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Hypochondria as a legitimate hobby

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  • How are you feeling now, ophy? Did they ever confirm your test? It's been two weeks for us now and I am the only one leaving the house semi-regularly. Mr. Issie with no sports is a real sad sight to see and at this point, I think he'd offer just about anything to get a fix. I am not sleeping well and can barely focus on life, much less work. I'm gonna get back on melatonin tonight because I'm always emotionally and physically exhausted. I can't watch any more updates from the White House because my rage is out of control and on top of that, I got invited to a covid 19 for healthcare workers page with like a bajillion people just asking each other questions about how they're troubleshooting on the fly and what treatments seem to be most effective and what they're using in place of actual PPE and my brain just can't handle it. We're not even through March yet and if we're gonna use China as a predictor of how this is gonna shake out over here, we're looking at a 4 month period of social distancing and/or shelter in place situations. That's JULY.

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    • My lungs feel much better now that I've been using the albuterol. But I'm just so fucking tired, y'all. Even sitting up to watch a tv show wears me out. I think I'm more on the upswing than the downswing, though.

      no word on my test yet. they said five or six days and it's only been three.

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      • I'm glad you're feeling a bit better, but it's so fucking dumb that it takes almost a week to get your test results back. Even as a send out, that is ridiculous. One of the docs on the covid 19 page offered up this super helpful summary and I bolded the blood work that can basically confirm a positive test without actually using a test.

        Clinical course is predictable.
        2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

        Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

        Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours. (Issie: this is what freaks people out, we give cancer treatments with a high risk of cytokine storm and staff taking care of those patients have to go through special training to know what signs to watch out for in the early stages because it lands patients in ICU within minutes if not managed correctly)

        81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

        Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

        China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

        Diagnostic
        CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

        Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
        CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
        Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

        Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

        A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

        An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.


        Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

        Disposition
        I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

        We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

        Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

        Treatment
        Supportive

        worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

        Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

        We are also using Azithromycin, but are intermittently running out of IV.

        Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

        Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

        Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

        Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

        The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

        Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

        We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

        One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

        I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. (Issie: samesies except I change in my car and spray my shoes with Microban and leave them in the garage. We have a no exceptions "Don't touch Mom" rule until I get out of the shower. And I'm not even in the ER or ICU, my exposure risk is actually medium to low). My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."

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        • I didn't understand 90% of that but the 10% I did was TERRIFYING. Stay safe, Issie!

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          • I am glad you are on the upswing, O! And take care, Issie! And all of us, too.

            I am not sleeping well and can barely focus on life, much less work. I'm gonna get back on melatonin tonight because I'm always emotionally and physically exhausted
            So, I am not a health care worker, but this is me; my anxiety has just been super high. I called my doctor the other day about getting back on Zoloft for the anxiety and whether that would be appropriate and he was like "Oh yeah; you definitely should." Something about how my baseline is higher than normal and so I need to get myself to the same level of anxious as the rest of the world (which is high). So I am enduring the ramp-up of that, which is super fun.

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            • Issie, you mind if I send that post to my BFF? She’s a surgeon in NYC and she just got the email that she’s about to get drafted. Our friend group has been trying to stay light and send her memes and stuff, but shit’s about to get real for her. Last night I tried googling “copper face mask.”
              Last edited by LaaLaa; 03-27-2020, 10:33 AM.

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              • YES! Share, share, share. It's literally the BEST, most comprehensive breakdown of signs/symptoms, labs to watch, and specific dos/don'ts for treatment and management that I've seen anywhere. The doc that wrote it is from New Orleans so at this point, they have SEEN some shit. Best of luck to your friend! I don't know how much longer before Houston hospitals decide to mandate staff, but if PPE scarcity continues, it's just a matter of days before nurses and doctors start getting infected too and then we'll have a shortage of providers. Liz Specht (PhD who's the director of science and tech at a nutritional company) basically laid all of this out on Twitter using the numbers from Italy and China in early March and was dismissed by a lot of people because 'Murica.

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                • Thanks for all the heads up, guys. Hugs to you all.

                  I keep thinking about posts I want to make in this board to thoughtfully dissect the situation we're in, but frankly I feel so depressed I can barely think about more than a few hours ahead.
                  sigpic

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                  • My sister's department had someone test positive so she moved out of their house over the weekend into a single friend's apartment. Our county predicted our peak to hit at the end of next week (I think that's optimistic) so Mr. Issie and I are now in what do we do mode. I'm only in clinic twice a week and we don't do procedures so there's limited touching, but the risk will obvs go up as we move further into April. It would make the most sense for Mr. Issie and the boys to pack it up and go live at my sister's where they could have a cool my 2 dads situation for a month and then my sister could be with me where we could have a sad contest of seeing who gets sick first. Every choice feels shitty and like I'm a terrible mom either way. My sister's kids are all teenagers or older so they get it, but my dudes don't even understand why mom is too dirty to hug when she gets home and it sucks. On the plus side, work opened up our gym so we can shower and change there instead of in the parking garage, yay!

                    Also, I've been avoiding all press conferences from the White House, but I saw someone post Trump talking about how employees are stealing and misusing PPE so that gave me a rage ulcer. How you 'sposed to steal what you can't even find?

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                    • I don't know guys. I understand the shitty situation you're in but everyone here is saying that you shouldn't change your living conditions after you start the quarantine. As I understand it, it actually increases the possibility of everyone getting it, if you move in with someone else.
                      sigpic

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                      • Every choice feels shitty and like I'm a terrible mom either way.
                        Every choice IS shitty and you are doing the best that you can.

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                        • Thanks, v! And just so it's clear, my sister, her friend, and I all work at the same (massive, multi-building) place so we get to enjoy the same gross petri dish. They work together closely in the same department and I'm down the street. They're tightening up everything at work so that even the docs who don't have clinic are being ordered to work from home so it probs doesn't make a huge difference at this point if I just stay home. Mehhhhhh.

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                          • Issie, whatever decisions you make for your fam will be the right ones. Your kiddos will look back on this as a brief, weird time, and they’ll know about the sacrifices you made in order to keep them safe. Hotels from my work are offering deep discounts and free food to medical staff who have to separate themselves from their people and are just looking for a place to pass out in between saving the world.

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                            • I truly don't know how to process everything that's happening, and I'm downright terrified for you, Issie, and all my friends in healthcare settings. I don't really like other human beings *that* much and can't imagine sacrificing for them when they won't even fucking get off the beaches, so I'm left in awe of you folks who are driven by something better and more human than I could muster.

                              I'm so lucky that I can work from home, that if one of us lost our jobs we'd still be able to struggle along and probably not lose our house, that I can sit on the sidelines for now and just try to make tricky ethical calls about delivery vs. takeout vs. grocery shopping.

                              I'm terrified and filled with rage that this incompetent psycho asshole is the president.

                              I'm scared for my friends who are not feeling well, awaiting test results, struggling through with illnesses and compromised immunities at at time like this.

                              I'm pretty selfish and consumed with self-preservation on my best days, so it's not like this is bringing out the best in me on any level.

                              Mostly I just wish all the people who understand the stakes could quarantine away from the dipshits who don't? I don't know. I keep trying to suss out the best choices and I keep finding myself frozen in confusion, fear and just anxiety about how all this can shake out.

                              I love you all! Please stay safe and update us when you have more time/energy, o! <3

                              Itís just really honestly so tiring and emotionally draining to have to get upset over reality constantly.

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                              • I feel all of that, yes. Well stated.

                                <3 to all

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