swamp
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Post by swamp on Apr 23, 2020 13:46:13 GMT -5
I read something last night, NYT maybe? I'm reading too much to keep it all straight. Docs are seeing tiny clots in the lungs of people that died from COVID. I'll see if I can find the article. Edit: It was WaPo. I can't link it here because of the paywall, and I don't know my password. I read WaPo on my iPad. We see these with many infections that cause DIC. Whether these are different in this disease is unclear.This is the reason that anticoagulation was tried in the past, and some people are trying it now DIC?
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pulmonarymd
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Post by pulmonarymd on Apr 23, 2020 13:52:15 GMT -5
We see these with many infections that cause DIC. Whether these are different in this disease is unclear.This is the reason that anticoagulation was tried in the past, and some people are trying it now DIC? Sorry, forgot not everyone knows medical terminology. Disseminated intravascular coagulation. Condition caused by a number of acute illnesses, most commonly sepsis. It is a process where you get small clots in a number of organs, sort of like you are getting with COVID. We tried anticoagulants for this, and it did not work. Question is if the same process is going on with COVID, or is it a different process. If it is the same, then anticoagulants will likely be ineffective. One of many questions that need to be answered.
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Post by pulmonarymd on Apr 23, 2020 15:54:44 GMT -5
The other interesting neurologic process in these patients has been delirium. They have been requiring a higher than usual amount of sedation to be comfortable on the ventilator, and when we try to taper the sedation, they get quite agitated. Takes a while to resolve, and another reason they stay on the ventilator so long. Lots of unusual findings with this virus.
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Post by justme on Apr 23, 2020 16:21:30 GMT -5
I read something last night, NYT maybe? I'm reading too much to keep it all straight. Docs are seeing tiny clots in the lungs of people that died from COVID. I'll see if I can find the article. Edit: It was WaPo. I can't link it here because of the paywall, and I don't know my password. I read WaPo on my iPad. WaPo removed the paywall for anything Covid related so you should be able to post it.
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mmhmm
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Post by mmhmm on Apr 24, 2020 12:38:42 GMT -5
The other interesting neurologic process in these patients has been delirium. They have been requiring a higher than usual amount of sedation to be comfortable on the ventilator, and when we try to taper the sedation, they get quite agitated. Takes a while to resolve, and another reason they stay on the ventilator so long. Lots of unusual findings with this virus. Out of curiosity, what is being used for sedation? Is it propofol or dex, or are they trying benzos? Long term on propofol has always been problematic in my experience.
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swamp
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Post by swamp on Apr 24, 2020 12:56:21 GMT -5
The other interesting neurologic process in these patients has been delirium. They have been requiring a higher than usual amount of sedation to be comfortable on the ventilator, and when we try to taper the sedation, they get quite agitated. Takes a while to resolve, and another reason they stay on the ventilator so long. Lots of unusual findings with this virus. Out of curiosity, what is being used for sedation? Is it propofol or dex, or are they trying benzos? Long term on propofol has always been problematic in my experience. My DH says they are currently using propofol, at least where he is.
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Post by Miss Tequila on Apr 24, 2020 12:58:48 GMT -5
Out of curiosity, what is being used for sedation? Is it propofol or dex, or are they trying benzos? Long term on propofol has always been problematic in my experience. My DH says they are currently using propofol, at least where he is. How is he doing there?
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swamp
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Post by swamp on Apr 24, 2020 13:04:26 GMT -5
My DH says they are currently using propofol, at least where he is. How is he doing there? He really enjoys what he's doing, but the administration is a total shit show. He was worried when he went that he would be not up to snuff clinically. He is actually the most experienced one there, and has some background in implementing systems, policies, and procedures. They are transitioning from military to civilian oversight, but the DOH is the civilian oversight, and they aren't in the actual hospital running business. He's just keeping his head down and doing his job.
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laterbloomer
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Post by laterbloomer on Apr 24, 2020 13:40:39 GMT -5
This virus has become quite the boogie man. If you get it you can have strokes, have to get amputations, need a ventilator to breath, and there is no real treatment. But if none of that happens you might still have it but be asymptomatic. In that case you're just a modern day Typhoid Mary out there killing everyone's favourite Grandma. I'm not buying it all anymore. I don't know what's going on but everything we are being told doesn't make sense when you put it all together.
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pulmonarymd
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Post by pulmonarymd on Apr 24, 2020 14:48:20 GMT -5
The other interesting neurologic process in these patients has been delirium. They have been requiring a higher than usual amount of sedation to be comfortable on the ventilator, and when we try to taper the sedation, they get quite agitated. Takes a while to resolve, and another reason they stay on the ventilator so long. Lots of unusual findings with this virus. Out of curiosity, what is being used for sedation? Is it propofol or dex, or are they trying benzos? Long term on propofol has always been problematic in my experience. We have used a variety, some of it based on availability. We preferentially use propofol because people wake up faster. Used precedes in some of the delirious ones, to various effect,. Have added fentanyl to either one, and have used a versed infusion in one. Typically add Ativan at times. Have been turning patients prone, so they have frequently needed more sedation, so we have had to mix and match. Has been quite a challenge to sedate some of them
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pulmonarymd
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Post by pulmonarymd on Apr 24, 2020 14:56:05 GMT -5
This virus has become quite the boogie man. If you get it you can have strokes, have to get amputations, need a ventilator to breath, and there is no real treatment. But if none of that happens you might still have it but be asymptomatic. In that case you're just a modern day Typhoid Mary out there killing everyone's favourite Grandma. I'm not buying it all anymore. I don't know what's going on but everything we are being told doesn't make sense when you put it all together. This is not out of the ordinary. The crazy things we saw with HIV were far more unbelievable than what is going on here, and turned out to be true. Many of the things we have seen in really ill people, we see in this disease. We do not know if it is at a higher rate than in other diseases because it is so new. Each new disease has its own unique organ involvement. Not all of the findings turn out to be true. Part of the problem is that things that were usually reported in medical journals are now in the news/internet and are more widely reported before we have confirmation. That is why physicians need to have a high degree of skepticism, and why we don’t jump on things like the public thinks we should. We always have to search through all kinds of information until we settle on the truth
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Miss Tequila
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Post by Miss Tequila on Apr 24, 2020 14:56:10 GMT -5
He really enjoys what he's doing, but the administration is a total shit show. He was worried when he went that he would be not up to snuff clinically. He is actually the most experienced one there, and has some background in implementing systems, policies, and procedures. They are transitioning from military to civilian oversight, but the DOH is the civilian oversight, and they aren't in the actual hospital running business. He's just keeping his head down and doing his job. I'm glad he likes what he is doing but how frustrating that it is a shit show.
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pulmonarymd
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Post by pulmonarymd on Apr 24, 2020 15:02:38 GMT -5
He really enjoys what he's doing, but the administration is a total shit show. He was worried when he went that he would be not up to snuff clinically. He is actually the most experienced one there, and has some background in implementing systems, policies, and procedures. They are transitioning from military to civilian oversight, but the DOH is the civilian oversight, and they aren't in the actual hospital running business. He's just keeping his head down and doing his job. I'm glad he likes what he is doing but how frustrating that it is a shit show. To be honest, any place where it is prevalent is not pleasant. Work flows have been disrupted, and we have to come up with workarounds on the fly. Have to deal with unexpected issues. It has been an uncomfortable experience, one I never want to live through myself, and we are not in nyc. Given the scope of what is happening there, I am glad I am here
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Post by thyme4change on Apr 24, 2020 15:39:14 GMT -5
Out of curiosity, what is being used for sedation? Is it propofol or dex, or are they trying benzos? Long term on propofol has always been problematic in my experience. My DH says they are currently using propofol, at least where he is. Is that the same stuff that killed Michael Jackson?
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swamp
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Post by swamp on Apr 24, 2020 17:11:52 GMT -5
My DH says they are currently using propofol, at least where he is. Is that the same stuff that killed Michael Jackson? Yes
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laterbloomer
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Post by laterbloomer on Apr 25, 2020 15:46:35 GMT -5
This virus has become quite the boogie man. If you get it you can have strokes, have to get amputations, need a ventilator to breath, and there is no real treatment. But if none of that happens you might still have it but be asymptomatic. In that case you're just a modern day Typhoid Mary out there killing everyone's favourite Grandma. I'm not buying it all anymore. I don't know what's going on but everything we are being told doesn't make sense when you put it all together. This is not out of the ordinary. The crazy things we saw with HIV were far more unbelievable than what is going on here, and turned out to be true. Many of the things we have seen in really ill people, we see in this disease. We do not know if it is at a higher rate than in other diseases because it is so new. Each new disease has its own unique organ involvement. Not all of the findings turn out to be true. Part of the problem is that things that were usually reported in medical journals are now in the news/internet and are more widely reported before we have confirmation. That is why physicians need to have a high degree of skepticism, and why we don’t jump on things like the public thinks we should. We always have to search through all kinds of information until we settle on the truth Add me to the group that is skeptical.
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Post by Miss Tequila on Apr 26, 2020 8:36:42 GMT -5
This is not out of the ordinary. The crazy things we saw with HIV were far more unbelievable than what is going on here, and turned out to be true. Many of the things we have seen in really ill people, we see in this disease. We do not know if it is at a higher rate than in other diseases because it is so new. Each new disease has its own unique organ involvement. Not all of the findings turn out to be true. Part of the problem is that things that were usually reported in medical journals are now in the news/internet and are more widely reported before we have confirmation. That is why physicians need to have a high degree of skepticism, and why we don’t jump on things like the public thinks we should. We always have to search through all kinds of information until we settle on the truth Add me to the group that is skeptical. What are your thoughts as to what is going on?
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Post by billisonboard on Apr 26, 2020 8:58:23 GMT -5
I am reminded of the blind men and the elephant parable In some versions, they come to suspect that the other person is dishonest and they come to blows. link
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Post by pulmonarymd on Apr 26, 2020 9:22:26 GMT -5
Add me to the group that is skeptical. What are your thoughts as to what is going on? Still a work in progress. This disease has been unique in some ways, both in the time course and recovery. It clearly results in pneumonia. We are seeing more kidney failure than with other viral illnesses, whether that is due to viral infection of the kidneys, or the kidney failure is a result of the severity of illness is unclear. We have had delirium in a number of patients, and there sedation requires are higher than usual, so it seems to have neurological involvement. It causes a hepatitis, although not sure how consequential it is. Those are fairly certain. There is concern about clotting, leading to strokes and clots in the lung. Jury is still out on how sign that is, and whether patients need to be placed on anticoagulants. This uncertainty is normal with any new disease process. No patient experiences every possible symptom, and if it is an low incidence symptom, you need to see enough cases to know it is not random. We are still figuring this out, but when you are overwhelmed, it is hard to do the necessary studies to understand this. With time, we will understand it. Only question is how long it takes. But, having lived through the beginning of the HIV epidemic, I am confident in our ability, in the immortal words of Matt Damon in The Martian to “science the shit out of it.”
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Post by pulmonarymd on Apr 26, 2020 9:25:02 GMT -5
I am reminded of the blind men and the elephant parable In some versions, they come to suspect that the other person is dishonest and they come to blows. link Things are chaotic in the early phases of all new diseases. You try to make sense of it and treat it at the same time. It is messy, but as time goes on, things come into better focus. We understand the process, but with all the information that is out there now, it can seem we do not have a clue.
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oped
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Post by oped on Apr 26, 2020 9:27:01 GMT -5
I’ve watched the Martian several times during this. I find it soothing. Recognize an amazingly huge and unfair problem... mourn it, rage at it... and then get down to fucking business.
And Sully... Tom Hanks being amazingly, calmly efficient ... and both have all of humanity coming together to help.
It’s my denial/refuge space as to our actual current state...
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Post by laterbloomer on Apr 26, 2020 10:20:57 GMT -5
Add me to the group that is skeptical. What are your thoughts as to what is going on? I don't know really. I think the virus is real but the information doesn't make a lot of sense and trying to keep us all from even leaving our homes is crazy. On the other hand none of the conspiracy theories I've heard make any sense to me.
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Post by dezii on Apr 26, 2020 12:40:08 GMT -5
Personally, since I had a stroke four or so years ago...know could be susceptible to another and have seen the results of those incapacitated in rehab...wheelchair living...don't want that have signed a non resuscitation form..posted around the house just in case..Am a senior in low 80's, talked it over with kids...they understand and concur just in case...
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dezii
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Post by dezii on Apr 26, 2020 12:48:52 GMT -5
What we are going through world wide...not just our country...a sci fi movie type thing...All are saying could be 18 months or more if anytime for a vaccine...and then to distribute...just in our country, over 300 million...world wide , billions of dosage...Definitely feel a depression awaits us...kind of reminds me of the happening that destroyed the dinosaurs... This is possible similar what world will face when the results of global warming, world wide pollution hits the point of no recovery anymore...and there are leaders such as our Donald , the Mitch McConnel types, are in power and supposedly in charge...
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Post by billisonboard on Apr 26, 2020 12:52:34 GMT -5
I’ve watched the Martian several times during this. I find it soothing. Recognize an amazingly huge and unfair problem... mourn it, rage at it... and then get down to fucking business. And Sully... Tom Hanks being amazingly, calmly efficient ... and both have all of humanity coming together to help. It’s my denial/refuge space as to our actual current state... Just watched The Martin. I have had too many hours with little to do and the movie today did help. Thank you oped.
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mmhmm
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Post by mmhmm on Apr 26, 2020 21:18:38 GMT -5
Out of curiosity, what is being used for sedation? Is it propofol or dex, or are they trying benzos? Long term on propofol has always been problematic in my experience. We have used a variety, some of it based on availability. We preferentially use propofol because people wake up faster. Used precedes in some of the delirious ones, to various effect,. Have added fentanyl to either one, and have used a versed infusion in one. Typically add Ativan at times. Have been turning patients prone, so they have frequently needed more sedation, so we have had to mix and match. Has been quite a challenge to sedate some of them Ventilated patients and sedation has always been difficult - more for some patients than others. From what I've been able to learn about this virus I can only imagine the difficulties encountered. Even once the patient has been extubated and is recovering, the lasting effects of long-term intubation with sedation offers its own challenge. I definitely don't envy those of you who are confronted with this. Thanks to you and all your colleagues for all you do.
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pulmonarymd
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Post by pulmonarymd on Apr 26, 2020 21:45:35 GMT -5
We have used a variety, some of it based on availability. We preferentially use propofol because people wake up faster. Used precedes in some of the delirious ones, to various effect,. Have added fentanyl to either one, and have used a versed infusion in one. Typically add Ativan at times. Have been turning patients prone, so they have frequently needed more sedation, so we have had to mix and match. Has been quite a challenge to sedate some of them Ventilated patients and sedation has always been difficult - more for some patients than others. From what I've been able to learn about this virus I can only imagine the difficulties encountered. Even once the patient has been extubated and is recovering, the lasting effects of long-term intubation with sedation offers its own challenge. I definitely don't envy those of you who are confronted with this. Thanks to you and all your colleagues for all you do. The long term neurological outcome is most important from my point of view. Studies need to be done so we can know how to minimize them. You should check out some videos by Wes Ely’s group at Vanderbilt about delirium in the icu. One was of a women who worked in the accounting department. She had been part of a study and had an IQ test. She scored a 115. She then had sepsis with multi-organ failure. She recovered and had trouble doing certain calculations. Makes you reassess what we do. Better ways of doing this are needed. We need better sedation, but we need to learn how to manage it better. Long term studies of survivors is also interesting. Thanks for your kind words. Difficult time for all of us. Feels like all covid all the time. Even when I am in my office it overshadows everything. I have had more enjoyment from doing this in the past than I do now. Hopefully, we get through this without it being so bad. But I worry about the younger doctors seeing this disaster. They haven’t had the ability to develop the coping strategies that is older ones have learned. This will probably affect them for a long time
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Post by justme on Apr 26, 2020 23:25:46 GMT -5
I've been thinking and I think that a lot of those that view the virus and information in...disbelief either don't have medical training or have only had relatively routine or straight forward dealings with medical issues. Having had many not normal diagnoses and on top of that coming from a family known for having against what you though tests/symptoms (to the point where I got a normal breathing test even though I couldn't breathe and was coughing up a lung my asthma doctor's office and the doctor walked into my room saying I'm not sure why your here until he heard me and then loaded me up on drugs) it just doesn't seem that crazy to me.
What is crazy is that we're in a time in the world that a vaccine less than two years after finding a virus is even possible. That's insane. (And I'm so with the post of a scientist working on it in Spain saying you pay football players 1M€ a month and scientists 1800€ a month maybe that's why.) Not that long ago people would just die for years. Hell I have a disease that for decades after it was discovered the best treatments tried not to kill you faster (seriously, think how bone marrow transplants were in the 40s - that's what they would try with this and you still died is the transplant didn't kill you).
This virus is at best 6 months old. That's nothing. Like damn can we give the medical community time to catch a breath from triage to then try and figure this out? Fucking balls.
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Post by thyme4change on Apr 27, 2020 10:49:08 GMT -5
I've been thinking and I think that a lot of those that view the virus and information in...disbelief either don't have medical training or have only had relatively routine or straight forward dealings with medical issues. Having had many not normal diagnoses and on top of that coming from a family known for having against what you though tests/symptoms (to the point where I got a normal breathing test even though I couldn't breathe and was coughing up a lung my asthma doctor's office and the doctor walked into my room saying I'm not sure why your here until he heard me and then loaded me up on drugs) it just doesn't seem that crazy to me. What is crazy is that we're in a time in the world that a vaccine less than two years after finding a virus is even possible. That's insane. (And I'm so with the post of a scientist working on it in Spain saying you pay football players 1M€ a month and scientists 1800€ a month maybe that's why.) Not that long ago people would just die for years. Hell I have a disease that for decades after it was discovered the best treatments tried not to kill you faster (seriously, think how bone marrow transplants were in the 40s - that's what they would try with this and you still died is the transplant didn't kill you). This virus is at best 6 months old. That's nothing. Like damn can we give the medical community time to catch a breath from triage to then try and figure this out? Fucking balls. Let's not give credit for vaccine that isn't out yet. Just because they say two years doesn't mean they will succeed.
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pulmonarymd
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Post by pulmonarymd on Apr 27, 2020 10:54:34 GMT -5
I've been thinking and I think that a lot of those that view the virus and information in...disbelief either don't have medical training or have only had relatively routine or straight forward dealings with medical issues. Having had many not normal diagnoses and on top of that coming from a family known for having against what you though tests/symptoms (to the point where I got a normal breathing test even though I couldn't breathe and was coughing up a lung my asthma doctor's office and the doctor walked into my room saying I'm not sure why your here until he heard me and then loaded me up on drugs) it just doesn't seem that crazy to me. What is crazy is that we're in a time in the world that a vaccine less than two years after finding a virus is even possible. That's insane. (And I'm so with the post of a scientist working on it in Spain saying you pay football players 1M€ a month and scientists 1800€ a month maybe that's why.) Not that long ago people would just die for years. Hell I have a disease that for decades after it was discovered the best treatments tried not to kill you faster (seriously, think how bone marrow transplants were in the 40s - that's what they would try with this and you still died is the transplant didn't kill you). This virus is at best 6 months old. That's nothing. Like damn can we give the medical community time to catch a breath from triage to then try and figure this out? Fucking balls. Let's not give credit for vaccine that isn't out yet. Just because they say two years doesn't mean they will succeed. Wemay also find some sort of effective treatment in that time. Not a perfect solution, but will also tend to improve the situation. Imagine if we had kept funding research at the prior levels. More people available to work on this.
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