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.

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.

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?

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.

Now They Tell Us

I took Ivermectin and HCQ when I got COVID. It sure didn’t hurt. It may have helped, I don’t know. It’s hard to tell when there is an illness with a 99% survival rate.

Vaccine Banned

The CDC has banned the Johnson and Johnson COVID vaccine and ordered all health care providers to destroy all remaining doses. I will say that I remember when claiming this vaccine was bad for you would get you a ban from social media. I’m betting that the friendly folks at the CDC and in government knew this all along, since they gave themselves AND the vaccine manufacturers complete immunity from all legal liability.

I will begin this by saying that I got the Moderna vaccine. I don’t regret getting it, because no one I know suffered ill effects after receiving it. At this point, I will not suggest that anyone take another dose of any of the COVID vaccines.

All of society, all of civilization, relies on trust. You trust that the person behind you won’t shove you onto the subway tracks. You trust that the cars in the oncoming lane won’t swerve into your path. You trust that the person who just cooked your meal in the restaurant didn’t poison your meal, or that the waiter didn’t spit in it.

Like society, the entire scientific community, the entire medical community relies on trust. You trust that the supplies in the package that says “sterile” actually IS sterile. You trust that the vial labelled as “dopamine” doesn’t contain something else, and that it actually will work for its intended use.

Likewise, when other medical professionals tell you that a vaccine is safe and effective, you have no choice but to believe them, because a failure in that trust means that the entire system will fail.

Believe it or not, nearly every medical professional got into the medical field because they want to make a difference. They want to help people. Only a person that is truly psychotic would deliberately harm someone else, but that is exactly what the CDC and the rest of the government has done.

Not only did they make the choice to deliberately harm people, but they did something that is far, far worse. They damaged the trust that underpinned the medical profession, and by extension, all of civilization. This was a deliberate attack. Not just a biological warfare attack, but an attack on the very fabric of our society.

EDIT: Now that Godwin’s law has shown its head, comments are closed.

Teaching Pigs to Sing

A report has come out, showing that math and reading proficiency dropped nationwide during the COVID lockdowns. Maryland students have the lowest test scores in reading and math of any US state or territory, with only 19 percent of Maryland students performing math that is appropriate for their grade level. Some schools in Baltimore had NO students who were proficient in math.

It doesn’t take long to figure out why. The scores are available online. It isn’t that the test is too hard or that teachers in general aren’t doing their jobs- there are schools in Maryland that had 91% of students proficient in math. In general, whites and Asians score higher on standardized tests than do other races, and the more affluent a student is, the higher the test scores.

The 5 cities with the best scores (racial makeup, median household income) were:

  • Bethesda: 88 percent white and Asian, $173K
  • Ellicott City: 83 percent white and Asian, $136K
  • Clarksville: 87 percent white and Asian, $161K
  • Rockville 68 percent white and Asian, $116K
  • Glenelg 88 percent white and Asian $181K

Some would see that and think that there was racism involved. That is what “equity” is all about- looking at outcomes, then trying to make them the same, but that is simply saying that correlation means causation. Instead, let’s look at the correlation and see if we can find the causation.

Parents who make more money do so because they value education, hard work, or some other trait. That doesn’t always mean college- it can mean trade school, learning to run a business, something. Those parents are also clever or intelligent, which is inheritable. The point is, parents who make money tend to impart the values that made them successful upon their children. Parents who are not successful pass their traits on as well. So children in affluent households tend to be successful. The children in poor households tend to be less successful.

How do you fix this? School and teachers can’t. Teachers who are with a student for less than 1100 hours a year can’t fix 18 years bad parenting coupled with the handicap of losing the genetic lottery. All of the programs in the world won’t turn a student with a 75 IQ and no motivation into a scholastically successful person. In that case, you are doing nothing more than trying to teach a pig to sing.

The other thing that I would like to point out is that the response to COVID had an effect on an entire generation of students, who lost learning opportunities that will hurt them in lost learning gains, thereby affecting them for their entire lives. The knowledge gap that they have as a result of missing a year or more of school will cause them to play catchup for years.

Back Pay

So now the military wants to reinstate those who were kicked out for refusing the vax, complete with back pay. So what happens to those who were kicked out, but whose normal EOAS date has since passed? Do they still get their checks? Or is it only the ones who agree to be reinstated?

But who says that any of them want to serve under the freak show that is their chain of command?

This One is a Better Example

Everyone who reads this blog knows that I don’t think that the collapse of Damar Hamlin had anything to do with the vax. However, if you want to see a great example of the collapse of a young athlete, look no further than the collapse of Old Dominion sophomore point guard Imo Essien. He collapsed about halfway through the first half a basketball game after having trouble catching his breath.

The team will be sending him to see a cardiologist before allowing him to return to play. Twenty year old collegiate athletes don’t typically collapse from idiopathic cardiac events. Granted, there is no evidence either way as to his vaccine status, but it would certainly be something to keep an eye on.

The pro vaccine folks are already calling it fake news because it isn’t like the collapse of Hamlin, but in my opinion the fact that it isn’t like the collapse of Hamlin is exactly WHY it needs to be looked at.