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Stories from the Front Lines (✨COVID-19 Healthcare Workers only: posting rules imposed)

  1. Wetworks Mar 29, 2020

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    I've only started administering it this week, so I have not seen anything, no. The benefit I have heard consistently is for mild to moderate infections. Naturally, the people who are discharged with this I haven't heard from, and the criticals I've administered it to are too early in the treatment. Jury's still out. I'll know more this week. If my head doesn't explode from the surge.

    ARBs, not BRA just so you know. And I've seen worsening outcomes on ACEis if I had to choose as these were sneaky turns down the drain. Patients were seemingly doing ok early on in the illness, then overnight go south precipitously, lung fields completely white. But there is never that classic presentation of labored effort of breathing, no real disorientation, just really low oxygenation despite hi-flow O2. I've only seen 2 ARBs-only patients, they presented classic hypoxia, retracting, accessory muscle use, disorientation. Age group has consistently been 40-60. I've had older folks with the virus fine for the most part, but no ACE/ARBs.

    Of course, there are mitigating factors for some; viral strains, other medications, whole host of stuff. But it's definitely a trend to watch.
     
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  2. Rasputin The Mad Monk of OF Mar 29, 2020

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    As an anesthesiologist, I take exception to what @Wetworks said regarding my response. The situation is constantly developing and to disregard established standards in favor of limited data is to tread in unchartered waters at your own risk. Have you managed patients on long term mechanical ventilation, managed a hypertensive crisis, or even attempted to titrate from one antihypertensive to another on a relatively healthy patient let alone one who is hemodynamically unstable on a ventilator? It’s not a plug and chug situation for many if not most patients. The medical community is straining to contain this pandemic while at the same trying to treat millions with other unrelated conditions. This is not designed to be medical advice but to offer alternate insights to consider. And yes patients are to follow the advice of their physicians.
     
    Edited Mar 29, 2020
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  3. sah Mar 29, 2020

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    I agree with Rasputin on the advised management of HTN patients. Also, frustrated (as I assume Wetworks is) that we have no useful data from the patients that have died to date. The observational data is out there but no one has put it together. Not as good as a randomized trial, but better than speculative hypotheses that play in both directions.
     
  4. Wetworks Mar 29, 2020

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    Not sure there's anything to take exception with, to be honest. I disagree that switching patients meds out of an abundance of caution is a particularly big deal, especially since their cohorts are experiencing deleterious escalations in their BP before crashing (in other words, the meds aren't helping them, aka, they are likely hurting them), you don't. You would know this is what's happening if you were getting the information first hand; I am, my impression is you are not. Anesthesiology is super busy in my place as the ER attendings are ridiculously busy with keeping up with intubations and managing ICUs until admission, plus the regular ER stuff. Your whipping out your skillset in an attempt to chop down my argument is telling. I'm sure you can speak expertly to your profession, probably even outside your scope of practice too, and likely better than I on a number of other things as well. However, this is very real, my colleagues and I are seeing it. You want to start pooling the data and making the argument for/against to chart the waters, be my guest. But your previous canned response is potentially very harmful, as it suggests that all is well simply because we don't know anything more at this moment.

    And to answer your questions, yes I've done all those things, and then some, but I will refrain from making it a pissing contest. Just so we are clear, this all started because you took exception to me offering "alternate insights to consider" where patients health may be concerned. That's informed consent, and it doesn't end with an agreement to fulfill a prescription.

    Here's a video that spells it all out. And yet the MD at the end advises the same thing, a wait and see status quo. While I could understand doing so in normal circumstances, doing so now seems so.....passive and wrong.

     
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  5. Wetworks Mar 29, 2020

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    Glad you liked it! Med Cram is a great resource, helps me a lot in both school and practice.
     
  6. Rasputin The Mad Monk of OF Mar 29, 2020

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    There's a reason we do studies: to try to standardize potentially confounding and contributing variables in an effort to isolate whether a single factor may be causative. You're dealing with patients of varying ages and medical conditions that may respond differently to various treatments including ARB and ACEi. Sure there may be an association of poorer outcomes in certain patient populations utilizing these antihypertensives but association does not mean causation. To my knowledge, discontinuing these medications esp in those with severe/uncontrolled hypertension or cardiovascular disease only because the patient is at risk for COVID or infected with it has not been accepted as standard of care at least in the US. Call it a "canned response" if you want but it is currently backed up with overall consensus of the medical community. This position may change tomorrow or next week or never but only because enough clinically significant data becomes available to support it... not primarily data from the frontline dealing with a subset of patients. I can see why patients with mild hypertension with no history of any other cardiovascular disease can be considered for discontinuation of the ARB/ACEi in lieu of another antihypertensive if there's potential to reduce COVID infection/complications. I choose to practice on the conservative end of the spectrum, so my analysis reflects this. Again this is not intended to be medical advice.
     
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  7. Wetworks Mar 29, 2020

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    Lol, well-stated!!! And to that (and @Rasputin overall position) I am not against that rationale when it comes to research (I have problems with the peer-review process as it stands now, and as an extension, consensus), I just don't think all those rules should apply now. As we are seeing with treatment modalities, the people in charge of making those determinations agree with that line of thinking. Extending it to mitigating cases of people who are potentially more at risk would make sense as well. That's really all I'm saying.

    For the record, I was pulling the ears.

    Report today there were ~12 vents in the ER today. I go back Tuesday. I've reset my mind, intend to amp myself up the day before with some inspiring music/movie/quote. Wish me luck
     
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  8. cicindela Steve @ ΩF Staff Member Mar 29, 2020

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    REMEMBER, this thread is for postings by Frontline/Medical Treament or providers ONLY.
    IF you have a question about a post, PM the poster directly and they can quote you or not, as they see fit, in answering your question.

    If you qualify to post in this thread I ask that you start each post with your profession (example MD., Emt) or your choice.
    At the least, you can use the short sentence: MP.
     
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  9. PNW206 Mar 29, 2020

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    I’m a primary care physician in Washington. Have been assisting in the Covid Testing Centers this past month.
    Saw a 65 yo M yesterday. Hx of loss of appetite 4 days, no cough, no SOB. Afebrile, Tachy 112, O2 93%. Diaphoretic on exam, lung exam clear. I sent him to the ER and he had bilateral patchy infiltrates with RLL consolidations on his CXR.

    Non classic pneumonia signs seems to be consistent with the Covid picture being reported by colleagues in NY and New Orleans. We are hoping to get more imaging and STAT testing capability to expand role of our testing center.

    1DA5AEB8-7D73-477F-965A-4F703746F455.jpeg
     
  10. t_swiss_t Mar 29, 2020

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    MP.

    @M'Bob
    The sentiment is nice but misplaced. The need for an evidence base has never been more crucial and abandoning it in “war” is saying you should stick to your principles until you really have to use them. Methods can advance/adapt but the underlying principles of medical evidence are grounded in logic and statistics, which don’t change according to the situation.

    @Wetworks
    As it relates to this particular case, the evidence presented has been anecdotal, which is not appropriate to guide recommendations in this setting. Like with many early reports of association they can be proven helpful, insignificant, or harmful, and we don’t know which is the case in this instance. Please refer to the wealth of data on “medical reversal.” Are these patients more susceptible to viral infection and have higher mortality because they are older, more frequently hypertensive, diabetic, and/or have renal disease? We have as much and more evidence for that as we do about the RAAS connection. In this light, “passivity” is both ethically and professionally sound. And yes, it may turn out that there is a connection, but until at least more data is reported arguments for or against are unfounded.

    I am pointing this out not to convince you but to note that we are on a public forum frequented at by many people who are not medical professionals and advocacy without evidence is not responsible, even in light of ending with “please check with your doctor.”
     
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  11. M'Bob Mar 29, 2020

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    Orthopedic and sports physical therapist.

    A question: does evidenced-based medicine tell you how to choose between two patients that need a ventilator?
     
    Edited Mar 29, 2020
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  12. t_swiss_t Mar 29, 2020

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    MP.

    Yes, it can help (see below), but we were talking about evidence for/against using ACEIs, not resource allocation. For the former you only need evidence, for the latter you also need scarce resource allocation ethics.

    If you want to talk more about ventilator allocation using evidence, I’m also a medical ethicist whose research focuses on scarce resource allocation and am part of a national effort to create coherent guidance on allocation strategies that maximize population outcomes during ventilator scarcity. For now, until that guidance is formally adopted, I’d use this Pitt-specific document from the head of this effort, Doug White. (see here)

    Basically, they use a SOFA score to assess short term outcomes and co-morbid conditions as a surrogate of long term survival to maximize life-years saved among a population. There are a few recent NEJM Sounding Board articles on resource allocation you can read to get definitions and the basic outline, though the article by Emmanuel has some opinions that aren’t widely held. In addition to the principle-based guidance, one of the main operational points is to separate the allocation decision from the bedside physician by using objective measures like those they discuss in the Pitt guidance.

    Hope that helps.
     
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  13. sah Mar 29, 2020

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    Being at war has some think outside the box. Try and match 2 patients to share a vent. Or have support personal hand bag the one who does not get the machine.
    Option 3, is triage resources to where or who will likely benefit more.
     
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  14. t_swiss_t Mar 29, 2020

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    agreed, and we hope that these such efforts will mitigate the need for allocation.
     
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  15. BenBagbag Mar 29, 2020

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    Edited Mar 29, 2020
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  16. t_swiss_t Mar 29, 2020

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  17. MedicMike Mar 30, 2020

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    I’m am a Field Supervisor for an ambulance service right in the middle of it. We are transporting patients into the local hospitals that are housing most of the COVID 19 patients. Without saying the hospital I will say it’s next to the CDC. My service has transported well over a hundred confirmed cases thus far. Personally I have been directly involved with over a dozen. We are short on N95 mask, gowns, and bleach / sani-wipes. We were fogging the units following all confirmed transports but we can’t get the chemical anymore. Larger facilities are buying it up. Now we down to bleach wiping and or using a spray then wiping down surfaces. I’m a critical care paramedic so I get the vent patients also. Which actually isn’t as bad since it’s a closed circuit at that point. I wish all the healthcare works in here the best. I recently joined the group and so far it’s pretty educational.
     
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  18. BenBagbag Mar 30, 2020

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    @Jwit

    I just stumbled on numbers out of Eerie and it is around 400 now. How's it going up there by you?

    Best,
    Ben
     
  19. Wetworks Mar 30, 2020

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    RN, ED

    This was posted to my feed today. Interesting theory as to why pts who are seemingly on the rebound go south. It was posted as a thought experiment by a GI doc.

    [​IMG]

    Still doesn't explain (from what I understand), why we are seeing patients on ACEs go south while still on their medication though. Or am I missing something (little deep for my educational background)?
     
  20. sah Mar 30, 2020

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    Unfortunately, the first step in the above diagram is still just speculation. We do not have data, which would be age adjusted or matched on the ACE or ARB meds. Until we do, the mechanisms are explanations of something that might not be there. The other steps are worked out, but for years are the new explanations why sick people crash with the cytokine storm and DIC type of blood reactions. Hopefully, some statisticians are reviewing death charts for this detail. We have well over 35,000 now.
     
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