purplekow

Well today was a tough day but not as bad as yesterday. Perhaps I am just getting inured to the chaos and numb to the fatigue. I find that I really need to concentrate to keep awake because the eyes get very quickly heavy and a rest my eyes for a second can turn into a 30 minute nap. Stangely enough, or not, the most common place for that to happen is in my driveway once I arrive home. A good song will be on the radio and I do not want to cut it off. I close my eyes to listen to the end and the next thing is I have been napping for 15 minutes. I now turn off the car and the car has a feature that after the car is stopped it allows the radio to continue for 15 minutes and then turns off automatically. The silence usually wakes me up. So my temperature was 97.7 this AM and the phone range five minutes before my alarm. It was the night call resident calling to bring me up to date on the new overnight admissions. There had been four before bed and then another 3 during the night. My alarm went off in the middle of his presentations so instead of 10 minutes more sleep, I got 10 minutes more presentation. A curious consideration about this Cover crisis is that just about every patient either has Covid or might have Covid, so all that is a given. This has gotten shorthanded to Known Covid or Suspect Covid. So the most basic presentation in the morning before I will see the patient could be as simple as Covid suspect, previously healthy, oxygenating well, afebrile. No need to belabor this type of admission but you cannot dismiss it either. Time is too valuable yet missing something crucial can change someone's life. But listening to details may delay your getting to the next patient who may turn out to be the sneaky one. IT is a tightrope walk. There is just so much you can hear before patients overlap and intertwine and start to merge and blur. So we try and keep the simple ones simple but always with a check back, are you sure there is nothing else. Then while a different resident presents, the one that just finished does a fact check to make sure. . The problem with this is the ones that sneak around and look routine and then aren't. They usually get seen last, sometimes not until afternoon and though nurses will call if there is a major change and slow but steady decline can slip through. Then when you get there, all hell has broken loose. This happens rarely but it is an ever-present threat and so it makes the shorthand a bit risky even with the check back and rarely do the presentations stay stay as brief as possible. Yesterday there were not shorthand patients. So you need to get a thumbnail picture of each patient and try to keep the pictures from running into each other as a water color paining might. A 37 year old who has a sister who is Covid positive nurse and is at risk due to multiple medical conditions. 36 year old who lives with his sister and thinks he is breathing a bit rapidly it his rate is not high and who has no other medical problems. The 33 year old mother of six with bipolar disease who was brought to the ER by the police after a ruckus at a walk in medical center because they would not test her because she did not meet their criteria even though her husband is positive but who takes Lithium and has a fever which can increase lithium levels and cause erratic behavior. The 25 year old who claimed to have symptoms to one examiner and denies them to another who is a known schizophrenic and was missing from his home for 2 days and was found wandering the streets of Brooklyn. The 47 year old house painter with 10 days of diarrhea and fever and shortness of breath for 48 hours. Who is the sneak. Which one, if any of them is the one who is going to fail. I run that through my mind on my drive to the hospital as I listen to the 60s on 6 on my subscription radio. There are several others also categorized considered and prioritized. Did you figure who sneak was? Was there even a sneak there? Well it could have been the mother with the manic depression, she did drop her blood pressure and require fluids 25 minutes after I told her husband by phone that she was doing well and that she may indeed be able to be home for Passover. It wasn't. She picker up her blood pressure after a few IV fluid bags and though she will not be home for Passover, it still looks like she will be home eventually. Could it be the schizophrenic wandered. No as it turns out he had parainfluenza and so far not Covid. He ripped out his IV. He refused his medications. He demanded benzodiazepines. finally dressed in full protective gear, I went into the room and very uncharacteristically told him to just behave. I said: You are the least sick patient here (really terrible bedside manner but I had no desire to be well mannered and while I usually win the battle to maintain that professional demeanor, this time I did not) and he would get complete care and everything he needs but he was not high on the priority list and throwing things was not going to change that. So he just needed to get a grip and wait his turn. This is not a technique I use. This time though, it worked. He swallowed the new dose of medication which was needed after he spit the previous dose out at a rather hunky male nurse. A daring move on the patient's part and great self control by the nurse. I think I ought to buy him a drink sometime soon. Was the sneak the patient with the sister who is a Covid positive nurse and who has about 4 major medical conditions. No he did fine, The sneak was the 36 year old who thought he was breathing a bit quickly. Strange thing with Covid, in my experience, which is very limited, most people who are breathing rapidly do not notice it until they are gasping or air. or fighting to complete a sentence. Even though this man was not breathing fast when counted, he was exhibiting air hunger, though he had not yet started to lose blood oxygen concentration. 4 hours later he was being evaluated for the ICU and he was placed on a ventilator almost immediately. He is doing a bit better now that he has been sedated, given the Tocilizumab which seems to help if you get it just at the right time. He was a bit late since he already had the tube in, but still he seemed to get some benefit. So rounds ended at about 3:00. I donned and doffed gowns about 10 times. I told a patient he was a low priority. I sent a 36 year old to the ICU. I sent two patients home, one who was ready and one who was not but who insisted that he was leaving. I do not think he will bounce back, he was almost ready, but not quite. We got him oxygen at home, HE has a six bedroom house 3 houses in from the beach, so he can afford the cost of the oxygen, which is not that much. There are others, though that cannot and providing for them on discharge is a real challenge. At 3:30 I sat down with colleagues to draw up a disaster schedule. It hopefully will not be needed but it includes having radiology residents and pediatric residents and orthopedic residents caring, under close supervision for hospitalized medical patients. The bigger problem is figuring out who will supervise them. That is tomorrows problem. Right now it is time for bed. The midnight check found no disasters. No sneaks. At least no sneaks for now. I have a sneaking suspicion that there will not be one by the morning, But hope springs eternal.

Steven, I have seen that steep decline in about 4 patients. They are doing reasonably well, but in retrospect their oxygenation is a little low or their respiratory rate is a bit high. The markers that we use: D Dimer. LDH. Ferritin. C Reactive protein are all basically indicators or inflammation. The may be unduly high and if the patient seems clinically stable, there is a wait and see view. Occasionally these fall fast. Now, as far as Tocilizumab is concerned, I have seen it turn people around in a very short period of time. Proning has also made a big difference. The keep to the Tocilizumab is getting it into the patient before they are intubated and it may avoid the intubation. Once they are on the ventilator, it is usually a long haul. So with many things, avoidance is better than treatment. In reporting here, I mentioned that each night at midnight there seems to be a patient suddenly doing poorly. These are the ones that we need to get treated with drugs and proning and get it done quickly. I start my patients with proving on admission even if their symptoms are not respiratory. I know, everyone thinks it is all a lung disease, but I have a patient right now who has had 10 days of almost continuous diarrhea and although he is doing better today, keeping up with fluid losses is easier if you start early and do no get behind. When you get behind, the blood pressure drops, oxygenation becomes more difficult and there is shock to liver, kidneys and the brain. None of those are built to work with low blood pressure. So if the Germans are getting them in early and they are being caught before the decline that can make the difference. The problem is, with so many people coming in and all of them looking reasonably stable, it is difficult to mete out scarce resources to to the ones who will need it. In order not to miss a potential crash, almost all patients would have to have full bore treatment that only a handful need. But trying to pick out the ones that need the intense treatment is the reason I am checking my patients at midnight before I go to bed. And even there, I have gone to bed thinking they are all tucked in for the night, only to be presented with a surprise, and not a good one, when I get to the hospital in the morning,.

To the person who asked about about Plaquenil, the answer is yes we are using it. The data is anecdotal and not totally convincing at that but we do use it. Now when Dr. Oarnge who lives in DC asks what do you have to lose, the answer is quite a bit. Patients get all kinds of side effects from the drug. The most serious is something called prolongation of the QT interval which can result in serious and at times fatal heart rhythm disturbances. Z pack, which is also being used can cause the same defect and so we are not using both together. The antimalarials were readily available for a bit until they were touted as a cure from on high. Now they are difficult to come by as an outpatient, as it should be, but hoarding has made them relatively scarce in the hospital as well. To be safe, a patient should have a QT interval evaluation on a routine EKG. As the QT interval varies with heart rate, patients with fever and rapid heart rates to begin with may suffer more should they get an arrhythmia. So in patients who do not have QT prolongation and may be monitored for it and who can tolerate less severe but problematic side effects such as diarrhea, liver inflammation, renal impairment, Plaquenyl is definitely a drug with no proven benefit but a few anecdotes that it helps which is being used here and elsewhere. Less and less as time goes by. /if I were to pick only one drug to the if I was worsening after 7 to 10 days, it would use a drug called Tocilizumab which alters the way the body handles Interluken 6 which a major factor in the development of ARDS, the adult respiratory distress syndrome. IL 6 (as in cleanup on aisle 6) levels can be measured. If elevated, this drug seems to help and may prevent patients from having to go on a respirator. But the timing needs to be correct. That is why, when lay people hear about this drug, they want their loved one to get it, but it is only really beneficial if given after the virus is not the main culprit of the disease, but rather the damage that has been wrought is the problem. This is kind of like turning off the gas after a gas main line break after a tornado. The tornado does the damage but until it is gone and it is clear there is a gas leak, turning off the gas will have little effect. It would be great if the gas leak could be prevented, but in this case, this drug does not do that, Give me a break on this cause it seemed like a perfect analogy until I had written it out and realized that there are definite flaws in the analogy. Stilll, the drug must be used at the proper time too early or too late is too bad. Thank you all for the kind words of support and I will be posting an update later tonight

Today is the first day of what is supposed to be the worst week of this. I am home right now and ostensibly I have made it through Monday. But a lot has happened, none of it good and I have received four phone calls since I got home. Just a quick update. I woke with a temperature of 97.7 my temperature now is 99, so I am a bit concerned for my own situation. Of the patients I have written about, the gardener has taken a dramatic turn for the worse. He is on a ventilator and is barely keeping his oxygen at levels compatible for sustained life. Now the first week on the ventilator in this condition is known to be a very rocky one. The patients usually have highs and lows and if they make it to week two, usually things will move along in a more positive direction. He is on day 4 on the ventilator, so just about 1/2 way through week one. The elderly lady with the good bye FaceTime with her daughter, succumbed to the disease at about 4:30 in the morning. Her condition had been slowly deteriorating and so it was not surprising that she would pass. Her last meal was vanilla pudding. She was well sedated with morphine and I hope that was enough to make her passing a comfortable one. This is my first death related to this disease. I know it will not be the last. The man who told me he did not want to die, has gotten somewhat better. He is on less oxygen and he was walking in his room and he said that he was feeling much better. His lab tests have improved and so it appears he will be one of the lucky ones. However, he is still requiring high flow. oxygen. One of the Pulmonologists told him he may be able to go home tomorrow, but he will definitely need oxygen and it is not at all clear that he won't have a relapse. Still and all, he may be home for the holidays. There were three new patients to come to my service. All three Covid patients and today, so far, there are four more. We are running out of high flow nebulizers and will need to improvise some other type of oxygen delivery system. The three new patients to my service are a 60 year old woman transferred out of the ICU with Covid and heart failure on dialysis. She is the poster girl for people who should not survive Covid, but she is doing well. She may also go home after three grueling weeks but arrangements need to be made for dialysis. The second is a 60 year old man who has had a fever for a week and who has been getting short of breath over the last two days. He is a fit man, he lives in Brooklyn but has a large house on the Jersey Shore to which he moved his family 4 weeks ago. He was hoping to outrun the virus, but he did not succeed. He looks pretty good and is complaining that he wants to go home but he is requiring more and more oxygen and he does not look to be headed home any time soon. I joked with him about his great shock of silver gray hair. I may have been flirting with him, but it has been so long since I had any playful adult conversation that I am not sure. The third patient is a 25 year old with schizophrenia who spent 5 days wandering the streets of NYC. His family was able to locate him and brought him back to his Jersey home. He develop cough, fever and said yes to every other symptoms although it is not clear he understands any of what we are asking. We are waiting for all his studies and if they are under good control, he may be able to go to the psychiatric ward. Right now, some poor soul needs to sit in a room with him and try to keep him for doing harm to himself by pulling IV lines or not wearing his oxygen, Though his CoVid test is not back, it seems likely that it will be positive. Being admitted this afternoon are two men in their early 30's and man in his 80s and a woman in her sixties who may not have CoVid and may wind up going home once her tests come back. In the "there but for the grace of God go I" category, two doctors were admitted to the hospital. One is in the ICU but is not on a ventilator. He and his entire staff are CoVid positive but he is the sickest of the bunch. He is a pretty fit guy in his 50s and has been healthy. The odds are with him, but with this disease, odds mean nothing. By the time you get to the ICU things are bad and so. far, in this hospital, if you are placed on a ventilator, no one has made it to be discharged. There have been 6 deaths of ventilated patients and a smattering of others who did not wind up being placed on the ventilator. The other doctor, is a member of the full time hospital staff. He is a tall thin Argentian who is very careful all the time. About two weeks ago a patient was admitted to my service who was having congestive heart failure. There did not seem to be anything tricky about the diagnosis. I heard about the patient over the phone at about 11PM and was told she was not in need of a visit from me until the morning. As luck would have it, I was not on call the next day, a Saturday and the doctor who was admitted was. He saw the patient and then later in the day, her condition deteriorated and she was sent to the ICU. Subsequently, about 4 days later, she started showing signs of Covid and she tested positive. All the personel who were around her were contacted and 6 of the 10 test tested positive for Covid, including this doctor. He is having some shortness of breath, but not having great oxygen demands, He is having fever and GI distress which has made it difficult for him to keep his fluids in balance. He is admitted so get some IV fluids and to watch for any worsening. It is easy to see how I could have been one of those 6 in 10. Lucky that time for me. Lucky that time for me, but each day I think that this may be the day that my luck runs out. Each cough is evaluated as to whether that is just an allergy cough or the first one leading down CoVid Lane. Do I have a headache or is it just eye strain? Is 99.3 the first step up a ladder I do not want to climb or is it merely a part of the diurnal temperature fluctuations we all have. When you are my age, in my physical condition and with the kind of risk I have, you cannot help but think that any sign might be an omen of things to come. I have joked with friends who are in a similar condition. They all feel the same. One gastroenterologist told me that every time he has a BM he is hoping, as he strains, that it is solid as a rock. A good friend who is an X-ray tech says he is so far into his head about this that he has a foot sticking out of each ear. Meanwhile, I have been trying to get my will done and my taxes done. lAs some of you may know, I have three dogs and what I have avoided mentioning is that one of them is dying. He has stopped eating He moves very little. He does go out to lie in the sun. I have been able to persuade him to eat a bit of Costco Roast Chicken breast and yesterday, half a piece of liverwurst. The other half just lay there next to his nose until finally I stopped chasing the other dogs away from it. I full expected him to die last night and spent the entire morning in the shower, getting dressed and generally avoiding leaving the bedroom suite. I thought for sure that last night, when I patted him on the head, rubbed his ear and saw the vaguest wag of his tail, that was good bye, our final goodbye. When I finally went out to the kitchen, he was not there. He was not in the living room, not in the den, not in my office, not hiding behind the couch. I went out and he was not on the patio in the back. I found him, lying in the sun in a corner of the backyard, resting comfortably. I called his name and again there was a tail wag. I was 15 minutes late for work because of the extra time I spent with him and I fully expected him to be gone when I got home. He was not. He had followed the sun and was in a different corner of the yard. He still won't eat. He really hasn't moved much and he seems uninterested in interacting with me at the moment. I think he is just enjoying the good life, lying in the warm sun and resting. I encourage you all to find that comfortable spot in the yard, the house, the patio. and to lie down and let the sun bathe your tired body and to think how lucky we all are. A slight change in a schedule and I might not be writing this or loving my dying dog or thinking about what I will make for dinner. Life is always tenuous, even more so now. My advice, is to do what my sweet loving half lab have Newfoundland friend and confidante has done.... Follow the Sun. https://video.search.yahoo.com/yhs/search?fr=yhs-dcola-015&hsimp=yhs-015&hspart=dcola&p=you+tube+follow+the+sun#id=1&vid=fa0bd89792e45ad6c960fc9c8be04817&action=click

I have a regular meeting with the Chief of Medicine to discuss ongoing issues in this crisis. One thing he has mentioned to me on more than one occasion is that surgeons in particular are desperate as they try to keep their practices going. They are laying off staff and without income or with decreased income, they are having difficulty meeting rent, insurance payments for malpractice and health, and maintaining their households. Most of these doctors live opulent lives by average standards, so I am not asking for charitable donations or for a telethon. but rather an understanding that even the well off among us may be suffering financially,

At the hospital at which I work, the residents in orthopedics, surgery, pediatrics and pathology are being trained as back up to the medical residents They spend one week shadowing a medical resident. There is no elective surgery so the surgical residents are doing emergency care and minor procedures on hospital in patients as well as placing central venous access. OB GYN residents are still caring for obstetric cases but only emergency GYN is being done, Orthopedic residents and surgical residents in particular are generally felt to be a rather smug group. This down in the trenches without the glory of the OR has helped increase camaraderie among the residents. That would not have been my guess when they first started this. One thing that has been very problematic is for non-covid patients who are discharged from the hospital, follow up clinic is not available. The clinic has been closed and is doing telemedicine or established patients, but new patients are more difficult to fit into the system. Also, patients who need post hospital testing has been a challenge. We are working through it but it is ever-changing in an attempt to find something that works well.

I heard a rumor that you were not opposed to flipping

I did not realize how much I needed sleep but after my sexy prone nap, which I posted about elsewhere, I slept for 14 of the next 18 hours. Just awake enough to post on here, call some friend and relatives to check in and to eat a peanut butter and jelly sandwich. I awoke this morning. Temp 97.7, Breathing easily and feeling pretty good, which is about as good as I get. A nice hot shower after a steam and breakfast. Finally, having indulged myself, I decided to check in on my patient's at the hospital. I have had the weekend off and fortunately the surge has not been as overwhelming as we had been expecting. Quiet before the storm is the phrase that comes to mind. I checked in with the covering physician and things are going reasonably well. The hospital continues to be a place of cooperation and compassion despite the chaos the disease wrecks on the patients. I have been mentioning three patients, well four, though there are others. So I will update you and discuss some of the issues which are resulting. The jockey, who was one of my first patient's was able to go home a few days ago and a phone call to him indicates that he is doing well. He is not quite in the category of cured as he has not been symptom free including fever free for a long enough period of time, but he stands to be one of the lucky ones. The elderly lady whose daughter did FaceTime and whose son caused a bit of difficulty with a threatening manner, is holding on but barely. It is not likely she will make it but we continue to offer the best treatment we can in view of the patient made decision to avoid ventilators. She is being kept comfortable with morphine on a regular basis and for the most part, she is making a slow and relatively peaceful transition to whatever is next. The gardener who was placed on the ventilator is stable but clearly he is having a difficult time. He is oxygenating poorly despite medication and despite high pressures on the ventilator. HE is clearly at a critical time but it may be a week or more before it is clear which path he is going to be taking. I have mentioned before that 10 to 14 days on a respirator is not unusual. It is also not unusual for people to do poorly even after that time and effort. This man has a good a chance as any in his position having lived a clean and healthy life. He would be a green if we had started to assess ventilator status. A green, for those that are not familiar, are those patient's who by the nature of their progress and risk factors, would continue on a ventilator and not be placed in the pool of those who may be pulled off if others needed it. The fourth patient, the patient who stated that he did not want to die, continues to improve. Some of his tests are better and the rest are stable. He is no longer on the respirator after his endotracheal tube was inadvertently removed. He does not appear to be in need of that kind of support right now. His breathing is slower and more efficient and things are looking well for him. This brings me to a topic of great controversy. Religion, religious gatherings and the pandemic. The hospital at which I work is a secondary hospital for a community that continues to hold religious gatherings. This is happening across the country as there are 14 states which have specifically exempted religious gatherings from social isolation decrees. Working in the hospital, there will be news programs on patient televisions and these stories are a major focus at this time. At the level of the caretaker, how a person contracted the disease has not been a factor in the care that they receive. Whether it is the elderly woman whose asymptomatic caretaker gave it to her, or another patient who attended a church service that was specifically against public health policies, the patient gets the best care possible. What does happen though, is these stories wear people down. You hear nurses muttering what are these people thinking. You hear bits of hallway conversations in which there is anger and intolerance, not for the religious but for the religious leaders who encourage these gatherings. The dismay, the feeling of disrespect for the caretakers and the additional burden being placed on the medical community by those going to these meetings is multifactorial. The patient's will receive the care. The caretakers will do their jobs. All we ask of the public is to not make it more difficult. Take responsibility as though your life depended on it, because someone's does.

I hope that all goes well for your husband at work and that you take good care of him when he gets home. Stay healthy. Would love to give you a little kiss on the neck in celebration of your birthday. So lets just say I owe you one.

I decided to start another thread about proving as I mentioned it in another post and thought it is an interesting phenomena. It is becoming standard practice to place Covid patients with significant respiratory distress in the prone position. This started with patients on ventilators after a small series showed that it improved outcome and eased the work o oxygenation. The reasons for this benefit were not immediately clear but it seems to have to do with recruitment o previously underused airways and movement of fluids within the lungs. On a practical level, some people can lie prone quite comfortably and others cannot. I am one of the ones who cannot. So today, when I decided to take a nap, I decided to try and remain prone. I initially became uncomfortable and wanted to move. I became restless and began moving pillows and making minimal adjustments with a slightly different wrist position, a different angle of the shoulder. I was able to find a position which was comfortable but felt the urge to resort back to my more usual and readily comfortable positions. This exercise was not just a game, who knows maybe being able to stay prone may save my life so I persisted. I needed a distraction and so while the prone position is not usually comfortable for me, I began to envision situations in which being prone might be fun. As most of you can imagine, my mind went almost immediately to sex. Past encounters, imagined encounters, film encounters, fantasy encounters they all came to mind and they all helped. Accept for a surprisingly rigid erection, the prone position became more and more comfortable. I feel asleep shortly thereafter and awoke six hours later still more or less in the same position. It may have been wishful thinking, but I did feel my breathing was easier and deeper. So I would like to thank Eric, Tristan, Vin, Steven, Victor, Stephen, Rick, and many others for their assistance in getting me to feel comfortable in the prone position and for helping reaffirm that I can get quite hard given the right thoughts, the right time and the right position. I suggest you try lying prone, if that is not usually a position that is comfortable for you. You can use my helpful tip about staying in that position, hell you may even use some of the same fantasy men and real man memories. It may get you a good night's sleep, a substantial hard on and it could save your life.

The one nonagenarian with Covid for whom I am caring had seen only two people for two weeks. So it is clear she got the virus from one of those two people. Both were her caretakers. One of them came to work and had a cough, the other was perfectly healthy. Now both of them are perfectly healthy and their charge is in the hospital and will likely die. The easy choice is to say that the woman with the cough transmitted it to her charge but when tested, it was the healthy woman who tested positive while the other was negative. There are no easy answers except total isolation.

To those who are hooking up, going to parties, attending religious services, attending celebrations, you may not believe you are going to get sick and if you are lucky you will not. However, someone will get sick and as shown in New Rochelle NY where more than 300 cases were linked to a single exposure, one person can cascade into dozens. Someone else will be caring for those people and some people may not get cared for because those reckless people increased the caseload.

I enjoy looking at the ads. I see no problem with putting up an ad which might generate future income. However, I am not hiring right now and if the escort is not planning on working now, that should be made clear in the ad. I encourage providers and clients to keep safe stay sane. You can't come when you are gone.

Proning helps move the fluids in the chest to areas of the chest that do less oxygen exchange, freeing up more efficient parts of the lung and recruiting previously closed off parts of the lung. This was first observed on patients who had mechanical ventilation and has been generalized to all Covid patients. The data is mostly anecdotal but in my limited experience, you can see a very dramatic difference in oxygenation in a short period of time with the change to the prone position. CPAP and Bi PAP have not been used as they are felt to aerosolize the virus and keep it in the air for longer periods of time. The thought now is that the virus already has a significant amount of aerosolization and that is why the recommendations are coming down from the CDC for all to wear masks of some type. The fact that our leaders and newspeople on TV on not wearing masks or are taking a "do it if you want to do it attitud" is probably making things worse. There is a segment of the population who will not wear masks no matter what. It is those that can be swayed by seeing examples on TV and by public pressure are the ones that will help slow the transmission. There are clearly exceptions. If you are out in a secluded area, the risk of aerosolized particles reaching you is minimal. Even with masks, the masks should be removed properly with the mask facing the ground to keep most of the viruses low. NYC is thinking of using BiPAP for continuous ventilation as it may be a choice that needs to be made even with the aerosolization risk.

I keep looking in at the patient's chart at midnight. It seems that hour, when the nurse shift has been complete or nearly so, is a time when things are recognized. Last night was no exception. The gardener who was admitted earlier in the day and who was looking pretty good took a big turn for the worse. He was suddenly very short of breath and feverish and he could not prone himself because lying on his chest was painful for him. For the short periods he was able to prone himself, his oxygen levels improved enough to keep him from needing a ventilator. Now, the pain was causing him to breath faster and shallow and he was fatiguing and when he got off his chest to relieve the pain, the breathing became shallow as a result of the suboptimal positioning. He was evaluated by ICU team and though he qualified for ICU care, there were no beds there. His critical status led to an exchange of beds with an ICU patient coming back to his bed as he went to the ICU. This happens all the time under usual circumstances, but usually there are patients in the ICU who have been ready to move out but logistically have not been moved. This is not the case now in that all the ICU patients are ill enough to be there now. As it turns out, the least sick of the very sick was the patient who had been sent there last night. the one who had implored that "I do not want to die". He had been placed on a ventilator and had been doing better. Although patient's with Covid may need ventilators for weeks, he had been doing well when his tube caught on the bedsheets and was inadvertently pulled out. The patient was surprisingly stable after this and it was decided that placement of tube could wait. His blood tests had peaked and were trending down and he had been monitored for about 12 hours of the ventilator. In that time, despite his precarious situation, he had become the most stable patient in the ICU and he was the patient exchanged for the gardener. It is almost like a game of ping pong, with patients going back and forth. Throughout the night the both of these patients did alright in the new setting. The gardener was not placed on a ventilator, the proning seemed to get him to a point that he was able to oxygenate well enough and IV Tylenol took the edge off the pain enough to allow him to stay in that position for longer periods. He is now the patient on the bubble should a bed there be needed urgently,. He is also the patient who could be placed on a ventilator, it changes so fast. They have now extended the range of the ICU doctors to cover non-ICU floors, which are now accepting patients with ventilators under the guidance of the ICU physicians and with nurses who have had respirator experience. The ICU has now add nurses who have not worked with ventilators much so as to get them experience while doing so by teaming them with nurses with plenty of supervision. Let me stop here and just say what an amazing job the nursing staff is doing. Dozens of young women and a few young men, taking care of these patients. I shudder each time I need to go into a room and gown up. They go into many rooms several times a day. They are there to bring the food, give the medication, adjust the intravenous fluids, clean the patients, evaluate the severity of the clinical condition on a frequent basis. They are talking with the patient, encouraging them and they are the ones listening to the stories and addressing the patient's questions and fears. . There is not enough praise to be heaped on these people. They are the reason that we will come out on the other side. They are willing to come in each day and work until exhaustion and then, many of them go home and do it all over again in caring for their families. So I encourage you, if you know a nurse, text or call and express your admiration and appreciation. Ask them if there is anything you can do to help them. I try to remember to thank them when I am working with them and after this is done, I will be sure I do a better job of thanking them each day I have the weekend off. I have called the covering doctor and she feels she has everything under control in our little corner of the chaos. The surge has not come, yet. The week ahead promises, by all accounts, to be the worst yet. I am getting plenty of sleep and have decided to open the carton of ice cream I bought for a special occasion. Take care of yourselves.

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.