I was just curious, as I mentioned in the directionless thread the State is not allowing transport unless the originating cannot provide care, but most of the outlying facilities cannot do ECMO or dialysis. We only have 2 perfusionists at the level 2 were based at, I assume the other local system is about the same.
Coronavirus Discussion Thread
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VFlutter
Flight Nurse
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Yes
I've see far worse vent settings than that.
Any word on how they are actually coming out. We haven't taken ECMO off the table completely but we are concerned that if patients are that sick that they will never come off.
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And even if it isn't, does that matter? Does that somehow abdicate us from taking public health steps?
E tank
Caution: Paralyzing Agent
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No one is suggesting that, but to suggest that regional differences exist is only being honest. Afton, Wyoming isn't NYC, NY, isn't San Francisco, isn't Seattle....folks were pretty confident that Seattle was supposed to be brought to it's knees by now and we're still waiting. Same goes for the Bay Area.
Making these observations in a non-anonymous forum will get you in trouble, to be sure because of the urgency of the situation but also because there is a lot of irrational fear and decision making based on speculation and best guesses.
There will be a lot to learn when this is all over. It's worth at least to be able to talk about it now.
Summit
Critical Crazy
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yes
Summit
Critical Crazy
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1. A coordinated national public health approach should be taken on the mitigation front for all regions and
2. the purchased time must be used to
a. stand up laboratory capacity,
b. expand public health tracing to isolate and stomp out clusters, and
c. institute absolute control over national borders to control for external reintroduction until a vaccine is deployed
Otherwise, discombobulated regional public health efforts are just be a short stay of execution as hot spots flare up again and the infection ping pongs from region to region requiring more mitigation than would otherwise be necessary and the concomitant economic impact.
2. the purchased time must be used to
a. stand up laboratory capacity,
b. expand public health tracing to isolate and stomp out clusters, and
c. institute absolute control over national borders to control for external reintroduction until a vaccine is deployed
Otherwise, discombobulated regional public health efforts are just be a short stay of execution as hot spots flare up again and the infection ping pongs from region to region requiring more mitigation than would otherwise be necessary and the concomitant economic impact.
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How are their outcomes looking?
Summit
Critical Crazy
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we are tubing early often skipping nippv
i've seen tubed people get off the vent and go home
i haven't seen anyone get off ecmo yet but the n is small
I'm mostly curious to see how the ECMO turns out. We are very hesitant to cannulate a COVID patient and fortunetly haven't been put in the position to do it yet. I am concerned that the damage that is happening to the sickest patient's lungs isn't going to be reversible.
Summit
Critical Crazy
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I've been arguing very hard to hire Paramedics to help run vents in a disaster level surge scenario
the data aren't clear even internationally... but it wouldn't be the first time a non-salvageable lung ended up on ECMO
In this age of Evidence Based Medicine, it seems odd to me that you blame the news media for the consequences of a pandemic. Seems like you are saying that that you are not sick until you know it and that so long as you do not know about a problem, risk or threat it does not exist in your world. I believe that is a corollary of denial.
Assuming that people turn to the news media to learn the facts of the world around them, competition would serve to foster and improve accurate reporting. Accurate reporting would be desired by those readers seeking factual information. Readers looking for comfort (regardless of accuracy) would be likely to be unhappy with factually accurate media. Does that sound like anyone you know?
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The rural hospitals I work in and the larger health system that we are part of has been minimally affected thus far. We are in a (relatively) sparsely populated region so we don't expect to be as overwhelmed as many areas, even though we have fewer resources (beds, ventilators) and sicker patient (on average) per capita. That said, we obviously don't know what is going to happen. We know there will be challenges and our doing our best to become as prepared as possible.
We are in a dire situation where a bunch of people are going to die no matter what we do. I would never make that statement flippantly or "shrug" when I do. However, it is what it is. We can't stop it. Of course we hope to minimize mortality and suffering, but, in large part because of our utter lack of preparation for what was an entirely predictable event, we are very limited in our capacity to do so.
Just like many thousands of other healthcare providers, I am planning on at some point being in a position where I will willingly risk not only my own health, but that of my family in order to provide care to sick patients. Also, I have family members whose health status puts them squarely in the highest risk category and who are likely to require healthcare services at some point while the system is overwhelmed. So please don't act as though I don't take this seriously just because I think hysteria and economic suicide are the wrong approach.
If we had a healthy financial system, we could probably shut down the entire economy and make everyone stay home and send every American a paycheck for months and stimulate all the important industries and deal with the economic ramifications of this thing easily. However, not only would many people still contract COVID-19 and die if we did that, but we don't have a healthy financial system at all. Our nation is well over $20TRILLION in debt in addition to many TRILLIONS more in unfunded liabilities and projections to add at least another $1T per year for at least the next decade. Some of our largest states, adjusted for scale, are even worse off. Our domestic economy is also debt-based with multiple bubbles growing at once (mortgages, student loans, credit cards), and the value of our money is based on nothing more than the willingness of foreign corporations to keep loaning us more. It's like a family with a house and cars they can't afford and massive consumer debt and no savings trying to deal with a huge unexpected expense. That type of thing makes families go bankrupt. Only the US can't go bankrupt, we can only default on our debts which means no one else will loan us money, which means that we'll have no way to pay for all of our massive programs. Or, we can print an unlimited amount of money and use that to pay our debts, but then the money becomes worthless. We've been warned for years that we were approaching a point where any number of unplanned for global events could bring the whole thing crashing down. I don't know for sure that this is it, but we should not be confident that it isn't.
The dollar value of a life is not limitless, especially a life that is nearing its end anyway. That sounds really harsh but it's a reality that we all implicitly accept, even if we never think about it, and even if we refuse to acknowledge the fact that healthcare, like every other scarce thing, will always need to be rationed one way or another. What follows is a very legitimate question: is it worth sacrificing millions of jobs and tens of thousands of businesses and resulting years (potentially decades, if this causes a real collapse) of economic suffering and all the health effects that come along with that, in order to hopefully save probably fewer lives that we lose to the flu in a normal year? I don't necessarily have the correct answer to that, but I suspect that when this is over, many more people will be asking that question than are asking it now.
What we should have done over the past decades was prepare our healthcare system for this. We knew this was coming. There are government agencies and offices in cities and healthcare systems and universities whose sole job is to anticipate and prepare for these types of eventualities. More than a decade since the H1N1 pandemic and only a few years since Influenza A killed 60,000 Americans and hospitals are STILL only keeping enough N95's on hand for the anticipated number of TB patients and we STILL have no strategic stockpile of PPE and vents, and they're telling us to wrap bandanas around our faces when we run out of N95's!?!? Great job, feds and planners and healthcare executives!
Another thing we should have done was not allow our federal government to put our financial system in such a precarious and helpless position so that something like this potentially throws us into a deep and prolonged recession.
I can do one more: giving the CDC and FDA so much power that they had the ability to **** up the early development and deployment of testing kits was just brilliant. Great job again, feds! We should totally keep trusting what you say!
So, all that said….now that the feds and the healthcare industry that they closely oversee have ****ed this up every way possible, what should we do? I think the best way to balance limiting the spread with keeping our economy going is to stress the importance of those in high risk groups self-quarantining, and encouraging social distancing such as people working and schooling from home as much as possible. If certain densely populated locales (NYC) think it's worth the cost of shutting everything down because of their increased risk, then fine. But that should be the exception rather than the norm, IMO.
Actually Fireman, I did NOT say I would call of sick. I said I would NOT compromise other patients and my loved ones by breaking the 'we do not enter unsafe scenes' rule. That means I would turn down calls that cannot be handled because of a lack of reasonably adequate safety supplies or substitutes. "Above all else, do no harm."
I would compassionately suggest that you consider the risk-benefit balance of you going into unsafe scenes abut increasing the spread of this disease in the process. You CAN think outside the box to find reasonably safe solutions without disregarding the fundamental 'never enter an unsafe scene' precept. It may cost your employer a few dollars more, but then your employer made the decision long ago to save then-current dollars by not stocking and maintaining an adequate stockpile of mission critical safety supplies. So it is understandable that the added financial cost of the late acquisition of those self-same mission critical supplies fail on those who saved those dollars in the past.
And, do not tell me there are none available. There are many items out there. They will cost more and you may have to de-con and re-use, assemble, retrofit, or accept additional inconvenience or expense but your employer can fulfill its mission. You and your employer just need to put on you big-boy pants and bite the bullet and do it. It wasn't pretty, by my agency finally saw the light and our EMTs, our patients, and the loved one of all of them re better off. It's worth the effort. You and I have dual roles. We are not only employees, we are professionals and that imposes upon us the duty and privilege of being advocates for our patients, current and future.
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If you don't think that news media intentionally sensationalizes and exploits situations like this for the purposes of their own importance and profit rather than for informing the public and that doing so causes unnecessary panic and real harm, than one of us is not only in denial but also ignorant of history, and it ain't me.
Residents of an island town where I own property are arguing that not only should it be illegal for non-residents to enter the town, but that anyone walking on the beach should be charged with attempted manslaughter, and some have suggested that doing so may even justify shooting those people in self defense.
Why do they think that? Because news sources have suggested repeatedly that coronavirus carries up to a 10% mortality rate AND have hosted quacks that imply the virus is not unlikely to be passed between people on a public beach many feet away from each other.
So what was that about evidence based medicine and denial?
If you think CNN and Fox News and countless columnists and bloggers have your welfare in mind, then I can't help you.
We will have to disagree on that one.
I share and support your willingness to risk your life. I am equally bothered by your (apparently unilateral) decision to risk your family, especially if your family include minor children. That can of course be a cultural and/or religious matter I suppose but please at least reflect on whether you truly mean what you say.
Medical professionals are being pressed to disregard the long-held fundamental rule of provider safety first (and assuring safe scene) by being asked to re-use single-use supplies and accept low-level protection devices. These "think outside the box" talking points cover up the fact (intentionally or otherwise) that they confuse the "safety" box with the "availability" box. It is never appropriate to think outside the safety box BUT searching for alternatives and creatively using alternate devices and procedures IS appropriate but does come with a financial cost. We should not put that added financial cost above our personal safety and the health of our loved ones. Buy and de-con re-usable, use available alternative masks or effective masking devices, use SCBA rather than N95, yell at, report, and shame government officials that are hoarding existing supplies, make the news media your friend for a change, do not be afraid to say "no, not until," explain that being told "no" is not acceptable, etc.
Remember your role as advocate. That is an import role for a professional. Attempting to be a hero at the cost of your family's safety is not appropriate in my opinion.
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FiremanMike
Just a dude
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I get hit with this about once per day at work, despite the fact that we actually have a pretty decent supply..
"Well I found respiratory filters right away on the internet"
"Well I found N95 masks on the internet just last night"
"Well I found.."
To which I say "folks, I'm open, I've been looking, and I can't find any. PLEASE send me the thinks so we can purchase these things ASAP"
Number of links I've received = 0
If you have links to supplies, send them to me.
Gurby
Forum Asst. Chief
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Thanks for writing this all out, this side of the argument feels a lot more reasonable to me now. My hospital is getting hit pretty hard, and the panic in the press makes it easy to forget that the sky is not falling everywhere.
Sled Driver
In a Wuhan Wet Market
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The NYC Morgue is near capacity, per Weather.com