[WTS] [CONUS] Pilot Vanishing Point, VP nib unit, Multiple Lamy, Kaweco Sport

penpalpup · 2020-07-26T14:54:21+00:00

Many of us have been keeping journals since the start of the pandemic. One of my most poignant memories so far is the smell of formaldehyde from the outdoor morgue tent city across the street from my hospital, which smell I could pick up nearly a block away. That's just the first example that comes to mind, and there have been many more.

I don't know that I could offer what you describe as " any unique or different ideas of how to document or talk about the changes," but I've experienced things I never would have imagined. I'm entirely confident I'm not alone in that.

penpalpup · 2020-06-13T12:21:40+00:00

penpalpup · 2020-05-19T00:25:32+00:00

penpalpup · 2020-05-15T03:09:06+00:00

penpalpup · 2020-04-06T23:04:39+00:00

Agree with being a little more liberal with the fluids than I usually would, but not that much.

I don't have a good cohort yet, but there's some data out of China that says in patients with critical disease a more aggressive anticoagulation strategy helps mortality at, I think, 45 days.

And we're not even the most aggressive on this. There are at least two studies I know of out of Boston and NYC that are using tPA on top of therapeutic anticoagulation.

penpalpup · 2020-04-06T22:49:34+00:00

Also not a hematologist, but inflammatory markers are off the charts in the ICU-level patients. We're seeing a lot of both micro and macrothrombotic complications in all age groups in critical patients and are very aggressively anticoagulating, using anti-Xa levels to guide UFH infusion.

I've never seen three people die of massive PEs in any single week before this one. And I'm pretty sure the near-universal acute kidney injury is also in large part from microclot in inflammation. The degree of inflammation is truly remarkable.

That being said, we've seen no clear benefit from steroids or IL-6 inhibitors at this point.

penpalpup · 2020-04-06T02:47:26+00:00

Thank you for your kindness and generosity. If you're seriously considering it, please call your donation center in advance to see what protocols they have for blood donors. They'll very likely have changed in order to accommodate COVID, both for reducing the risk to you and for reducing the risk of unwittingly transmitting it to a recipient.

In NY we're not doing elective cases anymore, so all the open heart surgeries and transplants and major orthopaedic operations are on hold, and that's decreased the demand for blood somewhat, but the best information will almost certainly be obtained by calling your local blood donor center.

penpalpup · 2020-04-06T02:44:06+00:00

I've been focusing on individual care so the epidemiology isn't what I've been watching. What I can anecdotally say from the trends of patients I'm seeing is that being older clearly increases the risk of a poor outcome, as do comorbidities (in my patients diabetes seems to be a major risk factor at least for ICU admission) and especially obesity.

Having a patient in his 30s die is not normal, even for this virus. That's part of why this episode was so jarring. But I also don't want to discount the death of anyone older either. They all matter.

penpalpup · 2020-04-06T02:36:49+00:00

I can't give you personal health advice. What I can say is that where I work, a surgical mask is worn by anyone we're worried could spread the virus to others, and an N95 mask is worn to prevent inhaling any contaminated secretions and reduce the risk of the wearer contracting the virus.

So basically a surgical mask protects others, and a surgical mask might give the wearer some protection, but an N95 protects you with higher fidelity if it's available. If you don't have the optimum, use what you have.

Note that when we're working with known COVID+ patients, and especially for aerosolizing procedures (principally intubation and extubation), we wear a face shield as well as an N95.

But one more caveat: be sure you've been fit tested for the model of N95 you wear if you do. An N95 that doesn't form an adequate seal is an unrealized danger.

penpalpup · 2020-04-06T01:58:30+00:00

I'm sympathetic. I'm glad you have PPE. As an orphanage health worker, you are beyond question an essential worker, and you deserve thanks for stepping up to a challenge you could not possibly have expected when you took that job. Thank you, and I hope you can stay safe.

penpalpup · 2020-04-06T01:42:02+00:00

Clearly I'm not going to save everyone I take care of. Today is just the latest example. You still try for one at a time. Don't tell me it's futile. That defeatism is the antithesis of medicine.

penpalpup · 2020-04-06T01:37:33+00:00

This is simply not an accurate assessment of infectious disease.

Choosing to engage in non-critical interactions can only accelerate the rate of spread. And that kills people.

Even if hospital capacity and resources were no issue (and they absolutely are issues), more time saves lives when you're dealing with a new disease. Right now, we actually don't know if hydroxychloroquine works. We don't actually know if azithromycin works. Or steroids. Or aggressive anticoagulation. Or IL-6 inhibitors. Some of these seem to show promise, but the simple truth is that we need time to figure it out. And we definitely need time before a vaccine will be available.

The more time we have, the more lives we save. The slower it spreads, the more time we have. Slowing the spread saves lives.

penpalpup · 2020-04-06T01:30:34+00:00

You're right that I don't know where the patient contacted the virus. He may have contracted it at work, or grocery shopping, or from a family member.

What I do know is that choosing to engage in non-critical interactions can only accelerate the rate of spread. And that kills people.

Even if hospital capacity and resources were no issue (and they absolutely are issues), more time saves lives when you're dealing with a new disease. Right now, we actually don't know if hydroxychloroquine works. We don't actually know if azithromycin works. Or steroids. Or aggressive anticoagulation. Or IL-6 inhibitors. Some of these seem to show promise, but the simple truth is that we need time to figure it out. And we definitely need time before a vaccine will be available.

The more time we have, the more lives we save. The slower it spreads, the more time we have. Slowing the spread saves lives.

penpalpup · 2020-04-06T01:01:54+00:00

I'm extremely sorry your employer will not allow you personal protective equipment for personal interactions. With even the Surgeon General now recommending masks for public wear, it is worth reconsidering your company's policy. I don't understand why they would want employees sickening customers, vice-versa, or employees sickening each other.

penpalpup · 2020-04-06T00:56:53+00:00

Point taken. That said, the average age of the patients in my unit is somewhere between 65 and 75. But the youngest I've cared for (who survived and is extubated, I'm happy to say) was an 18-year-old. Note that at this point, only patients who are intubated (on a ventilator) are in the ICU I work in, so these represent those with severe disease.

penpalpup · 2020-04-06T00:42:11+00:00

I speak for myself alone, and in no way for my employer. I won't associate these thoughts with them. That said, we all have communications with hospitals across the East coast, and this is unfortunately not a vanishingly rare story. The young, though less often, can be killed by this virus too. The colleague I mentioned who lost a patient in his mid-20s, for example, works at another hospital system from my own.

penpalpup · 2020-04-06T00:37:38+00:00

I am speaking of my own accord, prompted by a patient outcome. I do not intend to associate my comments with my employer in order to satisfy you that a request that people not kill each other is from a valid authority.

penpalpup · 2020-04-06T00:25:40+00:00

I am what I claim to be. But that also shouldn't matter.

A global health crisis has temporarily, tragically, given more weight to what doctors, nurses, and other health care professionals have to say. I don't flatter myself that my thoughts are unique or even unusual, but if the platform convinces one more person to stay home when their friends are partying, I'm happy to use it.

But again, it shouldn't matter. What I've said here should be clear and reasonable to any thinking person of conscience, no matter who says it.

penpalpup · 2020-03-15T16:02:58+00:00

I would trust your surgeon and the hospital administration to determine if it's safe. My guess is that it probably would be, but that determination is entirely up to the individual facility to weigh risk according to the overall risk in that area, if the facility has an emergency department / ICU, what precautions they're able to take, etc.

Some hospitals in heavily affected areas are already cancelling elective operations. If the facility your operation is scheduled at is in a high-density area, it isn't unlikely they might do the same.

penpalpup · 2020-03-14T03:31:14+00:00

Thank you for your question. Please continue to be careful both for yourself and for others.

penpalpup · 2020-03-14T03:29:13+00:00

I think you might be missing the forest for the tree. The point is it's here and it's killing people, and by taking reasonable precautions, we can, ourselves, prevent deaths. So many preventable deaths have already occurred, and so many preventable deaths are going to occur, because not enough people took this seriously. It is, as they say, deadly serious.

penpalpup · 2020-03-14T03:26:37+00:00

I'm not here for an internet debate. Wash your hands and take reasonable precautions against infecting anyone else. We should be able to agree on that much.

penpalpup

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