Arshdeep Kaur

(1/x) Intubating a critically ill patients is the most dangerous procedure we do in the ICU (3.1% cardiac arrest rate) not because of hypoxia or tube placement, but hemodynamic collapse 🫀 (Russotto et al. JAMA 2021) A 🧵on making high risk hemodynamic intubations as safe as possible.

7️⃣ COMMUNICATION is the key. Talk to the team, especially nurses. Great for learning and avoiding mistakes. 8️⃣Don’t forget to celebrate and take a break. Residency is done and you are almost there! I hope this helps and please share your thoughts!!

5️⃣ You will become the driving force of the team. Take charge, maintain balance between clinical care and resident education while supporting them. 6️⃣ Do not expect or pressurise yourself to know everything. It’s exhausting and impairs your education.

Back after a long break! Navigating the role of a fellow after spending 4 years in residency is confusing and a steep, scary curve. Here’s what I learnt in the first few months- 1️⃣ Break the ice! Instead of an awkward hello during rounds, go introduce yourself to the team prior

@heitorcbra @Jagdish26039718 Great thought! The timeline, coincident with the biopsy, resolution of most neurological symptoms starting day 4 prompts me more towards fat embolism. VTE will cause more lingering symptoms and morbidity as they would actually stroke out without treatment. Thoughts?

@TotoMynell @syaddana_neuro That’s a great thought! Morbidity is high with no treatment in those case because they end up stroking out. This particular pt started recovering without any specific Rx on day 4 and left with no deficits which makes me think fat embolism more likely. Thoughts?

@syaddana_neuro @drarshkaur Air embolism?

@syaddana_neuro Pt did have bright T1 signal in the concerned areas and very subtle microbleeds on SWI but not necessarily the pathognomonic distribution and pattern. Did have respiratory issues requiring oxygen but CT was not done. Did not fulfill the FES criteria.

@drarshkaur Isn’t fat embolism t1 bright also any micro bleeds in gre any skin findings or hypoxia/ lung involvement!!

@_aiswarya_raj_ Looks very cardio-embolic but negative extensive cardiac work up along with quick recovery prompted a diagnosis of fat embolism. It’s hard to prove unless patient dies and an autopsy can be done.

@drarshkaur Shower of emboli- cardioembolic

@nirmalregency @rohitmarawar Thank you for sharing @nirmalregency. It’s a diagnosis of exclusion but given no cardiac findings and negative monitoring for 4 months, quick recovery prompted us to have fat embolism as our diagnosis in this patient.

@drarshkaur @rohitmarawar We also had a similar interesting case. But this one followed long bone fractures, the more common cause.

5/⏺️ CEREBRAL EMBOLISM has: *starfield pattern” of imaging *The DWI changes can be reversible *Reperfusion happens earlier than cardioembolic and thromboembolic *Quicker recovery *Difficult to diagnose: lack specific criteria, rare occurrence limits multi centric trials

4/⏺️The distribution of the diffusion restriction does not respect the vascular territories. Distribution is more embolic. ⏺️Very rare cases of fat embolism associated with biopsy procedures have been reported in literature 👇🏻

3/Poll seems to be quite equivocal which I how we felt at the time. Our final impression was FAT EMBOLISM ⏺️No paroxysmal Afib during the procedure (pt was on tele). No abnormal rhythms captured on loop recorder 4 the next 4 months. Cardiac work up normal

@Jagdish26039718 Yes.

@drarshkaur Fat embolism. But the CT guided biopsy was for a mass?

🔟Lastly, enjoy it. It will be an emotional roller coaster leaving you with a group of friends you will call family. Here’s mine ❤️

8️⃣Believe in yourself. There’s nothing you can’t do if you are willing to 9️⃣Be compassionate and empathetic: patients and families are going through toughest times of their lives at times

Few aspects to this transition: sorry about long post 1️⃣Sudden pressure of being a doc & making decisions: Allow urself to be uncertain,think broad & loud, makes you a better clinician 2️⃣It’s tiring/overwhelming: Ask 4 help when needed. Lean on your peers 4 support & guidance!