Thank you. Your efforts to keep us updated and apprised of the situation is really appreciated, especially when this is how you're spending your downtime, not to mention what you're all going through (and risking) for the sake of the rest of us.
Four questions for whenever you have the time to answer:
1. What happens right now to someone who trips on a curb or on a step, breaks an ankle or an arm, and shows up to the NY Presbyterian ER? Same question re. patients presenting with excruciating pain for a condition like a badly-herniated disc that would normally constitute an urgent elective discectomy or treatment for a kidney stone, or something similar?
With the USN Comfort coming to NYC, hopefully much of that will be re-routed there. Amazingly, people have suddenly begun to re-assess just what constitutes a pain score of "10/10" and are coming to the ER less frequently. Equally amazingly, the drive for self-preservation has also led to LTCFs and nursing homes to send patients to the ER for routine staple removal(!) and "fevers" of 99.1F. These facility heads have by now hopefully been notified they have unnecessarily created new disease vectors in their facilities. Maybe they will get the message now.
Otherwise, it comes down to the patient and the provider. If the provider thinks it's serious enough, and the patient agrees, you will be treated and released/admitted.
2. When you're put on a ventilator, are you always heavily sedated or put to sleep to keep you still and spared the discomfort involved, or do people who have no choice but to be ventilated sometimes have to just lie there immobilized and in that kind of discomfort -- albeit less discomfort than suffocating slowly -- for days, until the ventilator is no longer needed?
Sedation is preferred, always. Unfortunately, many sedatives depress not only the respiratory drive (not a huge concern on a vent, but needs to be considered for purposes of possible extubation), but also blood pressure. As such, it can be a bit of a balancing act, complicated further buy tolerance levels (drug use/abuse, alcohol consumption), as well as each individual's 'preference' (what seemingly works better for some doesn't for others, all things being equal), and likely fluid restrictions for purposes of BP resuscitation due to the fluid overload in the lungs.
On the floors outside of an ER/ICU setting, many of the RNs aren't trained for handling sedation (or vents) and it gets complicated. I've heard of multiple patients extubating themselves due to lack of sedation. I've had some patients (rare) comfortable and happy to be awake, but most aren't. The former are usually on "sedation vacations", but I still will often restrain their upper extremities. I'm also lately, where possible, advocating for the use of larger ET tubes (less resistance in the circuit, slightly better perceived breathing for patients who wake up).
3. When patients are ventilated for days, how is waste elimination handled? Do they catheterize everybody on a ventilator, or what?
Any ICU patient gets a Foley, yes. It's important for measuring output (good indicator of organ perfusion in cases of ARDS/sepsis), and they can also monitor temperature in real time. The back end is handled by us, but you can use rectal tubes if the patient is experiencing frank diarrhea secondary to an infection like c.difficile.
4. Should someone who begins to experience dyspnea use an albuterol inhaler to try to resolve it at home first, or not, because of the possible detrimental effect of corticosteroids on the immune system? I was thinking that if I were in that situation, I might use the inhaler in conjunction with the disposable O2 cans that you see on NHL benches (because I happen to have a case of them for hockey).
Thanks again, in advance.
We are using MDI pumps instead of nebulizers for obvious reasons, and I have read conflicting recommendations about steroids. Some say no, while others say yes in cases of elevated interleukin-6.
This caught my attention:
"Coinfection was very common with other respiratory bacteria and common cold viruses, and >50% patients were positive for a co-infection with a respiratory organism."
When discussions around those in high risk categories has happened, it's usually talking about people with chronic illness. But is this now a possible indicator that if you are an otherwise healthy person (no chronic illness) that simply having a cold, or worse seasonal flu, can put you into a high risk category?
Thanks, Al
I mentioned this in previous posts, here and/or elsewhere. Before the wave really hit, people could have been experiencing seasonal allergies, or maybe had some mild congestion, a sore throat, or even an ear ache, and that could possibly be enough of a heightened immune response for some people where the addition of C19 turns into an overwhelming illness. Same holds true for the flu shot which was continuing to be recommended early on in this.
An old doctor axiom is 'when you hear hoofbeats think horses, not zebras.' So, what to do here? I think a bit of both, but I would get the cowboys ready.
Right now, one of the hoofbeats we are hearing is the seemingly common and often well-controlled condition of hypertension being in the top 2(?) of comorbidities. Since the virus inserts itself on the same protein associated with the primary mechanism of two of the most widely prescribed medications to control hypertension, that's reason to believe you've heard another hoofbeat. Add in a third one with the mechanism for the cytokine storm seen with ARDS responses being associated with that same protein, and I am going to go ahead and say it's a horse. But right now, people with more letters at the ends of their names than me are controlling the narrative and saying "we need more data, keep taking your medications as prescribed by your doctor." In other words, they still think there's a good chance that what they are hearing is a zebra. Ironic, and tragic.
