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

[+ g56whiz]

@purplekow I see I’m not alone in being moved to the core of my being by your posts here. In an ironic way you’re not only working to heal your patients as you can but your posts here help to keep us spiritually whole by demonstrating what practiced humanity can accomplish. G_d bless you, those that serve with you and your patients and their families (even those that rant over the phone).

[+ purplekow]

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

Edited April 6, 2020 by purplekow

[+ Oliver]

.... So I encourage you, if you know a nurse, text or call and express your admiration and appreciation ....

PK - first, thank you. Second I have two - my daughter and my daughter-in-law. Both are up to their ears, but are OK.

Virtual hugs!

[+ nycman]

PK thank you for your painfully beautiful posts. You are helping all of us

cope with this unmitigated disaster. Today I dared to hope as our local

numbers seemed to “bend” ever so slightly. Not enough to be a trend

and it’s far from over, but maybe, just maybe, we’re not still in the horrifying

free fall stage.

 

As one of my trusted mentors said when this started, “don’t worry about

how insane you sound today, in this coming catastrophe you will be seen

as a prophet within 2 days“. Unfortunatelay, he has been right over and

over during the last 4 weeks. Today it took 3-4 days for my doomsday

prophecies to come true....still crazy.....but progress.

 

Today one came off the vent and one went home. Small victories, and I try

not to think about the many who are not so lucky. Yes, luck is a major factor.

I sang through my N95 to the one who went home as he walked out the door.

I’m sure he thought I was nuts. I didn’t care. I’ll take any win I can get at this

point.

 

What you do matters. The world is weighing heavy on your shoulders right now.

Although I’ve never met you, I know you have the training, the strength, and the

resilience to see this through. And when this is over, the first lap dance is on me,

even if I have to come to NJ in full PPE and do it myself.

 

Lets be honest, I’ve worn worse on the PATH train...grin

[+ AntonGraza]

PK - I am not as versed as others here, but know you and all the people confronting these horrors everyday may receive all the warm, illuminating, life-giving Sunlight we can provide you. Please keep writing. My vet told me a dog will always give his owners love, and try to do this until they are physically unable. Enjoy and love each other, you are providing us with such powerful lessons and examples. EAT THE ICE CREAM!

[+ purplekow]

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

[+ stevenkesslar]

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.

 

I Googled it and found this. Any reaction, based on your experience?

 

Here are some of the existing drugs that may be repurposed to treat coronavirus

 

Actemra and other rheumatoid arthritis drugs

 

Doctors in China have used an anti-inflammation drug to curb the effects of the coronavirus on critical patients, and now the maker of the drug says it is talking to the Food and Drug Administration about clinical trials.

 

Tocilizumab, sold under the name Actemra and made by the Swiss pharmaceutical firm Roche, is a prescription medicine used to treat adults with moderate to severe active rheumatoid arthritis, as well as certain types of juvenile arthritis.

Chinese doctors have used Tocilizumab to prevent an overreaction of the immune system that has led to organ failure and death in coronavirus patients. An initial clinical trial in China used Actemra in 20 severe COVID-19 cases. Nineteen of the patients were discharged from the hospital within two weeks and one got better, according to China’s National Health Commission. The drug has now been approved for use in China, but has not yet been approved in the United States.

 

 

And while I am putting your medical expertise to work, I'm curious if you have any reaction to this:

 

A German Exception? Why the Country’s Coronavirus Death Rate Is Low

They call them corona taxis: Medics outfitted in protective gear, driving around the empty streets of Heidelberg to check on patients who are at home, five or six days into being sick with the coronavirus.

 

They take a blood test, looking for signs that a patient is about to go into a steep decline. They might suggest hospitalization, even to a patient who has only mild symptoms; the chances of surviving that decline are vastly improved by being in a hospital when it begins.

“There is this tipping point at the end of the first week,” said Prof. Hans-Georg Kräusslich, the head of virology at University Hospital in Heidelberg, one of Germany’s leading research hospitals. “If you are a person whose lungs might fail, that’s when you will start deteriorating.”

 

Heidelberg’s corona taxis are only one initiative in one city. But they illustrate a level of engagement and a commitment of public resources in fighting the epidemic that help explain one of the most intriguing puzzles of the pandemic: Why is Germany’s death rate so low?

 

If you read the whole article, it makes it clear that treatment is not the biggest reason for Germany's "lower" death rate. And at 2 % of all confirmed cases now, Germany's 2 % death rate is only "low" relative to Italy or Spain's death rates of about 10 %, or the US death rate which is a little above 3 % now. It's amazing that we are now at the point where a 1 % lower death rate in the US would mean 4,000 fewer dead Americans today. That's the equivalent of 9/11.

 

The two biggest reasons for the lower death rate are: 1) a lot more testing of the entire population, so they have more confirmed mild cases built into that percentage; and 2) a much younger average age of confirmed cases (49 in Germany, versus early 60's in France and Italy).

 

That said, it makes intuitive sense to me that there are probably people showing up at hospitals in the US who should just stay home. And other ones that probably should have come in earlier, before they fell over the cliff. That said, that's a medical diagnosis that's above the pay grade of people like me.

 

Does that line about "the chances of surviving that decline are vastly improved by being in a hospital when it begins" resonate for you? And if so, why? Is the issue that they can get you on a ventilator quicker? Or that if it is caught early enough, there are other interventions (like medication) that can prevent you from needing to go on a ventilator?

 

Not asking for professional medical advice, or course. You can just respond, if you wish, as part of the peanut gallery who knows more than the rest of us.

 

Thanks again for putting your heart into this, PK.

Edited April 8, 2020 by stevenkesslar

[+ Autumnal]

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

 

Thank you for these posts - I look forward to every one of them. I value the factual information that you provide that I don't get anywhere else, the inside stories of what is happening in the hospitals, and the very human side of the situation. I couldn't agree more with what you posted last night - "Life is always tenuous, .... Follow the Sun."

[+ purplekow]

I Googled it and found this. Any reaction, based on your experience?

 

Here are some of the existing drugs that may be repurposed to treat coronavirus

 

Actemra and other rheumatoid arthritis drugs

 

 

 

 

 

And while I am putting your medical expertise to work, I'm curious if you have any reaction to this:

 

A German Exception? Why the Country’s Coronavirus Death Rate Is Low

 

 

 

If you read the whole article, it makes it clear that treatment is not the biggest reason for Germany's "lower" death rate. And at 2 % of all confirmed cases now, Germany's 2 % death rate is only "low" relative to Italy or Spain's death rates of about 10 %, or the US death rate which is a little above 3 % now. It's amazing that we are now at the point where a 1 % lower death rate in the US would mean 4,000 fewer dead Americans today. That's the equivalent of 9/11.

 

The two biggest reasons for the lower death rate are: 1) a lot more testing of the entire population, so they have more confirmed mild cases built into that percentage; and 2) a much younger average age of confirmed cases (49 in Germany, versus early 60's in France and Italy).

 

That said, it makes intuitive sense to me that there are probably people showing up at hospitals in the US who should just stay home. And other ones that probably should have come in earlier, before they fell over the cliff. That said, that's a medical diagnosis that's above the pay grade of people like me.

 

Does that line about "the chances of surviving that decline are vastly improved by being in a hospital when it begins" resonate for you? And if so, why? Is the issue that they can get you on a ventilator quicker? Or that if it is caught early enough, there are other interventions (like medication) that can prevent you from needing to go on a ventilator?

 

Not asking for professional medical advice, or course. You can just respond, if you wish, as part of the peanut gallery who knows more than the rest of us.

 

Thanks again for putting your heart into this, PK.

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,.

[+ stevenkesslar]

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,.

 

That's actually why I asked, and sort of the answer I expected. That article about Germany mentioned blood testing people at home. I assume that would have to be a test that yields an immediate result. So maybe there are some markers they can use in home visits to make distinctions about who needs a hospital bed, and who should just stay home. But anecdotally I've read stories where doctors say the same thing consistently: one minute someone is fine, and then they take a sharp turn for the worse. So I also assume a lot of this is hindsight is always 20/20.

 

My biggest takeaway from that article about Germany on treatment is it makes a huge difference if you are not slammed on resources. Because of what you said: scarce resources. In an ideal world, in a limited outbreak, maybe everybody with COVID-19 would be isolated in a hospital bed and monitored, so that you could either prevent a steep decline, or be on it right away when it happened. That's not possible in places like New York and New Jersey now. This is why flattening the curve makes a huge difference. As slammed as they are, Germany says it is taking patients from France and Italy. (Wonder how they get them there?)

 

California's plan assumed that "hospital beds" would be needed for 20 % of all patients, including makeshift hospitals. It was never spelled out what that 20 % figure was based on. 20 % seemed on the high side to me, compared to what happened in at least some other countries. So my assumption was that the plan had built in the idea that they'd rather have anybody at the margin in the hospital under observation, as opposed to at home.

 

I'm assuming this is why they put Boris Johnson in an ICU. Better safe than sorry when it is your Prime Minister.

 

Chris Cuomo was talking a lot about breathing exercises on his show tonight. That surprised me. He said it was all he could do to force himself to get up, move around, do breathing exercises. But his attitude was clearly that this virus is going for my lungs, and I have to fight it.

 

So after watching him I Googled breathing exercises, too, and came up with this. Even JK Rowling has some advice to offer:

 

Lung exercises can help prevent severe coronavirus illness, doctor says -- and JK Rowling claims they worked for her

 

[MEDIA=twitter]1247121896082157568[/MEDIA]

 

 

Thank you again for sharing all this information and perspective. It is scary. Watching Cuomo and hearing your stories, as serious and sobering as they are, takes some of the scary unknown out of it.

Edited April 8, 2020 by stevenkesslar

[+ 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.

[+ purplekow]

T

 

Lung exercises can help prevent severe coronavirus illness, doctor says -- and JK Rowling claims they worked for her

 

[MEDIA=twitter]1247121896082157568[/MEDIA]

 

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.

[+ purplekow]

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.

Edited April 8, 2020 by purplekow

[rvwnsd]

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. ... 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.

 

PK, I am so sorry for your loss. I'm sure Mr Bear enjoyed the time he had you as his human. You're a good doggy dad.

 

Shedding a tear here in Phoenix.

[JulianLondon]

Mr Bear sounded a trooper. I understand this feeling very well, I'm glad you were there, we become extraordinarily close to our canine friends.....X

 

The Power Of The Dog

 

By Rudyard Kipling

 

There is sorrow enough in the natural way

From men and women to fill our day;

And when we are certain of sorrow in store,

Why do we always arrange for more?

Brothers and Sisters, I bid you beware

Of giving your heart to a dog to tear.

 

Buy a pup and your money will buy

Love unflinching that cannot lie—

Perfect passion and worship fed

By a kick in the ribs or a pat on the head.

Nevertheless it is hardly fair

To risk your heart for a dog to tear.

 

When the fourteen years which Nature permits

Are closing in asthma, or tumour, or fits,

And the vet’s unspoken prescription runs

To lethal chambers or loaded guns,

Then you will find—it’s your own affair—

But … you’ve given your heart to a dog to tear.

 

When the body that lived at your single will,

With its whimper of welcome, is stilled (how still!).

When the spirit that answered your every mood

Is gone—wherever it goes—for good,

You will discover how much you care,

And will give your heart to a dog to tear.

 

We’ve sorrow enough in the natural way,

When it comes to burying Christian clay.

Our loves are not given, but only lent,

At compound interest of cent per cent.

Though it is not always the case, I believe,

That the longer we’ve kept ’em, the more do we grieve:

For, when debts are payable, right or wrong,

A short-time loan is as bad as a long—

So why in—Heaven (before we are there)

Should we give our hearts to a dog to tear?

[thickornotatall]

I know how you feel....very sad for you....it's so cruel that our dog family has such a short life compared to ours...My Jack Russell died in November..I miss her every day....When I walk with our Goldendoodle people still ask for Allie....sad...

[Nvr2thick4me]

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.

You’re a hero. Thank-you

[+ Bryan Dube]

Thank you so much for sharing purplekow. you are a hero and inspiration to all. <3

[+ stevenkesslar]

Goodnight bear, you old sneak. I'll miss you. I see you after my work is done.

 

 

I'm sure God will find a way to comfort you.

 

It's not a matter of IF you will enjoy a new puppy.

 

It's just a matter of WHICH of the two puppies above you will choose.

[+ honcho]

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. ....

Goodnight bear, you old sneak. I'll miss you. I see you after my work is done.

 

I also grieve at your lost. Somehow just marking it with a frowning-face doesn't seem enough for me. Strength and love to you, Mr. Kow.

[+ purplekow]

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

Edited April 12, 2020 by purplekow

[+ Charlie]

We all die alone. We just want to have someone say farewell as we leave.

[+ purplekow]

We all die alone. We just want to have someone say farewell as we leave.

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.

[Jomo]

Thank you for your reports from the front line. I look forward to them each day. I hope you are doing well, and that your fever is just fluctuating.

[TruthBTold]

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 not 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 put 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 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 no 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 badpan 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

 

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