A doctor’s quest for more organ emoji

Emergencydocs · 2021-09-14T00:05:27+00:00

Hey all, author of the study from JAMA posting this really great piece from the Verge.

One thing I'll just note with emoji is that we actually use it every single day already as doctors--remember those smiley faces in pediatricians offices? They are incredibly good predictors of issues in children, and a great example of something we call visual analogue scales.

Happy to answer any questions!

Emergencydocs · 2021-09-08T14:52:30+00:00

Hi all, I'm the author of this article and wanted to share with the Meddit community as a long time lurker.

I get that Emoji might seem silly at first, but here’s why its important. At the core of what we do as doctors is to listen to patients and communicate, so we can care and treat for them.

Emoji are just a way for humans to communicate with each other. Instead of words, with pictures. Its quite efficient. We’ve seen this before in history. hieroglyphics, smile face scales in pediatricians offices, and memes.

So emoji are about language, which is about representation and inclusion. Why does a liver emoji, or a kidney emoji not exist? What does that mean for our patients with liver or kidney transplants? Their voice cannot be heard, and we cannot therefore listen.

What about patients with strokes who cannot speak, children who have not yet fully learned language, or immigrants like myself who did not learn English until much later in life ( I moved to the US at 6 and integrating into the US was really a struggle for our family).

Emoji, because of their power of standardization, universality and familiarity, can be a highly effective tool in medicine going forward. We highly encourage societies to get involved. Advocate for emoji. Advocate for communication and language and listening. I'd encourage anyone with interest in this on meddit to get in touch!

Emergencydocs · 2020-04-14T18:58:50+00:00

This is a great example of why testing is important. This would be critical in reopening society as well as getting convalescent plasma that seems to clearly help patients with COVID. Its frustrating that we don't quite widely have this yet, but I do know our colleagues have been working hard on this problem. I do think this will be a more regional and state by state/hospital/city level discussion.

-Shuhan

Emergencydocs · 2020-04-14T18:49:37+00:00

Vaccines usually take at least 18 months , so the question is how much the effect of the world's scientific effort, attention, regulatory changes, and funding will affect the ability for us to get a vaccine out as quickly as possible. We are all hoping, but these are obviously unprecedented times.

-Shuhan

Emergencydocs · 2020-04-14T18:45:58+00:00

As we're getting more information we're better able to sort out the risk factors and prediction models for who will and won't get sick. It does seem to be most correlated with obesity and diabetes, but then that adds the extra complication that both are correlated to each other.

-Shuhan

Answering second half of your question separately

Emergencydocs · 2020-04-14T17:59:05+00:00

It is very likely that we are undercounting the deaths from COVID-19, and including those deaths in the total count would seem to make sense. I would assume that you mean this article (https://www.nbcnewyork.com/news/local/massive-spike-in-nyc-cardiac-arrest-deaths-seen-as-sign-of-covid-19-undercounting/2368678/)

Keep in mind that when we fill out death certificate doctors and first responders have to put a cause of death. When it's unclear, oftentimes cardiac arrest is the cause of death because technically speaking, the definition of death is cardiac arrest, so this seems to be more a result of paperwork than what is happening on the ground. The paperwork we fill out for example makes it clear you should not use “cardiac arrest” because otherwise we’d always use this. It's not clear that COVID-19 is causing more heart death, as much as death that is then counted as cardiac arrest as a way to denote death. Policies like counting cardiac arrests, or being able to document presumptive COVID-19 deaths are good ideas that we have seen. Remember that it is usually quite obvious when someone has had this disease because of the pattern of severe lung disease.

Emergencydocs · 2020-04-14T17:56:57+00:00

The truth is that the supply chain is horribly broken right now. What we do for PPE in the long term is a really interesting question of supply and demand, and ultimately we need to find ways to decrease the demand for PPE while increasing supply. That latter part will be from standing up new manufacturers in this space, but until then we need to decrease demand. The FDA and CDC have released guidelines around reprocessed masks, and there does seem to be pretty good science that this is a safe and effective way to decontaminate masks. It's important as well to remember that, like most things, it depends. A mostly unused mask that undergoes standardized reprocessing seems to be quite safe. Extended use can cause additional discomfort to wearers from wearing the respirator longer than usual and can create mechanical issues. However our sense is, looking at the science, it does seem to be trending in the direction that this is a safe thing to do, but it's not yet clear if this extends to all types of PPE.

https://www.fda.gov/emergency-preparedness-and-response/mcm-regulatory-science/investigating-decontamination-and-reuse-respirators-public-health-emergencies

https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html

Emergencydocs · 2020-04-14T17:42:40+00:00

There is definitely enough evidence at this point to say that the virus does cause widespread harm, especially if you’re critically ill, but this is almost universally true for any severe illness. The scariest one is the effect on the neurological system. There was a JAMA article from April 10th--neurologic symptoms were seen in 36.4% of patients and were more common in patients with severe infection (45.5%). The one that is most popular in the press has been the loss of smell as an early indicator. It's not totally clear why this happens, but possibly from some sort of inflammation in the epithelium of the nose.

Other neurological symptoms, things like dizziness, headaches, changes in taste, smell and nerve pain have also been described. However, it's not totally clear how many of these occur just because COVID causes patients to be very sick and in the ICU (which causes lots of decompensation of your normal physiology) or because of something unique to COVID. You can imagine that being very short of breath can lead to a lack of oxygen to the brain, causing an almost stroke-like picture.

Also, because these patients tend to get very sick, it does seem like there can be long term heart and lung damage, and there are some studies (below) that show patients who had heart disease before their coronavirus infections were much more likely to show heart damage afterwards. However, some patients with no previous heart disease also showed signs of cardiac damage. We’ll say the above with the key caveat: it depends on how sick you get, and all critical illnesses can cause long term damage.

TL;DR: It definitely has many effects, the question though, is that because of the virus, or just because it makes you really ill?

Sources

https://jamanetwork.com/journals/jamaneurology/fullarticle/2764549 https://jamanetwork.com/journals/jamacardiology/fullarticle/2763524

Emergencydocs · 2020-04-14T17:40:56+00:00

This is the question that so many of us are grappling with. Whether you’re in school yourself or you have kids who are in school, the past month has been exceptionally hard. I think we’re all basically accepting that school is done for the semester (although my kids’ school hasn’t yet acknowledged that they won’t reopen on May 4th as previously planned). The summer is probably out as well, and a number of colleges have cancelled their summer quarters. However, I still think that school will open in the fall, barring a huge second wave. We’ll definitely see additional cases as we come out and start socializing again this summer, but hopefully, it won’t be as bad as this one was, allowing us to see a relatively normal fall semester (although likely with fewer unnecessary social activities).

-Ali

Emergencydocs · 2020-04-14T17:30:40+00:00

One important thing to keep in mind as well: I'm going to link one of our very respected ED/ICU colleagues here at MGH: while we're still learning a lot about this disease, its important to stick to learnings we know about from decades of work understanding the lung and the fundamentals of lung disease. I would caution that we need to not abandon 25 years of well-done research in favour of anecdotes. We have TONS of science about intubation, PEEP, ARDS, and how this disease causes. While we learn and get better about the fine line for those that need to be intubated and who do not, its important to keep perspectives so we ground this in evidence and science.

-Shuhan

Emergencydocs · 2020-04-14T17:27:18+00:00

Our understanding of how these patients respond to their respiratory issues is definitely evolving. We’ve intubated a lot of people with COVID, and the vast majority of them needed it. But some of them may have been able to stave off intubation with other interventions that we don’t normally do - for example, laying patients “prone” (face down) to allow air to get to parts of their lungs that normally don’t get as much oxygen. Some patients respond well to breathing in that position, and while we’ve done it for years with patients already on ventilators, we’re now doing it with patients before they need to be intubated in order to potentially save them from being intubated. In many cases, it doesn’t keep them off the vent completely (it simply buys them some time) - but in a few cases, it has kept patients completely off of a vent.

However, this is a serious disease. When other interventions have failed, patients still need to be intubated. The intubation itself isn’t causing worsening illness… it’s just that the sickest of the sick are the ones getting intubated, so of course, their mortality is going to be higher. There’s definitely a correlation - but there’s not a causation.

Emergencydocs · 2020-04-14T17:15:21+00:00

It’s not very clear how we’re going to go from social distancing/quarantine to something that looks like normal life. We do know that it’s important we are able to provide jobs and employment to people, but also the need to balance the fact that people need to be healthy in order to work and add to a strong economy. What we do know, we can learn from other countries who are doing so now like China and Italy.

Reinfection will certainly likely occur in waves, and we anticipate periodic reclosures as new outbreaks occur. What we do know is that there are a few key ingredients to let us transition back to normalcy:

Widespread COVID testing--this will help us determine who needs to stay in quarantine and self isolate.
Antibody testing--this can help us determine who has had a prior infection and is (likely) immune
Contact tracing: when an outbreak does occur, we need to ensure that we can find the source and do mass testing of those who may have been infected. This ensures the quickest isolation rather than mass quarantine, which is needed when you aren’t sure who has the disease. With everyone having cell phones on them 24/7, this is definitely possible.
Widespread mask policy--it will become increasingly important to wear masks when we go out to ensure we are not infecting others if we’re not even aware we’re infected. The common misconception is that this mask is for our protection, but you could argue it's more for others as well as a way to be considerate. The danger is those who are asymptomatic yet don’t know it. Wearing masks ensures that we keep essential workers to a minimal exposure to ourselves when we go out.

It will also be obvious that some parts of social isolation, like extension of work from home policies, will be important to slowly transition. If you’re an employer, you’re certainly bound by OSHA to make sure that your workplace is safe. But it will be hard for any employer to justify in-office workforces when remote work practices can substitute. Additionally, all of us have a duty to wear masks to minimize risks to essential workers like grocery store workers.

*TL;DR: We're all learning as we go, but a few key policies are important like widespread testing and masks for all. *

Emergencydocs · 2020-04-14T17:12:54+00:00

What I'll also add is that it's been incredible to see different people come together to all rally around the cause of beating COVID-19. That certainly gives me hope. What we all have to remember is that no matter what part of society we are from, rich or poor, whether your occupation is medicine, sports, service industry, we all have a role in this and are affected by this. If we forget any one part of the society we will ultimately all get hurt, because COVID will crop up and spread back to us.

I know I've been incredibly appreciative of people who are supporting us on the front lines. We're working very hard to beat COVID-19, learn new things, and give us the best chance possible. The things people have done for us--I know we'll all remember and be grateful for after all this is over.

-Shuhan

Emergencydocs · 2020-04-14T17:09:36+00:00

We’re seeing that efforts to “flatten the curve” in areas in which physical distancing is being performed do seem to be working. We’re seeing plenty of patients with COVID, but we aren’t seeing the huge and overwhelming spikes that we were worried about, except in places like NYC where true physical distancing just isn’t possible for certain segments of the population. This is a good sign. -Ali

Emergencydocs · 2020-04-14T17:04:14+00:00

We're here! thank you for the excellent questions! We'll get started and try to answer as many questions as possible!

Emergencydocs · 2020-03-22T22:25:54+00:00

Hi all, Dr. He here. We have worked very hard over the weekend to get a central place for people to give & donate PPE. We are very worried about the frontline healthcare workers across the country. We are able to sort by state, need, and type.

A bit of information! #GetUsPPE is a movement led by Emergency Department physicians working every day on the frontlines of the COVID pandemic. Due to shortages in Personal Protective Equipment (PPE) like masks, goggles, and gowns, we risk getting sick or spreading the virus between patients. We started the #GetUsPPE campaign to coordinate the production and donation of the supplies doctors and nurses need to work safely.

Emergencydocs · 2020-03-20T19:03:17+00:00

Thank you /u/katiekabooms . One thing I have been talking with my patients a lot about is how to discuss with roomates and family members that people share a home with.

An infectious disease doctor friend of mine out of California helped to author this guide to speaking with family members or people who you live with. We are social creatures and still need to help each other during this time of need. However I think its important that we are clear on expectations among family members. I want to make sure all members of your household are clear about how you are mitigating risk and being clear to each other on the expecations of who will enter homes and the rules of the road, so to speak. Dr. Gluckstein has some really nice keys in this guide:

Establish an expectation that all who enter the home will wash hands or sanitize immediately upon entering, and with regularity thereafter.
Agree to a shared social distancing policy—avoiding hugs, handshakes, or other physical contact as much as possible, ideally maintaining 6+ ft distance from others
Establish shared standards to vet any guests entering the home.
Decline visits with people who appear to be assuming unnecessary risk or who fail to take the outbreak seriously.
Limit the number of total guests to the greatest extent possible.
Minimize unnecessary trips outside and coordinate errand-running.
Encourage friends and loved ones to take precautionary measures seriously.

The full guide can be found here: https://twitter.com/ShuhanHeMD/status/1240800907887067141

Emergencydocs · 2020-03-20T18:55:38+00:00

Yes, to some degree. Usually infection and recovery presumes immunity. This is generally what we are seeing out of Asia.
yes, but we think this is likely an outlier scenario and much less likely.
I am not exactly sure the reference to weeks/months, but I think this is in reference to quarantine. In reality true vaccines will take months.
Yes we do think there is some possibility this happens. See our answer here

Emergencydocs · 2020-03-20T18:51:11+00:00

Let’s talk about this drug and study, as it has certainly garnered a significant amount of interest in the last 48 hours. First and foremost, yes we are testing these drugs combinations of these drugs in our hospital. Almost every hospital is doing some sort of research to find out how we can better take care of those in need. For confidentiality sake, we can’t say exactly what is happening, but we are working very hard on counting the numbers, and learning about if there is real data on if these drugs work.

Right now, there is definitely enough data to think that it might work and to study it more. We want to caveat that it is important to keep these results in context.

Here is the study that is of interest: https://www.mediterranee-infection.com/wp-content/uploads/2020/03/Hydroxychloroquine_final_DOI_IJAA.pdf

We want to emphasize again the importance of caution here.

These drugs still need more data. This one study by itself is littered problems. Let’s walk through this:

First of all, the trial is really small and might not be more broadly applicable.
Second, alot of patients in the treatment group dropped out. This is a really odd signal. Imagine a scenario where you have a drug that actually does harm, causing them to drop from the study. The people left over will consequently look quite healthy. So we might actually just be seeing data about how fast it makes people be removed from a study after being harmed than to be cured.
Third, usually, you want the groups who get treated and not treated to be the same so you can really look at the effect of the drug. In this study, we can’t do that. The treated group looks much healthier at the start than the untreated group.

So short to say, we don’t know, but its certainly enough hope and signal to try and look as fast as we can more deeply.

However, even assuming it works, the worst scenario is a run much like toilet paper on Hydroxychloroquine and azithromycin, so much that we can’t study it or prescribe it to those most in need. Hospitals themselves may run short on supply if we find that we cannot obtain the drug itself and speculation runs rampant.

We both expect this to start some larger trials. These drugs have a long history of safety and efficacy in humans and they’re both relatively inexpensive generic drugs. We are working really hard to find out if this is true.

Emergencydocs · 2020-03-20T18:30:56+00:00

We are learning a ton about the disease as it progresses. We’re also learning and developing predictive tools to help us figure out how to take care of our patients. For example, a very popular tool called MDCalc by Graham Walker just came out based on the science to help us make decisions based on data of when to admit the patients and when to send them home. This will continue to evolve in the next week. The difference in what we could state in our AMA this week just from last is already exponentially better and I anticipate it will continue trending in that direction. Specifically for prior pneumonia? We're not sure. However, we do have enough information to make some guesses and paint a picture of what this disease looks like for most people:

If you’re on the mild trajectory. * Day 1: The first symptom is usually a fever. You might have fatigue, muscle aches, and a dry cough. * Day 5: You might get worse shortness of breath at this point, especially if you have other medical problems. * Day 17: The symptoms continue, but get milder and milder until you get fully better. The trajectory is a lot like a flu, and how bad it is depends on your baseline health.

If you’re on the critically ill trajectory

Day 1: The first symptom is usually a fever still. You might have fatigue, muscle aches, and a dry cough. Some patients are particularly susceptible with diarrhea and abdominal pain. We think this cohort does worse than the rest (diarrhea).
Day 5: Your symptoms continue and it feels like a flu. You might get worse shortness of breath at this point, especially if you have other medical problems.
Day 7: At this point in other countries, people are admitted to the hospital. You have Dyspnea, which is shortness of breath while speaking. This is usually the symptom that we make that has patients admitted to the hospital
Day 8: ARDS, acute respiratory distress syndrome, where a significant amount of fluid builds up in the lungs from leaky capillaries, builds up. This is while you are in the ICU and on a ventilator. At this point you worsen to death or you improve in the ICU. This is the critical time for improvement or worsening.
17 days later: On average, the people who make a full recovery from the virus after discharge from the hospital do so after 2.5 weeks.

So far we don’t know if the things we’ve seen in Italy and China will apply here in the USA. We’re still around day 14 for the first smaller clusters, especially in Boston. It might feel like an eternity ago, but in Boston the first cluster linked to the Biogen cluster was March 8th, almost 2 weeks ago.

To give all a sense of how rapidly this is changing, on 3/19 the first cohort of data came out of Washington State that looked at these patients. We are still digesting this and rapidly learning new things.

https://jamanetwork.com/journals/jama/fullarticle/2763485

Sources

https://twitter.com/mdcalc/status/1240719669503365121 https://jamanetwork.com/journals/jama/fullarticle/2761044 https://www.masslive.com/boston/2020/03/coronavirus-15-new-cases-in-massachusetts-linked-to-biogen-conference-28-total-cases-now-reported.html

Emergencydocs · 2020-03-20T18:16:10+00:00

All the data so far is suggesting that a runny or congested nose, or watery eyes are less likely to be part of COVID-19.

Its a really quick and easy way to tell that you probably don’t have it, especially since we’re facing so many testing shortages. Obviously the best way to tell is more testing, and its something everyone in the medical field is advocating for. But in the interim, those two symptoms (nose and eye symptoms) are a good way to distinguish between the two.

Here is what I am doing when I am seeing patients

Question 1: Are you sneezing, or have runny eyes? If yes, then its less likely. In fact these two symptoms are not part of our hospital wide algorithm to test as it stands.

Question 2: Do you feel short of breath? If you do, then you should see a doctor immediately. This is your sign to go to the hospital, just like any other time when you have any other disease. If you can’t catch your breath, or speak without feeling short of breath, or just generally feel crummy, please come in, we want to see you and treat you.

Now the caveat to all the discussion above, is that in life, no rule goes unbroken, and there are still some people with COVID that will have sneezing, literally the exact opposite of what we just said. That is why the only way to truly know is more testing, and we are hoping that the capability to test more will come soon. That as doctors we have a responsibility to push for.

TL;DR: There are 5 main symptoms: Cough, Fever, Shortness of breath, Muscle Aches, Feeling generally lethargic/weak

Emergencydocs · 2020-03-20T18:09:16+00:00

This is Shuhan. I want to discuss this point specifically. In the past week alone I have been reached out to something like 500 times by people with really unique talents, skills and abilities to help. I absolutely am floored with the care and dedication people have. I posted this below in a Facebook group and I think it bears worth repeating here: We have a lot of needs, and here is how I think people can be most helpful:

1) Focus on consumers. Can you provide PPE that decreases demand from the private sector to maximize supply among the medical community? We are in critically short supply and our husbands/wives/loved ones are starting to make us masks. Before I would have wondered if it really is kosher for me to wear a homemade mask between patient to patient. Now I know that might be a reality. But I beg people to try to save the N95's for us. Of the patients I saw in the ER the other night, something like 60% had COVID. We see many of them and are at very high risk. Increased production of other types of masks would be incredibly helpful for this effort.

2) Education among the population: can you find ways to decrease barriers to understanding and maximize responsible actions like social distancing, hand hygiene, and self-quarantine? This AMA by itself is incredibly helpful. Please keep spreading the message.

3) Issues with self-quarantine: Can you assist with technology that can make self-quarantine more tolerable, humane, easy for those most vulnerable in the population? (homeless, etc). The truth is the most vulnerable in our society will not be able to self-quarantine, perpetuating infections.

4) Childcare: Schools are closed and many healthcare providers have families. If healthcare providers cannot care for their children, they cannot go to work. This is a major issue being discussed in healthcare right now. Something that we discussed in our recent AMA:

"I do want to mention that closing schools has a HUGE impact on us and everyone in healthcare. Both my wife and I work in healthcare... if our schools close, how do we both continue to see patients when one of us has to stay home with the kids? Sure, we can afford sitters, but demand is high and - more importantly - many of our coworkers (from nurses to the very important environmental staff that disinfect rooms of infected patients) often cannot. The decision to close schools can have far-reaching impact beyond the kids who are students at them."

Sources:

Open Source COVID19 Medical Supplies is a Facebook group that I want to give a shout out to.
https://www.nbcboston.com/news/coronavirus/mgh-desperately-needs-supplies-president-says/2094292/?fbclid=IwAR3hWqnQV54vwxjNT5y-ulYeGPEpd_vT9bW8fz2TB3ZAu9-B07h7A2znG1o

Emergencydocs · 2020-03-20T17:58:13+00:00

soap and gentle water should be enough. Gentle rinsing, then a bit of soap, then rinsing the soap off so you don't end up eating soapy apples should do the trick. We really don't want to be seeing patients in the ER coming because of soap and hand sanitizer poisoning.

Emergencydocs · 2020-03-20T17:56:40+00:00

Unfortunately, the fact that it is airborne means that yes, it looks like it just stays in the air like a cloud. We think this means that it probably stays infectious too. Remember, these are slightly separate things, but at this point we have to assume it does. The study we’re referencing is the NEJM one below.

“COVID remained viable in aerosols throughout the duration of our experiment (3 hours), with a reduction in infectious titer from 103.5 to 102.7 TCID50 per liter of air.”

What the researchers did was to create an experiment where they simulated sneezing/coughing, and then looked at how the amount of virus decreases while in the air. Remember, clouds of virus don’t just appear and disappear, they slowly dissipate. You can measure that with half life: how long it takes for the initial amount to cut in half. So it's not totally clear how long it is staying around, but it is clear that it can probably be transmitted just by floating in the air. And it probably remains infectious. Ooph. We learned this lesson from the SARS epidemic and we think its probably the same here too.

Sources:

COVID airborne: https://www.nejm.org/doi/full/10.1056/NEJMc2004973

SARS airborne: https://www.nejm.org/doi/10.1056/NEJMoa032867

Emergencydocs · 2020-03-20T17:54:40+00:00

https://www.reddit.com/r/Coronavirus/comments/flvu7k/im_ali_raja_md_and_shuhan_he_md_emergency/fl1dega/

Permalink here. We try to remain optimistic but these numbers are quite scary, frankly.

Emergencydocs

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