Author of the Internet Book of Critical Care ๐Ÿ–‹๏ธ Board certified in critical care, pulmonology, and neurocritical care ๐Ÿค“ Zentensivist ๐Ÿง˜โ€โ™‚๏ธ No COI ๐Ÿ’ฐ

University of Vermont ๐Ÿ„
approach by specialty: neuro: tPA cards: PCI GI: golytely pulm: bronch neph: furosemide hospitalist: IV fluid ID: rec consult surg surg: rec consult IR IR: inari flowtriever urology: tamsulosin neurosurg: mannitol anes: mcgill forcepts EM: ketamine derm: steroid obgyn: c-section
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evidence-based medicine versus hospital culture nitter.app/InterestingsAsF/statusโ€ฆ
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the RN shortage: Iโ€™m torn between laughing and crying
Dan Toomey
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Flight Attendant: is there a doc on board? Me: um, I guess I'm a doc? Flight Attendant: Fabulous, we're saved! Me: HELP I NEED A NURSE, RESPIRATORY THERAPIST, AND PHARMACIST STAT! (team assembles, saves patient, I do little) Me: that was exhausting, I need more coffee.
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treating septic shock with fluid boluses
O.A.G
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using a benzodiazepine to treat delirium-induced agitation nitter.app/ohshidt/status/1541404โ€ฆ
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neurologists intensivists ๐Ÿค nobody should die without steroids
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once in med school i was on a rotation with one other guy. we didn't know what to wear, so we agreed to show up in scrubs. the next day I roll in wearing scrubs & sneakers, and he's decked out with a shirt, tie, and dress pants like the king of Italy. med school was so weird.
one time in med school I had a classmate actually get mad at me because I said I was interested in applying into anesthesia and they said that they were applying into anesthesia and that I couldn't just blindside them like that
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Trump's latest bout of gaslighting scientists has pushed the NEJM editors to explicitly recommend leadership change. unprecedented but appropriate. #BidenHarris2020
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the new Surviving Sepsis 2021 guidelines are out! These are terrific guidelines for anyone who knows absolutely nothing about treating sepsis. For example, if @DGlaucomflecken actually needed to run an ICU, this would be perfect.๐Ÿ‘Œ๐Ÿ‘Œ link.springer.com/article/10โ€ฆ
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if youโ€™re working the ICU today like me, youโ€™re officially allowed to use whatever antibiotics you want. sunday AND christmas. nobody is paying attention. interested in what happens when you combine linezolid, tigecycline, ceftaroline, and isavuconazonium? GO for it.

ALT I Dont Make The Rules Nadia Vulvokov GIF

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PIPERACILLIN-TAZOBACTAM IS NOT NEPHROTOXIC: exploring the arc of a myth over time this was clearly a myth in 2016: emcrit.org/pulmcrit/piperaciโ€ฆ blog from 2022 exploring the evolution of this myth: emcrit.org/pulmcrit/myth-pipโ€ฆ fresh RCT to finally settle this: jamanetwork.com/journals/jamโ€ฆ
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be kind
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I SAW IT GO THROUGH THE CORDS โจ‚ ๐—ข๐—ณ๐—ณ๐—ถ๐—ฐ๐—ถ๐—ฎ๐—น ๐˜€๐—ผ๐˜‚๐—ฟ๐—ฐ๐—ฒ๐˜€ ๐—ต๐—ฎ๐˜ƒ๐—ฒ ๐—ฑ๐—ฒ๐˜๐—ฒ๐—ฟ๐—บ๐—ถ๐—ป๐—ฒ๐—ฑ ๐—ฑ๐—ถ๐—ณ๐—ณ๐—ฒ๐—ฟ๐—ฒ๐—ป๐˜๐—น๐˜†
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so it turns out that 1 family member at the bedside is roughly equivalent to 0.8 mcg/kg/hr dexmedetomidine.

ALT Tranquillo Tranquilla GIF

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THEREโ€™S NO SUCH THING AS A โ€œBETA-LACTAM ALLERGYโ€ OR A โ€œCEPHALOSPORIN ALLERGY.โ€ CROSS-ALLERGIC REACTIONS ARE LIMITED TO DRUGS WITH EXTREMELY SIMILAR R-SIDE CHAINS. SO YOU CAN ALMOST ALWAYS FIND A SAFE BETA-LACTAM. IF YOU JUST HAVE A WEE BIT OF COURAGE, THAT IS.
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working with respiratory therapists & anesthesia to troubleshoot helmet CPAP. surprisingly comfortable. #ThisIsTheWay
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albumin-corrected calcium level is *less* accurate than the uncorrected total calcium level ๐Ÿคฏ I think we all know that that albumin-corrected calcium is junky and you need an iCal to really know the biologically active calcium level... but I didn't realize how bad it is ๐Ÿ˜ฌ
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pulse oximeters were optimized for white people, causing them to underperform in Black people - thatโ€™s systemic racism. itโ€™s deeply disturbing that this remains a source of confusion within a journal claiming to be โ€œthe worldโ€™s leading medical journal.โ€
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updated evidence-based medicine pyramid:
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if youโ€™re ever thinking โ€œmaybe this patient has uremic encephalopathy?โ€โ€ฆ๐Ÿง your next thought should be: โ€œare they on any renally cleared meds that cause delirium?โ€๐Ÿ™…โ€โ™‚๏ธ iโ€™m lookin at you, gabapentin and baclofen ๐Ÿ‘€ you know what you did ๐Ÿ˜ 
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11 reasons the fresh NEJM paper on remdesivir is some hot garbage (blog: bit.ly/3b2sQcv)
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Martin Tobin explains the physiology of asphyxiation in brutal and convincing detail. Tobin testifies that *anyone* subjected to this would have died due to asphyxiation. (Tobin is one of the most renowned pulmonologists in the world.)
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how it started: how it's going:
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PSA: ๐Ÿ“ข the mRNA vaccine is 95% effective (amazing!!). it will be given to *millions* of people, so we *will* be hearing about many vaccine failures (5% x millions). anyone who doesn't understand percentages is welcome to repeat elementary school, via zoom. that will be all.
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FEV1/FVC is within normal limits and DLCO is preserved, but there is a reduction in FVC, TLC, and especially expiratory reserve volume. recommend clinical correlation. nitter.app/Drakayris/status/17876โ€ฆ
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first meaningful RCT on hydroxychloroquine - no effect on viral clearance (despite huge doses) - no effect on symptomatic improvement - increased side effects - for now, use of hydroxychloroquine should probably be limited to RCTs (blog bit.ly/2yf10LF)
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this is why patients with gram neg sepsis often fall apart a few hours after getting antibiotics. bugs explode, spilling LPS. everyone: the patient is crumping, we need to add vanco zentensivist: theyโ€™re crumping *because* your antibiotic is hitting the bug. try steroid ๐Ÿ˜
If youโ€™ve ever wondered what happens when penicillins kill bacteria... they EXPLODE ๐Ÿคฏ #MedTwitter
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To avoid renal failure, itโ€™s essential to avoid IV contrast CT scans and piperacillin-tazobactam. If you do need a contrasted CT scan, consider starting dialysis right afterwards to remove the contrast. Replacing piptazo with high-dose cefepime improves neurologic outcomes too.๐Ÿ‘Œ
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President Biden signs an executive order banning press releases of unpublished trials, stating โ€œEnough of this malarky, if itโ€™s that urgent then just post the data on medRxiv, thatโ€™s the dealโ€
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time for a fluid & electrolyte tweetorial ๐Ÿ˜ an asymptomatic adult human presents with these findings...
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status epilepticus: ๐Ÿ—๏ธ points - don't under-dose your benzodiazepine - ketamine is an enormously under-appreciated anti-epileptic - neuronal damage can occur after >30 min, so target neurolytic intubation @ 20 min if refractory (fresh IBCC chapter: bit.ly/2UD3yw2)
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Stop making fun of older kids who still believe in Santa Claus, there are grown nephrologists who still think LR is contraindicated in hyperkalemia.
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๐Ÿ™ thanks to all the pharmacists out there quietly saving lives. ncbi.nlm.nih.gov/pubmed/3113โ€ฆ
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every year I accept dozens of patients in transfer for possible dialysis, when all they truly needed was pH-guided resuscitation. a better understanding about how to resuscitate the acidemic uremic patient could improve care, save ๐Ÿ’ฐ๐Ÿ’ฐ, & free up ICU beds. emcrit.org/ibcc/fluid/#step_โ€ฆ
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am I the only person who finishes a week on ICUโ€ฆ and then the *first* thing I do on my day off is run the electronic list to see how theyโ€™re all doing? ok, Iโ€™ll see myself out now
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epinephrine stops mast cells from degranulating (exploding), whereas antihistamines just block histamine. thatโ€™s why epi is critical in anaphylaxis. #StopTheMastCellExplosion
Cool video of mast cells degranulating โฌ‡๏ธ Honestly it sort of looks like how allergies feel ๐Ÿคง #medtwitter
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in residency a senior attending gathered us up to teach the exam for ascites. 10 minute demonstration of shifting dullness, fluid wave then we tried to do a paracentese the pt. no luck. tried again. dry๐Ÿง US later showed that the patient was just obese. lucky they survived ๐Ÿคฆโ€โ™‚๏ธ๐Ÿ˜ญ
Scratch test for organomegaly. First do a "control". Won't hear scratching until very close to scope. Next put scope over organ (eg, spleen). Now you'll hear scratching when you reach edge of the organ (much farther from scope vs control). The organ "carries" the sound to scope.
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loading doses of antiseizure meds for status epilepticus are worth knowing & easy to remember: 20 - 40 - 60 1.5 - 3 - 4.5 anyone >75 kg maxes out, so you know their dose off the top of your head. please don't make up random doses based on your mood & anxiety level.
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how to place a consult: you MUST understand the five stages of consultant grief. once you can understand this painful and natural process, requesting consults will make a LOT more sense buckle up, it can be a little roughโ€ฆ ๐Ÿงต 1/6โ€ฆ

ALT Its Part Of The Process Tracy Kiss GIF

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a patient presents in AF with rapid ventricular rate, eventually requiring intubation. is this a *primary* cardiac problem, or is the AF *secondary* to an underlying disease? The answer is hiding on this ventilator screen! Explanation here: bit.ly/3tvL9Qk
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i wonder what medicine would be like if we compensated for palliative care the way we compensate for invasive procedures. i bet it would be a whole lot better.
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>1 million medical research papers are published annually. the vast majority of these papers are read by only a handful of people and have no impact on clinical practice.
What unpopular academia opinion would get you in this situation?
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coding department: Could you clarify whether this patient had a STEMI or an NSTEMI? The chart says both. me: actually the STEMI/NSTEMI pardigm is profoundly flawed, Iโ€™d classify this as an occlusive MI coding: thereโ€™s no code for that me: precisely coding: me:
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nobody: absolutely nobody: EPIC: Howdy everybody guess what?? We moved around all the buttons again! Youโ€™re welcome!!
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"the GCS was 8 so we had to intubate the patient"
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itโ€™s only urosepsis if it originates from the Champagne region of France, otherwise itโ€™s just sparkling bactiuria
Replying to @quality_nguyen
Urosepsis is sepsis that originates from Europe
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martin tobin is flexing hard on gattinoni about patient self-induced lung injury (P-SILI). this is truly the superbowl of ventilator nerdiness. get some popcorn ๐Ÿฟ (article: bit.ly/30wfVNx)
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breaking up the legend and placing text next to each panel makes it infinitely easier to understand.
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โ€œPlan: Start PO amlodipine in order to wean off nicardipine infusion.โ€
Crown
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amazing how deep the myth of contrast nephropathy has seeped into the medical literature. if you have a critically ill patient who needs a CT angio, just get the CT angio. don't pass go, don't collect 200$, don't check the creatinine - just get the scan. pubmed.ncbi.nlm.nih.gov/3266โ€ฆ
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good morning twitter, please provide some peer review on this (draft) algorithm for approaching the diagnosis of PE. i'm sure there will be no controversy about this whatsoever.
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โ€œno... we didnโ€™t recheck the Mg... yes, I want more magnesium... no, I donโ€™t know what the level is... yes, the level is definately too lowโ€ ๐Ÿคฃ
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"Penetrating trauma is a distinct possibility, but we should obtain a CT angiogram to exclude pulmonary embolism, just to err on the side of caution."
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so much shade from neurology ๐Ÿคฃ
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Hot take on dual diuretic therapy for decongestion of heart failure (ADVOR trial) ๐Ÿ”ฅfurosemide monotherapy is an amateurish strategy for decongestion (esp if this already failed as an outpatient) ๐Ÿ”ฅadding acetazolamide improves natriuresis & efficacy emcrit.org/pulmcrit/advor/
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a recent study shows balanced fluids tend to resolve DKA faster than saline. no shock here - giving acidic fluid to an acidotic patient is subawesome. but I want to deeper here to explore specific reasons *not* to give saline... (full article: bit.ly/3pJ0Q5d)
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icu version: bill: the CXR was significant for edema icu attending: yep, its super wet bill: so I think we should start some lasix icu: yessss bill: Iโ€™ll order 40 mg icu: ๐Ÿ™„ bill: 80 mg? icu: ๐Ÿ™„ bill: 160 mg??? icu: thatโ€™s perfect Bill, great stuff
Dr. Glaucomflecken
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20 meta-analyses of the same four RCTs nitter.app/Xudong1966/status/1764โ€ฆ
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some pearls from an article by Martin Tobin about when to intubate patients with COVID (yep, the same one who edited Tobin's textbook on mechanical ventilation)... (#1/6) (full article: bit.ly/2XDgovQ)
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โ€œthe patient is too unstable for a procedure to stop the bleeding, please continue resuscitationโ€
Radio Albacete
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fresh study: D-dimer >1,500 strongly correlates with DVT among COVID patients (85% sensi, 89% spec). many limitations, but this supports the concept of empiric anticoagulation if โฌ†๏ธโฌ†๏ธ DDimer & no contraindication. (fresh blog: bit.ly/3aXvUGE) #COVID19FOAM
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introducing the IBPH (internet book of hospital pulm) expansion to the IBCC section on pulm, with a goal of covering inpatient pulmonology more thoroughly๐Ÿซ please help support the project by sharing & peer-reviewing the new chapters (coming soon)๐Ÿฆ emcrit.org/pulmcrit/ibhp/
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Right Ventricular failure - fresh chapter! โค๏ธโ€๐Ÿ”ฅcommon in ICU - esp ARDS (25%) & complex patients w/ comorbidities โค๏ธโ€๐Ÿ”ฅdon't need to be very invasive (e.g. Swan) โค๏ธโ€๐Ÿ”ฅdo need to understand physiology & provide RV-friendly resus #ThePeoplesVentricle #DiuresisJedi emcrit.org/ibcc/rv/
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UPenn study shows that vanc-piptazo โฌ†๏ธ *creatinine* but actually causes a trend towards โฌ‡๏ธCystatin C. this dissociation between Cr vs. renal biomarker implies that piptazo is a pseudonephrotoxin that โฌ‡๏ธ Cr secretion, w/o hurting the kidney (1/2) @Miano81 vimeo.com/523925430
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introducing the Internet Book of NeuroCritical Care (#IBNCC) ๐ŸŽ† ๐Ÿง  26 new chapters, to create a full neurocritical care text integrated into the IBCC ๐Ÿง  review & podcasts from neurocrit gurus @caseyalbin @drdangayach @rkchoi ๐Ÿ˜ƒ ๐Ÿง  #FOAMed ๐Ÿ“ฒ details: emcrit.org/pulmcrit/ibncc/
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COVID-STEROID 2 ๐Ÿฅˆ5% lower mortality with 12 mg dexamethasone (vs 6 mg) - which is *huge* - but p=0.09 ๐Ÿ˜ฉ ๐ŸฅˆRCTs with toci/bari show that 6 mg dex alone is suboptimal. ๐ŸฅˆIf using dex monotherapy, 12 mg is now a sensible dose for sicker pts. Fresh blog: emcrit.org/dex12
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๐Ÿ”ช pearl for emergent surgical cricothyrotomy: extend the neck! ๐Ÿ”ช ask an assistant to extend the neck for you (thereโ€™s no time for fancy positioning) ๐Ÿ”ช neck extension brings the airway closer to the skin. if there is excess soft tissue, it gets pulled to the side
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OK fine, but we need some *balance* My recommendations for other elevators: Ask: could the blood culture be a contaminant? Ask: could it be rhinovirus? Ask: could it be excessive antihypertensive medications? Ask: can we stop antibiotics? Ask: does WBC really mean anything?
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when the student suggests bolusing 30 cc/kg normal saline to be in compliance with the surviving sepsis bundle
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context is critical to interpret INR: ๐ŸฉธINR 2.5 in cirrhotic: meh, likely hypercoagulable ๐ŸฉธINR 2.5 on warfarin: anticoagulated ๐ŸฉธINR 2.5 on apixaban: may be very bleedy ๐ŸฉธINR 2.5 in DIC: maybe clotty or bleedy so in diverse populations, INR often won't correlate with hemorrhage

ALT Perspective Pass GIF

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large Italian study on ICU patients with COVID just published. this may be the most accurate predictor of COVID in the USA, and it's a bit sobering...(#1/5) (study: bit.ly/2x07u0G)
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new shortages of IV lorazepam & diazepam ๐Ÿ˜ฌ if youโ€™re not allready using phenobarbital for alcohol withdrawal, now is a good time to learn ๐Ÿบ conserve IV benzos for situations where theyโ€™re truly needed (eg status epilepticus) โšก๏ธ emcrit.org/ibcc/etoh/#top
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the fact that the patient improved doesn't indicate that optimal care was provided. the fact that the patient deteriorated doesn't indicate that suboptimal care was provided. our brains are programmed to look for causality everywhere, but medicine just isn't this simple.

ALT The Office Reaction GIF

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donโ€™t forget to take joy in patients who come in with common diseases, get standard therapy, and do great. these folks donโ€™t require much brain power, but that doesnโ€™t dimish the importance of their recoveries.

ALT Keanu Reeves Matrix GIF

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given how immensely shitty 2020 has been, maybe this is a good time to bury our turf battles, support each other, and work together against coronavirus & racism. thatโ€™s the tweet.
Words matter. In the medical setting, *resident*, *residency*, *fellow*, and *fellowship* belong to physicians ONLY. โฌ‡๏ธ๐Ÿ“ƒ Every EM physician, resident, & student should be paying attention to the battle on scope of practice. ๐Ÿฅผ Thatโ€™s the tweet. emra.org/be-involved/be-an-aโ€ฆ
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Started writing a blog about problems in the new sepsis guidelines, but then realized that I *already* wrote this in 2017. And the problems remain nearly unchanged๐Ÿคฆโ€โ™‚๏ธ So I present you with: Six myths [STILL] promoted by the new sepsis guidelines๐Ÿคฏ emcrit.org/pulmcrit/sepsis-mโ€ฆ
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โ€œThe patient is a 95 year old with a prior medical history of mild hypertension, hyperlipidemia, prediabetes, hiatal hernia, diverticulosis, hammer toe, skin tags, traumatic shoulder dislocation, neonatal hyperbilirubinemiaโ€ฆโ€
Tampa Bay Rays
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understanding happy hypoxemia physiology: how COVID taught me to treat pneumococcus. (happy hypoxemia has existed forever, but we didn't fully recognize how to treat it... until now). #COVID19foam #zentensivist (blog: bit.ly/3beKCsS)
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Myth-busting the nephrotoxicity of piperacillin-tazobactam plus vancomycin: ๐Ÿช„Piptazo is a pseudo-nephrotoxin that increases Cr due to reduced secretion ๐Ÿช„Piptazo doesn't โฌ†๏ธ hemodialysis or mortality ๐Ÿช„New study: No effect on BUN or renal biomarker emcrit.org/pulmcrit/myth-pipโ€ฆ
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So, the NEJM just published a review on Contrast-Associated AKI โ€“ a disease that Iโ€™m not sure actually existsโ€ฆ this should be interestingโ€ฆ (rantorial 1/4) nejm.org/doi/full/10.1056/NEโ€ฆ
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the answer is doxycycline. next question please.
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we must continuously strive not to fall into the trap of chronic amateurism
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this is completely ๐Ÿ’ฏ wrong. we literally use VBG to assess ventilation (CO2) on a daily basis in ICU the O2 sat on the VBG helps give you a sense of how accurate it is - but as a general rule the accuracy is adequate more detail here emcrit.org/pulmcrit/vbg-abg/
We CANNOT use the carbon dioxide level on a VENOUS blood gas (VBG) to accurately assess the need for BiPap or intubation Ventilation problems cannot be assessed on a VBG
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Dear Journals, Iโ€™m not sure how to break this to you, but: Nobody cares what your impact factor is. Because itโ€™s not a measurement of quality. Sincerely, Everyone
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manipulating volume status affects outcomes less than we might have expected as long as youโ€™re in the right ballpark, a little less volume & more pressor, or more volume & less pressor - may not matter fluid never was, nor ever will be, the treatment for sepsis๐Ÿ˜› #zentensivist
Just released at #SCCM2023: Early Restrictive or Liberal Fluid Management for Sepsis-Induced Hypotension nej.md/3CWSXBA #SCCMSoMe @sccm
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ICU rounds just got burned ๐Ÿ˜‚๐Ÿ”ฅ
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diagnostic challenge: Patient presents to ICU with severe hypotension. History and exam are unrevealing. Based on this CBC ๐Ÿ‘‡, why is this patient in shock? ๐Ÿงฉ answer & explaination here: bit.ly/2lVGEAY
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lactate-guided resuscitation: please stop the madness ๐Ÿคช #resist jtd.amegroups.com/article/viโ€ฆ
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COVID, ARDS, recruitability & phenotypes - seven subtypes of "ARDS" - various definitions of recruitability - early COVID is pseudoARDS (nothing novel) - why I disagree with Gattinoni's L-type & low-PEEP/high-FiO2 strategies for intubated pts (blog: bit.ly/3ezhmPS)
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ACEP creates the cure for the common sepsis guideline! ๐Ÿ˜Fresh guideline is realistic & evidence-based. ๐Ÿ˜ This should *replace* the Surviving Sepsis Campaign guidelines (which are hot trash). ๐Ÿ˜E-mail this to folks going nuts about 30 cc/kg fluid ๐Ÿ˜ blog: bit.ly/2OT138q
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me: eeeek, I think we may need to intubate this guy nurse: NO JOSH, heโ€™s going to do fine me: ok ok ๐Ÿคทโ€โ™‚๏ธ narrator: and indeed, the BiPAP slowly took effect, and several hours later the patient woke up and demanded breakfast
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when everyone is stressed to the max, it's especially important to practice kindness and professionalism. viruses, antivirals, steroids, and PEEP strategies all come and go - but professionalism is evergreen ๐ŸŒฒ๐ŸŒฒ๐ŸŒฒ #zentensivist
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image to help you remember the GCS geriatric-millennial version
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Both major medical journals agree: this decision will kill women.
The just-announced U.S. Supreme Court decision in Dobbs v. Jackson Womenโ€™s Health Organization represents a stunning reversal of precedent that inserts government into the personal lives and health care of Americans. nej.md/3Aa5cKe
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'tis the season for influenza... ๐Ÿ™ please don't over-resuscitate your flupneumonia patients (their problem is hypoxemia, not hypovolemia)
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allowing rounds to run past noon is a crime against humanity

ALT Big Lebowski The Dude GIF

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