purplekow

Cats seem to be prone to covid19 though it is not thought that animals can pass it to humans. As for dogs, at one one dog was tested and found to be positive but why it was tested and if the test was reliable, I have no knowledge of that. I have made arrangements for my dogs should I get sick or pass. I think being home with a dog is great but you do need to watch out for separation anxiety. If you do decide to get a dog, I would make sure you left the house for some time during the day to get it used to being alone. Or get two and they will have each other. I have had as many as seven dogs at once and they Ade the most difficult times of my life bearable.

Talvin was a hot escort and I am sure he is a hot guy in whatever profession he is pursuing now.

Matt, Tocilizumab is being used in a variety of places. Antivirals are also being used in some places here in NJ with some reports of success. We are starting convalescent serum protocols this week. I am sure Dr. Fauci is aware of these drugs but as for the rest of the administration, who knows. Tocilizumab is not a cure all but in the right setting at the right time we have had success with it. The last thing that would be needed is for someone in a position of power to start talking it up as a cure all and suddenly the use of the drug becomes inappropriate. At my hospital, I as the primary care provider can only request that the ID specialist give permission for it to be used. I have done so three times and all three times it has been beneficial. In fact, all three have gone home after looking for all the world as though they needed to go on a ventilator. It is used to prevent cytokine storm which is a result of the damage that the virus has done and it does not kill the virus at all, so if you are not in danger of imminent cytokine storm, it is not of use. There is also an investigational drug. Otilimab which is a GM CSF inhibitor. (Granulocyte Monocyte Colony Stimulating Factor) inhibitor.. GM-CSF also induces a rapid production of white blood cells to help fight infection and may be overproduced in CoVid. The drug is probably being used but I am not familiar with it in CoVid or otherwise. There are several of these drugs used for multiple sclerosis which are designed to inhibit immune response. They all have toxicity but may be worth the risk in Covid but I have not seen data about it.

I watch Politician with Ben Platt. Interesting considering it is set in a high school. Platt's character has oldertwin brothers, in their 20's, who are seen infrequently without shirts. They are hot but not on screen enough to make it worthwhile to watch for them alone.

Well today is the last day of my break. I received a call from the doctor covering for me. She told me that the mother of six who seemed destined for the ICU responded well to the tocilizumab and improved almost immediately after given the drug. She continued to improve over the weekend. We also used anticoagulation on her. If those meds did anything or if she was just destined to get better you can never be sure, but I will be using that combination again. Another woman in her 50's also seemed to turn around yesterday after the tocilizumab. I had mentioned previously that this is a interleukin 6 inhibitor. Interleukin 6 stimulates cytokine release. Cytokines are vasoactive and inflammatory chemicals usually released in a control manner to fight infection but in this disease they are released in a manner called cytokine storm and though the infection is hindered, those chemicals worsen the damage. So the key it to get the cytokines under control at the proper time. In addition, we have been using anticoagulation to help treat these patients. The patients are noted to have an elevation of a substance named D Dimer which elevates at the time of blood clots in the lung. The CoVid patients do not have large clots, pulmonary emboli, but it is thought there are many many small clots which cause oxygenation problems and which cause the D Dimer to elevate. So now, when we see the D Dimer elevating, we are adding anticoagulation to try to prevent as many of those small clots as possible. None of this is standard, but so far we have had some success. While I was on the phone with the covering doctor, she started to have a catch in her voice. It was clear she was becoming emotional and I asked her what is wrong. She told me they had just played "the song" and she was still getting used to it and hearing it gets her emotional. What has happened is, someone came up with the idea that each time someone is discharged or has the tube removed from their throat, the play a brief burst of a song over the intercom. Today they were using Oh Happy Day. This is a new idea since Friday and I think it is a wonderful way to let the people in the hospital know, that there are successes. They only use the first two lines. (oh happy day, oh happy day, oh happy day oh happy day). Just a brief break in the efforts. Kind of like hearing a bell and knowing an angel got its wings. We also had the first person make it successfully off the respirator. I believe I had mentioned a healthy 60 year old gardener who came in and looked good and then in the morning was admitted to the ICE and placed on a ventilator. Well, I think it is 8 or 9 days later and he was extubated. The first one to get off the ventilator. I had been posting here that people were not getting off the respiratory. Now general reports are coming out that 80% of the people on respirators or even more are NOT making it off. So the plan now is to do everything possible to keep patient off the ventilator. So we are using more of the Tocilizumab to assist in that. I am rested and physically able to go back. Mentally it is still a struggle, but I am sure I will be ready in the morning. https://video.search.yahoo.com/yhs/search?fr=yhs-dcola-015&hsimp=yhs-015&hspart=dcola&p=oh+happy+day+song+you+tube#action=view&id=12&vid=ddd71b238b7b91fee7bada6b29e4aff0

Well even though I have the 4 day break, I am still receiving phone calls about the new admissions. Things seem to have slowed down this afternoon. The ER has usually had 30 to 50 people being treated and a dozen or so waiting admission. The first all I got today was at 6:30 PM and there is only one other patient awaiting admission. An Easter miracle? Wealthy are predicting that here in New Jersey the pack should be between April 10 and April 27 so we are in the midst of the period when a slow down should happen. Maybe this is a sign of that slow down. People have been doing social isolation and perhaps that is turning this a bit around. So a rare glimpse of good news. Stay safe. I will be back to work Tuesday so I am gearing up with lots of sleep and getting ready.

I. checked in to the hospital to see how the team was doing and if anything was new with the patients. Good news for the two men who were not discharge on Thursday, they both improved and arrangements were made for hoe oxygen, The hospital administration was convince that it made economic sense to send these men home on the oxygen at the hospital's expense than to keep them in the hospital for oxygen with the hospital picking up that bill. After a long discussion of precedents and numbers, the administration relented. It is better for the patients to be home and better financial for the patients to be out o the hospital. A one time expense for an oxygen concentrator is worth it.

ENT at this hospital rarely come to the hospital and do so under duress. If I wanted to spend a few hours arguing with people I could have gotten one to come but they would have come for a posterior bleed. Of course, a Foley catheter or two can handle that in a pinch. As to managing nose bleeds, I used to use a touch (but not too much of a touch) of silver nitrate on a stick or a lidocaine with epi soaked cotton ball packing. Ice to the bridge is not great but if the bleed is not too bad I have had some success getting the bleed to stop while we were getting the other methods ready. We also had cocaine to treat nose bleeds in the walk in back in the day. When I opened my walk in and when I worked in one in 1979, they handled much more than just coughs and colds. The facilities were looked down upon and called "doc in box" but I always contended that they served a need and were a great alternative to ER visits. At each hospital at which I worked , I spoke up for having several of them associated with the hospital. but the old guard did not see the advantage. There subsequent proliferation speaks to the utility of the facility. Much cheaper than Emergency visits and if staffed properly a great triage to all the ER to handle actual emergencies. .

I was on the phone with a grade school friend of mine who is a lawyer. Another call came in from the hospital and I excused myself and took the call. I got back to him in about a minute and when I did, he asked, "Good News?" I could tell it was a serious question but I just started laughing and laughing, I told him, I have been doing this for decades and if there is a phone call from the hospital, it is never good news. No one ever calls and says". "By the way, we cured cancer this afternoon." The only reasons for a call from the hospital is bad news and really bad news. This was just a bad news call, which was a relief. I had several patients, including the mother of 6 who have taken significant turns for the worse and a call, especially a call when you are not on call, easily could have been a very bad news call. As it was, the patient with the low platelet count had not responded to the initial doses of medication, which was expected outcome as it usually takes a few doses to stimulate the bone marrow and get the count elevated. The bad new was that his nose bleed which was just an occasional spot of blood when he blew his nose, had gotten worse and now is was a matter of whether or not someone going to go in and packi his nose in order to control the bleeding. As I have mentioned before, a major stress for the care providers with this virus is the increased level of work needed just to provide routine care. Someone needed to go in and see if this was just an anterior bleed, with blood coming out the nose which has a quick fix, or whether this was a posterior bleed with blood dripping or pouring down the throat, which usually requires a higher degree of tamponading. I asked the nurse to ask the patient if there was blood going down his throat. He said he did not think so, so blood was not pouring down the throat. I asked her then to take an ice pack and have the patient hold it on the bridge of his nose for ten minutes and if the bleeding was continuing, I would go in and pack it. There was no way an ENT was coming in to do this procedure and surgical residents are only seeing "emergency" cases and this did not meet that criteria. The medical residents for the most part do not have the experience in this type of procedure and they are not certified for it in any case. So that left the ER docs, who are overwhelmed with incoming patients or me. Clearly if was going to get done, it was going to be me. Having finished laughing, I finished the conversation with my friend and began getting dressed in case I needed to go in. One thing the pandemic has done is really lower the standard as to what people are willing to be seen wearing. However, even by the current low standards, my sweat pants with several holes in the butt and a convenient hole that allows for mindless genital stroking was not going to do it. Dressed and ready to go, I called to see if I needed to go in. The bleeding had slowed, the nurse had looked in his throat and there was no blood coming down (an act above and beyond the call of duty) and she would continue the ice. I told her to give the patient a sterile gauze pad and instruct him to roll it up and gently place it in his nose. As I listened, she told the Creole interpreter, I know I did not mention the patient did not speak English but language line is a beautiful feature, to tell the patient what to do and it was done. So from my home to the hospital room to the unknown location of the language line office, to the home connection of the Creole interpreter to the patient in the bed. We all stopped his nose bleed and that was a great thing for him and for me. No further calls from that nurse, though I learned the bleeding stopped and the patient felt better. He was able to resume using his oxygen by nasal cannula the trauma of which probably caused the bleeding in conjunction with the low platelet count. They did not call to tell me that the bleeding had stopped, because you never get good news when you get a call from the hospital.

Just to be clear, I am not condoning this as a safe practice, There have been a very few anecdotally reported cases of a second infection out of China but those numbers are minuscule. It may be that China is once again being deceptive about their numbers. We will have to see I we start getting second infections here. So I suppose he could have a second case, but the odds are tiny or so it seems. So the question is still worth asking. In addition, they are now taking plasma from recovered patients and testing those antibodies as a treatment for the acute infection. There is not doubt that antibodies form, the question is their duration and effectiveness in staving off another infection with a slightly mutated coronavirus which is different than the initial infection. The hospital where I work is part of the study though we have not started using the treatment yet. We need to have enough people recovered for.a month, that is the time being used to allow donation. In the meanwhile, would that make a difference to you is my question and at least initially, the forum seems to state that it would not make a difference, they would not hire.

There is some evidence that there is brain activity after the heart has stopped and breathing has suspended. This would be classified as dead and so, even after you are dead, you would not be alone, you would be aware, for a short period, of others around you.

I know an escort who had Covid and now is 14 days after the infection. Theoretically he is cured or soon will be. If he could show you a positive test from a month ago, would you consider hiring if all the other boxes checked off? I do know this escort and I am personally acquainted with his results so it is not a scam, but we are working in the theoretic right now.

Well I made it to my four day weekend. A new schedule for the Coronavirus has us working for 10 days and then off for four. It does not sound so bad, but if had been 11 and then 4, I am not sure I could have gathered the strength to get back into the gowns and masks and overheated rooms. The patients keep coming. On some of the floors they are now mating patients who have similar medical needs so that you can have two patients in. an isolation room. This will also allow for two patients to share one ventilator if it should come to that. Today I only had 10 patients, all Covid and there was hope for 4 of them to go home. The average age of the patients was 44 the mean was 37. The oldest patient is 81 and he has other medical problems and if not for those, he would not be in the hospital due to Covid. The hope is that the CoVid stays mild and the other issues, including a platelet count of 3000. Uusual platelet count is 140000, minor problems can start at 75000 and below 20000, some type of treatment is generally necessary. He is doing well so far and our hope is to get the platelet count up and him out of the hospital by the weekend. Of the other 9, discharging 4 was the goal and keeping 2 out of the ICU was the bigger goal. The other 3 are kind of in a holding pattern for now. Sick enough to be in the hospital, too sick to send home, but no so sick as to require intense treatment. Of the four going home, two were actually discharged. A 32 year old with Covid and a renal stone and a 37 year old with Covid and accelerated hypertension. In both of these cases, the CoVid just made the treatment of a common medical problem more complicated. There is always the donning of the gown to get into the room. Sending patients for tests and getting specialists to see the patients is much more difficult. Specialists, such as ID and pulmonolgists are boots on the ground full steam ahead busy. Others, such a neurology and gastroenterology are a lot less busy as their fields of expertise are not usually a major component of a serious component of the CoVid infection. So some are inundated and others are quarantining at home with their families. I known the media is fond of making health care workers during this plague seem like marathon runners down to the last bead of sweat, unclear as to whether they will make to finish line without a complete physical collapse. To be fair, there are some doctors and just about all nurses who fit into that category. But there are a few doctors, though they are suffering finanacially, professionally, they are sitting this one out, at least so far. When a staff of a hundred or more internists were asked to volunteer to help out the 25 or so doctors doing the yeoman's work in the hospital, how many would you have expected to volunteer. If you guessed most, you are way wrong. A quarter? No but thanks for playing. Surely a dozen? No no no. A handful? Only if you had a finger amputated. That is right out of about 113 doctors not already actively caring for these patients, 4 volunteered to assist should the medical team in the hospital not be able to handle to load. Now we have 35 residents but they do not manage patients independently and in this crises, they, so far, have been exempted from the routine examination of the patients though they do handle emergencies and order writing as guided by the attending physicians. Now the group of physicians caring for partients, about 90, 25 on ventilators and numbers increasing every day, include a team of 5 intensive care specialists, 5 hospitalists, 3 infectious disease specialists, 3 full time faculty members and occasional other specialists like renal doctors who may need to oversee dialysis. That is for around the clock care and a steady influx of new patients and the inevitable death of others. We have not gotten to the point as they did in Italy where they simply made patients considered non salvageable, not my term, comfortable and allowed them to pass with minimal medical intervention. So, if you are looking for heroes, look to the nurses. In and out of room after room. Trying to meet every need from life saving treatments to face saving bedpans. You see, even a bedpan requires someone to gown up, a process that takes 3 to 5 minutes if done carefully and go into the room. This is a job which might be done by less skilled individuals during usual times, but those people are not generally going into the room. So now to the two patient that did not go home though we had hoped they would. These patients are almost identical twins in a clinical sense. Both are physically active Mexican blue color workers in their mid 30s. Both had been sick.for 10 days or so before they came to the ER and both are otherwise healthy. Both had been tested for CoVid and knew they had it. One presented with diarrhea and the other with cough but neither was very sick when they came to the ER and both could possibly have been sent home to recover with instructions to return I things got worse. Both men had slight blood tests abnormalities which suggested that their course may be a bit rocky, and so both were admitted with the idea that they should be able to go home in a day or two. Now two days after each was admitted, they looked to be ready to go home. The man with the diarrhea had improved and was able to eat. The man with the cough and fever had not gotten worse. Neither was needing oxygen and so they were told that they would be going home. The man with the respiratory complaints began to cry when I told him he was going home. He told me :No quirero morir sin nadie, (I do not want to die alone). I tried to reassure him and he eventually collected himself. Two hours later he was unable to fully oxygenate and was clearly short of breath. I kept him in the hospital. His twin, was told he would go home and he was stoic about it. I noticed he had a slight cough but when I pressed him about it, he said that he was coughing up mucous and was feeling short of breath when he walked around the room. His monitor did not show him losing oxygen when he was walking. But the cough, the symptomatic shortness of breath without oxygen desaturation and most of all a half cup of thick brown mucous convinced me he should stay. I told him he would stay one more day. That is when he started to cry. He admitted that he was afraid, something he denied flat out when I asked him if he was afraid early in the visit. He was afraid that he was going to die alone and he thanked me for letting him stay in the hospital even though that meant things were not doing was well. . I think it is interesting that the fear that both of these men expressed is that they were afraid of dying ALONE. I think all of us have come to some internal understanding that we are not here forever but it is the fear that when we are leaving we will have to do it alone that terrifies people. It is also clear that people in the hospital with Covid, all of them with the mental capacity to understand their disease, know that they could die from this and that it could be just hours away. Even so, what they fear most is dying alone. That is what is so cruel about this disease. There are no visitors. There is no one to hold the hand, to shed a tear at the bedside, to say a prayer or to whisper that it is alright to let go. Nurses are there though. Thanks to all that is holy for them and their efforts

So you are thinking that this pandemic is going through the summer then.

Travel brochures. When this is done, I am headed to Tahiti and possibly Australia. You cannot keep putting off the future so give yourself a present. This is my new motto. That and "Mamas en la cama" which is my quick saying to my Covid patients who speak Spanish and need to prone.

I mentioned keeping you eye out for the sneak. Well, tonight, my dear canine friend Mr. Bear was the sneak. He passed just about when I finished my previous post. All week long I have been preparing. I would have a bit of a final visit each time I went to bed, because I was not expecting him to make it through the night, Then in the morning, he would still be there, wagging his tail when I called his name and lifting his head ever so slowly in my direction. He had stopped eating despite coaxing with some pretty good favorites of his. So he did not totally sneak away. When I would leave for work, there would be little confessional of love and most times, depending where he had settled, I would look in from a window or through the backyard foliage to get what I thought be my last glimpse of him. Then , each evening he would still be there. A little weaker, a little grayer but still with a wag of a tail though he had stopped coming to greet me at the door. Tonight he actually seemed a bit perky, He drank some water and though he did not move much, he did keep himself in the warmth of the sun the window let in. When I came to write my medical notes and then my posing here, I stepped over him and gave him a casual "How ya doing Bear boy". Soon after, he snuck away before I could hold him and pat his head one last time. Damned sneaks, the give you just a moments peace. They lull you into a space where everything seems like it always is and then they turn all of your expectations up side down. Well I got him up from the floor to the ottoman where he usually slept. I cleaned up the the area and I am set to go to bed. I decided to write this now so that the reality of it sets in and I can get some sleep knowing that my life has been better with him in it and that I hope he felt the same. Goodnight bear, you old sneak. I'll miss you. I see you after my work is done.

Similar to proning, expanding the lungs may recruit more oxygenation, It will not prevent severe coronavirus, but it may improve your response to the cytokine storm by having more alveoli open, I must admit I did not watch the video but as a respiratory therapist, I used to instruct patient's in these exercises and I used to do percussion on the chest to help mobilize secretions. All these things help a bit. However, just because you do something a bit differently and you make it to the other side, does not make it so that the action is what got you there. There was something on Facebook that said the Plaquenyl had 100% success rate in one hospital Either totally fake or totally misleading (two people used it two people got better). So if it does not requite professional time and special equipment , I will give most things a chance. While we are still learning what works best, these type of things such as lung exercises do not usually make a massive difference. Does it make sense that some well practiced exercises can change how your lungs function in a short enough period od tie to prevent a major disease? Not for me. Now a short course exercise to get 6 pack abs, I buy that.

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.