The worst has not begun and today, I found it hard to go on.

[+ sync]

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.

Well, I'm not liking the news of that.

[MikeBiDude]

Well, I'm not liking the news of that.

One more thing for you to worry about ??

[+ purplekow]

"It does not sound so bad . . ."? You are a much better man than I.

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.

Edited April 10, 2020 by purplekow

[+ Charlie]

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.

OMG. This is the first procedure you have discussed that I actually understand and could tell someone what to do! (My spouse occasionally suffers from serious nosebleeds.)

[+ nycman]

There was no way an ENT was coming in to do this procedure

One wonders why an ENT (ear-NOSE-throat) doctor wouldn’t come to the

hospital to see a thrombocytopenic patient with a NOSE bleed...but I digress.

 

PK I’m impressed that you know how to pack an anterior nose bleed.

If you tell me you know how to pack a posterior one....I may be in love!

 

Next time try Afrin nasal spray followed by intranasal tranexamic acid.

https://www.jwatch.org/na45649/2017/12/08/tranexamic-acid-more-effective-nasal-packing-treatment

 

I never thought ice packs did anything but make a mess. Glad it worked.

[+ purplekow]

One wonders why an ENT (ear-NOSE-throat) doctor wouldn’t come to the

hospital to see a thrombocytopenic patient with a NOSE bleed...but I digress.

 

PK I’m impressed that you know how to pack an anterior nose bleed.

If you tell me you know how to pack a posterior one....I may be in love!

 

Next time try Afrin nasal spray followed by intranasal tranexamic acid.

https://www.jwatch.org/na45649/2017/12/08/tranexamic-acid-more-effective-nasal-packing-treatment

 

I never thought ice packs did anything but make a mess. Glad it worked.

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.

.

Edited April 11, 2020 by purplekow

[+ purplekow]

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.

Edited April 11, 2020 by purplekow

[+ tassojunior]

[MEDIA=reddit]pics/comments/fz4oy4[/MEDIA]

[+ purplekow]

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.

[+ purplekow]

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

[MrMattBig]

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

 

I hate to overly pick your brain on your last day off but is there use of tocilizumab in spots across the medical community right now? And if so is there push to bring it to the attention of the adminstration?

After looking online, my rough understanding is that hydroxychloroquine is a rough target against and inflammatory response of the immune system in general, while tocilizumab is more targeted against cytokine release.

[+ purplekow]

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.

Edited April 13, 2020 by purplekow

[MrMattBig]

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. I am sure Dr. Fauci is aware of these drugs 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.

Thanks for the explanation ? It puts back in context that right setting and right timing is important in relation to a cytokine storm scenario.

Your right about the last thing needed is to tout it as a cure. To the lay person with no context that's what the rhetoric about hydrochloroquine seems to promote, which is annoying. I feel for those who use that medication for lupus and other conditions who have had to worry and struggle to get their everyday meds.

[LivingnLA]

@purplekow, thank you for your very informative posts. I'd heard cytokine storms were an issue for some cases and if caught early, they seem treatable. Actemra? Like other RA drugs, it seems to help in some cases.

 

https://www.latimes.com/world-nation/story/2020-04-13/coworkers-save-coronavirus-doctor

[LivingnLA]

I've been endlessly interested in the complex interactions and interrelations among life on Earth. Humans love to create discrete categories to try to understand reality yet they frequently blind us to how everything we do has effects and consequences.

 

https://www.newyorker.com/culture/annals-of-inquiry/the-pandemic-is-not-a-natural-disaster

[+ aeikaryoko]

Thank you and all the other first responders @purplekow for your selfless acts. I have been on this thread reading along with others for your updates sending me on a ride of different emotions. Please stay safe and well out there.

[+ sniper]

purplekow, I live in NJ and just saw that we are expected to hit peak hospitalization on 4/25, while NY seems to have already peaked. Given the fact we took measures at essentially the same time as NY, is that an indicator that NJ patients are staying longer in the hospital? Are we having better or worse mortality than NY?

Or does it just mean that NJ is actually getting more people to the hospital while a lot of people who live alone in NYC are dying in their apartments?

[Islesguy]

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.

While I am not a doctor, I can confirm that doctors only get called at home with bad news. When a friend of mine was diagnosed with a rare genetic disease, the examining doctor told him he would need to consult with a doctor who was at home, sick. He knew right then the news was going to be seriously bad.

[Islesguy]

purplekow, I live in NJ and just saw that we are expected to hit peak hospitalization on 4/25, while NY seems to have already peaked. Given the fact we took measures at essentially the same time as NY, is that an indicator that NJ patients are staying longer in the hospital? Are we having better or worse mortality than NY?

Or does it just mean that NJ is actually getting more people to the hospital while a lot of people who live alone in NYC are dying in their apartments?

It might be more because a higher infections of COVID started earlier in downstate NY, especially Westchester, which probably promoted people to individually start distancing earlier. The last time I went into the city was March 8th. There was a noticeable decline in the number of people using public transportation. Even on Feb 26, the morning rush was very noticeably lower. Both times, there were many people already wearing masks.

[+ tassojunior]

I wonder if your hospital has tried this......putting oxygen in blood outside the body while the lungs are not functional....

https://www.yahoo.com/news/first-arizona-patient-ventilator-survives-104531736.html

 

 

also, I hate to post items because they sell out but Amazon has this oximeter for $30 shipped by early May and there are other ads for sooner for more. Over $35 gets free shipping. https://www.amazon.com/CONTEC-CMS50M-Oximeter-Waveform-Carrying/dp/B07D8R4G5H/ref=zg_bs_3775161_11?_encoding=UTF8&psc=1&refRID=VJ6SRZ19QRK47WXARFV1

 

An oximeter is important for sleep apnea or coronavirus etc. I don't trust instruments so I ordered 2 cheap oximeters and 3 cheap thermometers. (and yes, I wear a cloth mask over my cheap surgical mask).

 

I also use this good Lung Meter. Only $15 shipped fast. https://www.amazon.com/Quest-AsthmaMD-Lung-Performance-Meter/dp/B00B9AOKP6/ref=zg_bs_3775161_49?_encoding=UTF8&psc=1&refRID=VJ6SRZ19QRK47WXARFV1

Edited April 15, 2020 by tassojunior

[+ purplekow]

Yes we have extracorporeal oxygenation and have tried it but that is not usually a long term solution.

Things do seem to be slowing down just a bit at the hospital at which I work and we are getting more and more therapeutic options. We are doing an in-house 150 patient study on the effectiveness of hydroxychloroquie vs placebo vs hydroxychloroquin + zithromax

We are also starting to use antivirals and convalescent serum but the anti IL 6 drug Tocilizumab still is the one showing the most benefit. We have success in getting a few more people off the respiratory. Still only 4 out o 56 with 27 still on ventilators but as of last week we had not gotten any people off. We are also intervening to try to avoid artificial ventilation. We have had a few people be right on the edge and then turn around with the Tocilizumab.

As for me, I was told to take the rest of the week off and to return next week. While there is a relative lull and there is a full staff, they are trying to give people time off so that people will be fresh if there is a further surge. NJ is still seeing increased cases though NY seems to have leveled off. While I understand the reasoning, I tried hard to convince the powers that be that I am fine and to give someone else time off. There are definitely inspirational people working a lot harder than I have been. But, while I have been a general most of my professional life, now I am not a general and so I am acceding to the request, with a noted protest.

At the hospital they have changed the song for success to (This is my) Fight Song. Now there is discussion of changing it again because it is loud and harsh. So while the idea of a victory song was a good one, finding the right one has been a bit of a challenge.

So I will be calling in each day should there be an unexpected event such as a provider illness or a critical surge but I have off until next Tuesday. I cannot help to think that I would have been leaving for Palm Springs and would have been there until Tuesday. My house is not bad but I do miss the fun and the interaction of Palm Springs Get Together.

Hello to all the guys and next year is a plan.

Edited April 16, 2020 by purplekow

[+ Archer]

How about "I'm Alive" by E.L.O.?

https://www.youtube.com/watch?v=nlPARsKX_Jc:2

[+ purplekow]

How about "I'm Alive" by E.L.O.?

https://www.youtube.com/watch?v=nlPARsKX_Jc:2

Only problem is some of them will not be by the end of the day.

[+ stevenkesslar]

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.

 

OMG. This is the first procedure you have discussed that I actually understand and could tell someone what to do! (My spouse occasionally suffers from serious nosebleeds.)

 

So inquiring minds need to know, @Charlie. Are you saying you understand the nose bleeding procedure, but not the genital stroking one?

 

I'm just surprised. You have a reputation, you know.

Edited April 17, 2020 by stevenkesslar

[+ Charlie]

So inquiring minds need to know, @Charlie. Are you are saying you understand the nose bleeding procedure, but not the genital stroking one?

 

I'm just surprised. You have a reputation, you know.

My genital stroking is never mindless.