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moriahcat

moriahcat

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  1. Oh, sorry. Altered mental status was the best way to describe why we felt admission was absolutely necessary. She was slurring despite no alcohol in 2 weeks, speaking very slowly, lethargic, not responding to complex questions, the day after some unusual hostility after overhearing a conversation and misunderstanding what had been said (a person she disliked was mentioned, she was clearly upset, when asked why she said she didn't want them over for dinner and was very sure we had invited them). They felt it was just hepatic encephalopathy -- and yeah, once I got to see the labs in her patient-accessible version of the chart, I could see why that would be the first assumption. But the part of her gut that absorbs thiamine is bypassed, and she'd just had a week of vomiting/not eating well from trying to dry out and refusing to go inpatient to do it. So despite no nystagmus, Wernicke's encephalopathy was a concern of mine -- both in making sure that wasn't what was going on, and ensuring she never *does* get her thiamine reserves completely depleted.
  2. My mother just got out of acute care for her first episode of apparent HE (ETOH abstinent -- by her own choice, yay! -- nearly 2 weeks before AMS was apparent so they didn't think it was late-appearing DTs, no nystagmus), and I was using all of my abilities to access her chart remotely to get information on just what was going on with her. 48-hour delay before lab results show there, though. I knew her nurses did not have time to go over labs, and certainly did not have the ability to change orders to her care. It was extremely frustrating that the hospitalist never called us, even once -- not just because we were left in the dark, but because her nutritional/digestive status is complicated by a prior bariatric surgery -- higher risk of WE, and she was having extreme ataxia along with the AMS. Even worse, though, was knowing she was experiencing new-onset confusion, all alone, without any family members to give her any sort of grounding. She wasn't able to answer her room phone without assistance, so during her entire admission she got to speak to me once, and to my sister once. It's hard but we fought to get her discharged to home and do home health vs dc to stepdown for OT/PT. She still doesn't have all her nouns back so I am still worried about her, but my sister and I both agreed that whatever was causing her confusion, it would be more likely to resolve at home where she knows people love and care about her. Or at least not get worse from being completely isolated from us. Edit to add: they did test her for COVID, but she's in the end of the queue and no results back yet. If they're doing that for every pt and not just the elderly, then at least HCWs at this hospital are going to know they've been exposed -- even if they might learn it only when their own incubation period is close to over.
  3. moriahcat

    Facial coverings effective?

    This infuriates me for you. I'm so sorry. It shouldn't be like this.
  4. moriahcat

    Facial coverings effective?

    I'm assuming you work in a medical field/clinic, compared to a retail worker wearing a mask. If I'm making the wrong assumption, please let me know. To address your article.... N95s were never designed to be worn all day, to be re-donned after use to use with a different patient, or to be used when they were no longer comfortable to breathe through. Current protocols to conserve PPE are taking all those laboratory-tested conditions and saying "To heck with them". Just as procedure masks, when worn, were to be changed between patients. Aka, not wearing the same mask all day. And while I hate to go ad-hominem on the MD who contributed the article to the paper, if you drink diet soda or eat food with MSG, according to him you're dying. (I don't care, gimme my soy sauce and side of Diet Coke please). If you're somehow wearing the same N95 for 6-8 hours, it wouldn't surprise me that you feel poorly at the end of the day. Not only have you kicked rear in a high-risk ward where you were trying desperately to save lives, but you have had to utilize PPE beyond its laboratory specifications. The hope for those who ARE having to do that is that it's still better to feel puny end of shift than to have gotten a huge dose of aerosols during an intubation. To be honest, for me, wearing even the same procedure mask all day helps my asthma from reacting as much to certain in-office allergens -- even toner gets me, and so it's kind of been nice to have to wear them even as a non-direct-patient-contact person. Of course, again, not an N95.
  5. moriahcat

    Facial coverings effective?

    If you mean they agree there is no evidence for or against, but that health care grade masks should be saved for HCWs and those dealing with likely COVID-19 cases, not the hopefully well... yes, yes they do. https://www.who.int/publications-detail/advice-on-the-use-of-masks-in-the-community-during-home-care-and-in-healthcare-settings-in-the-context-of-the-novel-coronavirus-(2019-ncov)-outbreak Helpful information, updated compared to their January recommendation that cloth masks should not be used at all.
  6. moriahcat

    Nursing Homes. The bodies are just pilling up.

    Well, it was always going to be optional for the patient, but there was to be mandated coverage of such visits no matter what your insurance was. Self-insuring organizations that erroneously (and sadly, still) think "Living Wills" are just statements of refusal of treatment (and also against the ACA for other mandated coverage provisions) jumped on the bandwagon, and soon the whole "conversation when not in crisis" turned into "OMG death panels!" Le sigh.
  7. I was more trying to help you deal with your current pts, and you still haven't answered whether you know for certain the ones that are being so combative are indeed "exploit(ing) the mental health system" after early release. But since you haven't answered it, you may not feel you are able to without violating their privacy, so I'm going to assume and give you the benefit of the doubt that yes, the combative pts you are dealing with are part of the "legions of released inmates". If there is no psychiatric diagnosis that can be treated in an acute inpatient setting, then perhaps you and the other nurses can explain that to the doctors and see if discharge (because if there is nothing psychiatric to treat, acute inpatient psych is not where they belong) just means they will come back in a day (with street drugs in them to boot) or might actually help. Or if discharge is not possible, heavy third-generation antipsychotics to treat the combativeness -- as in, enough to qualify as "chemical restraint"? I mean, it might make dealing with them easier. And surely you and your colleagues have seen NMS enough to know if it's happening (despite third-generation antipsychotics having far less likelihood of causing it than good old fashioned Haldol), so it would be a safer alternative for all involved.
  8. Thanks, reason I asked was that you weren't clear (perhaps purposefully to protect their privacy) if these combative pts were actually released inmates or not. If not released inmates, then I'd attribute the high acuity/high level of combativeness to already being in an extremely poor condition to get admitted in the first place, and then having no choice but to be in a hospital during a pandemic (where nurses/techs are trying their best to stay healthy but the individual themselves can't know that for sure). Anything that creates a sense of helplessness/hopelessness will exacerbate mental instability -- and you're used to the normal level of that which comes from admission itself (as a hospital is a place where the pt does not have control over their environment). Pdocs not admitting until pts are clearly off the rails combined with worry over a pandemic could potentially cause what you're seeing, regardless of past incarceration status.
  9. Without violating HIPAA, can you confirm if the combative pts you're dealing with actually *were* released from prison? I would imagine that, just like most non-COVID areas of care, psychiatrists aren't wanting to admit their pts unless they desperately need it. So lower acuity pts who would benefit from inpatient but can be managed with close psych guidance are probably not being admitted. Then add in being in a hospital (the place most people think they are going to catch COVID) to already existing mental health issues. Fear/anxiety about something they cannot control would exacerbate issues.
  10. moriahcat

    Why not quarantine McDonald's and ban soda pop?

    I seriously believe you misinterpreted Daisy4RN's post. She was talking about the attempt to cover a visit for discussing end-of-life options, vs the patient trying to make an Advance Directive on their own or trying to do it during a yearly physical/other visit. And yes, after kooks came out and called such discussions the beginning of "death panels", that proposal was killed. Such visits, however, ARE covered by Medicare. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/advancecareplanning.pdf
  11. moriahcat

    Nursing Homes. The bodies are just pilling up.

    The very good provision proposed in the ACA, to cover a visit for any patient who wanted to discuss their advance directive, was blown out of proportion and then removed thanks to those right-wing crackpots. Medicare, however, is covering those visits, so doctor and patient can discuss/create an advanced directive that shows what THEY want. Which may be full treatment, a trial of full treatment, supportive treatment, or comfort-based treatment only. Or whatever they add on in a POLST "extra instructions" section.
  12. moriahcat

    Nursing Homes. The bodies are just pilling up.

    I agree with you that coverage for the "hard conversation" about what a patient would really want should things get bad is a good thing. For example, my grandmother had her Living Will, and it included a DNR portion. She felt she had lived a long good life, and wanted to keep living it as long as she could, but when it was her time to go, she accepted that it would be her time. Passed not in the nursing home but the hospital (they xfered her for increased coughing, she had congestive heart failure) -- massive MI in the middle of the night. (The nurse with her said she had been resting comfortably, then suddenly said "I've never hurt like this before..." and the monitors started going nuts & she lost consciousnes.) She'd already stated her wishes, so they followed the DNR. But if the wishes aren't stated, or if families are in pain and want to delay their own grief by extreme measures, doctors are forced to do that -- to try to save a life, even if it's futile. They will even treat over the objections of a not-quite-there pt -- they have to, if they judge that the person is not truly capable of refusing treatment. When my father collapsed from high calcium and hadn't worn his DNR bracelet, the hospital couldn't confirm his living will/DNR (he was in end-stage AIDS), and they had to treat him until they were able to contact me. I advocated for the treatment he wanted, and we got him into hospice... but he fought the workers trying to save his life so hard, begging then to "just let (him) die", that they ended up sedating him. I think Advance Directives help a great deal, both for patients to determine while they are still in fairly good health what they would want, and so families know if their relative would want every treatment possible or would just want supportive/comfort care instead of a ventilator. And knowing a pt would refuse a vent would probably make a doctor feel better psychologically, as well as nursing staff, when they know that a vent going to be is close to futile and they have to deliver that news.
  13. I do think there will be "unrest". As in, people getting cabin fever, or protesting, or believing wild conspiracy theories. Remember that Youtube has a ton of disinformation on it, and there are many many people who drink the Koolaid (and even on one channel someone shared out, pay him to give it to him). That guy in particular kinda scares me, because his videos are 6+ hours long and people actually share them out thinking someone's going to watch. We already know that TV may make the brain more suggestible -- I didn't watch to see just how he was working his con (he looked stoned more than anything else as I skimmed the video to see the "slides" that ranged from 5G towers to naturally produced DMT -- raises another possibility of what drug he'd just come off of), but six hours of BS is apparently getting donations in the popular live stream so people are buying it. Will society "break down"? I haven't seen it so far. I do think we are going to have to deal with the segment of the population who is more afraid, for whatever reason, of government than they are of this virus. For example, people are already saying "no mandatory vaccines". They're looking at movies like Contagion and saying that since bracelets can be forged there will be RFID chips in the vaccines (and vastly overestimating the range/power of chipping technology while they're at it, claiming it's going to "let them track you everywhere". Sure, everywhere there's an RFID card reader and yes that could be put in a database, but no, not by GPS! Heck, you already carry a GPS device on you, your cellular phone! ... sorry, had to get that rant out somewhere. ANYway.... There WILL be resistance to a vaccine the same way there is resistance to "mandatory testing" (when in reality we can't test *enough* people) -- and whether it's home antibody testing or nasal PCR swabs, some people will make it a conspiracy. Also, churches cannot remain shuttered too long, or people will start going anyway. What can be done? Arrest the pastor? Megachurches have several, and he'd be a martyr. Arrest the congregants? Any unnecessary arrest potentially exposes essential personnel to COVID-19, and mass arrests would essentially turn what was already bad (people singing loudly, potentially spreading droplets much further as demonstrated by some of the church transmissions) into a real petri dish. (This goes for anti-lockdown protests, too -- dispersing a crowd is one thing, mass arrests are counterproductive.) Supply chain strain/breakdown? That's what I'm seeing right now, and it's not just from people hoarding. The people who grow/process food, reagents for testing, basic chemicals to make PPE, etc, are classified as "essential workers" like grocery store workers, etc, but we may not think about them in this, nor long-haul truckers -- who may be able to sleep in the back bunk and spend most of their time isolated, but have to touch gas pumps and use the restroom at least occasionally. People with CHLs will be harder to replace than grocery store workers, as will trained people in various factories making essential gear. And not everyone in manufacturing can do what one company did -- keep everyone onsite for 28 days while making things, to keep them free of COVID-19. One final thought, on that note. Prison workers (the way prisons get infected) don't want to live on-site, and that's what it's going to take to keep the virus out of prisons IMHO. Corrections officers do not want to feel like they're in prison themselves, but they too are hard to replace from the currently unemployed pool of workers. The potential results of short-staffing and angry/sick/frightened inmates scares me a great deal, particularly for our nurses in corrections.
  14. moriahcat

    Nursing Homes. The bodies are just pilling up.

    To try to address your point without attacking you for your poor word choice: 1) Many LTC facilities also have rehab wings -- including the very good one my grandmother was at (a decade ago) that also was one of the first three LTC facilities affected by COVID-19 in my state. So not all pts getting exposed in the facilities with outbreaks are there for the long haul -- some just need care while recovering from fractures and would have many quality-filled and independent years left. 2) One reason we would see higher death rates, aside from the fact that even rehab-wing LTC pts often have multiple comorbidities and are usually older, is that upon admission to LTC many pts fill out a Living Will. They've already decided that when it's their time it's their time, and don't want extreme measures. So many aren't going on vents and potentially aren't even getting more than oxygen, depending on their health directives. I actually hope, for the treating docs and nurses in those cases, that pts do have their wishes stated about life-sustaining treatment -- if they already know the pt wouldn't want a vent, it might be easier psychologically when they have to say how slim their chances would be even with one. (And if they do want it -- well, if a person has the right to refuse treatment they should also have the right to that slim chance if they really want to take it, as long as we have available vents.) LTC is not always the same as hospice, where patients know they are dying and the virus might be more likely an end to unbearable pain. Many in LTC still have a good enough quality of life to want to keep living it, just don't want to be put on machines if their heart gives out.
  15. I think it should depend on the individual state. States like mine that haven't been hit hard yet but continuously had testing bottlenecks in their attempt to test exposed health care workers and nursing home patients (lab capacity, reagents, many issues, not just "test kits") are not prepared to re-open the bars and beauty salons, or stop the 9 PM to 5 AM curfew, until we have at least twice the daily testing capacity we do now -- if not more. Considering less than 2000 people in my state have caught it and many are in the prison system, it is surprising that I do know one of the first cases in a particular county I used to live in (then again it's more like 3 degrees to any Arkansan, not 7, so maybe not that surprising). In the course of his treatment/trying to see if he was clear of the virus to count as "recovered", they tested him 6 times. Yet our prevalence rate (people tested who actually had it vs didn't) is much lower than neighboring states -- so our testing capacity IS an issue. If a person is negative and isn't tested again (over 90% of our people tested so far), that's just 1 or 2 tests (if they demanded two to come back to work). If our prevalence rate gets higher, we will need even more lab capacity than it would seem. I agree with you that the time bought by trying to hit "pause" by shutting down most of the country has come at a very dear cost. I have two people staying in my home because the breadwinner in that couple was a Lyft driver -- not too many people wanting to rideshare in this environment, and his primary clientele were drunks needing rides home from the now-closed bars. Two major religions in our country had to alter important holiday traditions, either from government edicts or the belief that preservation of life is more important than obeying religious law. Those who attended weekly have made even more sacrifices that are not just economic, but personal. And yes, Americans want to see more than a plummeting stock market and rising unemployment resulting from buying that time. I'd like to see things like state and public health labs being able to test more than hospitalized pts, health care workers, nursing home residents where there's been an outbreak, and prisoners/prison workers. And that's about all we can test right now, at least in my state. I am not laying blame for that, just stating facts. It's no surprise to me that people are frustrated -- on all sides. But if I may ask -- do you have a personal problem with Dr. Anthony Fauci, or just disagree with him? Because yes, the virus itself does set the timetable, at least with regards to incubation periods and time from first symptoms to any major ones (so therefore how long it takes to see results from mitigation efforts).
  16. I would respectfully submit that Dr. Anthony Fauci was {in}famous a long time ago, for his handling of very different virus. He's not in it for 15 minutes of fame or infamy at this late date, at least in my humble opinion.
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