her Hb was 7 is wrong, though she was actively bleeding so 🤷 . Platelets should be transfused to >50k not necessarily higher. They didn’t give FFP for some reason, which is not good. 5. The depiction of the resuscitative hysterotomy was realistic but not having OBs there? Pretty unlikely. If there are OBs anywhere in the building you better believe they will be at the bedside of the eclamptic seizure code! (When I’ve done resuscitative hysterotomy IRL, lack of OBs was not a problem!) From a realism perspective this is not as bad as ER docs declaring brain death within a few hours of an overdose (season 1) but really felt unrealistic in a big urban academic hospital.

@EMNerd_ There’s some data that a persistent non-gapped acidosis leads to reopening of the anion gap. pubmed.ncbi.nlm.nih.gov/37133440/ we have Bhb readily available and there are group of patients with “closed gap” but positive BHB.

Okay got in a discussion with Endo at work about the management of DKA on following the AG vs the serum Bicarb to assess for resolution. They cited the following guideline which recommends using the serum bicarb because the AG can be affected by the hyperchloremic acidosis.

@PulmCrit We started doing something similar to this in our unit a while ago. This paper is an anesthesia paper. The problem I’ve found is no one knows if the patient is on high peep for BMI or resp failure. No issues if for BMI, but If obese and I extubate on 12 of peep in flu ARDS 🤷

LENTZ EQUATION 🔥PEEP = BMI/3🔥 🙅‍♂️Stop under-PEEPing patients with high BMI 🙅‍♂️Stop trying to wean everyone down to a PEEP of 5 Patients with high BMI often need high PEEP as long as they are intubated & can be extubated *directly* off high levels of PEEP 😁

🩸Hematology for The Non-Hematologist🩸 (A practical educational series for internal medicine trainees and physicians) Episode 8: 📞 “Doc, patient’s WBC just came back at 150,000 with majority blasts…” 👉🏻 here’s what you need to know about acute myeloid leukemia (AML) Listen up - 🧵

1/ After residency at Mass General Hospital, I reported to Atlanta to meet my fellow CDC Epidemic Intelligence Service Officers. I have never felt so intimidated by my peers The best and the brightest, they were star clinicians, had served in disaster zones; MD/PhDs and MSF.

#CPR is the cornerstone of survival for cardiac arrest, yet one crucial aspect of CPR quality is never discussed 🫀 Here's why we need to rethink a one-size fits all approach to CPR and why "push hard and fast with full recoil" isn't good enough in 2024. A 🧵 #foamed #medtwitter

@emily_fri Great advice! When working with trainees I like to also say when I’m doing something that’s evidenced based or pure style/voodoo (I’m looking at you albumin plus lasix)

Every attending does things differently, and that's really annoying. Every time you're told to do something a new way though, take notes in your mind of what YOUR style will be when you're done.

@pulmtoilet @DrGarbs Second tube still sealed but in eyeshot to be grabbed by assistant. Bougie always at the ready. Not perfect - can’t say always but usually

@AndyDeitch @DrGarbs 2tube/2stylet every time Kinda guy?

You’re intubating a patient who has bad pneumonia and likely ARDS. The patient is on BIPAP and is being pre oxygenated with that. Sat is 94% despite 💯 % fio2. You position appropriately and do all steps for high first pass success. You get a view but the tube FALLS ON THE FLOOR

@DrGarbs @pulmtoilet Back up tube - same set up as @Drgarbs

@pulmtoilet 2 tubes in the room, one open and loaded, the other nearby but closed. I always have a backup stylet (usually a flexible one or a Bougie with the main on a rigid). Amount of time it takes to open and load the backup tube is equal/less than bending down, grabbing the original

@ross_prager @katiewiskar Depends more on level of trainee for me. Intern I usually want the patient story. Too many interns can’t present a cohesive HPI. They present a chief complaint with a hospital course. Senior resident should be able to go to a preliminary Dx and use the HPI & data to support.

@katiewiskar I want to hear what their diagnosis (provisional) is! I often tell residents that patient presentations are not murder mysteries. 🗡️🩸 By knowing what the trainees think is going on, it contextualizes things and allows me to entertain alternative ddx in real-time.

Question for the Attendings out there: When you review a case, which do you like to hear first?

1/ A 26 yo woman w/ spinal cord injury p/w AMS. She’s 39°C (102°F), confused, and has diffuse limb rigidity. EMR notes an intrathecal baclofen pump placed 5 years ago.🤔 ⛽️Pump interrogation=normal 🔋battery=charged A #ContinuumCase

@nickmmark Depends - many of my bronchs are ICU bronchs for PNA, mucus plugs, ARDS, sepsis etc.. usually on some form of steroids. Not sure the cell count helps but may add confusion if interpreted out of context. Cell counts when undifferentiated DPLD

When performing a bronchioalveolar lavage (BAL), do you send a cell count & differential:

@pulmtoilet Depends on the team for me. Interns need an exam and data so they can have plan. High level APP - can probably round with a lot less pre rounding

Attendings: when you round with the team (whatever that make up is: interns, residents, fellows, APPs, nurses, RTs, etc) you expect the patients to be :

New recs: Conditional recommendations in favor of: ✅ Steroids for ARDS ✅ VV-ECMO for select pts w/ severe ARDS ✅ NMBAs for early (<48 hrs) severe ARDS ✅ Higher PEEP without recruitment maneuvers in mod-severe ARDS Strong rec against: ❌❌ Prolonged recruitment maneuvers

[1] #Hemodynamics Tweetorial #2 Heart failure pt in ICU is -3.5L after 2d of aggressive diuresis. On day 3, urine output is ⬇️and BUN/Cr is ⬆️ You personally wedge #PAC at bedside and obtain a mean wedge 17 mmHg (a normal mean wedge is 6-10 mmHg). Admission wedge was 24

If a patient is in ICU and needs renal replacement therapy, does it matter if they choose to use CRRT or IHD first? For an answer have a look at this paper... link.springer.com/article/10.100…

🗓️ On August 8th at 12 pm EST, join us for an interdisciplinary networking event and roundtable discussion on phenobarbital use in alcohol withdrawal in collaboration with @SCCM_EM and @SCCM_Neuro. #PharmICU Register here: loom.ly/OWYueP0

@emily_fri Google PSLF loan repayment calculator or IDR estimate studentloanplanner.com/income-based-r… there are a few out there. If PSLF is your plan…goal is to obviously pay the least amount possible so figuring out what tax strategy for filling taxes this year may make a difference for you.

So I read that student loan payments will resume in October. When they paused I was a resident/fellow on income based repayment, now I’ll be a year into attending job. So will my monthly payment be calculated from my 2022 taxes (which was half attending/half trainee)?

Christiana care residents representing at #ATS2023 @sccmde2020