Are you hunkering down?

[westward]

Here’s my perspective as a moderate to conservative individual who owns and operates 2 small businesses and also works in acute/ICU patient care at UWMC in Seattle:

This too will pass. But... it’s much more stealth and contagious than the common flu, and no vaccines currently exist. Critical care most often requires ventilators, and isolation requires negative pressure HVAC and tons of protective gear. In other words a very high burden of care. We are indeed critically low on our PPE and gel, and are deferring ALL non-essential surgery and general hospital admission. (The nurses in particular are heroic and deserve everyone’s gratitude)

We need to slow down the infection rate enough to stay under ~ 95% hospital capacity or the system will become overwhelmed, and Italy-style chaos will occur. This is why “ the government “ is directing most to stay home. Not necessarily for oneself, but rather for the communal good. As someone mentioned earlier, this could impact everyone’s access to critical care, including surgeries, trauma, and acute level interventions.

I love my freedom and generally chafe at being controlled by the government. In This situation however it’s an easy decision to do as directed in good faith. I optimistically believe we’re going to have a quick economic rebound once we get over the infection rate hump, since the biggest enemy at this point is fear and uncertainty.

Where this virus originated, why we weren’t more prepared, and the noisy political background really don’t matter; we are where we are. We need to pull together as Americans and do what Americans do best, which is to rise above the problem, and focus on the solution.

 

[tsturm]

Are you seriously suggesting that doctors are politically motivated?

Oh Heavens no every one on the interweb knows All MD's are God like.
:lol:

 

[rogerbum]

Now when it comes to infectious disease and controlling it's spread to reduce deaths - who do I pay attention to? I pay attention to the experts in public health - virologists like Dr. Fauci, epidemiologists at the CDC and those advising local government. As my "day job" is faculty member in one of the best microbiology departments in the world, I'm able to accurately determine who are the experts and I'm able to understand the relevant data. I do microbiology research and teach it on a regular basis. Hundreds of current and future nurses have learned their microbiology from me. I really don't give a crap about random links to stuff on the net unless it's from the World Health Organization, the CDC or some other recognized expert source of health information. This is no different than how I deal with my boat, I listen to the actual, expert advice.

How many MD's are there today that are not politically biased? :wink:

I'm guessing about the same proportion as there is bias in people who need to drill holes in their boats. In either case, I'm still listening to an actual expert.

 

[tsturm]

I wonder why we/they stopped the Political Bullshit Fights on this
site 10 or 15 years ago?? :beer

Seriously, I hope everyone & all their Family are well in this time of Clusterf--K

:beer

 

[smckean (Tosca)]

This is just silly. The very concept of political requires that one make choices about what "side" you are on. Would it be possible to say that one can vote and stay politically neutral? No, it does not make sense.

I see this all the time (and find it rather sad). Folks use the word "political" toward others as if it were a negative condemnation. No one is failing in any way by acting politically. Indeed, being political is a requirement to have a functioning society. Now, what does often happen is that some denigrate others by calling them political because they strongly disagree with the other's choices. I'm on one side of an issue, and you're on the other side. Nothing wrong with that. That's politics as it should be, and as it must be. But to consider the other as bad, wrong, a conspirator, unpatriotic, as having evil motives, and on and on simply because you don't agree with them is silly.

P.S. I've always loved the theater of the absurd (Samuel Beckett is my favorite author.....think "Waiting for Godot"). One element of such existentialist thinking is to observe how strange it is (well, in the world of the absurd, it isn't strange, it is normal) that each of us thinks it's just chance, or perhaps that we are just smarter than the others, or that some holy book says so, but that somehow, and in some way, I am the one who always seems to be right, and you are the one is wrong and just doesn't get it.

 

[tsturm]

This is just silly. The very concept of political requires that one make choices about what "side" you are on. Would it be possible to say that one can vote and stay politically neutral? No, it does not make sense.

I see this all the time (and find it rather sad). Folks use the word "political" toward others as if it were a negative condemnation. No one is failing in any way by acting politically. Indeed, being political is a requirement to have a functioning society. Now, what does often happen is that some denigrate others by calling them political because they strongly disagree with the other's choices. I'm on one side of an issue, and you're on the other side. Nothing wrong with that. That's politics as it should be, and as it must be. But to consider the other as bad, wrong, a conspirator, unpatriotic, and on and on simply because you don't agree with them is silly.

P.S. I've always loved the theater of the absurd (Samuel Beckett is my favorite author.....think "Waiting for Godot"). One element of such existentialist thinking is to observe how strange it is (well, in the world of the absurd, it isn't strange, it is normal) that each of us thinks it's just chance, or perhaps that we are just smarter than the others, or that some holy book says so, but that somehow, and in some way, I am the one who always seems to be right, and you are the one is wrong and just doesn't get it.

:thup :thup :thup

 

[westward]

Tosca: as Long as you’re practicing strict infection control, you can practice any kind of politics you desire!

 

[hardee]

OK, so I'm not so into the politics but if you really need something to scare you into doing everything possible to NOT get the virus, think about this.

IF you do get Covid19 Corona virus, you may wind up on a ventilator

AND . . . you may not be the only person on THAT VENTILATOR :shock: :shock: :amgry :disgust

So, many (not that many) years ago I worked in a very busy ICU with a very busy pulmonology practice. There were times that we ran TWO ventilators on ONE patient, treating each lung differently due to individual lung trauma, surgery or disease processes. Both of those lungs were on the same patient.

I know it is possible to filter and separate the vent circuits, BUT, the volumes, and pressures for both circuits will have to be the same . . . on two separate individuals. :shock: :disgust

WHO WOULD YOU LIKE TO SHARE YOUR VENTILATOR WITH :?:

Harvey
SleepyC :moon

 

[smckean (Tosca)]

Harvey,

I'm amazed. I know nothing about ventilators (although since I turned 75 two days ago....maybe I should :wink, but are you saying that it is possible to ventilate each lung separately? Does that mean that to be on a ventilator means that some sort of tube goes down your throat all the way into the lung?

 

[thataway]

Most of the patients on ventilators more than a very short time (such as EMS transport) have endotracheal tubes in their trachea. I carried endotracheal tubes and a Laryngoscope in my fanny pack when I traveled with ball teams.

The other mechanism of putting a tube in, and used often in long term patients, is a tracheostomy. This is a tube in the "windpipe" or trachea j"Adams Apple". I also carried a tracheostomy surgical kit in my fanny pack. One of the trainers had a portable ventilator (first response: a manual bag). This can save your life if the trachea becomes blocked.

With the COVID 19 virus, the "hairs" on the cells which "sweep" the debris out of the lungs are paralyzed, there is damage to other cells specifically from the virus. Thus positive pressure is necessary to inflate and allow oxygen into the air sacs in the lungs. This is not simple, and the realm of respiratory therapists like Harvey to adjust and keep the proper flow.

It would be extremely unusual to run two patients off a single ventilator. The case of surgery or trauma is entirely different where each lung may have a tube into the main bronchus.

There is a real danger of the US being short of ventilators. There are several different types, and some may or may not be suitable for all cases. We may be in a situation where we have to use types which are not specifically designed for the type of use we need.

Our county in Florida had one known case when we got home from the St. John's River 5 days ago. We now have 18 known cases. There has been a drive in testing program for the last 2 weeks. But determining the scope of the disease is still an unknown. Since we have been home, all beaches, parks, bars restaurants etc have been shut down. Many businesses are still open, but that may soon change.

 

[hardee]

Harvey,

"I'm amazed. I know nothing about ventilators (although since I turned 75 two days ago....maybe I should :wink, but are you saying that it is possible to ventilate each lung separately? Does that mean that to be on a ventilator means that some sort of tube goes down your throat all the way into the lung?"

Yes, there is a tube that goes to each lung. It goes in the mouth or nose, and then splits and one side (end) goes into the left lung and one into the right lung. When we started doing this we were using 2 individual ET (Endotrachial tubes) but now (I think still) they are available for Anesthesia for certain lung surgical procedures.

From Bob Austin (above):

"With the COVID 19 virus, the "hairs" on the cells which "sweep" the debris out of the lungs are paralyzed, there is damage to other cells specifically from the virus. Thus positive pressure is necessary to inflate and allow oxygen into the air sacs in the lungs. This is not simple, and the realm of respiratory therapists like Harvey to adjust and keep the proper flow.

It would be extremely unusual to run two patients off a single ventilator. The case of surgery or trauma is entirely different where each lung may have a tube into the main bronchus."

The Covid19 is producing what appears on the x-Rays to be a very almost rubbery gelatinous substance in the lungs that blocks air from the air sacks, (alveoli), and sticks the alveolar walls together so that air cannot reach the walls and there transfer into the blood stream through the alveolar capillary bed to oxygenate rest of the body.

To open those air sacks it is going to take both pressure and volume, and special ventilator control. Pressure, volume and flow all work together to open the lung. Big Question. Will those same volumes work on the patient next to you in that bed? Hummmmm?

From my understanding, both in Italy and in China, they did run 1 vent for 2 patients. What I don't know is how that worked out for both patients. Right now, the US is on the verge of not having the number of Ventilators needed for meeting the projected needs unless we get the Virus curve flattened.

The "stay at home, stay healthy" call is for our protection. It should be heeded.

Best to all and hope that helps (with some motivation.)

Harvey
SleepyC :moon

 

[BTDT]

Harvey,
"The Covid19 is producing what appears on the x-Rays to be a very almost rubbery gelatinous substance in the lungs that blocks air from the air sacks, (alveoli), and sticks the alveolar walls together so that air cannot reach the walls and there transfer into the blood stream through the alveolar capillary bed to oxygenate rest of the body."

Thank you Harvey and Dr Bob? As I sit here perusing the news and surfing the internet your insight on Covid 19 'details' such as " and sticks the alveolar walls together so that air cannot reach the walls and there transfer into the blood stream through the alveolar capillary bed to oxygenate rest of the body" gives me plenty of reason to keep my 73 year old body home and at a safe distance from others.

Major problem now is our king bed is not wide enough to maintain a six foot sleeping distance so one of us has to sleep on the floor ;-)

 

[tsturm]

Thank you Bob & Harvey!! :thup

 

[RogerJuntunen]

Governor Little shut down the state yesterday,effective today. Many small towns like Stanley telling tourists to stay away. Out of state licence plates not welcome. This is not me speaking but a report on what I observe. Cheryl and I are considered essential because we are volunteers at the local Methodist food bank. R

 

[thataway]

"The Covid19 is producing what appears on the x-Rays to be a very almost rubbery gelatinous substance in the lungs that blocks air from the air sacks, (alveoli),

We have to remember that X Rays and CT scans only show "shadows". They do not show pathology under a microscope, or "visually" inspect tissue, as a surgeon might.
Here is what to expect on an X Ray or CT Scan:

Plain radiograph
asymmetric patchy or diffuse airspace opacities
CT
The primary findings on CT in adults have reported:
ground-glass opacities (GGO): bilateral, subpleural, peripheral
crazy paving appearance (GGOs and inter-/intra-lobular septal thickening)
air space consolidation
bronchovascular thickening in the lesion
traction bronchiectasis

These terms have specific meanings to physicians. Some are specific to the CV19 virus and some are general as in pneumonia or heart failure.


Histology: (I believe we have at least one histologist in our midst, and he may want to expand on this.
This is material taken at biopsy or autopsy. Several patients had lung surgery for a tumor, and incidentally were found to have COVID 19. This gave insight into the early stage microscopic nature of the disease. There were evidences of fluid accumulation (Pulmonary edema) in the air sacs.
Case 1
Proteinaceous exudates in alveolar spaces, with granules; (B) scattered large protein globules; (C) intra-alveolar fibrin with early organization, mononuclear inflammatory cells, and multinucleated giant cells; (D) hyperplastic pneumocytes, some with suspected viral inclusions.

Case 2
(A) Evident proteinaceous and fibrin exudate; (B) diffuse expansion of alveolar walls and septa owing to fibroblastic proliferations and type II pneumocyte hyperplasia, consistent with early diffuse alveolar damage pattern; (C) plugs of proliferating fibroblasts or “fibroblast balls” in the interstitium (arrow); (D) abundant macrophages infiltrating airspaces and type II pneumocyte hyperplasia.

At autopsy in more advanced cases,

Histological examination showed bilateral diffuse alveolar damage with cellular fibromyxoid exudates . The right lung showed evident desquamation of pneumocytes and hyaline membrane formation, indicating acute respiratory distress syndrome. The left lung tissue displayed pulmonary oedema with hyaline membrane formation, suggestive of early-phase ARDS . Interstitial mononuclear inflammatory infiltrates, dominated by lymphocytes, were seen in both lungs. Multinucleated syncytial cells with atypical enlarged pneumocytes characterised by large nuclei, amphophilic granular cytoplasm, and prominent nucleoli were identified in the intra-alveolar spaces, showing viral cytopathic-like changes. No obvious intranuclear or intracytoplasmic viral inclusions were identified.

The pathological features of COVID-19 greatly resemble those seen in SARS and Middle Eastern respiratory syndrome (MERS) coronavirus infection.

Basically what is seen on histology is the body's reaction to the virus which attacks cell walls and on occasion appears to infiltrate the body's cells.

For the most part use of a ventilators on more than one patient has been either theoretical (models) or short term. As Harvey notes each patient may require different flow rates, pressures (both positive and maybe slightly negative) depending on the specifics of the damage to their lungs.

There is also a very pressing question: Should all elderly COVID19 patients be Do Not Resuscitate? At several points in my career I had to make some very difficult decisions: example (UCLA 1965, I was in charge of the only dialysis unit in Los Angeles Co. We had a committee of transplant surgeon, Rabbi or Priest, attorney and myself, to decide what 18 people out of several hundred referrals would receive dialysis until they had a transplant.). This was a decision who lived and who died.

The same type of decision may have to be made with COVID--and an 83 year old with serious heart disease would not be on the survive list. This is right and fair. But what about two 60 year olds? One working one retired? etc.

 

[smckean (Tosca)]

Right now, the US is on the verge of not having the number of Ventilators needed for meeting the projected needs unless we get the Virus curve flattened.

This statement, and having heard about ventilator shortages on the news, really struck me that covid19 can not be "just another flu" or that covid19 isn't much more serious than the seasonal flu we are used to (as some have said).

Correct me if I'm wrong, but I don't remember anything like a nationwide, or even a statewide, severe shortage of ventilators in any flu situation in my lifetime. For that matter, I don't remember such a storage even under SARS or MERS. That tells me better than any other evidence I've seen so far that we indeed must take covid19 very seriously (and this observation doesn't even consider the shortage of medical staff, hospital beds, protective gear, and so on we are also seeing). I'm presuming covid19 is either far more easily spread, or far more life threatening, than the seasonal flu to explain this ventilator shortage.

I'm typically a risk taker......but this time I'm taking the "Fauci" type precautions very seriously.

Should all elderly COVID19 patients be Do Not Resuscitate?

WOW.....what a thought! A fascinating philosophical consideration if it wasn't such a serious issue. I can't fathom an answer.

 

[thataway]

Yes, those of us in the medical profession take the COVID 19 as a very deadly serious condition. It spreads far easier (no immunity, and aggressive infection), and is far worse in the way it attacks the specific lung cells.

Far too many are saying "its another Flu". In some ways "Flu" is a waste basket term, unless one is specific about the strain, and what the actual cause of death is. It is often put on the death certificate of elderly dying in a nursing home, or without direct medical attention. The actual cause of death may be a specific pneumonia, aspiration, dehydration a cardiac or vascular event etc....

This one is killing young and what appear to be healthy individuals. I believe that it did not evolve in one day--as noted above. It is probably more wide spread than we know. Only time and testing will tell.

Sure "just a bunch of people in a nursing home"....Far more than that. Once it got a foothold it was bad. Watch the prison population. My grand daughter was at Tulane. Many of her friends are now texting that they have the COVID 19, symptoms arose after they came home. New Orleans is a hot bed of virus...Hang on.

 

[dotnmarty]

Not to get too morbid about it, but many of us elderly already have advance directives which include DNR or "do not resuscitate " orders. This at least relieves the family and the medical personnel from what might otherwise be an onerous decision.

 

[thataway]

Not to get too morbid about it, but many of us elderly already have advance directives which include DNR or "do not resuscitate " orders. This at least relieves the family and the medical personnel from what might otherwise be an onerous decision.

We advise everyone, no matter what age to make these decisions. Also to have a durable power of attorney for health care, and for finances (with signatory rights on accounts). We carry these documents with us when traveling on the boat or RV. It's our "Red Folder". It also has copies of important insurance documents, dog's papers and medical history, our own detailed medical history, and a copy of our passports, credit card numbers and phone numbers of places to notify if card is hacked.

We also have all of our RX on one side of a small card and brief medical history/allergies etc on the other side laminated behind the driver's license in the wallet. Also on #1 speed dial is "Wife" or "Husband", "Daughter" #2 on the cell phone. These are the most likely places that EMS, LEO or ER personal will look if you aware injured or health compromised.

 

[westward]

If a patient without a DNR directive needed urgent assistance to stay alive (ie: they "coded"), a hospital could be forced to indirectly institute DNR with site-specific and disease-specific protocols re: how many personnel could enter a Covid (or rule-out) room at the same time, for staff and facility-wide safety. If our hospitals become too overburdened with Covid-19 patients, this is likely to happen. This is independent of the effects of equipment shortages.

In other words, stay home and practice strict infection control. Help keep yourself and others from needing a hospital admission. We will get the upper hand, but this disease is absolutely not a hoax.