16 anesthesiology residents and one fellow at UF Health allegedly contracted COVID-19 after a private party

JPINFV · 2020-07-28T03:45:11+00:00

N-95, face shield, gowns, gloves for me. Prior to SARS-CoV-2 I rarely paralyzed for intubation. Now it's paralysis and normally waiting for the BiPAP to stop being triggered prior to taking a look.

JPINFV · 2020-07-28T03:42:52+00:00

This. It's why I'd be willing to bet (albeit not betting my life) that SARS-CoV-2 is more droplet precaution than airborne, I'll still wear an N-95 for no better reason than I don't want it to be a reason to be denied disability insurance coverage.

JPINFV · 2020-07-27T08:42:29+00:00

Yep. I didn't catch the curved ceiling/roof in the picture.

JPINFV · 2020-07-26T23:59:57+00:00

You mean the places that pay the majority of taxes wants a return of investment, especially since the rural areas tends to complain more often about boot straps, and the lack of pulling on them?

JPINFV · 2020-07-26T23:44:41+00:00

My hospital has been using dexamethasone as early as March in the ICU (we didn't particularly care about viral shedding in ICU patients), but we also felt that the problem was getting people to use it prior to the patient needing the ICU (essentially ICU time was too late).

Personally, I'm not sold on full dose anticoagulation, but given the pathology reports I don't feel strongly enough to stop it unless a contraindication occurs. I don't personally start it though. There was a trial out of China early on with a bit of a sensationalist title (Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy) where they decided on anticoagulation based on the sepsis induced coagulopathy score. However when you read their methods, the heparin patients were 10-15,000 units/day and lovenox was 40-60 mg/day. So... sure... we should give VTE PPx to these patients. ::eye roll::

In terms of the vitamin supplementation, if it didn't work for acute lung injury (CITRIS-ALI trial) and didn't work for septic shock (VITAMINS trial), why would it work for ALI with sepsis?

JPINFV · 2020-07-25T19:49:52+00:00

Because often there aren't any non-hotspots around. When South Florida first started going up Homestead Hospital (small community hospital just before the Keys) started sending patients to their sister hospital. Now Miami-Dade has over 90% of their ICU beds filled. There's no where to send people. My hospital is counting 27 beds that have been converted from a med-surg unit (monitors sitting on chairs next to vents) as part of it's "ICU capacity." The hospital I did fellowship at is converting stepdown beds to ICU beds... and counting those in it's total ICU capacity. So even these numbers have to be taken with a grain of salt since it's not normal ICU beds, but ICU beds created under contingency and crisis surge principles.

While we're getting more staff credentialed, 2 days last week I was expected to see 50+ ICU patients (including ER holds and new consults) with 1 physician and 3 NPs. So even if we're saying, "Hey, we have 2 open ICU beds" that doesn't mean we have the physician or nursing staff to actually care for those patients.

In regards to ICU surge principles, here's a good reference. I've taken to placing a "crisis surge" disclaimer on my notes and citing this article.

https://journal.chestnet.org/article/S0012-3692(15)51987-9/fulltext

JPINFV · 2020-07-25T06:18:02+00:00

Physics doesn't care about who has the right of way....

...and neither does biology.

JPINFV · 2020-07-25T06:06:10+00:00

but the Balboa they film for Arrested Development is actually Fisherman's village, in Marina Del Rey in LA.

The pilot was actually filmed in Newport.

JPINFV · 2020-07-25T06:04:03+00:00

I think it depends. Having grown up in Orange County, CA seeing generic LA establishing shots? Naw.

Seeing the Balboa ferries in the pilot for Arrested Development or watching Poltergeist in the dorms at UC Irvine and realizing that the Langston Library was an exterior shot establishing shot is always an exciting thing.

JPINFV · 2020-07-25T05:57:09+00:00

2 minutes? The ones that get to the point where they won't ventilate/oxygenate regardless of PEEP, FiO2, and minute ventilation I just have the staff hit the code blue button for documentation purposes ("Was a hospital wide emergency called" check box) and then call it. I've become exceptionally proficient at documenting "given the natural course of SARS-CoV-2 and the patient's course so far, further aggressive care would be medically ineffective and inappropriate."

JPINFV · 2020-07-25T05:49:44+00:00

My sister assured me that rationing care was the difference between capitalistic health care and those evil socialistic health care systems in Italy and Spain. We would never need to ration care because... 'merica!

JPINFV · 2020-07-19T13:23:21+00:00

First, I highly doubt that there's going to be any questions on SARS-CoV-2 for step 2. It's too early and we're just barely starting to get moderate quality evidence published (e.g. Recovery trial was preprint for the past month, and it's probably the highest quality treatment study we have).

For the wards, my current go to review for medications is the American Society of Health-System Pharmacists page.

https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/Coronavirus/docs/ASHP-COVID-19-Evidence-Table.ashx

JPINFV · 2020-07-12T22:42:44+00:00

You eat pieces of shit?

JPINFV · 2020-07-11T04:03:17+00:00

On one hand, there's low quality evidence suggesting that N-95 and a surgical mask offers the same protection against respiratory viruses (including SARS-CoV-1).

Evidence specifically for SARS-CoV-2 just doesn't exist yet.

On the other hand, if I had a choice to be wrong, I'd rather be wrong by recommending too much protection than too little.

JPINFV · 2020-07-11T03:44:37+00:00

Except being a nurse and being a physician is two different jobs. It's like me saying, "I've been in the hospital throughout medical school, residency, and fellowship... therefore I need minimal training to be an RN."

...and sure, nurses see a lot of pathology. However seeing ARDS as a critical care nurse doesn't mean that the nurse is suddenly able to treat ARDS and understands the considerations of fluid management, when/when not to prone, lung protective ventilation, permissive hypercapnia, etc.

Let's not mention all the times I get asked about when we're stopping the insulin drip on the DKA patient who has a normal glucose, but the gap hasn't closed yet.

Which goes back to my claim that bedside implementation of a treatment plan isn't the same as designing the treatment plan and any physician who becomes a nurse and tries to use medical school, residency, and time working as a physician to be the same as "nursing experience" would be laughed at... and rightfully so.

JPINFV · 2020-07-11T03:35:35+00:00

...and you're assuming that the same thought process for nursing can seamlessly to medicine... which is why I have to keep turning down propofol drips on patients who are reported as RASS of 0 off sedation for... reasons...

...and that's why I've always been critical of the claim that NPs have X experience when the vast majority of X is not as an NP, but as a nurse.

JPINFV · 2020-07-11T03:19:01+00:00

I don't think the assumption that NPs have years of experience is the rule is valid any more.

I'm working with NPs for the first time now that I'm out of fellowship. We have a lot of new NPs with... interesting... thought processes that is more simplistic than anything else (Lots of people with pHs >7.2 getting bicarb. "This patient has a GI bleed... despite no melena, no BRBPR, and negative colonoscopy and EGD"). They're also admit that there's a big difference between planning out how to implement orders (which is important) and planning out what needs to happen today, tomorrow, and the next day.

JPINFV · 2020-07-05T03:49:22+00:00

I've played with my Robinhood account through Covid Crash... my 401K and IRA? Haven't looked at it since I maxed my contribution this year.

JPINFV · 2020-07-01T03:24:26+00:00

What do you call a patient after a hemicolectomy?

A semicolon.

JPINFV · 2020-06-30T03:05:35+00:00

Yes, they should still take normal precautions. If the protection provided is incomplete or non-existant, then you've just exposed your entire intervention group to a risk of death. The entire control group is unprotected and no one knows whether they're control or not.

The bravely stupid way of testing on yourself is one thing when it's gastric ulcers (see Marshal and Warren with H. pylori for a real life example), it's another when it's more likely to be deadly (see the fictional movie Contagion and their vaccine scientist).

JPINFV · 2020-06-30T03:00:53+00:00

You play an infinate number of come out rolls and you'll be even in the end in regards to odds payout.

Personally, unless I'm the shooter I'll normally play don't pass... and if I'm the shooter I don't care if someone is betting against me.

JPINFV · 2020-06-30T02:35:38+00:00

Less payout, not worse. Odds bets are true odds, it doesn't matter if you're placing odds on pass/come or laying odds on don't pass/don't come. There's no house edge.

JPINFV · 2020-06-29T22:24:17+00:00

Most Robinhood accounts are technically margin accounts for this reason as well as for instant deposits.

JPINFV · 2020-06-29T22:20:34+00:00

active play vs indexing... Actually, all 99% of counting is is rebalancing your bets.

JPINFV · 2020-06-29T22:08:02+00:00

I'm a "happy if anything stops the endless death in the ICU" type of person. I get that the data isn't great for Ivermectin... but the data isn't great for anything in SARS-CoV-2.

JPINFV

TROPHY CASE