Tim Cook
@doctimcook
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Bath-based anaesthetist/intensivist. I study medical complications to improve safety. Own views except where I knick others’. Insta @timcooksnaps . Airway goblin
Bath, England
Joined May 2015
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@wesstreeting
Thanks for asking
As some one who has worked in the NHS for 35 yrs and examined its working throughout that time my list of what needs changing would start with
Stop breaking the system by defunding it in the name of efficiency. It is way beyond the point at which trying to cut…
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@bbcnickrobinson
@drphilhammond
@BBCr4today
Excellent interview by College Admissions Tutor Prof Laura Ash. "As these students were not going to have sat any exams there was not going to be any new information that could justify rejecting someone to whom we had already made an offer"
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I’ve not seen this before….but is there anything on the page to disagree with?
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So here’s a plea.
No more ‘standard’, ‘full’ & ‘enhanced’ PPE
PPE matches the route of transmission
- contact precautions
- droplet precautions
- airborne precautions
Use of this language would cut through a lot of confusion.
1/2
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Great clear infographic
@ICS_updates
One to keep up the sleeve when someone asks why ICU occupancy hasn’t increased
Well done all ICU staff
Remarkable
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This letter from Italian Intensivists is measured and scary.
If your hospital hasn’t made these plans now is exactly the time to start making them.
#notbusinessasusual4icu
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Coughs make aerosols
It's long been time for ward staff to upgrade to FFP3 around coughing patients and those with COVID
The urgency for this is dramatically increased by the new variant virus
No one seems interested....
@TheLancet
@bmj_latest
@PHE_uk
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@bbcnickrobinson
@drphilhammond
@BBCr4today
Prof Ash
"The algorithm literally copied the inequalities that currently exist in our education system"
"OFQUAL..made the grade distribution across the country look right, but they can't possibly tell us they've given the right grades to the right people"
Guess that's about it
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Amidst the gloom at the NHS crisis its easy to forget one factor: sociomedical success
In the last 30 yrs UK health has been transformed.The predictable consequences required long term planning which appears absent
A 🧵 of old slides (2017) but they still make the point
1/n
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A thread on the (topical) high rate of COVID identified or acquired in hospital
The fact that this is up to 30% is being highlighted by some as indicating that hospitalisation numbers are inaccurate
1/
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PREVENTING UNDETECTED OESOPHAGEAL INTUBATION. A thread
@RCoANews
@dasairway
@ICS_updates
@FICMNews
@CollegeODP
@SaferSurgeryUK
@BACCNUK
@MartinBromiley
It is rare
It is fatal
It is avoidable
Sadly it still happens
1/16
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CARDIAC ARREST DURING OR AFTER SURGERY IN UK PRIVATE HOSPITALS
This is a timely reminder that all healthcare has risks & safety is at the heart of everything we should be doing.
Timely also as I was speaking today to the Independent Healthcare Providers Network (IHPN) about…
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The pandemic & ICU
There is questionable value of conversation with an individual who is either misinformed or intentionally misrepresenting recent history
However a thread to correct the record/explain apparent inconsistency in data that may lead others to honest error
1/n
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Been seeing the igel described as an LMA. Call me a pedant but it’s not an LMA. Here’s a history story & feel free to close your eyes.
The term LMA is (or was) a protected term for devices made by the LMA company/intervent orthofix. Now taken over by Teleflex. These include the…
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Media obsessed with asking interviewees whether they’ll stop wearing a mask ASAP
As masks are worn to protect those around the wearer this surely reflects how much the interviewee cares about others.
It’s not about ‘personal freedom’, rather ‘collective responsibility’.
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This is a rather concerning letter from out colleagues in Italy. Not people to panic
If you’re not making preparations yet in the UK now is the time to start
Preparing for COVID-19 - Message from the ESICM President & colleagues in Northern Italy
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@thatsnotmine125
@VirtueOfNothing
@telswood
@Matt_L_Nash
This does seem a bizarre conversation
Intubation of the critically ill adult is rife with risk & complications. Harm is common.
Intubation of the neonate (especially when critically ill) is a league up in failure, delay & complications. Harm is intrinsically less easy to…
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PPE made simple and logical...I hope
1 understand the modes of transmission
COVID-19 is predominantly droplet and contact
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As an aside for those advocating a US style private healthcare system note
The USA has
-enormous costs
-poor life expectancy
-high perinatal (birth) mortality
-high rates of bankruptcy due to healthcare bills
The UK has none of these
2a/n
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I don’t like to criticise on twitter but this article is hugely unhelpful
Ill informed, conflating arguments, misdirecting. Focussed on the wrong interviewees & presenting as simple, hugely complex topics. As colleagues battle to save lives this is no help
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Delighted to see this finally announced
It was, to be frank, always the front runner -
NAP8 - REGIONAL ANAESTHESIA
It will be a brilliant project as it will create the largest ever database of major complications of regional anaesthesia and IMO for the first time enable genuine…
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COVID-19
If you’re a clinician (or not) and still not sure what all the fuss is about I hope this might help
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contact precautions
= gloves + apron
droplet precautions
= gloves + apron + surgical mask +/- eye protection (risk assess)
airborne precautions
= gloves + eye protection + N95:FFP3 + fluid repellent long sleeved gown
3/3 & end!
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Anaesthetists, intensivists, surgeons & medics..
An unusual & personal editorial from the estimable
@JBC13Mar1967_
…some of you’ll love it
…some of you’ll loathe it
But I recommend you all read it
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COVID +ve patient
>2m away
- contact precautions
<2m away
- droplet precautions
Aerosol generating procedure
- airborne precautions
2/3
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A short thread on the revised list of AGPs
The AGP list has changed in England
The following are no longer considered to be AGPs
@TonyPi314
@_andyshrimp
@drjulesbrown
@NWilson247
@EuanTovey
1/6
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@mark_toshner
Accountant now in NHS management thinks doctors need less training
Been doctoring myself for 36yrs
I see no sign of it getting easier
I see no sign of patients getting less complex
I see no sign of expectations falling
Indeed all the evidence points in the other direction…
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Lots of interest in ambulance staff and risk of COVID today
Our December analysis of
@ONS
data in
@HSJnews
confirmed ambulance staff to be the healthcare staff at highest risk of death from COVID19
@DrSimonLennane
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Things that can make or break my day: include patient & surgeon
But right up there is the ODP*
Undervalued, often unseen & consistently underpaid. Loads of them travelling the country to bolster NHS work. Great folk.
*operating department practitioner :an anaesthesia factotum
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A complex matter
A newspaper leading a ‘commission for NHS reform’ (as if we’ve not had enough reform in the last 30 yrs)
An ombudsman (whose job of course is to examine only cases where things appear to have gone wrong) firing a salvo of attacks on senior doctors for their…
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Friends travelling abroad via Europe.
@lufthansa
require all passengers to wear FFP3/N95 masks. Must be valveless. To protect both the wearer & those around them.
A marked contrast to NHS hospital staff caring for Covid positive patients.
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Some reflections after a weekend on ICU
Most importantly, despite distractions like Brexit, COVID-19 remains our most pressing matter......and vaccination our most pressing priority.
There are major threats & real opportunities
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#hospital
on
@BBC
@bbchealth
Remarkable that anaesthetising
-patient with ruptured AAA
-a 91 yo with periprosthetic #
are all so simple as to be barely noticed in the narrative
Truly anaesthetists are magicians
Much focus on procedure & surgeons
Physicians strangely absent...
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Here’s a full analysis - rather then a news report - of deaths from COVID-19 among Health and Social care workers in the UK. 106 deaths up until 21 April.
Perhaps something for everyone in it!
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This is a mess. & is not ‘work to rule’
The understaffed NHS relies on senior staff working overtime or taking on roles additional to a full time job.
Tax laws mean the extra work may now either be unpaid or actually cost the staff .
They are simply declining this extra work.
It’s not a stand-off. It’s a poorly thought out tax increase that stops senior consultants from being able to offer additional hours, and to take up senior management positions.
#nhspensioncrisis
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Really good guidelines.
50 recommendations
Evidence base
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I rarely write passionately
Here’s an exception
I hope it’s passion driven by evidence but due to the weight of evidence I do feel strongly about it
To be clear, no animosity to authors of the recent editorial, but I believe they hold the wrong view!
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So high hospital acquired COVID rates are a problem
Mostly because this indicates
-a system under pressure
-failing IPC measures
-a threat to patients
-a threat to staff
We need to control the epidemic of hospital acquired COVID to protect patients, staff & services.
14/14
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A great response from the Morriston to Dr Hilton’s letter
Mostly because it’s
-where he used to work
-signed by 55 anaesthetists
[Though I note there are few winners in this]
Consultants respond to Peter Hilton - Swansea Bay University Health Board
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Adjuncts for tube delivery with HAVL. A short 🧵
Any adjunct needs to deliver tube tip round blade curve.
A standard bougie is no good. It unfurls, so even if pre-curved it only matches the blade curve very briefly
This
-adds unwanted time pressure
-increases failure
1/3
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On one level denying that all this happened (& I’ve only scratched the surface) is dumb & offensive.
Equally importantly, we need to learn the lessons of what has happened in the last two years. If we don’t we are doomed to repeat the errors.
Denial doesn’t help.
21/21
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Everyone seen the updated list of AGPs as listed by PHE.
Updated on 18 June on basis of review published 17 May
All non-respiratory surgery gone.
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New study:
- almost zero aerosols during intubation sequence
- not much during extubation sequence unless they cough. - both far less than voluntary cough
@Anaes_Journal
@bristoluniv
@NBTAnaesthesia
@RUHBath
Paper here...
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Very happy to have this in my hands
Great to work with Michael Kristensen
Excellent support from
@CambridgeUP
Too many authors to thank and whose twitter handles I don’t have but they were absolutely great!
Just not sure why I’ve published two books in a pandemic....
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10% of patients report penicillin allergy - 20% of in patients- but >90% not truly allergic. Second line antibiotics are more expensive, less effective, cause more resistance and more anaphylaxis. Can we identify true allergy better and improve stewardship
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One to ponder
I consider four types of airway difficulty
-anatomical
-physiological
-logistical
-educational
We need to control the controllable factors & eliminate the avoidable factors
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One hub for COVID-19 information for intensivists & anaesthetists.
Fabulous work by
@RCoANews
@FICMNews
@ICS_updates
@AAGBI
Collaboration is king!
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NAP7 Perioperative Cardiac Arrest starts today
Runs for one year
Please report any cases during or within 24 hrs of anaesthetic intervention to your local coordinator
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I’ve just been lucky enough to go through the whole of UCL airway matters MOOC.
Put simply I suggest every airway manager should do it.
It’s free and starts next month
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In about a week more people in the UK will have been vaccinated then have had the virus
Something to celebrate
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Boris Johnson has got it right saying lockdown is doing a lot of the heavy lifting in reducing hospital & ICU pressure
Looks like he’s read paper by
@john_actuary
& me showing exactly that
This shows impact of vaccines alone & the extent of possible rebound as lockdown lifts
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I've tried to add to
@COVID19actuary
@ActuaryByDay
excellent graph from & look at how vaccination impacts hospital & ICU admission
Several assumptions
- assumed vaccination 100% protective (its best protection is against disease progression)
1/6
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UK COVID-19 UK Airway guidance will be up on hub website today.
A lot of quick hard word by a lot of folk.
Hopefully it will save some effort for some and provide consistent approach based on what evidence we currently have.
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There hasn’t not got to be a less worse way of reporting non- inferiority trials than we currently don’t not do
@JAMA_current
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COVID ≠ flu
‘flu season 2018/19 (UK)
3157 ICU admissions
312 ICU deaths
96 ECMO cases
ICU mortality ≈9%
COVID 2020/21 (Eng,Wal,NI)
>35,000 ICU admissions
>14,000 ICU deaths
ECMO overwhelmed
ICU mortality ≈38%
See p 24 & 30
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@dannyjnwong
@stevemathieu75
@AlisonPittard
@RCoANews
@FICMNews
@ICS_updates
Practical.
We’re starting ICU-shadowing (anaesthetist joining ICU ward rounds) to reawaken those once honed ICU skills that every anaesthetist has. A day or two of this improves shared understanding & we hope will pay dividends in the weeks to come.
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@FabulousMrsFox
@Anaes_Journal
@JeremyFarrar
@john_actuary
@DavidDavisMP
@CharlesWalkerMP
@DesmondSwayne
@JamesDelingpole
@DPJHodges
@ClarkeMicah
As a doctor with 33 yrs experience in ICU, 20 as a consultant, I have not seen anything that even comes close to Covid as a burden on healthcare or patients.
I suggest Covid is very unusual.
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Staff infection is a major problem
-wave 1: staff infection ran at 3-4 fold higher than their community rate
-each infected staff member off duty 10d
-no staff = no service
Cambridge has shown increased use of FFP3 masks decreases staff infection
11/
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An airway death.
Complicated or contributed to by a lack of working capnography.
There are lessons for us all to learn
-capnography should be in use
* for all intubations
* whether in NHS or private sector
-it should be checked & working BEFORE induction for intubation…
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Please share in support of our Anaesthesia & ICU colleagues continuing to care for their countrymen & women throughout Ukraine.
It’s 2022 & difficult to fathom
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This is a tremendous elegant article. Brilliantly put together and well worth a read
Personal protective equipment (PPE) for both anesthesiologists and other airway managers: principles and practice during the COVID-19 pandemic | SpringerLink
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Inevitably bragging...
Very proud to work here
Where we all take part in RESEARCH & QI
Not all ground breaking but
-inclusive
-collaborative
-multispecialty
@RUHBath
@RUHCriticalCare
2019-22
Papers 119 (+collab 14)
Editorials 49
Reviews 21
Chapters 44
Lectures 293
Authors 199
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Obstetric cardiac arrest
Let’s look at the big picture….
So among 355,000 obstetric anaesthetic interventions in a year in UK (delivered to approximately 50% of all births & at all times of day and night almost exclusively in the NHS)
Incidence of obstetric cardiac arrest…
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Core topics in Airway Management 3rd edition
Reviewed in
@BJAJournals
"well presented, easy to read, & likely to become a favourite textbook for any clinician from the pre-hospital setting to the intensive care unit who manages the airway"
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Yesterday I posted a slide on the benefits of VL
That was unfair so I've made one for DL too so they can be compared
Have I missed anything?
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@ICNARC
report 19 Nov
shows us a system
-under sustained pressure
-dramatically impacted by the unvaccinated
-with pressures preventing care of many vaccinated patients
For staff and patients alike seemingly unending & miserable.
1/
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And another aside
No EU or other migrants aren’t costly
They are young
They work
They pay tax
They are small users of NHS
12a/n
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Staff working in Anaesthesia/ ICU are at (unexpectedly) lower risk of COVID-19 infection than others on frontline
The big question is whether this has more implications for anaesthesia/ICM or for the rest of healthcare
@DrSimonLennane
@Anaes_Journal
1/9
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A tragic case here for all involved
Capnography remains the most reliable way to confirm a correctly placed tracheal tube
A flat trace indicates a wrongly placed tube until that has been actively excluded
'No trace = wrong place'
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First pass success at tracheal intubation
A widely used measure of quality
Probably a poor one (it's a process variable & is gameable) but what is normal
Here's what I reckoned from the literature
Not as high as many quote
Thoughts?
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Sadly this doctor’s experience is an everyday occurrence this last year
I'm an NHS consultant anaesthetist. I see the terror in my Covid patients' eyes | Coronavirus | The Guardian
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This is a work of real collaboration.
Hopefully of use for many people as things scale up...
👉New COVID-19 guidance published for ICM & anaesthesia: AIRWAY MANAGEMENT
Thanks to
@doctimcook
&
@dasairway
.
@RCoANews
,
@FICMNews
,
@ICS_updates
&
@aagbi
are creating & sharing new guidance, info & resources to manage
#Covid_19
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Presumably the original plan was to do a pound coin - but this will be the value of a pound on 1 November.
If only that were funny.....
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PPE terms I’ve seen
Full
Normal
Enhanced
Full enhanced
Level 1
Level 2
Level 3
Standard
Basic optimal
Respiratory PPE
Proper
Sterile PPE
AGP PPE
A
B
C
Sensible
Fluid resistant
Complete
Protected
High risk
Low risk
Ward level
FFP/G3
FM/G3+A
Proper
Everyone clear?
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A thread on what studying "AGPs" tells us about 'aerosols and droplets'
Focus on this paper
Done in Sydney
Hats off to
@NWilson247
@EuanTovey
My role was microscopic
First: discussion should be 'what is the proportion of each in disease risk: not A vs B
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The fear of infection was huge for ICU staff. In SARS & MERS ICU staff had high risks of infection & death.
It is no exaggeration that in surge 1 it was an act of bravery just to go to work (as I was acutely aware while working from home)
9/n
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Jan Hansel - if you don’t know him yet, remember the name
Here presenting a poster of a systematic review as a cartoon he created
With AI he may soon run the world
…….keep an eye on him
Great to work with you Jan
@VirtueOfNothing
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Staff to patient infection is increased by
- low staff vaccination rates
-high rates of infection among staff due to poor IPC processes
@LawtonTri
has shown trusts increasing FFP3 masks associated with lower rates of hospital acquired infection
7/
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@rupert_pearse
Good thread Rupert.
Two reflections
-we remain in a state of ICU overload, not quite overwhelmed but on the brink
-mistimed relaxation of lockdown will rapidly unleash a further wave of cases
Only 15% have had COVID so far & 85% of the population remain unvaccinated
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This article is about PPE
It describes how confused & poorly communicated techniques add to risk of contamination & infection
I suspect the same applies to airway management & untested maverick ideas
Stick to SAS:
Safe
Accurate
Swift
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It’s interesting how much focus there often is in airway cases on intubation & eFONA
& how little on the choice of rescue SGA
Not all SGAs are created equal. I spent a decade evaluating around 20 different devices & my choice would never be a simple LMA/LM or igel
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Quite a challenging article from
@thetimes
and quoting
@rupert_pearse
Lots for people to agree, disagree and discuss.
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@bbcnickrobinson
@BBCr4today
“Buying time” is what we’ve been trying to do for 9 months
Time to..
-learn how to treat the disease (icu mortality down 30% March to May)
-develop therapeutics (dexamethasone decreases mortality in critically ill by a quarter)
-get closer to vaccines
Buying time saves lives
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Undetected oesophageal intubation
This 3 minute film (Ed: Dr Helena Smith) tells a tragic story
The messages provide a focus for all who manage the airway to improve
-safe design
-safe culture
-safe practices
We can & must do better
Please share widely
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Don’t read this lightly. Please.
Thank you and my thoughts to all struggling in Italian hospitals.
The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care just published the most extraordinary medical document I’ve ever seen.
To help people from Germany to America understand what we’re about to face, I am publishing translated extracts here.
[Thread.]
675
18K
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Pleased to see this published.
A study from
#AERATOR
published in
@Anaes_Journal
showing that even with a large intentional leak during PPV via SGA (here a ProSeal LMA) there was no evidence of aerosol generation
The full suite of airway procedures have now been studied.
The…
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@sally_ghazali
@SorbelloMax
@GAMCLondon
My first four rules of airway management
1 Don’t intubate if there is no good reason
2 Do intubate if there is a good reason
3 If intubating use a muscle relaxant
4 Position before all airway management
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...everyone involved in airway management should be able to interpret a capnograph trace
No its not complex.
Keep it simple.
In Bath we use hats and caps: posh hats are good!
6/16
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Hospital acquired COVID rates are a surrogate of system pressure & failure of infection control & prevention (IPC)
There are two routes
-patient to patient
-staff to patient
5/
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How FFP3/N95 masks work
masks vs sieves
aerosols/droplets
mass movement/brownian motion
electric charges
styrofoam and cats
Brilliant video
2
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Andy Klein steps down as EIC
@Anaes_Journal
What a tour of duty
-exposing fraud
-some anaemia
-covid, covid, covid
-a lone EIC who understood the intersection of aerosol science & medicine
-accessibility
-visibility
-SoMe
-diversity
Many thanks to him & his team
Good luck Matt
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Hugely important topic
6 months after leaving COVID hospital in Wuhan
-About a quarter too sick to take part
-Of the remainder significant deficits of lung function, activity & mental health.
We must not just focus on deaths.
6-month consequences of COVID-19 in patients discharged from hospital: a cohort study
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#NAP7
We spend a huge amount of time preparing for SHOCKABLE cardiac arrest
But in NAP7 cardiac arrests
-82% nonshocksble
HAEMORRHAGE was the single most common cause.
Do we need to rethink our mandatory training?
@NAPs_RCoA
@Anaes_Journal
@RCoANews
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@verboom
@BruceBiccard
This makes no political, ethical or medical sense.
There is no resilience in vaccinating one country if other countries remain unvaccinated
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First I agree that it leads to confusion & it would be much better to report -those admitted due to COVID
- those admitted ‘while infected’ (likely same as community rate ≈2-3% cases)
-those who acquire it in hospital
2/
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Why does hospital acquired COVID infection matter?
I think three reasons
-harm to patients
-infection of staff
-harm to service
8/
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