Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD [@_carlemd_] “My reputation’s never been worse, so …” -Taylor Swift Case A 54 year old woman with lupus nephritis – treated with mycophenolate mofetil and prednisone – is admitted with pancytopenia and worsening confusion. She was recently discharged after receiving levofloxacin and clindamycin [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “WANTED: Somebody to go back in time with me. This is not a joke …” -John Silveira Case A 78 year old man with known moderate-to-severe emphysema is extubated in the ICU; he was initially admitted with hypercapneic respiratory failure secondary to influenza pneumonia and pulmonary edema from the medical [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M. Canepa MD “For others, in spite of myself, from myself.” -Emmanuel Levinas Case A 52 year old man is admitted to the intensive care unit with bilateral pulmonary opacities, worsening gas-exchange and hypotension requiring peripherally-administered norepinephrine. His PaO2-to-FiO2 ratio is less than 100; he is [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I’m learnin’ to fly … but I ain’t got wings … comin’ down … is the hardest thing.” -Tom Petty Common Events Continued … Abdominal Pain Like chest pain, abdominal pain carries a wide differential diagnosis. Abdominal pain comprises 4% of all in-flight events and 10% of all diversions. An [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “If I could only fly … if I could only fly … I’d bid this place goodbye … to come and be with you.” -Blaze Foley Case ‘If there is a physician on board, can you identify yourself to the cabin crew?’ You are nearly 4 hours into a trans-Atlantic [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “What is REAL?” -Velveteen Rabbit A 42 year old woman with poorly-controlled type II diabetes is admitted with a severe soft tissue infection of her left lower extremity. She is hypotensive with altered sensorium and she is noted to have a rapidly progressing border of deep, crimson erythema and edema [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “One of the symptoms of an approaching nervous breakdown is the belief that one’s work is terribly important.” -Bertrand Russel I read with great interest a recent letter penned by Taylor and Camporota in response to an investigation on airway pressure release ventilation [APRV] by Zhou and colleagues. Their brief [… read more]
Jon-Emile S Kenny MD [@heart_lung] “What is memory but a story about how we have lived?” -Mark Doty During the recent ‘Hospitalist and the Resuscitationist’ conference in Montreal, there were discussions around the hemodynamics of prone positioning as well as using venous Doppler as a hemodynamic metric. Much of this discussion was generated and driven [… read more]
Jon-Emile S. Kenny MD [@heart_lung] Lung Stress in Pulmonary & Extrapulmonary ARDS Initially described in the late 1990s, the distinction between direct pulmonary insults [i.e. pulmonary ARDS] and indirect pulmonary insults [i.e. extra-pulmonary ARDS] is important [1]. Additionally, direct pulmonary injury such as gastric acid aspiration may have a different molecular phenotype from indirect, extra-pulmonary [… read more]
Jon-Emile S. Kenny MD [@heart_lung] In the previous segment, time constants [t] – and their limitations – were described as a lesson in applied respiratory physiology for setting T-Low and prediction of auto-PEEP in airway pressure release ventilation [APRV]. In this brief missive an alternative approach to titrating T-low is described and critiqued. As well, [… read more]
Jon-Emile S. Kenny MD [@heart_lung] While the lung in the throes of acute respiratory distress syndrome [ARDS] is shrunken, edematous and inflamed, a basic management maneuver is to ‘recruit’ lost pulmonary surface area. In other words, unfold alveolar-capillary units with the ventilator like a respirothoracic party horn. One ‘unconventional’ method of maximizing and maintaining lung [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The real process of education should be the process of learning to think through the application of real problems.” -John Dewey On April 18 & 19, 2018, I had the pleasure of participating in the inaugural conference “The Hospitalist and the Resuscitationist” in Montreal. The entirety of this meeting was [… read more]
Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “Each time new experiments are observed to agree with the predictions, the theory survives and our confidence in it is increased; but if ever new observation is found to disagree, we have to abandon or modify the theory.” — Stephen Hawking A 47 [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “I grow old … I grow old … I shall wear the bottoms of my trousers rolled.” -T. S. Eliot Background While it is tempting to isolate nasal high flow [NHF] into one’s cognitive schema for hypoxemia, NHF rightly deserves an esteemed position within one’s cerebral scaffolds for both hypercapnia [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “… when you walk around a kitchen, you will say to yourself, this is interesting, this is grand, this is beautiful like Chardin.” -Marcel Proust Background Titration of positive end-expiratory pressure [PEEP] in the acute respiratory distress syndrome [ARDS] is achieved by a diverse assortment of practices undergirded by equally [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “The truth is rarely pure and never simple.” -Oscar Wilde In part 1, the crux of this ‘Great Lactate Debate’ was distilled into the unclear origin of the proton in the setting of ‘lactic acidosis.’ Is the [H+] secondary to biochemical work and ATP hydrolysis or is the proton from [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “…. She was here on earth to grasp the meaning of its wild enchantment and to call each thing by its right name …” -Boris Pasternak Background Over the last half-decade, there has been a distinct shift in the approach to lactate elevation. The long-held belief that elevated serum lactate [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “It’s these expressions, I never give, That keep me searching for a heart of gold … And I’m gettin’ old.” -Neil Young An 86 year old woman is admitted with progressive dyspnea and lower extremity edema. 8 months ago she received a trans-catheter aortic valve replacement (TAVR) for severe aortic [… read more]
Jon-Emile S. Kenny MD [@heart_lung] With the birth of ‘fluid responsiveness’ physiology [1], there has been a slow and solemn drumbeat ushering the central venous pressure [CVP] up the squeaking planks of the hemodynamic gallows [2, 3]. Despite this, a few years ago I made a humble defense of the central venous pressure. Importantly, I was [… read more]
Jon-Emile S. Kenny MD [@heart_lung] “Upward, not northward.” -E. A. Abbott A pressure chamber within a pressure chamber; the heart within the thorax. These are two pumps beating in-and-out of time, varying in physiology and pathophysiology between patients and within any one patient during the arc of an illness. As such, when we inspect the [… read more]
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