Michael Fishman

AI CDS is here #MedTwitter #MedX @ycombinator @Initialized @GlassHealthHQ

Our Glass AI CDS platform has been upgraded with a new core feature...🥁🎁 Glass Consult is our NEW clinical reference chatbot✨ Consult uses physician-validated context to answer clinical reference questions with in-text references at glass.health🎊🦾 #MedX

#tilt Acute respiratory alkalosis can cause hypophostatemia through ⬆️ intracellular pH, which ⬆️ phosphofructokinase thus ⬆️ glycolysis, thus ⬆️ ATP production, ⬇️ intracellular phosphate and drawing in from the serum. Should begin to resolve with normalization of pH.

Also friendly reminder that LR does not cause hyperkalemia and can be safely used in hyperkalemia (NS is actually worse due to its hyperchloremic metabolic acidosis...) #MedTwitter PMID 15845718, 18569935, 22237237

#tilt Reminder that IV fluids are medications as well, and should be treated as such. Know what the components are (lytes, buffers, etc), what the pH is (NS is acidic!), and know effective osms (tonicity). Be intentional about your fluid choices!

#tilt Why can metformin poisoning cause elevated lactate levels? 🧐 ➡️ Drug accumulates in mitochondria, inhibits complex I of the electron transport chain (ETC), thus 🚫 oxidative phosphorylation. Leads to ⬆️ pyruvate ➡️ ⬆️ lactate.

Feedback doesn't make better doctors. ➡️Unbiased and effective feedback does. Proud to share our small contribution to this important body of work. @OPENPediatrics @BAiyanyor @carolynhmarcus @KWarlaumont + Marcella Luercio. youtube.com/watch?v=kMr1NK…

@KateMichelson2 @DrDanSchumacher Ariel Winn, and many others! onlinelibrary.wiley.com/doi/abs/10.111…

#meded #tilt Fascinating paper on prospective entrustment decision making from competency committees. Want to know the main factor that CCC’s look for to entrust? Trainees’ ability to know limits and seek help. Asking and knowing limits is always a sign of strength. 🔑

BCx time to positivity (TTP) not only useful for determining contaminants, also independent predictor of ⬆️mortality. Adult studies➡️TTP=independent predictor for both Staph aureus+S. pyogenes! Use info to risk stratify! #tilt tinyurl.com/ycktjc45 tinyurl.com/2s3dva74

#tilt Neonatal mastitis➡️full SBI work up? Retro study of >600 infants: 🔑 Low prevalence of SBI (contam BCx >> true pathogens) - concurrent UTI/Blood/CSF rates [1.1%/0.3%/0.2%] If well-appearing: likely no SBI testing, but admit for close 👀. pubmed.ncbi.nlm.nih.gov/34187909/

#tilt Amazing in vivo study of HFNC demonstrating that it's mechanism of action ⚙️ to reduce work of breathing 🫁 is through dead space wash out, rather than PEEP. No consistent end-expiratory lung volume (EELV), tidal volume (TV) with use. #PedsICU pubmed.ncbi.nlm.nih.gov/35305971/

For an upcoming @TheCribsiders episode, we just had a fantastic discussion with @DrPrathima and Dr. Alex Hirsch about APPENDICITIS! Unfortunately, Riverside.fm did not do a screen grab with them on, but you can see how pumped the production team was!

Retrospective study, but >1000 doses of hypertonic saline through PIV in peds demonstrate overall safety of use, esp bolus. In acute situations (often when reaching for HTS), feel reassured using a PIV, but always monitor for extravasation! #tilt tinyurl.com/bdfrp7ub

@therealMikeToce Such a great point, and getting more than 1mL in a nostril may not be the most pleasant either. Knowing alternative route strategies (IN, IM, etc) is so helpful to have in your back pocket.

@_FishmanMD Your last point is key: need to demonstrate that more=better. Given the absorption limitations of IN administration, there might be a limit to the perceived benefits. But always good to have rapid, non-IV dependent ways of administering analgesia. Don’t forget about IN ketamine!

#tilt Pediatric pain control, esp w/out an IV, in the ED is 🔑. New retrospective study ➡️ safety/minimal AEs of higher dose IN fentanyl (2-5μg/kg; max 200μg) in peds, even in combination w/ IN midaz. F/u to show ⬆️pain control needed, but good start! pubmed.ncbi.nlm.nih.gov/35100749/

🦴Lisfranc injuries in peds: - 💥direct blow to foot after jump/fall or forced dorsiflexion w/ rotational force - pain/swelling at base of 1st/2nd metatarsal - test by holding hindfoot, abduct/pronate the forefoot --> pain=concern - 🩻 WEIGHT-BEARING films, AP/lat/oblique #tilt

So honored and excited for all of the amazing humans that will be joining the @TheBCRP family! 🥳🍾🎉 What a TRULY phenomenal class of pediatricians. So excited to work with and learn from all of you!!!! 🩺 #pedsmatch2022

Delayed hemolytic transfusion reactions (DHTR) are rare but life threatening. Mgmt 🔑: 1) Stopping hemolysis (IVIg, steroids, eculizumab) 2) ⬆️ RBC production (EPO, iron, vitamins) 3) Optimize DO2/VO2 given critical anemia and shock-like state #tilt tinyurl.com/72v3mzt2

QTc is a vital sign for poisoned patients. Bazett formula most common (⬇️🎯 w/ extremes of HR), though ⬆️use of QT nomogram developed to link HR-QT pairs + risk for TdP/dysrhythmia. Being prospectively studied in kids, ?⬆️🎯 and true neg rate. #tilt tinyurl.com/mrydn5mb