#CHF exacerbation

[mcatmemoranda]

Signs to monitor with CHF: JVD, pitting edema, crackles, urine output, weight

Every 1 increase in bicarb equals an increase of CO2 by 10. Pts who are heavier need more prednisone. We have a pt with BMI >50, and she needs 60 mg prednisone for COPD exacerbation.

[monkeymeghan]

Sorry I've been MIA. Life has had some pretty good highs and some really horrible lows recently. Christmas was great, but a few days later my mom went back into the hospital. After spending a day in the ER she was transferred back down to Philadelphia. She has a bad exacerbation of her CHF and it's not looking great. It's already gotten to the point where being the primary caregiver for both mom and dad has gotten to be too much, but now there's no way I'd be able to take care of her post-discharge, whenever that may be. Thankfully I have an amazing brother and SIL who are here for me and we are all going to do this together. My SIL drove me and dad down to Philly today to visit with mom. It took about an hour to get there. It was so nice to be able to see mom, not on facetime, but in person, and be able to hold her hand, talk to her, give her a hug and a kiss. But it was so fucking hard to see her like that. I don't know how long she will be in the hospital, but it's going to be a long stay. In the meantime, once the social workers reach out this week, we will all have to work together to figure out what type of facility is best suited for mom's needs, is close to home, and can safely provide all the care she needs. It kills me knowing that mom won't come back home. Just sitting here writing this, sitting in the living room where I usually am watching TV with mom at this hour, being here alone is hard. I'm crying just thinking about it. I hate this. I hate all of this. Coincidentally enough, the weekly email from church last week included a flyer about an anticipatory grief support group that another place nearby will be hosting. I signed up for it, its virtual, for 8 weeks, and starts February 1. I'm glad, because I don't know how to do this. I'm so scared.

[healthcaretoday1]

Advancing Cardiovascular Therapy Exploration through FDA Interventions and Addressing Unmet Needs in Congestive Heart Failure (CHF) Congestion

Worldwide, cardiovascular illnesses continue to be one of the primary causes of morbidity and mortality. The most common and serious of them is chronic heart failure (CHF), which affects millions of people. Congestion, which is frequently characterized by fluid accumulation and insufficient blood circulation, is one of the major problems that CHF patients must deal with. Even though there are a number of FDA-approved therapies available to treat congestion in CHF patients, figuring out what cardiovascular therapeutic needs are still unmet is essential for enhancing patient outcomes.

Write to us at enquire@grgonline.com Learn how GRG Health is helping clients gather more in-depth market-level information on such topics

Understanding Chronic Heart Failure and Congestion

A complex clinical illness known as chronic heart failure occurs when the heart's ability to pump blood is impaired, resulting in a variety of symptoms and a decreased quality of life. Congestion, which results from fluid retention and insufficient fluid evacuation, is one of the defining signs of CHF. If not treated properly, congestion can cause lethargy, edema, shortness of breath, and even hospitalization.

FDA-Approved Interventions

The FDA has approved a number of therapies throughout the years to treat congestion in CHF patients in an effort to lessen symptoms and enhance their general wellbeing. These interventions can be divided into many groups.

Diuretics: Diuretics, such as furosemide and spironolactone, are commonly prescribed to increase urine production, reducing fluid overload and congestion.

ACE Inhibitors and ARBs: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) help dilate blood vessels, reduce fluid retention, and improve cardiac function.

Beta-blockers: These medications slow down the heart rate, decrease blood pressure, and improve heart function, ultimately alleviating symptoms of congestion.

Vasodilators: Vasodilator drugs relax blood vessels, easing the workload on the heart and improving blood flow.

In more severe cases, ultrafiltration may be considered, where excess fluid is mechanically removed from the bloodstream.

Identifying Unmet Needs

While these FDA-approved interventions have undoubtedly improved the lives of CHF patients, several unmet needs persist:

Personalized Medicine: CHF is a heterogeneous condition; not all patients respond equally to the same interventions. Developing personalized treatment plans based on a patient's unique characteristics could significantly enhance outcomes.

Long-Term Efficacy: Some interventions might initially alleviate congestion but lose effectiveness over time. Researching the long-term effects of these therapies and identifying strategies to maintain their efficacy is crucial.

Reducing Hospitalization Rates: Hospitalizations due to CHF exacerbations contribute to healthcare costs and patient distress. Innovative interventions that can prevent these hospitalizations are needed.

Novel Therapies: While current interventions are valuable, there's a need for novel therapies that can directly target the mechanisms underlying congestion, potentially leading to more effective and targeted treatments.

Patient Education and Adherence: Ensuring patients understand their condition and the importance of adhering to their treatment plans is essential for achieving optimal outcomes.

Conclusion

Managing congestion in chronic heart failure patients is a pivotal aspect of cardiovascular therapy. Significant progress has been made in improving patient outcomes with a range of FDA-approved interventions available. However, identifying and addressing unmet needs remains crucial for advancing cardiovascular care. Personalized medicine, exploring long-term efficacy, reducing hospitalizations, developing novel therapies, and emphasizing patient education are all avenues that researchers and healthcare providers must continue to explore to enhance the quality of life for individuals living with chronic heart failure. Through ongoing research, innovation, and a holistic approach to patient care, we can hope to achieve better outcomes and a brighter future for these patients.

[anantradingpvtltd]

Price: [price_with_discount] (as of [price_update_date] - Details) [ad_1] Updated yearly. Last in July 2018. Over 390 illustrations and color photo's. We added detailed information on the treatment of the the most common admitting diagnosis. 1. Respiratory failure: ARDS. Pneumonia. Exacerbation of chronic lung disease (Asthma, COPD, Bronchiectasis). Pulmonary Embolism. 2. Shock: Hypovolemic (GI Bleed and Diarrhea). Cardiogenic (Acute MI / Infarct). Distributive (Sepsis and Anaphylaxis). Obstructive (massive Pulmonary Embolism. Tamponade. Adrenal Insufficiency / Crisis | 3. Cardiac disease: Acute MI / Unstable Angina. Heart Failure (CHF). Valvular Heart Disease. Hypertension Emergency. Arrhythmia’s with hemodynamic instability (see cardiology module). 4. TRAUMA: massive, involving multiple organs. Rhabdomyolysis | 5. Burns. 6. CNS injury: Stroke. Head injury. Hemorrhage (Subdural / Epidural). Status Epilepticus. Coma. Delirium. 7. Infections: Septic shock. Toxic Shock Syndrome. Meningitis. Neutropenic fever. Endocarditis. Diarrhea 8. Metabolic derangements: Acute Renal Failure / uremia. Diabetic ketoacidosis (DKA) and HHNKS. Severe Hyponatremia or Hypernatremia. Severe Hypokalemia or Hyperkalemia. Severe Hypophosphatemia. Intentional or accidental poisoning (See Trauma-Tox module for Toxidromes). 9. GI diseases: GI Hemorrhage. Acute Liver Failure / Encephalopathy. 10. Hematologic disease: Anemias. Thrombocytopenia. TTP-HUS. DIC. 11. Psychiatric diseases: Suicide attempt. Neuroleptic Malignant Syndrome. 12. Postoperative Crises: Post-Op Confusion | Hypotension | Fever & Infections | Oliguria & Short-of-Breath | Hyponatremia & Other Pearls | Filled with detailed work-ups, treatments, pearls, illustrations, differential diagnosis, references....Everything you ever needed to know about critical care and nutrition issues in an easy to read and navigate format created specifically for the handheld device. Edited by multiple specialists. The perfect text for internists, family physicians, urgent care clinicians, residents, medical students and mid-level providers. ASIN ‏ : ‎ B004I5BTW6 Publisher ‏ : ‎ Primary Care Software, PC; 18th edition (18 December 2013) Language ‏ : ‎ English File size ‏ : ‎ 9265 KB Text-to-Speech ‏ : ‎ Enabled Screen Reader ‏ : ‎ Supported Enhanced typesetting ‏ : ‎ Enabled X-Ray ‏ : ‎ Not Enabled Word Wise ‏ : ‎ Not Enabled Print length ‏ : ‎ 2167 pages [ad_2]

[themdmc]

Are you Artificially Intelligent enough to Catch that Aortic Insufficiency heart murmur? lol

[doberbutts]

What breeds would you consider to be food options for outcrossing with the Doberman, and why. Have there been any promising outcrosses in your opinion? I’d love to learn more about this. It’s so interesting.

Hehehehe food options.

I think it is more than breed. I think it's going to need to come down to useage and temperament. Certain common mixed breeds and types may be better suited than purebreds to add into the gene pool.

First I would start with what we know. German pinscher, rottweiler, manchester terrier, and greyhound.

Greyhound we know was added mainly for aesthetic, and we really need to consider aesthetic last when it comes to this breed. There are plenty of dobermans that look correct that we can breed to when the time is right to regain aesthetic. If the addition of a sighthound is truly necessary, I would say something more akin to a RR or sloughi for the more protective/wary temperament, or ibizan for their robust health is probably better than a greyhound at this point.

Manchester terrier makes up the bulk of the terrier traits of the doberman, with hints of german pinscher thrown in. I wouldn't be mad about adding either or both to the pile however manchesters do have a known DCM problem and GPs do have CHF, so I can understand why many doberman people are leery of returning to the known terrier roots when trying to avoid heart problems in the first place. My suggestion- the airedale- also has a known heart problem unfortunately. However I do think terriers as a breed group should not be wholly discarded, simply that we would need to find a feisty terrier breed or type that is hardy and fearless. Feists as used by hunters, especially boar and bear hunters, are a solid possibility if we can find one that's actually health tested. Personally I wouldn't be too mad about a bully breed working in protection sport or big game hunting but that may add a little too much dog aggression to the mixture. Dobermans are described as "belligerent" with other dogs, but they IMO should still be controllable around another dog and not act like an idiot.

Rottweiler as "butcher's dogs", where they were more of an even mix of herding and mastiff traits instead of the heavily mastiff influenced breed they are now, provide an interesting perspective. Right now, the european show line doberman (often just called "euro") is far too molossus and far less terrier than it should be. Adding rottweiler as they are now would continue to exacerbate this problem, unless we added fairly fine-boned rotties which is technically correct (a "good doberman" should be difficult to tell from a "bad rottweiler" after all) but then we are seeking incorrect dogs in the breed we're borrowing genes from and that gets us into a whole additional mess. We may need to break it down into two separate pieces: herding and mastiff.

I'm actually not mad about the known mal/dobe and dutch/dobe crosses as I think that could have been fairly successful, if only the folks involved had used good dogs rather than just picking any old doberman and any old mal/dutch and expecting these puppies to be fire from birth. What ended up happening is that the puppies are largely fairly lackluster in protection, but okay as active pets and other performance sports. This is mainly a result of using dogs that were already lackluster themselves- a better result would have happened if they had used proven parents. How do I know this? Because for a very long time the most recent doberman ancestry dog that did anything in KNPV was not a purebred but a mal/dobe cross (in between a purebred dobe owned here in the states 20 years ago, and a handful of purebred dobes owned overseas a few years ago). The cross can work. You just need the right dogs for it.

As far as mastiff goes, personally I would prefer the mastiff traits to be somewhat diluted through a different type before being added to the doberman. What I mean by that is while I'm willing to acknowledge that the corso/dobe outcross was one of the more successful in creating a doberman-appearing and doberman-seeming dog, both physical and temperamental mastiff traits continue to appear in the dogs produced by the project, making them continue to occupy a weird "not really either" space. This problem is compounded by the fact that, once again, lackluster dogs were used in the first place. Perhaps with a proper working doberman and a proper working corso a better temperament result could have occurred, but we'd still be fighting those mastiff traits in the face and body.

Instead I again would bring up bully breeds, especially bully breed crosses with other working dogs, to dilute these mastiff traits and combine them with other traits we are actually looking for. The bandog [APBT x working mastiff]/dobe cross in I believe Czech Republic is, so far, the most successful by temperament. This is because the dobe used is a successful bitesport dog and the bandog used is successful in real life working fields as a security guard's dog. The resultant puppies are following in their parents' footsteps quite well from the looks of things. They mostly look like pit bull mixes but this is a much better result because the quality of the dogs used was better to begin with. I wouldn't even be mad about those bull terrier x malinois crosses I've seen occasionally for sport (which, btw, mega heart eyes) as that would combine THREE traits we're looking for.

I also think that this would need to happen more than once, more like several crosses of each of these suggestions to multiple different dogs as distantly related as possible, then bred together and with the wider doberman gene pool to spread the (hopefully) improved health throughout the breed. We will lose a lot in aesthetic initially but that is the least concern as that can be gained back fairly rapidly. The most important thing should be health, and immediately following after should be temperament.

No more of this "english bulldog to doberman" "smooth collie to doberman" "pointer to doberman" "husky to doberman" nonsense. It's nonsense. These dogs add absolutely nothing to the breed except traits we don't want, neither look nor act like the breed, and some of them only add more health problems that we already didn't want to worry about. No more of this "well I just wanted to make pets". The doberman is not a pet dog. It's a working dog. If you want to help fix the doberman breed then your first goal should be to create more working dogs. The health is in jeopardy but so is the temperament, and completely losing temperament for the sake of preserving aesthetic and maaaaaaaybe fixing health is completely unforgivable.

[redrobin-detective]

o great robin, tell us about organ failure. i wanna know what happens when someone's pancreas decides to nope out

ok so I’m on a stepdown ICU which means you’re not quite sick/unstable enough to warrant being in Intensive Care but you’re also not well enough that you can be on a regular floor bed. I’m on a general Medical floor (as opposed to Surgical, Peri-Op, etc) so we see patients with lots of chronic issues and comorbidities in addition to acute issues. 

Top things I see: DKA (high sugar, need insulin drip and education), Sepsis (blood infection, antibiotics and wound care usually), CHF Exacerbation (heart failure, usually fluid overload so diuresing), cancer (chemo, radiation, surgery, preventing secondary issues from killing them) HTN emergency (high BP, get them on BPs meds, diuresing), various respiratory illnesses from Pneumonia to Covid (o2, antibiotics, steroids), AWS/COWS (alcohol or drug OD, gently getting them past seizure threshold with benzos) and Pre/Post- Transplant d/t organ failure.

Listen, modern medicine is amazing but transplants suck. They save lives but the a) exhaustive work up to transplant b) anxiously waiting for transplant c) going through the surgery d) the rigorous process of keeping the transplant e) the very likely possibility of rejection/failure within 5 years is just... not great. The failing organs/transplants we see on my floor most often are liver, kidney, lungs and occasionally the pancreas which can be paired with kidney transplant. Hearts have their own unit bc that shit is cray (they just... leave the chest open after surgery in case they need to go back in. They essentially cover the open chest with saran wrap. This image haunts me and I want nothing to do with that shit)

Kidney transplants usually are the easiest with the highest chances of success. I’ve had patients come in with transplants that have been going strong for a decade. Lung transplants are tricky and its so hard watching people do bad both before and after the transplant, watching the grief in their eyes when they realize the transplant isn’t a magical cure all. I think livers are the worst for me, liver failure (both alcoholic and NASH) causes swift physical and mental decline in which the patient can become a whole other person. Most of my liver patients have tried to physically fight me at some point, in between vomiting and having their abdomen swell to terrifying proportions from ascites. We pulled 8 liters off a man’s belly about a week ago. That’s 4 two liter soda bottles my friends.

When I first started my job, we had a lung transplant work-up on our floor. She was with us for an entire year, too stable for an ICU but on waaay too much oxygen to go home. We loved this lady, walked her around the unit every day shape which took almost an hour because she had to go so slow less we overwhelm her crappy lungs. She got transplanted and we celebrated only for it to not take well and her to spend another year in the cardiac ICU when her new transplant caused heart failure. We heard she died during Covid times after never leaving the hospital for 2 years. It still makes me sad to think about her.

Some people just live with chronic organ failure, too unstable to risk surgery or deemed by the powers that be not to be a suitable candidate for whatever reason. We have maybe a dozen patients that we see every 6 mo or so for exacerbations of these issues that we can’t really treat the underlying cause so we just patch a bandaid over the failing organ and send them away until next time. One lovable frequent flyer said “it’s good to be home” one of the times he was wheeled up to us from the ER. 

TLDR: organ failure sux but so too does transplant, they’ll both cause you misery. Kidneys are fab, livers make you punchy, lungs make you sad.

[heard-in-the-emergency-room]

Provider: I believe this is a CHF exacerbation. I’m ordering some lasix for you.

Patient (in his late 60s): Oh, that drug is dope

[gaia-prime]

Two of my patients yesterday:

Patient A: Stopped taking his Lasix, ended up in hospital for (surprise) CHF exacerbation

Me: “what a great guy. Hope he learns from this and takes care of himself.”

Patient B: Traveled to South America for some cheapo plastic surgery and ended up with a dehisced and infected incision.

Me: “she’s so sweet and has a great sense of humor omg I’d change her wound vac any day”

Weird how I find myself having compassion for people who make horrendous decisions that have disastrous consequences for their health but when it comes to 💉 refusers (derogatory) I’m just 😠😒😒

[theglowstickchronicles]

We are down to one (1!) covid patient in my entire hospital, and the patient is extubated and on the stepdown unit on medium flow oxygen. I don’t have any official data, but it’s been well over a week since our last new covid+ patient. We are mass testing employees for asymptomatic carriers and have had 0 positive tests. Every single patient admitted to the hospital and every single patient getting a procedure, from ultrasound to surgery, gets a covid swab- which means lots and lots of patients on precautions, but no more surprise exposures. It’s all very exciting and we could not be happier in that aspect.

But that’s the problem. We couldn’t be happier. No more long shifts plastered in sweat from PPE for 12+ hours, no more long sleepless nights thinking about if I was good enough for my patient whose hand I held while he died instead of his family, no more wondering if today would be the day one of our coworkers would infect the rest of us.

Instead there are days filled with beach trips and travel plans and drinking at the 50% capacity bar. Offhand comments about Florida and Arizona while we get together for birthdays and graduation parties. Celebrating that quarantine is over.

500 people died in this country of Covid19 yesterday. 500 in one day. 

That’s my entire middle school.

That’s like if every single person in the entire building, staff and patients alike, suddenly all died today. 

Florida had almost 12.5k new cases yesterday. That would be like if every single child in the school system of my hometown was diagnosed yesterday. 

62,000 new cases in the country yesterday. That’s my entire hometown. As if every single one of them tested positive yesterday. 

Quarantine is not over.

Get back inside your house. Put your damn masks on. Stay 6 feet apart.

Beach trips are not stimulating the economy.

Can’t stimulate the economy when you’re intubated. Or broke from the rehab you need after Covid causes your stroke or heart attack or limb amputation. Or trying to pay off your DME (that is, the oxygen that you had to go home on). Or the funeral expenses of your grandparents that you killed. Can’t stimulate the economy when you’re in therapy trying to overcome your PTSD from being intubated for 3 weeks, the guilt you feel when you pass this on to your best friend and they die. 

You can’t stimulate the economy when you’re on chemo for the cancer that progressed to stage 2 or 3 or 4 because your appointment got pushed back due to the pandemic. While you’re visiting -one at a time- your mom in the hospital for her CHF exacerbation that was 10x worse than it needed to be because she didn’t want to come in during the pandemic. While phases of reopening are being pushed back due to increases in cases and lack of following the quite simple rules put into place. Bars and restaurants and shops aren’t profiting from 50% capacity while you leave shitty tips and complain about wearing a piece of cloth in between apps and entrees. 

We could be back to normal by now if we had all listened at the beginning instead of whatever the fuck it is we were doing the last 4 months but here we are, continuing to make it worse. 

I won’t get into the blatant bigotry in the wording of this tweet, but even our piece of shit POTUS has finally broken down and started to understand, on some (I’m sure extremely basic) level that we can’t seem to get out of our own fucking way. 

There are patients in hallways, intubated, covered with ants, attached to oxygen tanks because the wall flowmeters don’t work, in a hospital in Texas. 

There are people in the north east who tear up every time they look at a black trash bag because that was all that was standing between them and a virus we still seem to know nothing concrete about.

And there are people hosting Covid parties and attacking employees when being asked to put a mask on.

Every morning I get up and wonder if today is the day I wake up from this nightmare. 

[mcatmemoranda]

In pts with CHF exacerbation and AFib with RVR, avoid beta blockers and diltiazem as these will just slow the HR more. Dilt might be ok if the pt has a good EF.

[appalachiananarchist]

The brown paper bag situation is very real and it sucks a lot. I currently have one mask I have been using for a week. Someone did sew us all mask covers to go over them, and mine is very nice, but it doesn’t fit my head. I will have to engage in some crafting tonight to fix it.

I am also quite worried that, in the wake of the coronavirus fears, many people are going to die from other causes due to not seeking care when they should. I received a call from a patient clearly struggling to breathe (bad CHF exacerbation) who said, “I can’t breathe. Should I come to the hospital with the virus going around?” Yes! Yes, right now! Also, a lot of my patients are trying to schedule telehealth with me instead of coming in, which is fine for some things, but not all. I had one whose CC was “blood pressure problem” but then when I talked to her what was really happening was repeated syncopal events and palpitations. Not exactly a telehealth-appropriate encounter...

Not good. Really not good.

[healthcaretoday1]

FDA interventions & unmet needs in CHF congestion: Advancing cardiovascular therapy exploration

Cardiovascular diseases remain a leading cause of morbidity and mortality worldwide. Among these, chronic heart failure (CHF) is a prevalent and serious condition affecting millions of individuals. One of the critical challenges CHF patients face is congestion, often characterized by fluid accumulation and inadequate blood circulation. While several FDA-approved interventions are available to address congestion in CHF patients, identifying unmet needs in cardiovascular therapy remains crucial for improving patient outcomes.

Read more: https://www.grgonline.com/post/fda-interventions-unmet-needs-in-chf-congestion-advancing-cardiovascular-therapy-exploration

Understanding Chronic Heart Failure and Congestion

Chronic heart failure is a complex clinical syndrome wherein the heart's ability to pump blood is compromised, leading to various symptoms and reduced quality of life. One of the hallmark symptoms of CHF is congestion, resulting from fluid retention and inadequate fluid removal. Congestion can lead to shortness of breath, fatigue, edema, and even hospitalization if not managed effectively.

FDA-Approved Interventions

Over the years, the FDA has approved several interventions to manage congestion in CHF patients, aiming to alleviate symptoms and improve their overall well-being. These interventions fall into several categories.

Diuretics: Diuretics, such as furosemide and spironolactone, are commonly prescribed to increase urine production, reducing fluid overload and congestion.

ACE Inhibitors and ARBs: Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) help dilate blood vessels, reduce fluid retention, and improve cardiac function.

Beta-blockers: These medications slow down the heart rate, decrease blood pressure, and improve heart function, ultimately alleviating symptoms of congestion.

Vasodilators: Vasodilator drugs relax blood vessels, easing the workload on the heart and improving blood flow.

In more severe cases, ultrafiltration may be considered, where excess fluid is mechanically removed from the bloodstream.

Identifying Unmet Needs

While these FDA-approved interventions have undoubtedly improved the lives of CHF patients, several unmet needs persist:

Personalized Medicine: CHF is a heterogeneous condition; not all patients respond equally to the same interventions. Developing personalized treatment plans based on a patient's unique characteristics could significantly enhance outcomes.

Long-Term Efficacy: Some interventions might initially alleviate congestion but lose effectiveness over time. Researching the long-term effects of these therapies and identifying strategies to maintain their efficacy is crucial.

Reducing Hospitalization Rates: Hospitalizations due to CHF exacerbations contribute to healthcare costs and patient distress. Innovative interventions that can prevent these hospitalizations are needed.

Novel Therapies: While current interventions are valuable, there's a need for novel therapies that can directly target the mechanisms underlying congestion, potentially leading to more effective and targeted treatments.

Patient Education and Adherence: Ensuring patients understand their condition and the importance of adhering to their treatment plans is essential for achieving optimal outcomes.

Conclusion

Managing congestion in chronic heart failure patients is a pivotal aspect of cardiovascular therapy. Significant progress has been made in improving patient outcomes with a range of FDA-approved interventions available. However, identifying and addressing unmet needs remains crucial for advancing cardiovascular care. Personalized medicine, exploring long-term efficacy, reducing hospitalizations, developing novel therapies, and emphasizing patient education are all avenues that researchers and healthcare providers must continue to explore to enhance the quality of life for individuals living with chronic heart failure. Through ongoing research, innovation, and a holistic approach to patient care, we can hope to achieve better outcomes and a brighter future for these patients.

[icu3po]

“[...] one of the worst fears of the pandemic—that hospitals would become overwhelmed, leading to needless deaths—is happening now. [...] This is such a searingly ugly idea that it is worth repeating: Americans are likely dying of COVID-19 now who would have survived had they gotten September’s level of medical care.”

It’s here folks. I’ve seen it. And yet I’m STILL listening to people talk about having parties and hanging out with people outside of work and extended families. STILL. ಠ_ಠ We were all advised of the sacrifices necessary to avoid this outcome and yet...

It’s not just COVID. This affects anyone who has a medical need. Clinics are closing in order to divert staff to hospitals. As a result, thousands of patients across the country risk falling through the cracks without their needed checkups to maintain chronic conditions such as heart failure, diabetes, hypertension, and COPD. Inevitably those people will become more acutely ill, requiring a trip to emergency room. For example: CHF exacerbation, hypertensive crisis, DKA or HHS, and acute respiratory failure are some of the most common reasons for hospital admission and are all considered “acute-on-chronic” problems.

This time, however, if you need to be admitted, we may not have a bed for you. Neither will any hospital for hundreds of miles. If you’re lucky, you might be transferred to another hospital after hours of waiting in the emergency department. Or, you might be sent home after being stabilized with instructions to just come back if you get worse again.

How about planned surgeries to replace hips and knees, or to remove cancerous tumors? What will be the complications from delaying those procedures? Oncology patients who have a dangerous reaction after starting a new chemotherapy treatment? They are already severely immunocompromised. Can they wait in a bed in a hallway? I’ve cared for oncology patients who are routinely admitted to the hospital every two weeks in order to receive an 8-10 hour chemotherapy infusion. If those patients can’t be guaranteed a bed and a chemo nurse every two weeks for 6 cycles, how will that impact their treatment plan?

I’ve decided to share my unique perspective as an ICU RN in order to lift the veil somewhat and allow you all to grasp the reality of the situation.

🩺A typical Full Code COVID patient in the ICU, in my experience:

•A tube is in their mouth, extending down into their trachea, where it is held in place by a balloon to prevent air leaks. This tube is their lifeline and so it is secured to a device which is adhered to their cheeks to prevent dislodgment. The tube is connected to a machine at the side of the bed which forces air into the lungs at a set pressure, volume, and rate. We use a wand with suction to clean out their mouths every two hours. If needed, we occasionally thread a smaller tube through their endotracheal tube in order to suction out the gunk that makes you cough so it won’t clog up the breathing tube. If we switch modes to allow the patient to control their breathing, COVID patients will try to breathe 30-40 times a minute (normal rate is 12-20). They will also try to take deep breaths and cough. COVID makes tissue in the lungs so fragile that inflating them with high volumes and pressure will cause damage and scarring. We can’t let these patients breathe the way they want to breathe or else they will destroy their lungs and die.

•All of this is uncomfortable for the patient and so they are sedated. Medications to make them sleepy and to prevent agitation are given through continuous IV infusions. These medications also drop the patient’s blood pressure and so they also receive continuous IV infusions of medications called “pressors” which raise blood pressure. These “drips” are titrated up and down constantly by nurses to keep the patient sleepy enough to breathe with the vent, while also maintaining enough blood pressure to perfuse their vital organs.

•These pressor medications are very caustic and can burn and scar peripheral veins, so the doctor will place a central line. This is a long tube that’s threaded into a vein in the neck to almost reach the heart. In order to closely and accurately monitor blood pressures, we will use another long tube that’s inserted into an artery (either wrist or groin). That line continuously measures the average arterial pressure and nurses adjust those pressors based on that number.

•When your body is very sick it has trouble self-regulating to achieve homeostasis. Your kidneys are one of the first organs to suffer damage when you are very sick. Healthy kidneys help regulate blood pressure, electrolytes, and the acid-base balance of your blood. In the ICU we have to regulate all of that for you. We draw blood to check labs frequently, sometimes hourly, to monitor: how well you are getting oxygen in, how well you are breathing carbon dioxide out, how well your body is managing your acid-base balance, your electrolyte levels which will cause cardiac arrhythmias and even brain swelling if they are too high or low or if they change too quickly, blood clotting factors, level of waste products in your blood, etc. The nurse is constantly drawing these labs, reading the results, and giving medications or making ventilator adjustments to correct imbalances.

•Because the patient is asleep and has a tube in their mouth, they are unable to eat or drink anything. We put another tube in the mouth with the vent tubing, but this one goes down the esophagus and into the stomach. We then attach it to suction to remove gastric contents, use a syringe to administer medications, or hook it to a pump with a bag of liquid nutrients called “tube feeding” that will slowly trickle in just enough fluid (20 mL/hr) to ensure your gastrointestinal tract stays active and you have enough calories to meet your basal metabolic needs (the amount of calories your body burns by lying in bed).

•Because you aren’t eating or drinking or moving and the sedation medications are making your bowels sleepy, we give you laxatives to keep you pooping. Since your diet consists of a bag of liquid calories, it comes out of you much the same way. So we even have a tube for that, called a rectal tube (or “fecal containment device”) that’s held in place by a balloon in your butt and your poop just runs into a bag.

•It’s important for us to monitor how much urine your kidneys produce each hour. In order to be as accurate as possible, we insert a tube into your urethra which is held in place by a balloon in your bladder. Urine runs continuously into a bag where it can be assessed and measured.

•We monitor the heart via 5 wires stuck to the chest that give us a continuous visual representation of the electrical activity of your heart. COVID damages cardiac tissue and so arrhythmias and cardiac ectopy are common. If your heart beats too fast it can’t fill with enough blood to maintain your blood pressure, so sometimes we need to add even more continuous IV medications that prevent the heart from galloping off or doing too funky of a beat too often. The heart can sometimes be so damaged that it can’t squeeze effectively either, so we use other IV drips to help the heart beat and prevent it from giving up entirely.

•When we’ve done all we can do and the patient is still not improving, we will try “proning” and/or paralyzing. Medically paralyzing involves giving a continuous IV drip that stops muscles from being able to contract. This removes the extra oxygen demand of muscles, maximizing the oxygen that the COVID-damaged lungs can process. We need to give the least amount of paralytic medication necessary to prevent long-term complications. We are able to check the degree of paralysis by attaching electrodes to the patients face or wrist, sending electrical pulses (like a bark collar does), and then counting the muscle twitches. Paralytics also affect the body’s ability to create tears, so we need to pry open your eyes to administer eye gel regularly.

•Putting a patient in a prone position (on your stomach) helps by increasing blood flow to different areas of the lungs. It takes 5+ people to roll a patient VERY CAREFULLY onto their stomach without pulling out any of their tubes or lines. These are very sick patients and sometimes the movement can be too much of a strain on their heart and lungs. It’s a delicate, time consuming process. Patients remain proned for 16 hours, then returned to their back for a few hours. We may repeat the process again several times over the next 2-3 days, depending on if it is helping or not.

So how does this COVID patient get out of the ICU? Rarely, a patient improves enough to be awake and off sedation with the vent settings allowing breathing at the patient’s own rate. If the patient continues to improve, they are extubated (breathing tube out) and moved to a progressive care unit in the hospital to continue recovery. Unfortunately, the patient will often return to the ICU after only a day or two in the PCU. They deteriorate again because of all those COVID complications: heart damage, clotting (in lungs, legs, brain, etc), worsening pneumonia, etc. They can also develop complications that occur just from being hospitalized, such as: MRSA, cDiff, ventilator-associated pneumonia, bloodstream infection from the central line, UTI from the urinary catheter, peripheral limb ischemia from high doses of pressors, delirium (confusion/hallucinations), or injury related to falling.

•If the patient is still requiring mechanical ventilation after about 10 days, the next step is to have a surgeon create an opening in the neck called a tracheostomy so the ventilator can be attached through the hole in their neck. This way they can have long term ventilator support while continuing to attempt treatment. These patients are then transferred to a long-term acute care hospital where they will have to survive months of therapy to try to optimize their quality of life. After their prolonged hospitalization they will need to learn to breathe on their own again, swallow again, walk again, and learn how to take care of themselves as much as possible again. If they survive all of that then the patient will next move to a rehab center or nursing home. By this point, many do not survive due to new complications, the stress of prolonged sickness and comorbidities, or because the patient and family decided to pursue comfort cares instead.

🩺Some real talk here because knowledge is power:

I encourage EVERYONE (regardless of age or current health status) to fill out a Healthcare Advanced Directive, and choose who will make medical decisions in the event you are incapacitated. Consider your wishes NOW, and make sure you also know what your parents, grandparents, and spouse want. If your family member is hospitalized with COVID-19 and becomes so sick that even BiPAP is not helping, the doctor will ask you to make a decision between invasive mechanical ventilation (and everything that I described above) or “comfort cares.”

The specifics of “comfort cares” is individualized, but it essentially focuses the plan of care to acknowledge the patient’s decision that their quality of life is more important than extending it artificially without reasonable chance of recovery. The doctor prescribes medications to ease anxiety, and pain and the patient eventually passes away naturally without aggressive measures like a breathing tube or chest compressions. Families can be present with their loved one via telephone or Zoom video, though visitor restrictions may be eased for end-of-life patients, depending on the facility.

If you already have existing health complications (comorbidities) that make your chance of recovery from cardiac or respiratory arrest unlikely, you are able to let the doctor know from the beginning whether you are okay with CPR and a breathing tube, or if your wish is to make your code status DNR/DNI. DNR means that if your heart stops beating, you don’t want us to do chest compressions or shock your heart to try to restart it again. DNI means that if you can’t breathe on your own, you don’t want a breathing tube in your throat with a machine to breathe for you. You can choose one or the other, or both. You can also change your mind at any time, revoke your code status, and be considered a Full Code again. Full Code that means that we do everything medically possible to keep you alive, including breaking ribs during CPR, and putting a tube down your throat.

It’s important to not only have in mind what your own wishes are, but to discuss with your loved ones about their wishes. Very often, patients are either unconscious or too sick to communicate clearly and so the doctor will ask the next-of-kin or Healthcare Proxy to make the decision. Don’t make that emotional moment be the first time you think about it. And don’t put your loved ones in that position either. Have a conversation, put it in writing, and free them from the burden of that decision.

Feel free to ask me if you have questions and I will answer them to the best of my ability.

If you choose to share my words, please give credit and/or link to this page. Thank you.

[cranquis]

TSK: (surprise) update

So remember the elderly patient with the moron family members from yesterday?

They did take him to the ER (surprise) -- but informed the triage nurse “We only came to get lab tests drawn, we don’t want the ER doctor to see him” -- and then left in a huff when (surprise) the ER wouldn’t agree to that stupid plan.

And then they brought him back the following day when he was too weak and disoriented to eat or get out of bed (surprise), and the workup done by the ER doctor (surprise) showed:

sepsis

hypokalemia

acute renal failure

CHF exacerbation (”but he doesn’t have any heart problems!”)

UTI

(SURPRISE)

...and so the family got upset that the ER had “once again” found more problems than the family expected him to have, and tried to take him home AMA. (sigh... surprise)

And then Social Work and Adult Protective Services got involved.

[doctorofwhut]

Honestly? 

One of my favorite parts of inpatient medicine is when I see a patient I took care of in the past and they remember me and I get to over-dramatically wail “why are you back in the hospital?” and then we get to have a nice friendly chat about how things are going. 

(Obviously I don’t like how a lot of my patients are frequently back in the hospital for CHF exacerbation or something but it’s nice to be remembered)