purplekow

Once again, last night, before bed, I checked the computer charts of my patients and again there was a patient whose condition had turned for the worse. The elderly woman who first triggered me to write had become more short of breath and was requiting more oxygen. During the day she had seemed a bit worse and I contacted her daughter to let her know about the developments and to set a plan for further care should things continue to worsen. That plan included the patient's wish not to have mechanical ventilation or cardiac resuscitation. That plan also included arranging for a FaceTime visit. Her daughter told me she had not seen her mother for two weeks as she was being extra careful not to bring the virus to her. Unfortunately, one of the patient's caretakers was not as scrupulous and came to work with upper respiratory symptoms. Soon after that day, the patient first became ill. Now it had been two weeks since she had seen her mother and as they are not allowing visitors to the hospital, she would not likely see her again. The daughter said that she really wanted to speak to her mother one last time and could a FaceTime be arranged. It is a sign of this situation that this request had already been completed several times before for other families, allowing family the comfort that would usually accompany a held hand and a stroked cheek, and perhaps an eye opening with a final loving look. Most of this is either impossible or unlikely with a phone visit, but at least there would be a chance to see her mother, a chance for her mother to hear her daughter's voice. That visit lasted about 10 minutes and the daughter was able to say: "Good bye Mom. Don;;t ever forget how much I love you.: The phone switched off and I am sure tears flowed on the other end, but on our end, the patient continued to breathe fitfully and she was given some morphine to ease the breathing and air hunger. Several minutes later, the patient's son called and announced that he held the power of attorney and he wanted to know why more wasn't being done to help his mother. He lambasted the resident who had returned his call and told her he wanted his mother on higher flows of oxygen. Despite the residents reasonable answers, the son was having none of it and the call was terminated when he threatened to sue her and everyone else concerned in the care. Throughout that call the patient lay impassive and breathing without any difficulty, the morphine having worked, at least for now. All that had transpired between 7 and 8 PM and now, at midnight, she was starting to breath fast again. She did require high flow oxygen and she appeared uncomfortable. She was given additional morphine and returned to her previous sedated state. In between all this, two other patients were admitted both of whom, I saw in the morning. One, a clean living, otherwise healthy 64 year old Hispanic gardener and the other a 90 year old who came with a swollen foot which was red. The gardener had been diagnosed with Covid 19 7 days ago and had very slowly gotten more short of breath. He was on no medications and so he was quickly started on the usual regimen for this disease. It is strange to say usual regimen for this as 7 days ago there was no regimen and 7 months ago there was no disease. He was responding well. He was alone here, his family back in his home country. We spoke a bit in Spanish, as despite his long tenure here in the US, 14 years, he said he spoke little English. I have found in the past the best way to get Spanish speaking patients to speak to me in English is to speak with them in Spanish. My guess is they figure if I am not ashamed of my American Spanish, they should feel confident in their English, which usually is more than sufficient. This time however, that technique did not work and so I got the remaining details in Spanish. He was definitely tired, a bit short of breath and requiting of oxygen but he did not appear to be in any eminent danger. He wanted something to eat and as it did not appear that he was going to need intubation, he was given breakfast. i told him: "Portanse bien" loosely translated as behave yourself. It garnered a laugh, as it usual does and I was out the door, ripping off the gown, the face shield, the gloves and the masks. These days those o us in the hospital do not get to breathe unmasked breath very often and so the seconds between masks is a treat, a possibly deadly one but a treat nevertheless l The 90 year old who had come in with a swollen foot, looked to have a superficial infection and he could probably be treated with oral antibiotics. A test was done to check the blood flow in the foot and as that was sufficient and as the infection had already greatly subsided after one dose of IV antibiotics. we were going to tell him he was able to go home. It is interesting that this man was really very healthy for a 90 years old with only two medications, one for blood pressure and the other an occasional dose of the little blue pill. When I went in to see him, I told him that he was probably able to go home today he seemed genuinely happy. He then said, you know, I want to die. That stopped me in my tracks. Especially in view of other patients who now pleaded not to die. I asked him why he said that and he said that he had enough, that he was tired and that he did not feel the desire to go on. I questioned him about suicidal thoughts and ideas of hurting himself and he had none of those. He simply wanted to give up. I told him I would have someone come to speak with him about this and that he would not be leaving, at least until then, On any other normal day, I would have spent more time with him, but there were other patients to see and updates to incorporate and residents to supervise. We contacted the psychiatrist who, agreed to speak with the patient as soon as possible. So it was a long day, The elderly woman stabilized and was comfortable on morphine every 3 hours. the Gardner remained stable and felt a bit better later in the day. The elderly man with the Viagra as needed spoke with psychiatry and it came down to the fact that he was upset about living as his wife was dying from Alzheimer's. He though if he died, she would not know it, but if she died, his life would be over. He was kept overnight for further evaluation but he will likely go home tomorrow because the hospital is not a safe place for anyone, let alone a 90 year old. His foot was improving. The man who had told me he did not want to die did not die. He actually was fairly stable in the ICU. He was proning and his oxygen demands had not increased. His wife presented a particular set of social problems, but I will discuss that tomorrow. When I woke up this morning, the radio announced the death figures for Cover in NYC.. There was an announcement that NYC would be out of respirators come Monday. The first doctor to die from this disease in the US was an ER doctor in NJ, the radio reported, though he had never been tested. My temperature was 97.5. It was time to get out of bed and face the day.

I agree. He was my last hire two and one half weeks ago. I would certainly consider a third encounter but first there is this business of the pandemic and hopefully a rapid test that will allow more carefree hiring. There are rapid tests that take only 15 minutes but they are individual tests and requite special equipment. I am betting on a rapid test like a pregnancy test will be available. As to those who do not intend to hire. That is certainly an option, but are you now not going to have sex or are you merely going to be more circumspect about the persons with whom you have sex?

I know some of you are curious as to what is going on in the world, the numbers, the policies, the what ifs, the should have beens. I just want to give you an idea of what goes on down where the results of those decisions which have been made come home to roost. So I will be posting a brief update on what is going on here based on truth but changed enough so as to not have any patients identifiable. . At midnight last night, after I had written my patient notes for the day and before heading to bed, I got on line to check how my patients were doing so the number of surprises are minimal for the next morning. Just as I signed on, I notice one of my patients, a 51 year old man who had had Covid for 10 days and was at home and then started doing worse and had been admitted to the hospital 2 days ago, was reported as having a respiratory rate of 30. He was not oxygenating well and they had increased the oxygen and then changed from a nasal oxygen supplying cannula to a face mask. I called the hospital and spoke to the nurse caring for the patient. She had called the resident who was on call but he was in the room next door intubating a patient who was being sent to the ICU and being placed on a ventilator. She told me the patient, despite the numbers, looked significantly better than he had an hour ago. 6 hours early, when I left the hospital, he looked very well and when I spoke to him and then his wife by phone, I mentioned that he was doing better and a discharge to home might happen in the next few days. Suddenly, at 11:30 everything became worse. He still said he was well but clearly he was not. I asked the nurse to have the resident call me after the resident was done with his other patient. I scanned the other patient's charts and except for the elderly lady I spoke of in the beginning of this post, they all were fairly stable. The older woman was requiring more oxygen and was now a bit agitated whereas during the day she had been calm, sleeping, not easily roused. This kind of change in behavior is common in patients with dementia who are hospitalized or have a dramatic change in their environs. When I called her nurse, I was told the patient was just settling down and had shown some improvement. After an hour or so, the resident had not called and so I called back and spoke with him. The patient had responded well to the additional oxygen. His breathing rate had dropped from 35 to 20 and he was oxygenating well on the higher concentration of oxygen, The patient did not feel short of breath but when he was treated, he admitted to feeling more relaxed. The resident went off to work and I went to bed. It was about 3AM. At 7 AM I got out of bed and felt a bit warm and took my temperature as is that is now part of my morning routine. Wake up, hit the snooze alarm for another 5 minutes and then lay there as I take my temperature, listen to the news and generally see if body parts are working. Then I get up and into the shower. My temp was 99.3, Not a fever but higher than I usually have. I showered and as the water ran over me, I could not shake the temperature reading. I took it again. 99.5. Probably went up as a result of the how water in the shower. The phone rang and it was the morning check by the team leader. She told me that one of the local hospitals had closed to admissions and that we would be taking their overflow. I told her about my temperature and she quizzed me about my health, advised me to take it again and instructed me to stay home if I felt at all ill. I continued getting dressed. I told her I would drive over and if I felt unwell or the temperature was higher, I would go home. I arrived, I sat in the parking lot taking my temperature and contemplating that perhaps I had contracted the disease. It is a thought all the care provides I have spoke with about this have several times a day. Standing on an elevator, at a stoplight, any second that you are not otherwise distracted that thought can jump up at you. I suppose many people get that thought. The temp was down to 98.6 and I headed in. My first stop was the man who had had a bad turn the night before. He had improved before I went to bed but he was having some difficulty this morning. I was helpful on with my gown by the spotter that ensures that each person gowning up to see a patient is properly prepared. The patient had gone from droplet precaution which is basically a six feet away and basic protective apparel including a mask and gloves and gown, to aerosol protection because of the high rate of oxygen which aerosolizes the virus and gives it a wider spread in the room. So now it was gown, gloves,N95 masks, already in short supply at the hospital, I was reusing one I had cleaned and placed out in the sunlight. Sunlight may help kill the virus on surfaces and I had not worn the mask for a long enough time that it was probably safe to wear. Then a surgical mask, a plastic face shield and a quick entrance into the room. He greeted me with a smile but it was clear he was breathing more rapidly. After a greeting you might give a frequently seen acquaintance you meet on an elevator, we got down to the hard conversation. Things were not looking good. His oxygenation was poor. His respiratory rate was fast. His screening tests for activity of inflammation in the body were all going up after a few days of a plateau. I explained to him what this meant and then broached the subject of a ventilator. I explained to him that it was likely he was going to need to be placed on a ventilator. We would try to do everything to prevent or postpone that, but we needed to be sure that this is what he wanted. I told him there was no guarantee even with the ventilator that things would turn around. He half asked half implored why this was happening to him. I had no good answer so I gave him the answer that I had, which was that I did not know why some people do worse than others with this virus. I did not have the answer to the question as to why he had been doing well and then suddenly was not. I did not have the answer to how long he might be on a respirator if he needed one but I did tell him it would more likely be weeks rather than days. As to what he could do, all I could offer is that he lie prone, chest and abdomen down, as that seemed to aid in this situation. It is called proning. He had tried it before and could not tolerate it. I encourage him to do the best he could and that half the day each day that way may make a difference. He asked why he could not eat or drink and I told him that if a tube was needed we did not want him vomiting as they put it in. He asked me to call his wife. I asked him how much of the details he wanted me to share with her. He said he wanted me to tell her everything, He then said: "I don't want to die". I am tearing up now as I type that but at that time, I needed not to show the desperation I felt for him. I offered him: "We will do our best to send you home to your wife" We will watch you closely. Lie prone. I will see you later". He thanked me as I left. He was sincere and I know I did all that I could, but I definitely did not feel that I was deserving of thanks. But if he had thanked me only to make me feel better, he had succeeded. The next time I saw him, four hours later he was sedated, in the ICU and on a ventilator. He was prone. In the interim, I called his wife who had clearly been hitting the computer sites hard. I answered her questions, sometimes the same one twice or three times and then finally went on to the next patient. The next patient was the elderly lady who had been looking worse last night and did indeed look worse this morning. I will likely report on her tomorrow if there is interest in this kind of posting. IF not, I will not burden you guys with all of this if I get the sense that this is not of interest, but I think it was important that you at least get a sense of the minute to minute horror of this. I did report that I am doing better today. I am doing better. My temperature never went up to over 99 again and I am home now The onslaught from the closed hospital was not very severe today and up until now, no one under my care died today. That pretty much is the best day I could have. I am going to be finishing up my notes, doing a quick computer check on the patients and then try to get some rest.

My condolences on your loss. I hope your friend knew how loved and appreciated he was. Thanks for your support of me on a day when I was not my strongest. Today, I am a lot better and your note and the notes of the many men here who have taken time to jot a note or send a missive has really helped reinvigorate me. Thanks to all here and again my condolences/

I do not usually have a difficult time coping. Life is hard and mine has been easier than most. But today, I have just hit the wall. Working in a New Jersey Hospital is not nearly as difficult right now as working in a NYC Hospital. We have most equipment. We have beds. We have staff. We have patients and each day we have more and more patients. Right now the numbers are not overwhelming but they are increasing and more and more compromises are being made. Most of the staff are just doing their job. But there is an air of anxiety and trepidation hanging around every corner. There are hollowed shells walking the halls. Fear and uncertainty is everywhere. There are no laughs not even at jokes with a dark humor, I went into work today and started the day as part of a physician conference call. The conference call was to inform us that the governor has given physicians immunity. This is not being widely publicized. Essentially, within the scope of good medical practice, we cannot be be sued for actions that previously would have been not only malpractice but quite possibly criminal. That is, we were informed of the plans for the upcoming ventilator shortage. It is not first come first served as it is in the toilet paper aisle. There is no hoarding or buying for a friend, When the respirators are 90% in use, which is the case in several hospitals in New Jersey, then patients are assigned a color code. Green patients are those that get to keep the respirators. Yellow are the patients about whom clinical status and general condition are favorable. Red are the patients that are first in line to have their respirators removed should others in higher categories need them. Blue, well blue never get the respirator from the onset. I could barely contain my anger, fear, frustration, and utter disappointment. We knew this was coming, I knew it was coming but now it is here and it is a palpable real pain, physical, mental, emotional and spiritual. We were given guidelines as to what to tell family members when it is time to take their loved one off the ventilator. They do no have the final word. There is an appeals process, but that process can only last 30 minutes while the patient waiting for the ventilator is manually ventilated, Two more hours will be needed to clean the ventilator and reequip it. Three people will take turns manually ventilating the patient, Oh did I mention that once you are assigned a color, the person coming off the respirator would have had to be on the respirator for 5 days, so theoretically long enough to turn the corner and get themselves into a higher color group. However, the decision as to who comes off the respirator is made by random computer selection of those in the lowest category. This is not to say that the assignment of the color group is random. Patient's are stratified by a variety of factors, age NOT being one of them. Today, I had a new patient with possible Covid admitted to my service. She is 87 with a touch of dementia and lives at her daughter's home with a loving family. I spoke with her daughter on the phone to get information about her mother. She told me to try and do everything to help her mother but that if it was clear that there was no hope of her returning to her previous level of functioning, or close to it, that her mother had decided long ago that she did not want to live that kind of life. When I went into see the patient, I gowned and gloved and on the way in , I noticed her lunch tray and decided to give a hand to the other staff by bringing it in. PPE (personal protection equipment ) is still sufficient but not plentiful so my act saved one set. I brought her lunch tray in with me and saw a pleasant looking woman who appeared about 15 years younger than her age. She had eyes closed and did not respond when I called her name. I put down her lunch tray next to her untouched breakfast tray and did my exam. She appeared to be comfortable and was definitely someone who was doing much better than her numbers (lab values vital signs and other measurable qualities). I went to leave and the empty breakfast tray and the new lunch tray just haunted me. I opened the packet for her utensils and the vanilla pudding put a bit on the spoon and placed it by her lips. She opened her lips and took a taste. Then another. Some of her fruit cup and then most of her mashed potatoes followed. A bit of meatloaf and then the rest of her pudding. She said nothing. She did not open her eyes, even as I tried to coax her to do so. Finally, on a bit of the meatloaf. She refused to open. Another offer and another refusal and so I knew after 30 minutes of being fed, she was not taking any more. I said out loud to her, I guess that is it for now and as I left I heard her faintly say: Thank you. I turned and her eyes were open and then, a second later, they closed again. For that second they were so clear and blue and aware and I imagined her quite the beauty in her youth. After that second, she was back in that space where she was when I walked in, but she had let me know she was there. Next week, her condition may worsen and she will be a blue. She won't get a chance at a life saving machine, She will likely pass alone in a hospital with a loving daughter sitting at home hoping for all the world for her mother to get better. Even if I could do more medically, which I cannot, I could not alter her course. Even now, the most I could do for her he be present, give her some pudding and hope that time and some combination of medications we are giving her make a difference, I do not usually have difficulty coping, but today I hit the wall and next week this day will be the good old days when I had 30 minutes to spend with one patient.

https://www.youtube.com/watch?v=_10msPMEick Dear Evan Hansen Originator Ben Platt and a variety of cast members sing You Will Be Found at the end of a James Cordon Show from Home. I have always loved this song but more so now.

I would not be surprised to see some concession to COvid concerns. Perhaps temperature checks before boarding or if there is a rapid Covid test that can be done easily, having the test prior to boarding. The recycled air in a plane is a have for stray viruses. Some airlines will look to further improve their filtrations systems. Still there are people traveling now with no extra precautions in place but to get to more people, the airlines will need to make people feel safe. I do not know what cruise lines can do to reassure people except lower the price so the more daring among us will travel on a cruise ship.

Seems obvious that there are young men with tight clothes and tight bodies. That is the very definition of homoerotic.

Most of my patient's of greater than 80 who are competent and who have been asked to complete a POLST. (Physician Orders for Life Saving Therapy) opt out of ventilators and most other extreme measures. It is when they are incompetent and family is making the decision that the extreme options are often taken. When I was the medical director of a PACE program, an all inclusive plan for care of the elderly with 55 as the minimum age, 70& of the patients opted out of invasive care with the youngest members being the ones most likely to self include in extreme measures. Not to say that this woman was not sweet in declining a respirator, but it is likely that she would have made that decision without the Coronavirus situation if she had been asked.

I enjoy giving a good spanking but only with the hand and only for a few minutes. I particularly like to give a few spanks and then, once my partner thinks that part of the play is over, to sneak in a particularly hard one or a series of hard ones. By doing it this way, they have usually relaxed the glutes and the sound and the effect are magnified. I think most escorts who check off spanking are thinking of this kind of spanking, as an appetizer and not a main course. If you are thinking that the spanking is to be a main feature or to involve paddles etc, I would check with him to avoid being disappointed.

If you read the full question in the Sunday Magazine, the younger man seems to just want his partner to agree with him that in all circumstances sex or pay is wrong and should never be condoned. He does not question his partner's fidelity but does find it hard to swallow (pun intended) that the partner might go back to sex for pay if they were to break up. Anyway, I though this was a forward thinking question for The Ethicist to tackle. As I mentioned, I enjoy this weekly column quite a bit.

Little Shop of Horrors is a fun musical without much mental strain. I am considering watching that. The Ellen Greene one where she does an aching version of Somewhere That's Green. https://video.search.yahoo.com/yhs/search?fr=yhs-dcola-015&hsimp=yhs-015&hspart=dcola&p=youtube+somewhere+that%27s+green#id=2&vid=0f0292268e3fef2b504757fac149a97b&action=click

I know the terms top and bottom are merely shorthand for sexual act preferences but I have been thinking about that term quite a bit lately. I have been the anally inserting partner in the large majority of encounters I have had but on exactly three occasions, I have been both the receptive and then the inserting partner, more out of curiosity than desire. None of those occasions led to my wanting to be a receptive partner with any increased frequency. Now with the aging process taking its natural toll, I have considered that perhaps I should broaden my horizons. However, in most sexual encounters I enjoy the interplay and power of sex and part of my sexual enjoyment comes from a feeling of power I have when inside my partner or in some other dominant form of interaction. I know that "bottoms" will say that they feel that they are in control during the sex act, but I have never had that experience in my limited number of encounters as a bottom. So can a man with a "top" mind set learn to bottom without changing his mind?

The Ethicist is one of my go to columns in the Sunday NYT. The title this week is: I think Sex for Pay is Always Wrong. Should I stay with a partner who disagrees? In brie, a 20 something gay man has difficulty with his 50 something year old monogamous partner having had sex in the past with male escorts. In addition, though the 50 something has been monogamous, he has said that if the two should break up, he would have sex for pay again, The questioner states: "I strongly believe that sex for pay, in any circumstance, is morally wrong because I don't believe sex should be a paid service and because sex for pay reinforces a very deep problem within out society , even with good intentions." He later states that this is a "fundamental issue for me and for people in my social circle." I found this to be a strange divisive question in a relationship and the vehemence of the 20 something was surprising to me. So have any of you run into friends or partners who are so vehemently opposed to escorting that they would look down on you or even break up your relationship because he held a different opinion even if you are not actively pursuing this path?

My last hire was more than two weeks ago and I was somewhat concerned about it then. For now, it is my last hire.. Lovely memory though

Just curious, is he hiding a football in those briefs?

I can't seem to get the pic to post

I have it on good authority that there is a more inclusive picture which might shed some light on that, though that picture also shows that Mr. Baldwin could not see that light.

Tell me how one with a photographic memory can ever get that photo out of his mind?

I guess that was much too easy.

Sorry to have been a bummer earlier. The world has not changed but I have tried to change my attitude. I saw that 69 medical students from NYU who have finished their required courses and were waiting for 2 months until graduation have volunteered to graduate early and volunteer to help out with the situation in NYC. That has renewed my faith in the willingness of first responders and medical care and health care workers will do what is necessary to get us to come out on the other side of this.

Just a quick note. Headed to work. It gets tougher each day and we are no where near the peak. Hospital is short o protective equipment. Two patient deaths last night and 7 more admissions. There is a palpable sense of foreboding at the hospital, which is strangely quite amid the chaos. No visitors are allowed, so the patients see only the staff which I think adds to the general anxiety, but allowing visitors would only enganger more people. I hope the rest o the country is better prepared or this than NYC area was. Still nowhere near enough tests. Free standing testing sites are open for a few hours and then run out o tests. Cars are lined up or miles and then turned away. A friend of mine who got a positive result was called by the health department and the CDC soon after he got his result and he was questioned about his symptoms and the like but they did not ask at all about contacts or try to get demographic information about people he may have contacted. Need to go.

I met him twice. First time was okay. Second time was meh. So that was that. Verygood looking and a great body. Hard cock that stayed that way. Kissing was not good and his giving oral was painfully awkward. Still, the first time I had a good enough time to try again. Turns out it was me supplying the good time, not him.

It is true as we age, without or without Alzheimer's the sense of smells well as taste, hearing and eyesight all diminish. With Covid, it is a sudden perceptible loss of smell and taste. In normal aging, it usually goes unnoticed or happens over a long period of time.

By the way, an interesting bit of information which may help. There seems to have been an increase of anosmia related to CoVid. Anosmia is the loss of smell. It seems that many people are losing a sense of smell and taste during the infection AND while still otherwise asymptoimatic. Now this may just be apocryphal, urban legend, but I know of one person who complained to me about the food at his favorite restaurant was bland and his wine was off. Four days later he became more traditionally ill. He has subsequently tested positive and has stayed relatively healthy though miserable with the body aches, headache and low grade fever. So, if you find the food doesn't taste right or your sense of smell is not right, it may be time to be tested, if you can find the test. I must admit to going out of my way to check my sense of smell against some usually harsh smells like bleach and cologne. My friend told me he could not smell bleach and he drank his coffee with soured milk until he noticed the curds floating on top. When he took a sniff of the container, it did not stimulate the usual grimace.