Syed (Faisal) Ali

Husband - Father - Physician -Hospitalist - Now EM trainee 😅- POCUS - critical care- RLA fellowship grad #FAOMed views are my own not my employer’s.

[Syed (Faisal) Ali @syedmalimd]

@DrBruggeman Hits home for sure! I had wanted to change specialties to EM after being a practicing hospitalist for 6 years which required me to do another 3 year residency. It takes time to learn a new specialty…1 more year to go!

[Syed (Faisal) Ali @syedmalimd]

@EM_RESUS Do not consume your ( OR anyone/anything else’s) urine in attempt to remedy medical ailments**

[Ross Prager @ross_prager]

Lasix is NOT nephrotoxic 🫘

Please retweet so we can end this myth once and for all 🦄

Rising creatinine is more often an indicator of inadequate Lasix dosing than excessive!!

Lasix can only harm the kidneys if it decreases cardiac output by dropping preload to the point of reducing stroke volume... as someone who scans these patients regularly this is surprisingly rare!

If a patient still has venous congestion (on Doppler), then Lasix is not driving the AKI. Instead, their AKI is from untreated congestion!!

[Amal Mattu @amalmattu]

Less than 12 hours to the FREE virtual Emergency Cardiology Symposium, but there's still time to register at https://t.co/2KqdXFfxgr #FOAMed

[Dr. Rick Pescatore @Rick_Pescatore]

Emergency medicine is a lifestyle, not just a job.

You’ll see the sickest patients, the worst luck, and the darkest corners of humanity—& still be expected to smile, move fast, and get it right every time. A thread on what they don’t tell you about EM. 🧵

[Ross Prager @ross_prager]

(2/X) #1: ETCO2 monitoring intra-arrest

For some clinicians ETCO2 use in cardiac arrest is routine - for many others -- it is not available (or being used). It is easy to use and very useful.

Read more: https://t.co/82NSG7KBuu

The theory behind using ETCO2 in cardiac arrest is that to produce CO2 and exhale it (End tidal CO2), you need to have perfusion to the lungs. Thus, assuming the patient isn't being horribly overventilated, the ETCO2 seen in cardiac arrest is a reflection of the amount of perfusion making it to the lungs (surrogate of CPR quality).

If the value is <10mmHg, this is either a bad prognosis or CPR isn't effective

10-20mmHg - common during cardiac arrest and not super reassuring

20+ high quality CPR and when even higher, potential ROSC.

Intra-arrest - if I see a CO2 of 25mmHg with one provider then 10mmHg with the next, I look at rate, depth, recoil, and position of CPR (see tip 3 - LVOT or aorta compression?)

Post arrest, I find it very useful too. When a patient is post arrest and their ETCO2 is 50, if I start seeing it drop to 40....30...25 I know the patient is likely about to re-arrest and can intervene, even when the blood pressure is "OK". The pressure might be maintained because of high SVR from the epinephrine etc.

There is a lot more nuance to ETCO2 in cardiac arrest, however, so check out the post linked above as ETCO2 can tell you even more about CPR quality.

[Justin Gregory Briggs @JGBriggsPhD]

We need #healthcare reform in the U.S. Here’s the latest version of my idea. I welcome your feedback.

The National Medical Bill Registry (NMBR)

The NMBR is a direct pay model designed to benefit people across the socioeconomic spectrum. It is neither a single payer system nor a third-party payer like insurance, Medicare, or Medicaid.

The NMBR leverages existing banking and payment technologies to provide a streamlined, efficient approach to medical billing and payment. Compared to insurance, Medicare, and Medicaid, the NMBR is far less administratively burdensome and much less expensive to operate.

The NMBR cuts healthcare costs by removing bureaucracy, requiring price transparency from providers, and incentivizing direct pay of medical bills with tax credits.

The NMBR serves as an alternative system to the health insurance, Medicare, and Medicaid systems and could be introduced alongside existing systems.

The NMBR’s operating costs would represent only a small fraction of the billions of dollars required each year to run health insurance companies and programs like Medicare and Medicaid.

NMBR: How it Works

Functionality: The NMBR is a website and app that serves as a payment passthrough mechanism rather than a third-party payer. It records payments for tax credit purposes and allows other taxpayers to cover medical bills for those who cannot afford to pay them.

Tax Benefits: Taxpayers receive a dollar-for-dollar tax credit for medical bill payments made through the NMBR, directly reducing their tax liability, unlike a tax deduction which only reduces taxable income. There would likely have to be a cap placed on this tax credit.

Voluntary System: The use of the NMBR would not be mandated; it's an option for providers and patients within a free market context, where current systems like insurance, Medicare, and Medicaid continue to operate unless market forces deem them unnecessary.

Government Role: The government does not pay for or regulate services provided but supports the system by allowing tax credits for anyone who pays medical bills through the NMBR.

Provider Price Transparency and Accountability: To receive payments for services, hospitals and medical providers would be required to create a list of fees for each medical service they offer. If they are caught cheating the system (e.g., lying about providing medical care, performing unnecessary procedures, price inflation), they are held accountable and penalized.

NMBR: Account Creation

Provider Accounts: Providers would have to set up an account with the NMBR, similar to the set up with a credit card processor or Electronic Medical Record (EMR) system. Providers input the cost of each medical service they provide and input their bank account details, which will be used for direct deposit of payments.

Patient Accounts: Patients also need to create an NMBR account. This is a one-time setup where they enter personal information for identity verification and are assigned a medical ID number.

NMBR: Billing and Payment Process

Billing: After services are rendered, providers bill the patient directly for the service.

Payment Authorization: Patients then authorize payment through the NMBR system. This involves identifying the healthcare provider and the fee they were charged for receiving medical services. Alternatively, patients can provide consent for providers to bill them directly through the NMBR system, which could be integrated into the provider’s existing billing system.

Paying Medical Bills for Others: Patients who cannot afford to pay their medical bill can opt in to having their medical bill listed publicly on the NMBR (no information other than treatment cost and medical ID number is listed publicly on the NMBR). Anyone can log into the NMBR and pay medical bills for patients who have posted their bill to the system.

NMBR Transaction Processing

Fee Confirmation and Transfer: Providers confirm that the medical fee information in the NMBR system is accurate and accept the payment. The funds are transferred from the patient's (or other payer’s) account to the provider's bank account directly by the NMBR. Both patients and providers receive payment confirmations to their NMBR accounts. Providers should receive their payment at the speed of a credit card transaction deposit.

Record Keeping: All parties receive confirmation of their transactions. NMBR payments serve as tax credits when payers file their taxes, reducing their tax liability directly.

Acceptance of the NMBR

Healthcare providers would adopt the NMBR because it is a direct pay system that significantly streamlines the payment process and greatly reduces the administrative overhead compared to insurance, Medicare, and Medicaid.

Taxpayers would utilize the NMBR because it allows them to gain more control over their tax dollars while lowering their tax liability.

All Americans stand to gain from the NMBR. It puts healthcare decisions in the hands of patients and their providers. It encourages wealthier individuals and corporations to cover healthcare costs for those with fewer resources. The NMBR creates opportunities for people of all income levels to benefit from direct payments of their medical bills.

Thanks for Reading

I would only consider the NMBR successful if it helped everyone across the socioeconomic spectrum. It would require careful planning and broad support to overcome challenges that would accompany the creation of any alternative healthcare system.

I'm eager to hear your thoughts or any suggestions you might have to refine the NMBR. If you don't like this idea, that’s okay. If you think it’s a good one, be sure to share it with others.

I am sharing this specifically with @realDonaldTrump @JDVance @RandPaul @DOGE @elonmusk @VivekGRamaswamy @RobertKennedyJr @cenkuygur @AnaKasparian @megynkelly @joerogan
because all have expressed interest in hearing good faith ideas for improving healthcare.
#HealthcareReform

[Syed (Faisal) Ali @syedmalimd]

@CoffeeBlackMD Well written, your words took me back to the chaos, fear and uncertainty of that time. Holding the hands of patients as they died with their families watching on an IPad. Glad it’s over and glad there were docs like you caring for these folks

[IMCrit @IM_Crit_]

As usually, great case by @EM_RESUS! Pls see how TEE i) revealed immediately the cause of the arrest &amp; ii) showed chest compressions were ineffective because they were delivered over the LVOT

We do have a trial now in abstract form 👇 that studied the effect of TEE-guided CPR

[Ross Prager @ross_prager]

(1/x) The term 'pre-renal' acute kidney injury is dated and should stop being taught in medical schools.

Why? The term pre-renal is inextricably linked to the idea that the treatment of pre-renal AKI is IV fluids.

Here's the paradigm of hemodynamic AKI and why it is helpful.

A 🧵

#foamed #medtwitter #meded #hemodynamics

[the EMCrit Crew @emcrit]

EMCrit 387 - Emergency Department Charting for Legal Protection and Patient Safety with @embouncebacks.
I have read 6 page notes that missed the two sentences that would have kept the doc out of court--don't let that be you!
[#FOAMed for now]
https://t.co/fOGoan8frI

[Syed (Faisal) Ali @syedmalimd]

@intensivaev Infiltrative CM, probably amyloid

[Syed (Faisal) Ali @syedmalimd]

@ThinkingCC For those of us unable to attend will there be recordings offered after the conference?

[Ross Prager @ross_prager]

We just finished the #HRvexusmasterclass - a 1 day curated dive into all things hemodynamics, perfusion, and congestion.

Here are my 10 most important take homes.

A 🧵

ping @ArgaizR @ThinkingCC @KiranRikhraj @khaycock2 @heart_lung @DCBrotherston @john_basmaji @WBeaubien

[M Velia Antonini @FOAMecmo]

Transesophageal #echocardiography in cardiac arrest, from ED to #ICU:
🫀why using #POCUS in CA & why TEE better vs TTE? close anatomical proximity = superior image quality, ability to view wider range of structures staying away from chest + continuous imaging
🩺TEE diagnostic value
🚦TEE feasibility in ED
🖥️scanning protocol in CA
🩸applications to #ECPR: #ECMO cannulation,
#ECLS/cannulae monitoring, LV unloading, weaning & decannulation
⚠️TEE risks
@ResusJournal #echofirst #POCUS @EchoSoliman
🖇️ https://t.co/jd9Dv4fQZx

[Eddy J. Gutierrez, MD @eddyjoemd]

IVC assessments were the “hot new thing” in POCUS when I was a fellow. Today, it’s a very small component of my practice. There are too many variables involved to help one make a volume status decision based solely on this. 🎩 tip to the authors.

https://t.co/4Ise540F2X

[Alexander Mladenow MD @alex1708ander]

@NephroP @Ahmed43101178 #echofirst #CardioTwitter
🔘BASIC HEMODYNAMICS🔘

[Syed (Faisal) Ali @syedmalimd]

@ogi_gajic @phlegmfighter @ThinkingCC @PulmCrit @iceman_ex can’t prove it but I’ve recently had a patient with acute abdominal pain and profound mixed picture shock initial 3 pressors we dx small bowel atony 2/2 SGL2. She was extremely vol depleted. CT had no perf and no sig mesenteric stenosis. She improved with ivf and after large BM

[NephroPOCUS @NephroP]

A quick run through of #VExUS scan
#POCUS #FOAMed #Nephpearls #FOAMcc

[korbinhaycockmd @khaycock2]

1/ 44 yo patient came to ED with SBP 70 mmHg, HR 150-160 atrial fib. Was s/p ablation for atrial fib 12 days ago and had sudden presyncope and palpitations. POCUS: plethoric IVC and reverse S on HV,diffuse B-lines, TRpv 35 mmHg (so sPAP about 55-60), &amp; the following other images: