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Critical Care

Content by MunoRN

  1. Don't shoot the messenger on this one, I'm probably as skeptical of any suggestion that Covid-19 isn't anything other than highly transmissible as any of you, but there are surprises in the data we have so far. And coming from Atul Gawande adds some credibility for me at least. The take away is that while Covid will gladly take advantage of any opening it can to spread, it may not take as much to close those openings as we think. When it comes to Covid, less might be more. Keeping the Coronavirus From Infecting Health Care Workers by Atul Gawande, the New Yorker - https://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers
  2. MunoRN

    Acute COVID, What We're Seeing

    COVID-19 has been in my area long enough that we're getting an idea of how it plays out, curious what others are seeing. The most surprising thing has been the duration of acute illness, I sort of figured it would be like other respiratory viruses just more severe, but with acute symptoms lasting up to 7 days or so. We've seen timelines similar to what China was reporting; about 10 days from symptom onset to needing ICU care, then critically ill for weeks, the shortest recovery we've seen is 3 weeks of aggressive life support. Time from symptoms onset to death has ranged from 2 to 8 weeks in China. So it's not just the number of patients that will require vents and other equipment, it's the length of time they will need them for. The first week or so on the vent is similar to a bad influenza; lots of vent support, maybe proning, maybe flolan, not typically requiring inotropes or vasopressors, then they seem to have turned the corner and are out of the woods. Then they crump, big time. From nothing to max pressors and inotropes and an EF that drops from normal to 10-15% in as little as 12 hours. Sudden onset renal and liver failure, with impressively severe liver failure in such a short amount of time. Deaths appear more cardiogenic than respiratory, lethal rhythms have varied the full gamut; VT, VF, PEA, and asystole. We've had enough ventilators so far, but what likely lies ahead will be the need to figure out a process for taking ventilators and other life support equipment away from patients less likely to survive to make them available to patients more likely to survive. Things seem dicey now, but that's a whole 'nuther level of dicey.
  3. The OSBN's answer to the question you pose in the beginning is quite clear from their statements, they do not expect nurses to work without the PPE recommended by the OHA. I don't know who these "other nurse attorneys" are that you're having conversations with, but I would suggest finding a more informed peer group.
  4. Read article in its entirety: Quarantined Nurse's Scorching Anti-CDC Rant Goes Viral: 'I'm Appalled at the Level of Bureaucracy' on Coronavirus Testing
  5. MunoRN

    Does Having More Ventilators Even Help?

    There is certainly a subset of patients who may benefit from being on a vent, but no, not all patients who require a vent will benefit from one and we have enough data at this point to know who those patients are. And no, prolonging a non-survivable dying process is not a benefit of putting someone on a vent.
  6. MunoRN

    Does Having More Ventilators Even Help?

    I think more importantly there is the question how many patients can be saved with a ventilator. The number of patients who need a ventilator and the number who would benefit from a ventilator are two very different things. As the criteria that predicts mortality is becoming more clear, I don't think the answer is more ventilators, it's more palliative care consults.
  7. MunoRN

    COVID-19 and extinction of human species

    I'm not sure where you're getting your 10-20% mortality rate from, but even if that were true, it's not mathematically possible for this to result in extinction given the concentration of high mortality risk in certain (older) age groups.
  8. MunoRN

    Venti vs nonrebreather

    I would first consider that neither is likely to relieve the patient's respiratory distress, so additional steps will need to be taken anyway to address the dyspnea, but if they're hypoxic then it's generally considered in the realm of a "prudent" nurse to apply oxygen while also initiating the process of notifying the physician. A sharp increase in CO2 level is more of a driver of dyspnea than hypoxia, with the other main source of dyspnea being a restricted or impaired ventilation; bronchospasm / constriction, pneumo, pulmonary edema, etc. If this is an acute change where there isn't already a treatment plan in place for this scenario, then this would be when you would initiate a Rapid Response if that's available to you. When calling the Doc, you should have additional assessment info ready including lung sounds, vitals, LOC, etc. This might indicate prns that are already ordered; are there wheezes? Or worse, were there wheezes and now there's not even enough air moving to make a wheeze? In terms of the NRB vs Venti, the advantage of the Venti is that you can titrate the oxygen concentration, but if they're hypoxic and/or rapidly dropping sats, then it would make sense to skip the Venti and go straight to the NRB. Keep in mind that the mask, as opposed to the cannula, can potentially work against you. If the sensation of the mask strapped to your face increases the fight-or-flight response, which isn't unusual as a reflexive response to pressure around the nose and mouth, then that can increase the respiratory demand that they already aren't meeting. Or it might feel reassuring and do the opposite.
  9. MunoRN

    How to Operate Hospital Bed

    The air pumps in the Hill Rom Progressa are actually "on" all the time with the exception of a few settings, max inflate as you noticed for instance, and yes they make a sound like a turbine spinning up. The purpose of this is that it's continuously adjusting your daughters pressure points to avoid skin breakdown. Max inflate will stop the noise once it's inflated, but that will automatically time out, as well the custom "patient comfort" firmness settings, which I would assume is intentional so that the skin protection settings aren't overridden long-term.
  10. He said it can be transmitted by aerosolized droplets, not airborne transmission which refers to a particle that remains in the air for an extended period of time. Aerosolized droplets can remain in the air for some period of time, but still less than airborne particles, which tend to be particles with a large surface area relative to its weight, the dry skin particles that facilitates varicella shedding for instance. Your general point is correct though, coughing produces aerosolized droplets that can transmit to someone else through the air. The reason why airborne precautions are recommended is that those precautions are the best way to keep staff protected from infection by those droplets. 'Normal' droplet precautions aren't actually intended to protect caregivers from infection, they're only intended to prevent staff from being a vector of the pathogen from one patient to another.
  11. We could start with the article you linked to that accurately describes the mode of transmission as being droplet, and yes I agree that a coughing patient or really any COVID patient can aerosolize droplet nuclei and the proper form of respiratory protection for all staff caring for these patients is at least an N95 level of filtration, although I'd argue even that is insufficient, N100 (HEPA, ULPA) are the appropriate level of respiratory protection. A thread on the topic: The aerosolized droplet nuclei that are the mode of transmission are airborne, but it's different than airborne transmission which leads to confusion, it might be better if we called airborne transmission 'sustained airborne'. Airborne transmission refers to pathogenic particles that can remain suspended in air for extended periods of time. Droplet nuclei can remain suspended in air for some amount of time, but not in the range of true airborne particles.
  12. "Airborne" transmission refers to a pathogen than remains suspended in the air for extended periods of time, which you correct that Covid doesn't do. It does commonly transmit from one person to another through the air, often expelled by one person and then inhaled by another, spreading the virus. You only have to receive a few of these viruses to become infected, and even N95's only block 95% of the pathogen. So when a cough can produce anywhere from a few hundred to a few hundred thousand of individual droplets of these pathogens, and it only takes a few to get infected, that's why N95s are considered better than procedure masks, which typically block anywhere from 10 to 50% of these pathogens.
  13. I don't know that this has been closely studied with this particular strain of coronavirus, but a common characteristic of viral infections is that unlike bacteria where there is a dose-dependent relationship between the amount of bacteria you're exposed to and the severity of illness or infection, the severity of a viral illness isn't dependent on the actual number of viruses that enter your body. Although the amount of exposure might affect the length of the incubation period. It's just as likely that inhaling 100 viral droplet nuclei will cause a severe illness as it is that inhaling 100,000 viral droplet nuclei will result in a mild illness. This is likely because of differences in how viruses and bacteria cause illness. The effects of a bacterial illness are a direct result of the bacteria and their byproducts; the more bacteria the worse the illness. Whereas a virus effectively tricks your body into harming itself, and it only takes a small number to do that. This is why complete respiratory protection is so important, unlike a bacterial infectious risk where reducing the amount of inhaled bacteria by 80% serves some purpose, this has little benefit with viral pathogens, where that 20% you're still inhaling will do just as much damage as all of them would.
  14. MunoRN

    Acute COVID, What We're Seeing

    A COVID unit is basically one big isolation room.
  15. MunoRN

    Acute COVID, What We're Seeing

    That's been sort of back and forth, there's been an ongoing debate based on supply, evidence, limit it to a clinical trial? etc. I wouldn't say the effect has seemed as apparent as with Remdesivir, although that might also just be seeing something that isn't actually there.
  16. MunoRN

    Doctors not assessing COVID patients?

    There are certainly reasons for the physician to go into the room, but they also shouldn't be going in just for the heck of it. With COVID there isn't actually much purpose to a direct Physician assessment. It's reasonable to limit the number of staff entering the room and not have multiple staff members doing different tasks that could be done by a single staff member instead.
  17. The debate we should be having is whether an N95 is sufficient, it's a failure of Nursing leadership in the US that we're debating whether procedure / surgical masks are sufficient. As an example, from a journal article during the 2002-2004 SARS Coronvirus outbreak: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC156669/
  18. MunoRN

    Acute COVID, What We're Seeing

    We've weaned a few from vents, the shortest time on the vent I think has been just under 3 weeks. I should warn this isn't necessarily a scientific observation, but the ones that seem to have improved the quickest have been those able to get Remdesivir.
  19. MunoRN

    Acute COVID, What We're Seeing

    This is closely related to ARDS, but really the COVID symptoms are distinct from typical ARDS. The most effective vent settings have been spontaneous modes which wouldn't work with paralytics. But mainly, as paralytics are given for longer and longer periods of time (more than a few days) you get to where long-term or permanent neurologic damage becomes inevitable, particularly in the setting of renal or hepatic impairment, which is not unusual in these patients.
  20. MunoRN

    The ANA is killing nurses

    All the unions in not just my state, but region are affiliated, essentially subsidiaries of the ANA, so I'm not sure how supporting unionization helps oppose the ANA.
  21. The board is concurring with rules even more relaxed than the CDC. The CDC recommends N95 or better for HCWs caring for coronavirus patients. They only support the use of surgical or procedure masks when attempts to provide proper protection have failed, although this has been often misinterpreted. The Oregon BON is concurring with Oregon Public Health, which has taken the position that even if N95 or better protection is available, the recommended level of protection for nurses caring for Covid-positive patients is procedure or surgical masks, which is not supported by any current evidence. They leave the only exception as being when patients are undergoing Aerosol Generating Procedures (AGPs). The basis of concern for exposure with AGPs is that they may include similar mechanisms that cause droplet aerosolization with a cough, or even worse, they may trigger a cough. Close proximity transmission through respiratory mechanisms, particularly a cough which is a well known symptom of Covid, is a well established source of infection. Backing an employer's intention to not provide meaningful respiratory protection when nurses are caring for Covid patients, even when such protection might be readily available, is a disturbing position for a BON to take.
  22. CDC guidelines are for N95 or 100 level protection, some states and hospitals have opted to instead go with surgical mask protection. The level of protection these provide is not really known since they aren't intended for that purpose and therefore aren't tested for wearer protection performance. Some studies have been done and find that these masks typically filter about half the inhaled air, which in the case of a virus is basically pointless. As far as limiting more effective airway protection to certain procedures there is absolutely no evidence these procedures produce significantly more virulent droplets than a cough does, and these patient are almost always coughers. I think there's been confusion about the level of respiratory protection required to protect the wearer from droplet transmission, not just airborne. For viruses, where reducing the amount of inhaled pathogens, rather than full protection, is basically useless, N95s are arguably insufficient, N100 (HEPA) is really the only worthwhile protection.
  23. MunoRN

    Crisis travel assignments for Covid-19?

    In my area the offers are around $5000 per week for a 3 week commitment.
  24. MunoRN

    Covid-19 is Quite Unpleasant: A Personal Testimony

    Since what you're describing is an upper respiratory tract infection it's unlikely it was Covid, but those URIs can hit people pretty hard and are no fun either.
  25. I'd take those "ALL IS WELL" reassurances with a grain of salt. Trump had a conference call today with all the governors, and they all reported told him they're screwed when it comes to vents and equipment. You have to consider how many vents we're talking about for instance. Some states have said they've managed to scramble together extra vents, the largest number I've heard is 100 vents. Hopefully these numbers aren't right, but they have been so far: One third of the population will become infected, about 6 percent of those will require ICU care, almost all due to the need for a ventilator. On average, that means each state will have about 130,000 people requiring a vent, so scrounging up an extra 100 vents doesn't do a whole lot. Again, hopefully our numbers don't keep going in that direct, some countries are surprisingly unscathed so far, but then there are countries like Italy where their numbers are far worse than that. Their current mortality rate in confirmed cases is about 7%, and that's with most of the confirmed cases not yet being to the point where deaths are known to occur.

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