Medical News

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

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

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

What is Cancer?

Since many of you don’t seem to understand my problem with Somers and her cancer plan, perhaps a bit of a lesson in what cancer is will help. This is simplified for ease of understanding and for brevity, but you will get the point. Even though simplified for brevity, this is still a much longer post than I usually make. Cancer is a complicated subject.

Normally, your cells do their job. Each cell has a job to do, and they sit there and happily carry out their cellular business 90-96% of the time. During this time, a cell is very busy synthesizing proteins, copying DNA into RNA, engulfing extracellular material, processing signals, whatever its job is. The rest of the time, 4-10% of the time, the cell is busy copying its DNA and dividing to create its own replacement in a process called mitosis. Mitosis happens about once every 24 hours, on average. Some cells like hair follicles do it more often, while other cells like nerve cells, less so.

Your DNA is like a novel contained in the nucleus of your cell. It contains all of the information that your cells need to do their jobs, live their lives, and carry out everything that your body does- from your intelligence, to your looks, your health, and even your behavior. It’s all programmed in there using “words” spelled with chemicals called base pairs. These base pairs are made of four “letters”- G, C, A, and T. There are 3.2 billion of these letters in human DNA. They each must get copied when the cell undergoes mitosis, and they must be copied with complete accuracy.

The process of copying their DNA so the cell can carry out mitosis is incredibly accurate. The error rate during DNA replication is as low as 10^−9 to 10^−11 errors per base pair. Errors can be caused by exposure to chemicals that alter the DNA, by certain viruses, by ionizing radiation, or simply a bad chemical reaction. There are “checkpoints” built into the process that detect and correct errors in the DNA replication and will halt the process or even cause the cell to die if correction can’t be done. Cells are programmed through their DNA to only copy themselves a limited number of times before they die off in a process called apoptosis. They will also undergo apoptosis if errors in this DNA copying process happen.

Sometimes, there are errors that slip through. Most of the time, these errors aren’t a big deal. Sometimes they are, and that is what causes cancer. When this happens, there are processes in your body’s immune system that are supposed to locate and destroy these out of control cells, because cells damaged by cancer release a chemical called tumor necrosis factor (TNF). More on that in a future post.

Cancer cells flip the whole mitosis process on its head. They not only fail to undergo apoptosis, they also spend most of their time in mitotic division- making copies of themselves. They multiply out of control, creating tissue that is using more and more of the bodies resources as they multiply out of control.

So cancer is a failure of two parts of the body: the cancerous cells that have lost the ability to undergo apoptosis through a transcription error that appears in their DNA, and the immune system whose job it is to find and eliminate cancerous cells.

There are no magic foods that halt this process, because it is an error in the DNA of the cancerous cells that are causing the problem, and once there is a “spelling” error, there is no way to correct this spelling error in a cancer cell’s DNA. The best you can do is kill off the cancer cell. The “daughter” cells, being an exact copy of the cancerous cell, will also be cancer cells.

The tumors eventually grow large and numerous enough that they use up all of the organism’s resources. This is why cancer patients begin losing weight and looking so sickly. The tumors are spending so much time and energy replicating that there aren’t enough resources remaining.

There are a few ways to get rid of cancer. The main ones are:

Surgery. We use surgery to literally cut tumors out of the body. This doesn’t cure the cancer, it merely lowers the size of the tumor, and thus the energy requirements being used up by the cancer. The issue is that surgery can’t possibly get every cancer cell, so all this does is buy time.

These multiplying cells create their own environment- they cause the body to create new blood vessels to feed the growing tumor in a process called angiogenesis. There are drugs that prevent angiogenesis, and taking these causes the tumors to be starved out.

The growing cells also have one exploitable flaw- they are spending so much time multiplying that they don’t have time to repair damage to themselves. This can be used to our advantage. That’s what chemotherapy and radiation therapy do- they damage all of the cells in your body. The healthy cells then repair themselves in between sessions, the cancer cells do not. The more sessions of chemo or radiation that you undergo, the more unrepaired damage is done to the cancer cells, and the cancer can eventually be killed off this way.

No treatment is 100% effective at eliminating cancer, because no matter how effective, there will always be a cell or two left that the treatment didn’t eliminate. The earlier that a cancer gets detected and treatment begins, the better the results. Although there are no curable cancers, melanoma, Hodgkin lymphoma, and breast, prostate, testicular, cervical, and thyroid cancer have some of the highest 5-year relative survival rates. The 6 cancers with the lowest survival rates are lung cancer, liver cancer, brain cancer, esophageal cancer, stomach cancer, colon and rectal cancer.

Since everyone is different, and so is the DNA error that causes the cancer, each person and each cancer will respond differently to treatment. That’s why one person can get breast cancer and survive, while another does not. This is why people like Suzanne Somers live for twenty years, while someone else doesn’t. Writing a book about how your special diet is the reason why you aren’t dead yet is a complete scam. You are alive because of the random chances of fate and the simple mathematical variances of chance, not because you have the cure for cancer by eating beet roots.

What makes her claims of a cure so despicable is that the people who forego medical advice to try her cure frequently discover the truth that it doesn’t work months or even years down the road, and it is then too late for them to be treated for what may have been a cancer that was easily treatable.

By Divemedic, ago

Government Screws Things Up

When government gets involved in anything, they screw it up. Maybe on purpose, maybe not.

Do you run around and scream that gun stores can’t be trusted? Or do you place the blame where it lies: with that individual, or with the government that made the law that caused the policy? Do you recognize that it is unfair to ask someone to forgo their livelihood so you can circumvent a law with which you disagree?

Do you then blame the pharmacist for not giving you drugs without a prescription?

There are plenty of laws with which I disagree. Some of them even dictate my behavior at work. We all have that happen. A friend who works at the county health department recently had a guy throw used needles at her because she wouldn’t accept them for disposal unless they were in an approved Sharps container. (Even though I happen to agree with that law)

When I was a paramedic and posted on a now defunct gun board, I was accused of being a “jackbooted thug” because I disarmed a patient who had sustained a head injury in a motorcycle accident and was carrying a pistol. I transported him to the hospital with his gun in his backpack, which I put in the cab of the ambulance. Why? Because people with head injuries aren’t in their right mind, and will often get violent because of the “fight or flight” response. It was for everyone’s safety. If I had gotten the cops to take that gun, he likely wouldn’t have seen it again. Believe it or not, I did the guy a favor.

The same accusation was made against me when I said that we occasionally take people to the hospital against their will, for example people who are threatening suicide or who have had a head injury or stroke. Why? The law says that they aren’t in their right mind and don’t have the capacity to make informed decisions. I did a post on that back in 2010. I am a firm believer in patients making their own decisions after being presented with the facts. The only thing that we truly own is our bodies, and we have every right to control them. However, a person who is not able to make an informed decision still has a moral right to receive care.

So why do I bring that up? Because the job that I work in is FAR more regulated than the firearms industry. I don’t make the rules, and neither does anyone else in the hospital. We are dictated to by a lot of agencies: CMS, AHCA, the Joint Commission, state nursing board, DOH, tons of agencies. They run everything from what medications we give to how much we can charge for what we do. If you don’t follow the rules, you lose your license and can be barred from ever working in this field again.

So I disagree when people blame the medical field for what happened in 2020 with COVID. The lockdowns, the vax mandates, all of that nonsense came from the government. Don’t think I am just defending myself and my actions here, because if you will recall, I didn’t return to the health care profession until 2021.

The TikTok dance videos? They were stupid and damaging to the reputation of the medical field, but when you understand that the videos were coming from the outpatient surgery centers that were shut down as a result of COVID mandates, that makes it a bit less shocking. Then consider that surgical nurses aren’t the same as ED or ICU nurses. It takes a year at minimum to train an RN to a basic level of competency in emergency medicine, and that’s a year after licensure, on top of nursing school. It’s a complicated subject that takes years to master. So those nurses who weren’t in fields like the ED, ICU, or ECMO were left with nothing to do and made stupid videos. Still not a damning indictment of all medical professionals.

No, what the people who comment on here about how COVID was the fault of doctors and nurses don’t seem to grasp, is that the lockdowns, the mandates, all of that were the fault of government wannabe dictators getting their tyranny on.

Crying about the way COVID was treated shows a complete lack of understanding of respiratory illness and its treatment. Health professionals were doing what had always worked for respiratory illnesses in the past.

Those treatments worked until COVID came along. Scientists have found that a section of the genetic material that makes up the COVID virus genetic sequence was patented by Moderna for cancer research purposes in February of 2016. The sequence is 19 base pairs long, meaning that there is only a one in three trillion chance that the virus happened naturally. It just so happens that this engineered sequence gave the virus a special affinity for human lung tissue. That makes COVID fall firmly into the category of a biological warfare agent.

Then the shutdown and the turmoil that followed was an engineered crisis that in my opinion was designed to put Joe Biden in the Whitehouse. I have posted on that as well.

So don’t come on here and disparage what the medical professionals did for the COVID outbreak. It isn’t them that caused the problems- it was the people that YOU elected and put in charge. Government receives power with the consent of the governed. What have you done to change what is happening?

Have a problem with it? Get the law changed. You say that you can’t? What makes you think that I can?

By Divemedic, ago

Teens and Consent

I agree with Fenix Ammunition on this one.

The law on this really sucks. If a 12-17 year old comes to the hospital, we are legally not permitted to discuss anything involving reproductive health with anyone that the patient (child) hasn’t permitted, including the patient’s parents.

It gets even more confusing. Let’s say that a 17 year old girl is involved in a car accident. Let’s look at a few scenarios:

  • Being a minor, she legally cannot refuse medical treatment and must be transported to the hospital, even over her own objections.
  • If she is pregnant, she can refuse care because the car accident can affect the unborn child, so she is considered to be an adult
  • If she has a baby in the car but is not pregnant, she can refuse medical care for the baby, because she is the child’s mother, but she cannot refuse care for herself because she is a minor

This is what happens when the government gets involved in anything. They always make it muddier and more screwed up than it needs to be.

By Divemedic, ago

Organ donation

I got an email asking about this, so here is my take:

Whenever a person is about to die, let’s say that they are brain dead but on life support, the hospital will evaluate the patient’s record to see if they are an organ donor. Whether they are or not, the organ donation people will be contacted. That organization will then determine if the person is a candidate for donating organs (not everyone is medically capable of donating their organs.)

If the person has previously agreed to be an organ donor, the person will immediately be screened to see if they are a match for anyone on the recipient list. The transplant team in the recipient’s hospital will be contacted, and they hop on a plane to harvest the organ.

If the person hasn’t indicated either way, the organization will contact the next of kin and attempt to gain consent for organ donation.

No one is taking anyone’s organs without consent. All the organization is doing is acting as a coordinator for the process. If you don’t want to be an organ donor, make sure that you indicate your wishes in your will or living will and make sure that your next of kin is aware of your desires. It’s up to you.

With that being said: No, the hospital doesn’t change your care if you are or are not an organ donor, other than keeping a person that is brain dead on life support a bit longer before “pulling the plug” so as to preserve some of the more sensitive organs like heart or liver. No, it isn’t like signing a DNR.

They aren’t less likely to try and save you for increased profits or anything like that. Chances are, the recipient of your donated organ is hundreds of miles away in another state. As an ED nurse, I work a lot of codes. I do not know, nor do I care, what your organ donation status is before I call your code.

The only thing this is for is to save lives by giving people with defective organs a shot.

A great example of this: A guy comes into the ED by EMS and is brain dead due to some sort of accident. He isn’t savable, his brain is gone, but he is otherwise young and healthy. Why leave his organs to rot when so many people need donations? So the organ donation people get a call, and those people review the record to see if he is an organ donor. If he isn’t, they will try to gain consent of the next of kin. Either way, once they gain consent, they will send out the notifications to the appropriate recipient teams.

Nothing nefarious. It’s all consensual, and it doesn’t change the potential donor’s care one whit.

By Divemedic, ago

So What Are You Doing About It?

Republicans are complaining that nursing schools are teaching nursing students to ask children about their gender orientation. The thing about that is, it’s their own fault. The reason why so many hospitals and other health care institutions are doing this is because…

It’s the law.

Section 1557 of Obamacare prohibits discrimination on the basis of race, color, national origin, age, disability, or sex (including pregnancy, sexual orientation, gender identity, and sex characteristics). So to the Republicans- if you don’t like it, what are you doing about it?

The Democrats see something that they don’t like, and they fight to change it. The Republicans see something that they don’t like, and they… do nothing but bitch and complain.

It took a maverick like Donald Trump to fix the number one target of Republican ire- abortion, and they hate him for it. The Republicans need to stop being useless power mongering whores and actually do the job they were elected to do.

By Divemedic, ago

How the Sausage is Made

From SocoRuss

Do you think you could do a post about what you see as a medical person and covid. We hear from the govt and CDC we are all going to die and the latest variant will wipe out the world so we should hide and take the next 27 booster shots . We dont get to hear that much from someone like us who who skips the bullshit. But what are you seeing? Are you see large numbers of cases, how severe are the cases, what type of people are coming in? The healthy, the old and weak, the immune compromised? Is the large influx of illegals the cause of the number to rise? The big question would probably be who is getting covid more now, the vaxxed or unvaxxed. there seems to be more and more doctors studies saying the vaxxed are getting covid more now, whats the truth?. Whats you opinion and advice on this? I think a lots of your readers would like to hear this also.

OK. My ED sees between 200 and 300 patients per day. We are seeing about 50 to 60 people who have respiratory complaints each day. The majority of them wind up with cardiac, emphysema, COPD, and other infections like pneumonia and the flu. About 15-25 of those 50-60 wind up being diagnosed with COVID. How does that happen? The following is going to be a bit heavy in technical details, but I will simplify it as much as I can, so that it is more understandable.

We are a protocol driven hospital. Under the law, nurses can’t do anything that they aren’t ordered to do by a doctor. So hospitals using protocols have a set of SOPs that nurses enter into a patient’s chart, and a doctor (or other provider) signs off on it. These protocols can be entered by the nurse that is using their professional judgement, or they can be initiated by the nurse after being alerted by our computerized charting system generating a “best practice advisory.”

Hospitals have something called SIRS criteria, as pretty much every hospital in the nation does. When a patient arrives in the ED, they are initially triaged. The computer (and nurse) looks for the following:

  • Body temperature over 38 or under 36 degrees Celsius.
  • Heart rate greater than 90 beats/minute
  • Respiratory rate greater than 20 breaths/minute
  • partial pressure of CO2 (either end tidal or arterial blood gas) less than 32 mmHg
  • Leukocyte >12000 or <4000 per microliter
  • >10% immature forms or bands

If the patient has two or more of the above, the nurse will enter a standardized set of orders for tests. Those tests include tests for lactic acid, a CBC, CMP, and if appropriate, COVID/Flu tests, urinalysis, and other tests. If the nurse doesn’t enter those orders, the computer will alert them that it is best practice to do so. If the nurse STILL doesn’t do so, the computer requires them to enter a note in the patient’s chart explaining why they didn’t. The system is designed to do this so as to prevent human error from missing something important. Once those orders are entered, a e-note is sent to the provider (doctor, nurse practitioner, or physician assistant) who is in charge of that patient, and they will sign off on those orders. It’s a quick, efficient system that is designed to be safest for the patient.

If any of those tests or a physical exam shows that an infection is also present, the patient is said to be positive for Sepsis criteria. This activates an entire other process. Every attempt is made to identify the particular pathogen involved, but the important thing is to start aggressive treatment at that point, before the patient goes into septic shock. So they get IV fluids and probably antibiotics while we are waiting for the results of testing. Time is of the essence here.

If a patient tests positive for Flu A or B, or COVID, they follow a different path. They don’t get antibiotics. Flu patients get flu drugs like Tamiflu. We check COVID patients to see if their blood is clotting normally (INR, PTT, and other similar tests), they get a chest Xray, and we monitor their oxygen saturation. They get some IV fluids, and oxygen (if indicated) and that’s it.

Does this sound like familiar advice? For decades, we have known that viral respiratory illnesses need fluids and rest. Remember that water is nature’s expectorant. It thins out respiratory secretions so that they are thinned enough to be easy to cough out. If you are sick enough to meet SIRS criteria, you likely haven’t been drinking enough water, so we give you a liter or so of either Normal Saline (0.9% NaCl in water) or Lactated Ringers solution. The vast majority of them get sent home after being monitored for a couple of hours. Occasionally, one will get admitted, maybe one or two a day.

The demographics haven’t changed a whole lot. The ones who are the sickest have underlying conditions like cancer, advanced cases of diabetes, COPD, or other inflammatory or respiratory diseases. My hospital doesn’t see a whole lot of illegals, so I can’t comment there. COVID vaccine status doesn’t seem to matter one way or the other. I really don’t think that the vaccine does anything. That’s why I got the first series back in the spring of ’21, but haven’t gotten anything since. (I had COVID twice just a couple of months after I got vaccinated. I haven’t worn a mask since, yet I have been exposed to COVID at least once every working day, and haven’t gotten shit.)

I haven’t seen a COVID death in at least six months. We admit a few, but the VAST majority are treated and released. I will say that we are getting more cases lately, but I don’t see the cases we are getting now being as severe as the ones from 2020. I think that this is because of a few things:

  • We know how to treat COVID now. That wasn’t true three years ago.
  • COVID already killed off the weakest and sickest.
  • The original strain of COVID was the most virulent, IMO. These new variants are not as deadly as the first one.

We have had a lot of staff testing positive for COVID. We had 15 call ins just in the ED staff on the last day that I worked. It seems to be going around and is more contagious than before, but it seems to be no worse than the flu. I have been beefing up my immune system in the meantime by taking vitamins (especially C, D, and E), calcium, and zinc, trying to be a bit proactive.

Understand that this is the experience of one nurse in one hospital, and we all know that anecdotes are not data.

By Divemedic, ago