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Liitunud: 17 Veebr, 2009 22:30
Postitusi: 1899
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Noppisin mõningaid säutsuposte, mis vahetult NY epitsentrit sündmusi kirjeldavad. No ma ei tea, kuidas teiega, aga minu jaoks on sellised vahetud muljed hoolimata oma teatavast subjektiivsusest väga huvitavad. Leora Horwitz Oli 23.03 - 29.03.2020 NY ühe nö. ICU - le patiente filtreeriva üksuse vedaja (ei tea tegelikult mis peaks antud juhul see vaste unit -ile olema) Alustasid 7 -e ja lõpetasid nädala 12 üksusega. Üksuste tegevusest/eesmärgist/funktsioonist kirjeldab: We were limiting to nasal cannula or non rebreather but now allowing high flow (with airborne precautions) to try to spare some vents; still no bipap.https://twitter.com/leorahorwitzmdJa tagasivaade: In my 7 days on one of our (now 12!) non ICU #COVID19 units, I admitted 58 patients for COVID rule out, of whom 50 tested positive. Two died (DNR), 2 went to hospice, and 5 went to the ICU. That is… not my typical gen med service week. Following, some clinical observations.
My experience perfectly matched published reports. Procal universally low. Ferritin, CRP, d-dimer elevated. Lymphopenia prominent. Patchy infiltrates on CXR. Diarrhea common. So, I want to share some other things I haven’t seen talked about as much.
1st, I was shocked by the persistence of fevers. My patients had fevers every day, often all day, often >39, for days on end, not especially Tylenol responsive. And they had all had several days fevers before admission.
2nd, the fevers did not seem particularly related to outcome. In fact most of my ICU transfers did not have persistent fever. They did, however, make patients miserable.
3rd, this is not your usual sepsis picture. NONE of my patients, even the deaths/ICUs, developed meaningful AKI or liver failure (most had trivial transaminitis). There is no multiorgan failure. Just respiratory failure (I know reported later cardiac; I didn’t see those).
4th I did have a bunch of mild troponin elevations, but mostly demand ischemia. No EKGs c/w myocarditis. Suspect too late a complication for me to see.
5rd, as noted by others, just about all of my patients had had symptoms for 7-10 days before needing admit for O2. This posed a conundrum for the few who were admitted with <5d sx (all on RA) – keep to await nadir? Can’t afford the beds. Had to discharge with warning.
6th, I found CRP and ferritin often to move in opposite directions (usually CRP down while ferritin still up; CRP leading indicator?). This was confusing. Moreover, I had patients with ferritin >3,000 who did well and others with <800 who struggled. So, not universally helpful.
7th, as noted by others, these patients deteriorate fast. Really fast. I started calling ICU for any patient who went from RA to 6L in <24 hours; nearly all wound up at least on 100% NRB or high flow if not intubation.
8th I kept underestimating their exertional hypoxia. Learned my lesson when I transferred one pt to lower acuity floor and he had a syncopal event getting from wheelchair to new bed. Walked all patients with pulse ox prior to d/c.
9th On the topic of syncope, I admitted 3-4 COVID+ patients with presenting complaint of syncope (2 with head lacs), all early in course, with orthostatic hypotension without significant antecedent fevers. Could COVID be having some effect on autonomic system?
10th Our standard protocol right now is azithro/hydroxychloroquine/zinc but I have little faith in efficacy. For the patients I really worried about (fast O2 requirement rise, high inflammatory markers) I gave tocilizumab off label. Clinical trial of sarilumab starting this week.
11th Proning is now standard in our ICU and I tried hard to get my sicker patients to do it too to head off intubation. This is much harder than it sounds. Most patients couldn’t get into position on their own, found it uncomfortable (back pain), refused.
12th Most of my patients didn’t eat anything. Partly lack of taste/smell, partly misery with fever, partly hypoxia with exertion, partly lack of visitors/staff in room to encourage and help. Several asked me for soft diet to reduce effort of chewing. Must attend to nutrition.
13th Lastly, one of the biggest concerns for non-critically ill patients was persistent painful cough. Most had paroxysmal dry, wheezy coughing spasms, often precipitating desaturations. Tried cough syrup, albuterol MDI with spacer (avoiding nebs), codeine, with little effect.Proovidest: NP (ninast) only (used also for flu,resp virus panel to conserve materials). Mine all tested positive first shot. Retested some high prob negatives, all neg second time too. We have had some positives on repeat institutionally though.Kordustestide tegemise kohta, kui vastus negatiivne: never. insufficient materials. just told people to stay home another week or two or until fevers/sx gone.Hooldekodude (hooldekodu ei ole vist õige mõiste hospiit on asutus, mis pigem on "suremiskodu"), kes suhtumisest Koroona positiivsete vastuvõtmisesse: Admittedly big battle (and on weekend too!) for the home hospice one. (Other one inpatient hospice, more options there.) Found one agency willing to do home. Our biggest agency telling us they will start accepting Wednesday. #1 priority for many is not to die alone in hospital.
I believe our senior hospital leadership had strong words with local hospice agencies. They initially told us couldn't do because staff not fit tested and then because didn't have #PPE; both very solvable, if necessary through collaboration with health system.Protokolli kohta, mis ravimeid anda küsiti jägmiste kohta potentsiaalsed midikamendid - azt (atsidotümidiin - HIV/Aids ravim) + zinc (tsink - aneemia vastu vist?)+hcq(hüdroksüül klorokviin - malaariaravim): Not particularly. Some giving to all hospitalized. I personally didn't for those on room air/little O2 near end of course (i.e. >12 days sx); little anticipated benefit, potential for harm. Also hesitated in those with active CAD/risk for arrhythmia. Tracked QTc of course.Patientide vanuselisest suhtest: Matching published reports but plenty young (3/5 ICUers <60, one in 30s) and comorbidities largely mild - well controlled DM, HTN etc. My two transplant pts, e.g., actually did well. Of course worse comorbid could have gone straight to ICU.Tavakodanike maskide kandmisest NY -s ja kas soovitab: good question! there is still no need for N95s (which is what my thread was about) and never will be. but, at least in NYC, given the degree of community prevalence and potential for asymptomatic spread, I think wearing procedure or cloth masks is now sensible to reduce spread...don't waste an N95 when we are desperate for them in hospitals.Nende 41 juhtumi (50 -st kes ei sattunud ICU -sse, ei surnud või ei suunatud hooldekodusse surema) edasisest käekäigust: These were all hospital admissions.Ja veidi hiljem 30.03.2020 tagasivaatavaid mälupilte: The need for constant vigilance was exhausting. I felt pretty safe in patient rooms with gown, mask, gloves. But on unit, constantly reminding myself to open doors with a paper towel, wipe computer/phone with bleach before using, not touch face: v. tiring.
The frustration of knowing certain patients were going to deteriorate and not being able to do anything about it except watch it happen was very tough emotionally. I’ve been spoiled by modern medicine – in general, I’m not used to feeling quite so helpless.
The emotional toll of seeing sick, terrified patients without any visitors was also high. Made it my top priority to get deteriorating patients to call/video chat family before too late. Sometimes this took hours and use of my own Skype account.
The visiting policy was very hard on families too. They were frantic trying to reach staff every to find out what was going on. Our operators overwhelmed. Gave my personal cell to families of the sickest patients.
Also, everything took so much time. Assume donning+doffing takes 5 min per room entry – with 17 patients on unit that’s 1.5 extra hours just to see everyone once, let alone more often if sick or to see new arrivals after old ones transferred. My days were much longer than usual.
I rented an apartment for the week as I live far from hospital and also wanted to keep my family safe. This was lonely and I missed my kids/husband.
On the plus side: this is a great stint for those of you (like me) who are medical minimalists and #ChoosingWisely fans. On my 58 patients I ordered: 0 CTs, 0 echos, 0 ultrasounds. Turns out, you don’t really need them and minimizes iatrogenic spread and staff exposures.
Also, the goals of minimizing room entry and maximizing situational awareness prompted an outburst of creativity. Partway through the week some nurses had the bright idea of writing the info we most cared about right on the doors: oxygenation.
https://twitter.com/leorahorwitzmd/stat ... 58/photo/1
https://twitter.com/leorahorwitzmd/stat ... 58/photo/2
Some tips: ditch the rings, the watch, the white coat, the necklaces, the dangly earrings. First time in 18 years I haven’t worn my wedding ring. Weird feeling. But made donning/doffing much safer & easier. I got to pretend
https://twitter.com/leorahorwitzmd/stat ... 60/photo/1
More tips: A snack bag size ziplock is perfect size for an iPhone. Put it in a clean one every morning. Touchscreen, microphone work just fine through it. Wipe it down with bleach wipes periodically. Discard bag at night to have clean phone in home. (Explains blurry pics.)
Final tip: Hack the EHR. Make a dedicated COVID note template (history/plans monotonously similar). Reconfigure patient list to add crucial info like oxygenation and COVID test result. (Adding O2 was game changer for helping me track sickest patients.) Use COVID order sets.
https://twitter.com/leorahorwitzmd/stat ... 54/photo/1
Lastly, lean on your colleagues.
_________________
Ceterum Censeo Russiam Esse Delendam
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