emergency medicine / critical care / telestroke puzzles for @nytimes @wsj @latimes @AndrewsMcMeel "Views are my own."
NYCx
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Backstory on today's puzzle. Thanks to @DebAmlen for letting me share.
(spoilers)
nyti.ms/38cdlxQ
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We are now a monolith. We started with a medical ICU, surgical ICU, cardiac ICU, neurosurgical ICU, and a cardiothoracic ICU, plus a dozen mixed specialty floors. Every floor and unit is becoming a COVID unit. There is no more specialization โ weโre all treating one thing.
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"aaaaand here's when we decided a big in-person celebration in Times Square was still a good idea", i said amongst the smoldering remains of Manhattan
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once upon a time, all health insurance in this country was not-for-profit, everyone was charged the same, and no one was denied coverage because of age, sickness, or preexisting conditions.
that sounds like a fairy tale, but it's just straight-up history.
why can't we go back?
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So in between fighting cancer and continuing to serve on the court, #RBG solved my #NYTXW puzzle with her granddaughter and sent me an autographed copy!
@NYTimesWordplay
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We intubated nine patients today alone and the outbreak is barely in full swing. Vent beds are not a bottomless resource.
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Sobering @NEJM COVID reccโs: โWe believe that removing a patient from a ventilator or an ICU bed to provide it to others in need is also justifiable.. the decision to withdraw a scarce resource to save others is not an act of killing and does not require the patientโs consent.โ
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An hour into my shift and already pronounced two patients โ including a 33-year-old with no medical history who had a fever x 1 week. They are both likely COVID deaths, though who knows if they get tested post-mortem and join the โofficialโ stats. The curve does not feel flat.
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And @realDonaldTrump is out here talking about opening up Outback Steakhouse again ASAP.
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"No longer were there individual destinies; only a collective destiny, made of plague and emotions shared by all." Camus and #COVID19 -- a thread.
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itโs a horrible, painful, life-limiting disease, and i teach the residents to ask them what works for their pain, then smile and nod and give it to them as often as necessary
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Exactly the same. Day 7. Hypoxic, no distress. Fine, then intubated. Underwhelming x-rays, terrible CTs. Don doff don doff don doff. Hands cracked and stinging. Groundhog day.
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On the heels of that disquieting @NEJM article โ some hospitals now considering blanket DNR orders for #Covid patients. wapo.st/2Jepkzl
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"What we learn in time of pestilence: that there are more things to admire in men than to despise."
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Really looking forward to not knowing what to do with my #COVID19 antibody results
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good god, 86k cases reported in NY in a single day yesterday.
keep in mind that up until last week, the all-time record since the pandemic started was about 20k cases of #COVID19 in one day.
the curve is still going straight up.
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It's March 21st. We are roughly 2 weeks into the outbreak. I am still sending people with fever/cough/likely #covid home and telling them we don't have enough tests to swab them.
Also, can someone tell me where the f Joe Biden is this entire time? Is he awake?
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I think the #COVID19 surge in TX and FL is aggravating to New Yorkers because we beat it down. We flattened the curve, cleared out our ICUs, and showed the path forward. We fought for it.
And now, we watch the rest of the country piss it all away, for absolutely no reason.
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Agree. Frustrating to read clickbait stories about people who died after being "turned away" for testing, since that has no impact on their care (and I've "turned away" dozens of people personally).
However, I do think people would take quarantine more seriously with a + test.
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My point: if patients chronically on antimalarials do develop COVID19, but 75% less often than matched controls, that would be a big deal. No one has that data. Proclaiming antimalarials ineffective, or mildy effective, or very effective, are all irresponsible in their own way.
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Successfully extubated my first COVID ICU patient this afternoon.
...
Iโve been here three weeks.
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Bad news: the >100k #COVID19 cases reported yesterday was the highest single day total in almost 6 months.
Good news: 50% fewer hospitalizations and 66% fewer deaths compared to the July wave last year with similar infection numbers.
#VaccinesWork ๐๐ฅผ
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"There's no question of heroism in all this. It's a matter of common decency. That's an idea which may make some people smile, but the only means of fighting a plague is โ common decency."
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"Once the faintest stirring of hope became possible, the dominion of the plague was ended."
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Short on vents for #COVID19 patients? Hereโs a quick and easy how-to video describing how to convert a V60 non-invasive ventilator (BiPAP/CPAP) into a traditional vent. h/t Hugh Cassiere MD, Stanley John RT, Todd Goldstein PhD
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37 year-old woman presents with runny nose and salty taste in her mouth after #COVID19 swabbing.
Fluid from her nose comes back positive for beta-2 transferrin.
To answer your question: yes, it's exactly what you think it is.
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When N95s were scarce, not only did I clean mine, I also stapled the rubber straps back together when they broke
Not a recommendation -- just remembering how few supplies we had, and how lucky we are now!
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#COVID19 cases exploding in NY in the last 48 hours โ more cases reported today than any other single day throughout the entire pandemic.
And itโs going to get a lot worse before it gets better.
Vaccinate and/or boost before itโs too late!
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Nope. We donโt have the data to say it works, and donโt have the data to say it doesnโt work. The fact that youโve treated lupus patients for COVID is almost a nonsequitor. Ergo, my facility.
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"Many continued hoping that the epidemic would soon die out and they and their families be spared. Thus they felt under no obligation to make any change in their habits, as yet. Plague was an unwelcome visitant, bound to take its leave one day as unexpectedly as it had come."
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good point just be sure your password contains at least three special characters and at least one sign of the Chinese zodiac and change it every 11 days and also the EMR password is different from the PACS password for some reason so memorize these three different IT desk numbers
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Tweets like this make me look forward to the upcoming Biden bestseller, โWhat Happened: 2020โ.
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"The public lacked, in short, standards of comparison. It was only as time passed and the steady rise in the death-rate could not be ignored that public opinion became alive to the truth."
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Great read re: the enthusiasm of @ewarren and @SenSanders supporters as opposed to the โpragmatismโ of @JoeBiden supporters. โPragmatismโ failed in 2016 โ why do we think 2020 will be different?
newrepublic.com/article/1567โฆ
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#COVID19 cases are up 50% in NYC in the last week.
Thanks for the 2 month break though!
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also there have been hundreds (thousands?) of โmost powerfulโ civilizations in the world throughout human history at any given time
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The bigger scandal is thinking your patients need to know the date at all. Most of the time, all I care about is the month, and Iโll even give a few weeks leeway on that.
One should be testing general awareness of their surroundings, not the ability to impersonate a calendar!
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I hope you're not referring to me as the "some", because my point is the paragon of EBM: we can say nothing useful about antimalarials in #COVID19. Touting their benefits is as uninformed as dismissing their utility.
If the "some" referred to @realDonaldTrump, then, duh.
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Playing devilโs advocate. The implication of the original tweet was โlupus patients get COVID, plaquenil probably ineffectiveโ. Pointing out those patients are immunocompromised was one of many possible counterpoints.
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Washington State has straight-up pancaked their #COVID19 curve. Confirmed cases down by 90% in the last two weeks. Nice job @NickJohnsonMD!
Source: Washington DOH
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doctors are no longer management; weโre labor. that means itโs time to organize, unionize, and take back whatโs ours!
Thatโs right, ANOTHER ONE! The over 400 resident physicians of Kaiser Permanente have filed to form a union!
Weโre unionizing, not only to make actual change that impacts our day-to-day well-being and patient care but to show how healthcare can be transformed. โ
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That is a dangerous assertion based on a single, wildly incomplete patient snippet. As others have said -- what's the PaO2? Have they been beta-blocked? Is the patient mentating? And more importantly, is this patient still alive??
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Because neurologists have the AHA and AAN and big pharma and everyone else and their mother pushing thrombytics for every teenager whose leg falls asleep as the Standard of Care.
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the โfighterโ mentality is so poisonous. it means the people who succumb to their illness werenโt โfightersโ, or didnโt โfight hard enoughโ
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That was literally one of my primary deterrents from any kind of surgical career: the constant fear of touching something and being โcontaminatedโ. Now I get to spend every minute of the day like that! Wheee!
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like malik nabers
@StateFarm is there
start working on it, guys
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Holy cow. If not for those little pockets of aerated lung, Iโd tell you someone was screwing with the contrast.
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Not bad, but a little condescending.
Just to play devil's advocate, the converse headline: "Doctors Who Have Been Arguing About the Definition of ARDS for 25 Years Come to COVID Conclusion in Fifteen Minutes".
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so @hackney_hw and I have the Memorial Day #NYTXW โ there will be lots of oohing but very little aahing
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#crosswordtwitter PSA: if you submitted a puzzle to the @WSJ in the last few years, be aware a 1099 decimal error has led them to report some constructors as earning 100x what they were paid.
Currently trying to convince the IRS I didn't earn 40 grand on crosswords in 2019.
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A uniquely American dilemma: when youโre too emotionally fatigued to think about the human toll of #COVID19 pandemic any longer, consider the wave of bankruptcies that might follow in its wake. bit.ly/3bttuPP
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the job will never love you back. people would be sad for a few minutes, then things will go on as if you were never there in the first place!
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everyone crossword-adjacent needs to stop what they're doing and watch Ludwig -- about a crossword constructor (!) -- played by David Mitchell @RealDMitchell (!!) -- investigating his twin's disappearance (!!!)
it's like if House was played by Will Shortz instead of @hughlaurie
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so youโre basically saying it was due to overwhelming demand from people clamoring for todayโs fresh, lively offering
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People keep asking: where are all the heart attacks and strokes?
Hereโs where: my wife, an oncologist, often has to tell patients to go to the ER for severe anemia, neutropenia, etc.
The answer these days is always the same:
โNo way, doc. Iโll take my chances at home.โ
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itโs wild that you can try to bring a loaded gun on an airplane and the TSA will just say โLOL you rascal leave the gun here and get on that plane, crazy guyโ
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For those who havenโt gotten their fill of Tina Labadie yet, someone claiming to be DCDD has posted a very long on-brand rant about not consenting to have the puzzle published at all, WS is the real enemy, etc. Scroll down to the last comment:
rexwordpuzzle.blogspot.com/2โฆ
#nytxw
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a reminder of BMJโs finest:
ncbi.nlm.nih.gov/pmc/articleโฆ
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My old EHR (Cerrner I think?) had orders for clowns, leeches, nipple stimulation, and vodka. Talk about a party!
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Sorry, but I believe you are mistaken -- patients with lupus have significant inherent immunosuppression apart from the drugs used to treat the disease. See here for a good recent overview, for example:
ncbi.nlm.nih.gov/pubmed/3120โฆ
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what a first class treat โฆโฆ@AmericanAirโฉ! a chewed wad of gum and a used napkin waiting for me at my tray table! can you imagine what the hidden surfaces must look like?
seat 1D, XNA to LGA today. clean the damn planes!
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And now his watch is ended.
Dr. Frank Gabrin, a New Jersey ER doctor, has died in his New York City apartment just one week after he noticed coronavirus symptoms, his family and colleagues told @NBCNews. on.nbc10.com/VNmq3WJ
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another #medtwitter and #crosswordtwitter mashup: my #JAMA debut today with @AOhringer and the good Dr. Haight
jamanetwork.com/journals/jamโฆ
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Has the Left Moved Too Far Left? We Polled Nine Guys in Panzer SS Pins at a Truck Stop in Sheboygan to Find Out.
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I understand your sentiment, but I donโt understand the physiologic basis for thinking a 3 year old would have such a qualitatively different immune system vs. a 1.5 or 5 year old. Especially if safety was established.
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The old teaching that was drilled into us in residency was, "If you don't think it's going to be better tomorrow, don't use BiPAP today".
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ok first of all you need to specify which subset -- ICD-10 is the newest iteration. ICD-9 would actually be more accurate in this instance, for a number of reasons, especially as it pertains to diagnostic related group (DRG) incentives
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I work with some incredibly kind nurses and PA who are volunteering to go into patient rooms on their time off to facilitate phone/Facetime calls between sick COVID patients and their families.
Literally risking their lives to do it!
abc7ny.com/coronavirus-nurseโฆ
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because the patient is either โtoo sick to scopeโ or โtoo stable to scopeโ and hasnโt hit the goldilocks level of illness yet. also itโs after 4pm
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There will be two "second waves" this fall -- the #COVID19 rebound that follows reopening, and the deluge of other patients that won't be able to delay their medical care any longer.
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On behalf of ER physicians everywhere, we agree to stop saying that if you agree to stop telling patients what will be done for them when you send them to the ER.
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Never one to be outdone, Florida also reported 70k #COVID19 cases yesterday -- shattering their prior record -- and has seen a one thousand percent (!) increase in cases over the last 14 days:
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Again, can you imagine if I wrote on all my radiology orders โif clinical correlation is needed, examine the patient yourself DOCTORโ
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What if much of the bad #COVID19 pathology was due to widespread micro/macrovascular thrombus?
Pulm: dead space/hypoxia
CNS: encephalopathy without large territory infarct
Renal: impaired perfusion/AKI
Peripheral: limb loss
Dimers through the roof.
Weโre seeing all of this!
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