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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

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.

By Divemedic, ago

Drugs

During the first few weeks of my new ED experience, I can tell you that the community of this new hospital has a larger drug problem than the last. At least a third of my patients have been on Meth or Tranq. Every patient that I have ordered a tox screen for has been positive for one or more of the following: opioids, Benzodiazepines, cannabis, or methamphetamines- in one case, even an 80 year old woman who came in unresponsive and wound up dying- she tested positive for benzodiazepines and cannabis.

In one day alone, I had four different patients come in that were combative because they were on Meth. One of them required 4 nurses, 2 paramedics, and 8 security guards to hold down. We wrestled with him for almost 45 minutes and had to give him 6mg of Ativan, 50 mg of Benadryl, and 10mg of Haldol before he took a nap.

By Divemedic, ago

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.

By Divemedic, ago

The Physics of Manslaughter

Today’s post comes from the UK, and I try not to talk about legal issues in other countries because I just don’t understand the laws in other nations, and don’t want to stick my nose in them. The difference here is that the case involves some technical issues of SCUBA diving and of dive medicine, areas where I feel like I have some level of mastery. This is a technical post, so for those of you who are not interested in physiology and physics of SCUBA, this may or may not be interesting.

A diving instructor in the UK was teaching an experienced recreational diver a course on deep diving. The dive that they did was to 115 feet.

On this dive, they were diving at around 4.5 atmospheres, and this requires some level of care. I don’t see in this account where the instructor messed up, with the exception that I wouldn’t have had a student doing a check dive like this with an 80 cuFt cylinder (which is what the Europeans call 12 liter).

In this case, however, the government brought in a diver from the UK Navy as their expert witness. He testified that the instructor was wrong in three ways- the dive violated the rule of thirds, they were down longer than the dive tables dictated for that depth, and he held his struggling student underwater when the student was attempting to get to the surface, causing his death by drowning.

Let’s start by addressing each of these in turn. The rule of thirds. The rule of thirds is a rule that says you use one third of your air supply to get into the dive, one third coming out, and hold one third in reserve. This rule is generally only used when you are “diving in the overhead,” meaning that there is either a physical or physiological barrier that would prevent you from surfacing. A physical barrier would be diving in a cave, a shipwreck, or diving so deep for so long that you cannot surface because you have a decompression obligation to work through before you can surface. Neither of those was the case here. In that case, the rule is to ensure that you surface with at least 500 psi of gas left in your tank.

The second argument, that the dive tables’ “no decompression” limits for that depth had been exceeded is ridiculous. When you are a new open water diver, you are taught to use tables, but no one, and I mean no one, follows them. The invention of dive computers has rendered them obsolete. The reason for this is that the dive tables assume that you descend at the maximum safe rate from the surface to the maximum depth, then ascend at the maximum safe rate to the safety stop. This is called a “square profile” and no one dives like this in real life. A dive computer monitors your depth every 30 seconds or so, and gives you “credit” for time spent at shallower depths. This has the effect of more than doubling your permissible dive time. Everyone today “dives their computer.”

A great example of this is the standard dive on Florida’s coral reefs. Off the coast of West Palm Beach, there are several reef lines. The most interesting one from a SCUBA perspective is about a mile or so offshore, in 60-100 feet of water. If you were to dive the top of that reef, the tables say that you can spend a maximum of 40 minutes at 70 feet of depth before exceeding the no decompression limit. Most divers will spend a minute or two at that 70 feet, maybe 5 or 10 minutes at 65 feet, then more time at 55 or 60 feet, etc. The result is that divers with computers might well spend 55 to 65 minutes and still not exceed decompression limits. The Commander would have known this, himself being a certified PADI divemaster.

Instead, he contends that the “out of air” situation was so dire that the diver should have been permitted to make an unrestricted surfacing, despite the fact that the student was breathing on the instructor’s plentiful air source. Ridiculous.

I actually did this exact dive here in the states when I got my own extended diving certification some years ago. It is standard practice at the end of any dive that is deeper than 40 feet to stop at a depth between 15 and 20 feet for three minutes. This is called a “safety stop” and is intended to give any gases that have been absorbed in the blood time to diffuse out of the blood and prevent hyperbaric injuries. It’s recommended by each of the three big certification agencies. (NAUI, PADI, and SSI)

Another protocol that some divers follow is to stop for one minute at half of your current depth. So if you had been at 120 feet, a one minute stop at 60 feet is followed by a one minute stop at 30 feet, followed by a one minute stop at 15 feet. No matter how you do it, coming up as slowly as you can is how you avoid hyperbaric injury.

In fact, three of the dive accidents that resulted in injury, and the only diving fatality I have ever been present for was related to a diver ascending too quickly. The physics and physiology of breathing pressurized gases is technically demanding, especially so when diving to depths below 99 feet. Safety stops are VERY important, especially when you are diving at pressures higher than 4 atmospheres of pressure (99 feet).

I myself have had four diving emergencies that required either emergency surfacing or my buddy’s intervention. Three of them were due to equipment failure, and one because I was a moron. One of them required sharing air. We still had time to do our safety stop.

Even so, it’s obvious that the prosecution wanted to railroad this guy. The student in question had a history of high blood pressure, and the autopsy showed that he had alcohol and cocaine in his system. None of this was known to the instructor at the time of the dive.

In this case, the signs of immersive pulmonary edema were there. For those of you who may dive, or who may work in the medical field, pay attention. Immersive pulmonary edema is very similar to the flash pulmonary edema seen with heart failure patients who are suddenly taken off of CPAP. It’s complicated by the changes in pressure caused by depth changes messing with the Renin-Angiotensin-Aldosterone System (RAAS), which regulates blood pressure. Also adding to the complications is the creation of nitric oxide that occurs with sudden pressure changes in SCUBA diving. In patients with hypertension, heart problems, or kidney problems, this combination can be life threatening.

The signs were there: The student was easily winded with mild exertion, he couldn’t perform underwater navigation while at depth (indicating possible mental status changes from hypoxia), and was complaining that he wasn’t getting any air, even though everything was working perfectly ( a sign of shortness of breath). If he was taking an ACE inhibitor for his high blood pressure, this could even make this condition worse.

So how do you treat this? While diving, adopt the rules that I have always followed:

  • Any diver on any given dive can terminate the dive for any reason. This is done by giving any diver in your group a “thumbs up” sign, and is called “thumbing a dive.”
  • Any diver having apparent confusion, disorientation, or an equipment problem should cause the thumbing of the dive.
  • Any diver having shortness of breath should be placed on oxygen as soon as they are on the surface.
  • On the way down, take a few seconds at 65 feet or so to get organized. Look each other in the eye and make sure everyone gives you the “OK” sign.
  • At any dive below 60 feet, make sure that you do your safety stops.
  • Follow other safe practices like ascent rate, NDL limits, and make sure that everyone is diving within the limits of their training and experience.

My Qualifications

My Internet handle has been Divemedic for more than two decades for good reason. I am a certified Master diver, deep diver, mixed gas diver, public safety diver, and Rescue diver. I am certified by all three of the big US recreational SCUBA training agencies at one level or another: NAUI, PADI, and SSI. I have been SCUBA diving for about 30 years. I used to be on a professional dive rescue team. I have been employed at various times as a rescue and salvage diver and had more than 2,000 dives in my logbook, representing more than 900 hours underwater before I stopped bothering to log them, 16 years ago. Enough dives that I have literally worn out a few sets of equipment. I have been present for half a dozen dive casualties, one a fatality. So I understand many of the issues. With that being said, let’s get into the post.

By Divemedic, ago

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.

By Divemedic, ago

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?

By Divemedic, ago

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.

By Divemedic, ago

What is Commotio Cordis?

Athletes are more prone to sudden cardiac death and arrhythmias than nonathletes. Sudden cardiac death in athletes is rare in the absence of heart disease, with the exception of commotio cordis. It is common enough amongst athletes that commotio cordis should be suspected if an athlete collapses suddenly after a chest impact and is unresponsive. So what is commotio cordis?

The heart is driven by the movement of electrolytes across the cardiac cell membranes. That movement is controlled in part by electrical signals, in part by pressure differences, and in part by small channels in the cell membranes that open and close, called ion channels. This complex dance can be measured by watching the electrical impulses that are caused by the movement of those electrolytes. That organized movement of charges causes organized muscle contraction, causing the heart to pump blood. It looks like this:

In the above diagram, note that each peak is labeled, and each of the small squares in the horizontal plane represents 40 milliseconds. You will note that the normal cardiac cycle lasts about 360 milliseconds in our example.

An impact to the area of the chest that includes the cardiac silhouette during the 10 to 30 milliseconds before the highest peak of the T wave that causes a pressure wave to wash over the heart, if that pressure wave is between 4.8 and 9.6 psi, can stretch some of those ion channels to the point where some will open when they are not supposed to. (Mostly the K+atp channels) That in turn causes some electrolytes to move, creating random movement of electrical charges. It changes a heart rhythm from the organized one we are all familiar with to the one below:

In order for this to happen, the impact has to occur within a narrow timeframe (20 ms wide out of 360 ms total) and within a narrow pressure range. Too low, and nothing happens, too high and you get a cardiac contusion and tissue damage.

With these rather strict parameters, the phenomenon still manages to happen about 20 times per year in the US, usually with fatal results. It’s mechanism is well documented and mostly understood. More than 90 percent of the time, the victims are men. More than 85% of the time, the victims are between the ages of 13 and 20. This is mostly because the vast majority of people who participate in contact sports are males between 13 and 20 years old.

There is a genetic correlation. People with known long QT syndrome in their family history are known to be more susceptible to this- for example, Brugada syndrome. We all have heard of athletes periodically dropping dead during and after practice. It’s one of the reasons why high school and college athletic facilities are equipped with AEDs and why some states require that athletes be screened for long QT before they can compete in school sports.

Look, the vax is certainly causing some unexplained deaths. If you want to be convincing, you have to be able to tell the difference between what is a sudden death and what is normal background. You aren’t going to convince people if you are sounding like an ill informed moron with a political axe to grind. Think of how the anti-gunners look when they start talking about “shoulder things that go up.”

Be informed. Don’t come across like a paranoid moron.

Sources for this post:

Athletes and Arrhythmias. Journal of Cardiovascular Electrophysiology. 2010

Commotio Cordis: Ventricular Fibrillation Triggered by Chest Impact–Induced Abnormalities in Repolarization. ADVANCES IN ARRHYTHMIA AND ELECTROPHYSIOLOGY, the American Heart Association. 2012

Fatalities in High School and College Football Players. The American Journal of Sports Medicine. 2013

Incidence of Sudden Cardiac Death in National Collegiate Athletic Association Athletes. Circulation, the American Heart Association, 2011.

Pathophysiology, Prevention, and Treatment of Commotio Cordis. Current Cardiology Reports. 2014

Sudden Cardiac Death in Athletes. Methodist Debakey Cardiovascular Journal. 2016

By Divemedic, ago