Alex Smith

@bryan_johnson @talmagejohnson_ What utter nonsense. Ignoring the fact that the evidence base for TPE is weak…stating that the technician said “it was the cleanest plasma he had ever seen” is laughable. That’s not a thing…perhaps the most useless opinion of anything medical that I have ever heard. Charlatan.

Completed my first total plasma exchange (TPE). Removing all the plasma in my body and replacing with Albumin. This is different from what I did last year: removing 1 L of plasma from my body and then replacing it with 1 L of plasma from my blood boy @talmagejohnson_ . I gave my one liter of plasma to my father. This time around there's no blood boy involved. TPE removes all of my body’s plasma and replaces it with Albumin. The therapy objectives are to remove toxins from my body. The evidence is emergent. Others use TPE for autoimmune disorders, blood disorders, neurological conditions, transplant-related complications, and replacement of missing plasma components. As we normally do, we completed a bunch of baseline measurements before this therapy including toxins but other things too such as speed of aging, organ ages, microplastics and many other biomarkers. I'll do six total treatments. The operator, who’s been doing TPE for 9 years, said my plasma is the cleanest he’s ever seen. By far. He couldn’t get over it. When we finished, he couldn’t bring himself to throw it away. He was imagining all the good that it could do in the world. On people’s face as PRP therapy. In their body, rejuvenating organs. There is probably a path to auction off or donate my plasma on this next go around. Liquid gold. Remember that when my father received 1 L of my plasma his speed of aging dropped by 25 years and stayed that way for six months. We don’t know if it was from my super plasma or if it was from removing his plasma, but the results are interesting nonetheless. The whole procedure took just under 2 hours.

@ross_prager If people are doing vexus on tamponade patients, then they’ve gone too far down the rabbit hole.

Here's are the key pericardial tamponade findings on #echo. Key points: 1) Clinical suspicion - pericardial effusion + organ failure (not just frank hypotension) 2) Swinging heart (severe) 3) Dilated IVC (not always, but usually) 4) Any size effusion (size of accumulation matters --> in trauma, small effusions cause tamponade) 5) RV diastolic collapse (be careful it isn't just the RV contracting --> look at TV) 6) RA collapse during systole (but ventricular systole!) 7) Excessive MV inflow variations (different sources different thresholds) 8) Excessive TV inflow variations (variable thresholds0 9) Low LVOT VTI (surrogate of stroke volume) - **not commonly discussed but super helpful** 10) Venous Congestion - #vexus what!?! Large effusions and tamponade can cause organ failure via congestion. What am I missing? Oh. And be wary of the sneaky post cardiac surgical tamponade which can be regional --> look at each chamber carefully to look for localized compression. #echofirst #medtwitter #foamed #meded

@iamritu @iceman_ex @JaeKOh2 @echonepean @DanXAugustine @NMerke @load_dependent Is anything truly load independent in echo?

Transmitral flow E depends on preload, but not mitral annulus e’ which is rooted into LV and follows LV contraction #echofirst

Question for #pocus/#echofirst community: Can you comment on diastolic function in a patient who is not at steady state (eg anaesthetised, critically unwell on inotropes)? Ping @iamritu @JaeKOh2 @echonepean @DanXAugustine @NMerke @load_dependent

@iceman_ex @iamritu @JaeKOh2 @echonepean @DanXAugustine @NMerke @load_dependent It shows the importance of common language and context…there’s times where we want to communicate with cardiologists in their terms and times where we want to communicate with physiologists (intensivists). With no disrespect to either, we use it in different patient cohorts.

@doc_smithy @iamritu @JaeKOh2 @echonepean @DanXAugustine @NMerke @load_dependent This is the exact debate I was hoping for. I still see many echoes read in non-steady states describing “grade 2 diastolic function” I can translate that in my head to “likely raised LAP”. But should that be necessary?

@salmannaeem217 Congratulations. 🙌

Alhamdullilah PG Dip in medical ultrasound ✅ Now onto my dissertation and completing my masters #POCUS

@IM_Crit_ @msiuba @ross_prager Great summary…are these talks recorded and available for a fee? Looks like a great session. 👍

@msiuba @ross_prager Matt: sorry I missed it; I am on service in the ICU this weekend. Ross: thanks for summarizing! Are you using an AI-summarizing app?

@msiuba discusses all things pulmonary hypertension at #HR24 Here are some of my biggest take homes including a simple management approach he beautifully outlines👇 My favorite point though... most (almost all!) PH patients do NOT need fluids and need fluid removal when decompensating. --------------------------------------------------------- 2022 Classification of PH mPAP>20 Precap PVR > 2 Postcap PAWP > 15 Combined: elevated PVR and PAWP Lecture's Focus - not on the garden variety group II/III Focus on severe precapillary (PVR > 5) or any PH with significant RV dysfunction or patients on vasodilatory therapies. Cautionary Notes 1. Rare diseases often need expert opinions - contact their PH provider/center. 2. You CANNOT stop the pulmonary HTN therapies, even if hypotensive and hypoxemic. Talk to a PH specialist. If on IV/SubQ therapies you need to get this sorted with pharmacy. No oral intake, need an enteral tube. Early Goal Directed Palliation Consideration Where are they on their disease process? Functional? High risk of PPV CPR unlikely beneficial Candidacy for transport and ECMO? Partial List of Causes of Decompensation 1. Volume overload part of the problem until proven otherwise 2. Infection (indwelling lines?) 3. Arrythmias - 30% of CO from atrial kick can be devastating for this population 4. New VTE 5. Treatment nonadherence Diagnosis Physical Exam Features to look for On IV therapies might have a lot of blushing and asymptomatic hypotension (SBP 80s). Ask what is your baseline? Perfusion exam is the most important - cap refill, UO, mental status. Can be confounded a little bit by flushing of the skin. Filling pressure - JVP vs. ultrasound Peripheral Edema POCUS Parameters to focus on LVOT VTI, Portal vein pulsatiity, and RVOT VTI valuable as these reflect the current state of affairs, and not chronic features (e.g. chronic RV dilation). Portal vein pulsatility a reliable marker of congestion in PH patients (@ArgaizR has done some of this work) Don't rely on.... IVC or TR severity. Not really helpful! Management and Treatment Goals Many PH patients will never have a normal LVOT VTI... hard to normalize often. 1. Preload optimization --> almost certainly reduction. The idea that PH needs volume as a rule is FALSE. MOST NEED REDUCTION. 2. Afterload optimization - keep normal pH, SpO2, CO2 etc. Inhaled pulmonary vasodilatiors. 3. Contractility optimization. They love sinus rhythm. Consider cardioversion early. Maintain SBP > RV systolic pressure (to maintain coronary prefusion). . Inotropes as needed. Keep in mind transplant candidacy throughout. #medtwitter #echofirst #cardiotwitter #cardio #meded #foamed

@DrEilidhMaria @AswinMalhotra It’s a culture of UK training where we seem to do ABGs as a reflex. I spend a lot of time on outreach trying to dissuade people that an ABG isn’t needed. Worked in Oz for a few years and they laughed at how often the Brit docs wanted to do one.

@DocEd @DrEilidhMaria @wesstreeting Not to mention pension implications for consultants.

@salmannaeem217 @Aidan_Baron Fully agree. Evidence behind fluid responsiveness is so challenging to actually use in the patient in front of you. I think the future is shifting towards fluid tolerance. And I find the IVC of very little value.

@Aidan_Baron I am still not convinced. IMO the question to be answered should be 'what type/s of shock patient has?' rather than is IV fluid needed. For most shocks IV fluid is not the treatment & we should not simplify it so much as there will be harm.its better than current approach though

The SLICE protocol by Justin Bowra A framework for the implementation of POCUS by junior medical staff and beginner POCUS users

@Manoj_Wickram So nerdy-cool…love it!

Beautiful!

@RY51MMO CDC meaning? Only Google help I found was community diagnostic centres?

Reaching out to the #POCUS Community in the UK. Does anyone have any contacts in their CDCs or aware of anyone doing any POCUS within them? £250k funding up for grabs!

@RobertLeoTucker There is an argument to say that med students shouldn’t be spending their time doing projects/posters/publications. Few will actually make a difference. Just adds to the CV arms race and doesn’t result in a better clinician. Enjoy being a student before the chaos of F1 begins.

Huge Loss for Medical Students: From next years UKFPO applications, students publications, posters, presentations, and leadership roles are no longer taken into account for SFP. This could harm the future #MedEd and will disenfranchise those who have worked hard toward academia!

@iceman_ex @FICMNews Slightly controversial point maybe…but If we increase the supervisor/mentor pool…should there be an entry requirement of having FUSIC heart/BSE L1 to doing an echo SSY? Means you can hit the ground running and really get into it whilst you have some dedicated time.

@iceman_ex Great addition by @FICMNews that I had completely missed! The UK training generally is too rigid…any scope to tailor to your interests will make the effort much more enjoyable…and more likely to be continued moving forwards in your career.

I think this is really important- thanks for pointing out and sharing Justin. This now means that you can tailor your SSY to one (or multiple) POCUS modalities based on your interests and available training opportunities. Thoughts? Ping @doc_smithy

@AndyThornley @iceman_ex @josopala @cardiacACCP @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho Hugely important point. Sometimes I think knowing all the limitations ICU echo is the main part of accreditation in ICU echo! But i think the goals are different perhaps…not aiming to be as diagnostic (grading valvular severity to guide surgery for example) but titration of Rx

@doc_smithy @iceman_ex @josopala @cardiacACCP @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho Cardiologist butting in - cardiac echo is hard - I’ve done a fair bit and I don’t think I’m good at it. I’ve also done research involving echo on ITU and itu patients are the worst to echo (wrong position, ventilated). Even LVEF assessment is difficult with big operator variation

HMMMMMM Discuss, U.K. ICM Twitter. #pocus not being our curriculum now means we are no longer in line with COBATRICE (But then we’re not European anymore so…)

@em_echo @josopala @cardiacACCP @iceman_ex @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho Perfect example of the problem…system runs on good will of enthusiastic experts like you. And this will always be needed to progress the speciality…but how much better would it be if there was more paid/scheduled/dedicated time.

@iceman_ex @josopala @cardiacACCP @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho I agree that lots of people are doing different pathways…but the opening line paragraph of the curriculum document suggests that is at least the aspirational target. Maybe I’ve missed the point though.

@doc_smithy @josopala @cardiacACCP @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho So that’s actually not the target… The SSY is more complicated than that (ping @icmteaching @ICUltrasonica)

@josopala @cardiacACCP @iceman_ex @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho It’s a problem within the medical training programmes…not the BSE itself. But the @FICMNews target for echo specialist skill year is BSE ACCE L2…but IMO (& that of peers) you’re not given the capability to achieve it without ruining your work/life balance for a second year.

@josopala @cardiacACCP @iceman_ex @DentonGavin @ICUltrasonica @easypocus @DrDan2410 @DrDavidRouse @RCEMLearning @FICMNews @icmteaching @NHSmallwood @FAMUSultrasound @acutemedicine @ICS_updates @BSEcho Great to see it recognised by BSE as that would help a lot of ppl. I wasn’t LTFT so that wasn’t a barrier for me…my issue was getting dedicated enough echo time around my ‘day job’. So the LTFT extension more helpful for physiologists.But a great effort to minimise the barrier