cjosephy.bsky.social
Emergency Medicine | Critical Care Medicine | U of Washington SOM | U of Arizona Emergency Med | UCSF ACCM
51 posts
70 followers
246 following
Getting Started
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Agree wholeheartedly 💪🏼
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💯%
Lots of em😂
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Well. I think i hear ya.
But Flu = CAP. Many (most?) CAP is viral, flu is a common pathogen.
So youre saying lobar consolidations, elevated procal etc youre using steroids, but diffuse GGOs, lower procal, but still sick, no.
Thats reasonable honestly, just seems like a lot of overlap.
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Very rational. I mean, theres quite a few observational studies that are consistent, despite the fact that none are controlled. Not exactly cause and effect type science but consistent observations in various settings strengthens a hypothesis, right?
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Oh boy 🤦🏻♂️
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So not up front huh? Just when things are getting worse despite standard treatments? Reasonable.
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Right? I mean pooled data on very heterogenous groups of lung injury seem to benefit and until theres some prospective data or at least a tested mechanistic hypothesis (?innate immunity to recurring exposure to seasonal flu?) as to why its different I cant imagine it would be exempt 🤷🏻♂️
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#foamed #foamcc #meded #medsky #idsky #emimcc #cccsky @imcrit.bsky.social @pulmcrit.bsky.social @nickmark.bsky.social @emcrit.bsky.social @zentensivist.bsky.social
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So during this bad flu year with the many people we are putting on IMV and even VVECMO, knowing that theres no updated evidence for FLU+ patients specifically….
Are we using steroids for severe CAP or ARDS in FLU+ patients?
Disclosure: I have been 🤫 🤐
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IDSA/ATS still recommends against steroids in FLU+ patients.
CAPECOD excluded FLU+ pts.
Yet many severe CAP and ARDS are caused by FLU and a non trivial number of them are c/b bacterial PNA.
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Ah come on. Ive never done that! 😂
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I use it a lot. Anecdotally it seems to be less sedating and probe to side effects than the antihistamine/anticholinergic versions of “msk relaxers”
I use to use it routinely in trauma pts and msk related pain but i dont see those pts much these days
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Cool review. Good on the authors. I was hoping they would delve into the catheter based therapies evidence or lack thereof (the big black box) but i did think it was cool they brought up VAECMO. Good stuff.
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Wow. Ibutilide. What a concept. Ive never given it. Good point though about aaF in the ICU vs ED. Different disease practically. Its kind of fun in the ED, kind of a bane in the ICU. Thx for the recommendation ill have to look further into that.
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Another scenario may be when you have VAECMO and an impella in, your PAC estimates of CI are kind of unreliable so was wondering if VTI + flows from MCS devices may be the way. Gets tricky ya know.
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Can I come too?! 😂
Would be a pretty cool study.
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No real clinical question specifically. Just another data point for titrating inotropes and assessing readiness for MCS weaning and liberation.
Had a situation the other day where the PAC and Fick CIs were wildly disparate and the PAC was finicky so i was trying to get a third eye to adjudicate🤷🏻♂️
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I dont know. Anecdotally i find you can often get a pretty crisp ejection doppler envelope under the artifact. But youre right. If you cant its not useful.
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Great point abt RVOT. Thats def useful in pts w ecmo/impella for sure. Anecdotally in pts w impellas i have compared LVOTVTI CI estimates (plus impella flow) to FICK and/or TD and as pulsatility improves and as native ejection returns it seems like its in the ballpark. Would be a cool study.
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I agree. But even if you do have to do it emergently using landmarks at least stick a finger in there and feel where you’re at. I mean a finger relieves tension. Take your time after that 🤷🏻♂️
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You and me both. Ive seen that a few times in the trauma bay. Everytime i do a procedure i hope its not my turn. Especially chest tubes and airways. Stressful job. 😬
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Yea. Good rule of thumb to simplify life. Cognitive offloading strategy!
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In patients with an impella whats the best way to estimate CO/CI? Lets say you dont have a PA cath. Is there any utility in looking at VTI estimates of SV/CO and combining it with your impella and /or ecmo flows
Im trying to wrap my head around best methods to estimate CO/CI in pts with MCS devices
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109° F. Guy collapsed working outside during a memorable California heat wave on a construction site. Basically half dead w MOF and ALF. We supported him in ICU, got him to liver txp and he walked out of the hospital and had renal recovery as well 😳
Wild case.
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Wow. That is bonkers. In 2025 no less. Still talking about contrast and kidneys. So much harm done delaying diagnoses over the years. Mind bending really.
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Obviously this is a nuanced topic not well suited for a soc media thread but in my experience i have to agree that AR tends to be more operative than risk/benefit in general as Josh points out. Admittedly i think in my ED practice its a bit diff. ED docs tend to have a better intuition of this issue
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Really Seth? In my ICU practice i routinely see questionably indicated procedures done on relatively well pts (often w consequences) and find myself pushing to get procedures done on the sickest pts due to a myriad of decision matrices. I realize we “try” to take “all that into account” but IRL??
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So good. Thanks! Suoer helpful and appreciated
This platform is turning out great. Such a respite from twitter.
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You know it when you see it??🤷🏻♂️
Great question
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😂😂
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Also thanks for the write up! Really hit home for many of us. Ive had a number of other intensivists and emerg doc friends comment on it. Preachin our language! 🙏🏼🙏🏼
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100%. I agree totally, well said. That is being charitable tbh. From our vantage of the world, the things we see, we could certainly be whole lot less charitable. Not only does this article reflect poorly on the specialty ( this issue only!) , it leaves me angry and disappointed in the specialty
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This is a pretty interesting read. A survey of medical oncologists. Its particularly interesting from the perspective of the intensivist who sees these pts in crisis and wonders why end of life planning seems like a foreign concept to the patient and family
apm.amegroups.org/article/view...
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Gotchya. This is such an interesting part of medicine. Very nuanced and every situation is different for sure.
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I cant tell you how many times ive heard pedantic attending physicians have ranted on about how the abg HC03 either “is” or “is not” accurate for all sorts of strange reasons.
I love this simple explanation that ive never even heard about. 🤯
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I want to make sure i understand this comment. After all social media’s not the place for nuances.
Just because we can do something, we should/must offer it?
this comment defies the primary directive of not offering non-beneficial (aka harmful) care. Our whole system needs a reboot i think.
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Another good one here. Its always a bit interesting and surprising to me how often these RP bleeds happen. Ive never fully understood the anatomy or physiological reasons why they are so common and why they always happen at 2am. Must be an explanation.
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Oh how Ive missed your posts (haven’t been on twitter and just signed up here)! 💜💪🏼🔥
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Probably a great opportunity to summarize the recent buzz about the role of nonadrenergic vasoconstrictors like MB and hydroxycobalamin and dare i say vitC Growing talk of earlier use in vasopressor refractory vasoplegia w ongoing RCTs. Interesting moving target/ topic in spite of not great evidence
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Lately ive been getting recs from psych to give vit D in acutely suicidal patients 🤯
How do you like them apples?!
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Seriously. Lung ultrasound is definitely better as the arbiter of truth and to guide decisions. But it doesn’t obviate the utility of CXR.
Well said. Synergistic.
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Its a little over the top. What they see in an hr we might see in a day. But the struggle, the trauma, the impossible scenarios and the endless distractions and anxiety is definitely on point. In the US ER however we are furiously documenting all day which is NOT well represented in the show.
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☝🏼yup. I felt the same way. Very difficult to watch bc it triggers the physiological trauma.
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Acknowledge what happened? What do you mean?
To be clear its pretty good and entertaining. Its hard to watch bc it reminds me how traumatizing the ED and ICU are, and all the horrors endured. I guess that makes it fairly realistic (except they dont document all day!)
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Thats not how i would describe it. Theyre trying to portray how horrifying and scary it is in the ER. About as far from Dr House as i can imagine