Divemedic

A Few Errors Here

Kudos to the 14 year old girl that had the presence of mind to collect her 4 year old sister, her dog, and then escaped the house when a man broke in to their home while holding a stolen shotgun. There are some lessons to be learned here:

  • The man got the shotgun after earlier breaking into a different house, hitting the woman who lives there, and taking it from her. If you don’t have the guts to USE a firearm when it is clearly indicated, you shouldn’t own a firearm.
  • No one in this case pressed charges because they want him to “get the help that he needs.” There is no help that will fix this guy’s problem- dementia. This guy will get out of the hospital in a few days and be free to do this again. Maybe he kills someone next time.

A dude breaks into your house. You have a gun. Shoot him. If you don’t, then both of you have a gun, then eventually, HE has a gun. How would you feel, knowing that the guy hit you, stole your gun, then killed two little girls with it?

By Divemedic, ago

Ventilation

The lungs are the organ that allows oxygen to enter the body and carbon dioxide to leave the body. They accomplish this by permitting gas to enter small sacs called alveoli. These sacs allow the exchange of gas across their membrane. The alveoli stay open through the use of a surfactant. In an infection, it can travel to the lungs and cause a potentially fatal condition called acute respiratory distress syndrome (ARDS). In ARDS, the alveoli fill with a fluid that is essentially pus, which diminishes the lungs’ ability to provide vital organs with enough oxygen. There are ways that we can fight that.

If the patient is conscious and able to keep their own airway open, we can put them on CPAP or BiPAP, which is a mask that pressurizes the air that the person is breathing. This extra pressure forces the fluid out of the alveoli and back into the bloodstream. If a person can’t maintain their own airway, they will be intubated and placed on a ventilator. That ventilator will provide pressurized oxygen, and this is called PEEP. You can see it at work here, where a mechanical ventilator is working on a set of pig lungs as a demonstration:

As doctors have gained more experience treating patients with COVID-19, they’ve found that many can avoid ventilation—or do better while on ventilators—when they are turned over to lie on their stomachs. This is called prone positioning, or proning. Because of how the lungs are positioned, this lets you use parts of your lungs that aren’t being used when you are on your back, because it reduces pressure from the heart and diaphragm on the lungs, which allows them to inflate more easily.

If we are talking about emergency intubations (IOW not for procedural reasons), the only people who get intubated and placed on a vent are really sick. People colloquially refer to this as “being on life support.” Anyone can tell you that a person who isn’t adequately breathing on their own is pretty sick. So, for starters, anyone who is being intubated is a pretty sick puppy.

The most common complications in COVID-19 infections are bilateral pneumonia which may progressed to ARDS, sepsis and septic shock, acute kidney injury and others such as acute cardiac injury, coagulopathy, hyponatremia (low sodium levels in the blood) and acidosis (blood Ph too low). Complications are more likely in serious sickness versus non-extreme illness.

On top of that, there are risks for mechanical ventilation: overinflating the lungs, oxygen toxicity, and other issues are possible complications. These complications are more likely in people with ARDS, diabetes, high blood pressure, chronic heart or lung disease, and obesity all are at higher risk of complications from mechanical ventilation. You will recall that these same risk factors also make a patient more susceptible to COVID.

If your COVID infection is bad enough that it is collapsing your alveoli, you likely have problems with other organs as well- specifically the liver, heart, and kidneys. Remember- the same cytokine storm that is damaging the lungs is also damaging other organs as well. This can cause the development of something called MODS (multiple organ dysfunction syndrome). What causes about 20% of COVID deaths is MODS, and is not due to the use of a ventilator. Three quarters of the people who developed MODS already had underlying problems like kidney or heart disease, diabetes, or were morbidly obese.

The simple fact is that we in health care are using other methods for treating low blood oxygen caused by COVID, such as high flow devices (up to 60 liters of oxygen per minute) to try and delay or put off the need to mechanically ventilate a patient, but once you are sick enough from COVID to need a ventilator, you are really sick and your likelihood for surviving is low.

By Divemedic, ago

Antifa Organization

The reason for all of the medical posts is that I have been under the weather for a few days, and I had those on deck in the event I couldn’t post anything. I have some kind of respiratory infection that has knocked me for a loop. I was working last night and had to leave work early because I just couldn’t do it. I’ve been sleeping for the past 14 hours, and now I am going to try to go to work again tonight, fortified with more drugs than Motley Crue.

For the moment, take a look at this post from Matt Bracken which is a photo breakdown of this video. You can also read Peter’s comments on these events here. Now ask yourself (and be honest- there is no point of lying to yourself out of bravado)

Do you and your prepper friends have this kind of command and control? Drones for recon, fast reaction ATVs, radio coordination? These guys are effective because they are willing to do whatever it takes to win, and they are obviously getting training and equipment from somewhere. Look at the ambush tactics here. Even two years ago, they were well trained, funded, and equipped. They have a nationwide organization that is operating like a CIA led operation. Think about the implications.

Tons of people responding on both threads, complete with chest thumping about how “If that had been my car…” derp, derp. Watch the video. There is a woman in the crowd yelling “shoot him.” You can say that we have guns all you want, but most people are not willing to take the actions that will be required of them. Most don’t even understand just how savage they will have to be in such a conflict. Don’t underestimate these people. They’re not fucking around and they’re zealots. It’s time to stop with the chest thumping and bravado. They are preparing, while we are sitting around talking about how the war will be short.

Election season is underway. There will be more and more violence leading up to that. Know where the cells in your area are.

Get ready for what is coming.

By Divemedic, ago

Intubation

Intubation is a process where a healthcare provider inserts a tube through a person’s mouth or nose, then down into their trachea (windpipe). The tube keeps the trachea open so that gases can get through. The tube is then connected to a device that delivers oxygen and other materials to the lungs (mechanical ventilation). The device to deliver oxygen can be a bag valve, or a mechanical ventilator. Certain liquid medicines (Narcan, Atropine, Valium, Epinephrine, and Lidocaine) can be delivered this way, although that procedure isn’t as common as it used to be. Gaseous anesthetics can also be delivered this way.

Intubation is a procedure that is done under one of two conditions: Procedural or emergent. It’s done for patients who for whatever reason can’t control their own airway, to permit the healthcare team to protect and control that airway. If, due to drugs, illness, or injury, you can’t keep your own airway open, you will likely be intubated.

The main indications for intubation are:

  • general anaesthesia
  • congenital malformations
  • diseases or trauma to the upper airway
  • the need for mechanical ventilation
  • perinatal resuscitation
  • acute respiratory distress

It’s a procedure carried out in any given hospital dozens of times each day, mostly under procedural conditions. A procedural intubation is carried out for the purposes of surgery. A patient that is to be placed under general anaesthesia can’t keep their own airway open or breathe very well on their own, so they are sedated and then intubated before being placed on a mechanical ventilator of some sort. An emergent intubation is done for a sudden, unplanned reason like trauma to the airways, cardiac arrest, or acute respiratory failure.

How is it done? There are a number of methods, but here are the basics:

Once that tube is in place, we now have a secure airway that enables us to use some form of mechanical ventilation to breathe for the patient.

There are risks to intubation that include trauma and damage to the airway, and unrecognized esophageal intubation, which is where the provider inserts the tube into the esophagus instead of the trachea and doesn’t recognize the error. There are ways to mitigate these errors, but the risks can only be minimized. That is why in medicine we always weigh the risks against the benefits of any procedure.

When people complain that intubation is bad for COVID patients, they aren’t really talking about intubation. They are talking about mechanical ventilation, which is a different, but related proedure. We will talk about that in a future post.

By Divemedic, ago

What If Police Can’t or Won’t?

The purpose of the police is not supposed to be enforcing the law. The people themselves are pretty good, some would say too good, at protecting themselves and stopping crime, if left to their own devices. In fact, they are so good at stopping crime, that many people have been accused of crimes and punished, only for it to later be proven that the person punished wasn’t the culprit.

No, police are actually there to protect people who have been accused of crimes and protect those people to ensure that their rights to a fair and impartial trial are protected.

A convicted pedophile has set up camp directly next to a children’s school. He has signs out, offering free drugs. The police say that their hands are tied, and either can’t or won’t do anything about it. What happens when the police can’t or won’t do anything to protect children? Sooner or later, someone is going to take care of it themselves. It may be a parent of a molested child, or even a molested child or someone who feels like they themselves are a victim. At that point, the cops will fall all over themselves to find the culprit.

On the other hand, you see police and the legal system setting their sights on people who haven’t committed a crime. They are being used as political tools to destroy the opponents of those who would seek power.

This is a deadly combination. Once people feel like there is no justice to be had, they lose respect for the law. Anarchy can be the only result of this.

By Divemedic, ago

How Do Viral Infections Work?

Every cell in your body contains a mechanism for manufacturing the proteins and other substances that the cell needs to manufacture during its interphase. Review yesterday’s post for an explanation of interphase. Again, for those who know the details, please excuse the fact that I am simplifying a terribly complex system. This is years of schooling condensed down into a blog post. I can’t be comprehensive here.

There are different types of infections, and a virus is but one of them. What is a virus? It’s a segment of genetic material that enters its target cell, takes over that manufacturing center, and instructs that cell to begin manufacturing copies of the virus. The cell will do that until the interior of the cell is filled with copies of the virus, then the cell bursts open and releases them. Since a virus can’t reproduce by itself, it is not technically alive. Since viruses aren’t alive, antibiotics don’t work on viral infections.

When a person gets a viral infection, there are no magic treatments. The way that these infections have been treated is to suppress symptoms and support the patient until their own immune system can rally and defeat the infection. For example, when you get a cold or the flu, we give you Tylenol for fever, cough medicine to suppress a cough, decongestants, etc.

So how does your immune system work to do this? There are two parts to your immune system: the innate, and the adaptive. The innate system is a number of general responses that fight the infection until the adaptive system can analyze the infection, develop a counter to it, and manufacture that counter. Once the adaptive immune system develops a counter to a particular illness, it will remember that, and you won’t get sick from it again (with some exceptions).

All of those symptoms that you get from an infection (fever, congestion, etc) are caused by your immune system creating what’s called inflammation. The inflammatory response (inflammation) occurs when tissues are injured by infections, trauma, toxins, heat, or any other cause. The damaged cells (that broke open when filled by viruses) release chemicals including histamine, bradykinin, chemokines, interferons, interleukins, lymphokines, tumor necrosis factor, and prostaglandins. Many of these chemicals are referred to as cytokines. When released, they signal the immune system to do its job.

Cytokines are responsible for all sorts of things- runny nose, mucous in the airway, fever, cough, fatigue, all of the symptoms we normally associate with symptoms of being sick. Some infections, and COVID is among them, cause too many cytokines to be released in some people, and the result is caused a cytokine storm. A cytokine storm causes an extreme overreaction of the body to the infection. The immune system actually begins to attack the patient’s own body. This appears to happen to as many as 15% of the patients infected by the original version of SARS-CoV-2, the virus that causes COVID. In some of these patients, and no one yet knows why, the cytokine storm is enough to cause a deadly pneumonia. The only thing that IS known is that having certain preexisting conditions that are already creating inflammation increases the risk of this happening. Things that create inflammation are numerous and varied: diabetes, obesity, asthma, smoking, etc. That’s why there are so many risk factors for COVID being serious.

In these patients, it is cytokines called Interleukins, such as interleukin-6 (1L-6), interleukin-1 (IL-1), interleukin-17 (IL-17), and tumor necrosis factor-alpha (TNF-α) that play a significant role in lung damage in ARDS patients through attacking the tissues of the lungs. A pneumonia develops which requires hospitalization.

Normally, if a patient’s immune system is attacking them, we just give them antihistamines and steroids, which combine to shut down the immune system. That’s what we do to asthmatics, for example. We can’t do that in the presence of an infection, because the immune system is what we are expecting to fight the infection and shutting it down would be a bad idea.

When a patient comes into the emergency room with a suspected infection, there are things that we look for that indicate that the patient has too much inflammation going on. They are called SIRS criteria. (Systemic Inflammatory Response Syndrome). When a patient meets those criteria, there are a set of orders that the nurse implements without consulting the doctor. IV Fluids, chest Xray, drawing blood cultures and other labs, etc. Testing for a host of respiratory viruses is done (Influenza, RSV, COVID, and others). Urine is tested for signs of a UTI. We then give Ofirmev (IV Tylenol) and oxygen as needed. We also give precautionary antibiotics. All of this must be done within 90 minutes of the patient arriving at the ED door, per hospital policy. I average about 55 minutes for getting it all done if I am uninterrupted. It’s a lot of work.

If the patient comes back positive for COVID, they are usually sent home with instructions to return if the symptoms get worse, but if they are one of the unlucky ones who have ARDS, they get admitted. This means that about 90% or so of our COVID patients are discharged home.

The ones who do get admitted are usually fairly sick. I wasn’t here during the early days of COVID in 2020, but I did work in the COVID units in 2021. Many of them were in septic shock, had coagulopathies, and were in pretty bad shape. About one in ten of the patients admitted for COVID died. I really do think that the disease is less lethal than it once was, because in the past two years I can count on the fingers of one hand the patients I have seen die from COVID, with at least two of them having cancer and one of them refusing all treatment because he didn’t believe that COVID was real. Right up until he died, he insisted that we were making it up and purposely making him sick so we could make more money. Just two weeks ago, I had a patient telling me that COVID wasn’t real, and it was all a conspiracy that the doctors were using to make more money. I told him, “OK, well, you have COVID and we are discharging you home. If you feel worse, come back in. Other than that, drink lots of fluids and get some rest. Here are your discharge papers. I hope you get better soon.”

To be honest, that’s all you can say to people who won’t listen to reason.

As a related note, I want to take a minute to describe and explain Remdesivir.

I already said that viral replication uses the cell’s own manufacturing system to make copies of the virus. The virus in this case is a segment of RNA. How Remdesivir works is that it terminates the RNA transcription that SARS-CoV-2 requires in order to replicate itself.

In late August of 2020, patients who received Remdesivir made a high number of reports of liver and kidney problems. This was due to the government not testing this drug in clinical trials, upending decades of precedent in approving medications. For that reason, many hospitals required patients to sign a statement of informed consent following a full disclosure of the risks and benefits of receiving Remdesivir. At least at my hospital, all patients who received the drug after October of 2020 or so had to sign this consent form.

Now you know.

By Divemedic, ago

Figures Don’t Lie, but Liars Figure

Interesting article in the Guardian on FBI crime statistics. The left is pissed because crime is going down, and this will make it harder for them to pass laws that are soft on criminals while still allowing them to outlaw guns. They can’t have that, so they are going to blame Ron DeSantis.

“The issue of crime is deeply weaponized and politicized and we see that come up especially during election cycles. Florida has very incomplete data but Governor Desantis’s campaign is stating they’ve made Florida the safest state.”

In Florida, only 8% of the police departments are represented in the 2022 data, according to the Marshall Project.

The real money quotes are located towards the end of the piece.

  • Black Americans, who make up 13.6% of the population, accounted for 56% of the more than 16,000 homicide victims in the US.
  • of the 19,200 weapons used to kill someone in 2022, 15,000 – or 77% – of them were a firearms, usually a handgun.

Let’s take a look at the FBI Report and see the data for ourselves. The FBI numbers themselves seem to have some confusion in them that isn’t due to spotty data.

First, race. There were 8,694 homicides committed by blacks in 2022, out of a total of 16,724 homicides.

Let’s look at just homicides. Of the 16,724 homicides, 5,803 (34%) of them had handguns listed as the means. That’s on the “crime” page with homicide selected as the crime.

Now look at the “expanded homicide data” page, and you see that 7,937 homicides were committed by handguns out of a total of 19,200 homicides (41% of homicides). Why the discrepancy? Why are there 19,200 homicides on one page, but the same dataset on a different page says there are 16,724? How can we trust these numbers?

Even so, looking at the data. There were 542 rifles (<3%) of all types and 186 shotguns (<1%) used as homicide weapons. More people were killed by “unarmed” assailants than were killed by assailants with rifles.

The obvious answer here is to make it illegal for black people to own guns. That would have prevented far more homicides than banning concealed carry or banning “assault weapons.” Wait, you say that’s ridiculous? I agree. Gun bans won’t stop evil people from doing evil things.

By Divemedic, ago