Allison

• RN • CCEMT-P • Firefighter

[Allison @Alclare1]

Guys. I delivered my first baby in the field last night.. there’s lots of positives of being an EMT, but this was something so much greater than anything I’ve felt or witnessed before.

[Daredevil Shots @_DaredevilShots]

We have a new NO NO NO. #ThePunisherOneLastKill

[Allison @Alclare1]

Since the listening party I felt like 23 was going to be ‘my song’ off the album and while I’m lucky to not have a closed one dealing with addiction I think the way he sounds angry resonates with my anger at the world lately. Thank you Noah ❤️

[Allison @Alclare1]

🥹🥺 buggies

[Noah Kahan @NoahKahan]

The Great Divide: The Last Of The Bugs

4 extra songs

Out now on all streaming platforms

And yes you get Staying Still

https://t.co/qrQPcZzihZ

[Allison @Alclare1]

*inserts uno reverse card*

[emily 🐛🐞 is the great divide biggest fan @omniaintempore]

4 years ago stick season dropped in the both the literal and metaphorical coldest/hardest time of my life and today the great divide will drop and its warm and the sun is shining and im not so angry anymore

[lily 🛸 PHOEBE MSG @lilys_garden13]

“gotta stay for mom” in american cars NOAH KAHAN WHEN I CATCH YOU

[Allison @Alclare1]

WHERE IS THE LOVE FOR 23.

[Allison @Alclare1]

Dashboard and 23 (and looking forward to lyrics) because I’m learning I require closed captions in all aspects of life

[Noah Kahan @NoahKahan]

Song ur most looking forward to on TGD?

[Allison @Alclare1]

Hi, I’m one of those people and I can’t wait to listen on repeat and cry in my car. Thank u 🥰

[Noah Kahan @NoahKahan]

The concept of people having heard this album freaks me out lmao

[Lucius George ⬛️🟨 @SageOfScoob]

Let the bootlicking ensue

[Dancing through the lightning strikes @Miss_AshG]

And then he’s going to court for strangling a woman

[it's me, syd @Adabear_Art]

Hues and Cues is getting heated tonight

[Ron Iver @ronnui_]

Either we ban AI or we reinstate Panera Suicide Beverages, I just want us to be consistent

[Dr. Nikhil Agrawal @DrNikhilMD]

🦠 PCP Pneumonia
The infection every clinician must recognise early because a delay can be fatal.

Let’s break it down in the simplest and most practical way 👇
#MedTwitter #FOAMed #InternalMedicine

🔥 What is PCP
● Caused by Pneumocystis jirovecii
● A fungus that behaves unlike any other fungus
● Lives in alveoli and fills them with foamy proteinaceous material
● Major killer of immunocompromised patients

🎯 Who is at highest risk
● HIV patients with CD4 count below 200
● Most cases occur when CD4 drops below 100
● Cancer chemotherapy
● Solid organ and stem cell transplant
● Patients on high dose steroids
● Patients on rituximab, TNF inhibitors, cyclophosphamide
● Severe malnutrition
● Those unaware they have HIV until they present with PCP
#HIV #CriticalCare

😷 How does PCP present
● Slow onset in HIV patients
● Rapid and aggressive in non HIV immunosuppressed patients
● Fever
● Dry cough
● Progressive breathlessness
● Hypoxia out of proportion to chest findings
● Exertional desaturation is very characteristic
● May appear stable but can crash suddenly

🩺 Exam hints
● Chest exam may be normal early
● Later: diffuse crackles
● Cyanosis and respiratory fatigue indicate impending failure
● Always check walking saturation

🧪 Lab clues
● LDH often elevated
● ABG shows A–a gradient rise
● Beta D glucan may be high
● CBC often nonspecific
● HIV positive patients may have surprisingly normal WBC

📸 Radiology
● CXR: bilateral interstitial infiltrates
● HRCT: diffuse ground glass opacities
● Presence of pneumatoceles or spontaneous pneumothorax points strongly to PCP
● A normal CT almost rules out PCP

🔍 Diagnosis: What confirms it
● BAL is the best sample
● Induced sputum works if done by experienced hands
● Silver stain, toluidine blue, Giemsa
● Immunofluorescence stain is highly sensitive
● PCR is very sensitive but may pick up colonisation
● Negative PCR helps rule out active disease

💔 Why hypoxia is severe
● Organisms coat the alveoli
● Surfactant dysfunction
● Impaired gas exchange
● Alveoli become filled with foamy protein material
● Severe V/Q mismatch

💊 Treatment
🌟 First line
● TMP SMX for 21 days in HIV and severe cases
● 14 days may be enough in mild non HIV cases

💊 Alternatives
● Atovaquone for mild cases
● Clindamycin plus primaquine
● IV pentamidine for severe or intolerant patients

⚠️ Important cautions
● Primaquine can cause hemolysis in G6PD deficiency
● Pentamidine is toxic: renal failure, pancreatitis, hypo or hyperglycemia, arrhythmias

🔥 Steroids save lives in moderate to severe PCP
Use when
● PaO2 below 70 on room air
or
● A–a gradient above 35
Start at the same time as antibiotics. Do not delay.

📅 Steroid regimen
● Prednisolone 40 mg twice daily for 5 days
● Then 40 mg once daily for 5 days
● Then 20 mg once daily for 11 days

💥 Treatment failure
If no improvement by day 4 or worsening
● Re evaluate diagnosis
● Switch to pentamidine or clindamycin plus primaquine
● Consider adding steroids if not already given
● Check for CMV, bacterial pneumonia, PE, ARDS, drug toxicity

🧬 ART in HIV patients
● Start within 2 weeks of PCP treatment
● Watch for IRIS
● Delay only in severe respiratory compromise

🛡 Prophylaxis
Who needs it
● CD4 below 200
● History of PCP
● Prolonged high dose steroids
● Rituximab, TNF inhibitors
● Transplant recipients
● Hematologic malignancy

Best options
● TMP SMX single tablet daily
● Or thrice weekly double strength
Alternatives
● Dapsone
● Atovaquone
● Aerosolised pentamidine monthly

[Allison @Alclare1]

What hurts the most is knowing I’ll never get an @AldiUSA Christmas rat because they’re only sold in the UK.

[Allison @Alclare1]

I don’t think I got my typical birthday depression this year and it’s solely because I spent the whole day sad that I turned 28 and then my fiancé corrected me that I turned 27 and that fixed it!

[Allison @Alclare1]

At this point someone take my idea and just make it happen: customizable alarm sounds for vents and bipaps…. I’m sick of hearing alarms and not being able tot ell which room they’re coming from.

[Jimmy John’s @jimmyjohns]

am i wrong tho?

[Allison @Alclare1]

I love everything about this.

[Buffalo Bills @BuffaloBills]

We see you, @NoahKahan!

#GoBills | #BillsMafia

[Buffalo Bills @BuffaloBills]

We see you, @NoahKahan!

#GoBills | #BillsMafia

[Allison @Alclare1]

@bayhuff22 @francisdominiic @jen_strings Mine says 2 left now. So what the heck