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Cowboyardee

Cowboyardee

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Cowboyardee's Latest Activity

  1. Cowboyardee

    Covid Vaccine

    I have an alternative (but equally unsettling) explanation for the rise in non-covid excess deaths above the threshold: covid has overwhelmed hospital infrastructure to the point that we are seeing higher mortality rates from non-covid conditions due to ineffective care, under-triage, inadequate medical and personnel resources, etc. Basically failure to rescue on a mass scale. As a hospital wide STAT and code blue responder, I see it happening as the covid cases pile up, and many patients that would normally come to critical care for closer monitoring are left in telemetry beds. Of course, the truth is that we probably have both things happening simultaneously. We are doing worse with normal medical care due to the systemic stress of covid AND we are undercounting covid deaths given the lack of available testing and the relative low sensitivity of our tests.
  2. Cowboyardee

    Lessons learned from Covid

    Hmmm... I've learned that proning works well (maybe even better) even before intubation. Got reaquainted with ultrafiltration. Learned a lot about the immune system. Learned that N95s are surprisingly effective even when reused for weeks on end. Learned that hospital administrators by and large have learned nothing at all from covid and would love nothing more than to go on treating emergency medicine and critical care as loss-leaders rather than as critical to the mission of the hospital. They seem to aspire to nothing greater than making a really nice PowerPoint for their bosses and investors about how their new plan (top-down and clueless, naturally) will save money while keeping up with developments from that other nearby competing hospital (which is also, of course, horrifically failing both its staff and the community it serves). Seems they'd prefer to let the place burn to the ground rather than identifying who actually knows what they're doing in a given specialty, making any effort at all at retaining those individuals, and letting those individuals make decisions about how to do things in their areas of expertise, or at least soliciting their advice.
  3. Cowboyardee

    I Really Do Not Want the COVID Vaccine 😞

    To the best of my knowledge, none of the quoted section above is correct (with the exception of your mention of the flu vaccine's 40-60% efficacy, which I included to preserve your context). Sars-cov-2 appears to have less genetic drift than the influenza virus, which is promising for higher efficacy of the vaccine and longer immunity. And I have heard nothing at all about health care workers developing immunity without contracting covid and would appreciate a citation of any reliable source for that claim. Initially, there was buzz about healthcare workers actually faring worse than the general public after contracting disease based on reports out of the wuhan region. Though I have not heard much continued support for that claim, I have certainly not heard any compelling argument or evidence that healthcare workers are somehow at lower risk either.
  4. Cowboyardee

    ER to ICU?

    Hmmm. I think people gave you the kind of answer they usually give to nursing students looking to work in an ICU. The truth is a little more complicated. Having trained a few dozen ICU nurses over the years, I'd say on average that nurses with med surg or ED experience are easier to train than new grads and become competent and independent noticeably quicker. Of course, individual differences apply, but on the whole it's not even a particularly close race. And I'd even go so far as to say that most people who genuinely understand ICU nursing would readily agree with me on this (note that not every ICU director actually understands the ICU, and certainly not every HR rep hiring for ICUs does). The whole bad habit line has an element of truth to it - a bigger element once we start talking about experience in specialties that have very little skill overlap with ICU nursing. But it's overstated, and doesn't really apply well to med-surg, step-down, PACU, or ED. If it did, new grads would need shorter orientations than nurses with other acute care experience; in the real world, the opposite is far more commonly true. However, you're certainly right that some places seem to prefer to hire new grads. There are reasons for this, but not the ones you gave: - Hospitals, in their infinite wisdom, have mostly abandoned the concept of merit pay or paying for relevent experiece, and almost across the board now pay nurses a scale based on total years of experience. That means that an ICU pays a nurse with 20 years pf ICU experience more or less the exact same wage as a brand new ICU nurse with 20 years of experience working in a doctor's office. So in theory, that means once you put your time in in the nursing profession, you don't need to take a pay cut to change fields. In practice however, it actually means that it's harder to switch fields at all after a while because managers don't necessarily love paying for experience that was not in the specialty they're recruiting for. New grads are cheaper. - Many hospitals especially like hiring new grads into desirable positions because they can then leverage new grads into signing contracts requiring them to stay for 2 years or so or else have to "pay back" $10K or so for the costs of theor training. This is better than indentured servitude, but not much, and it can make new nurses feel compelled to put up with some real BS. Which is, of course, the point. It's a way to enforce retention. - Hospitals that are worried about nursing staff pushing back against hospital administration or about the threat of unionization often find it advantageous to keep themselves staffed with a revolving supply of people new to the field.
  5. Hi all. I've used the prismaflex crrt machine for a number of years. Of course, on crrt you'll often have issues where the access pressures abruptly become extremely negative, or in other words, the patient's dialysis port temporarily occludes. Might be a clotting issue, might be a kinking issue, and often it seems to just be collapse of the vessel the dialysis catheter is situated in, the port sucking onto the vessel wall, etc. Long term, there are plenty of solutions to this problem, but I'm not asking about those. I want to know about the first step you do to unclog a temporarily clogged port. With the prismaflex, it seems we clamp the access line and catheter, disconnect the two, flush the catheter with a saline flush, reattach it to the access line, and restart therapy. Does that sound like what you do in your ICUs? Anyone have a different strategy? If it seems like I'm asking for people to spell out a very simple, obvious procedure... I am. Disconnect, flush, and reconnect, right? Beyond that, I havent used other crrt machines. I'm aware that the NxStage is popular as well. I've heard that we use the same process for that machine. Disconnect, flush, reconnect, restart. Right? Do any CRRT machines have internal flushing built into them? Are any hospitals routinely rigging up flushing systems (e.g. a stopcock and a saline bag) to their access ports to avoid disconnecting and reconnecting? Have you seen or used some other strategy that I haven't heard of?
  6. Cowboyardee

    Take the Shutdown Skeptics Seriously

    Good article. I tend to reflexively get defensive when people advocate reopening because that camp so often either buys into crackpot theories or seriously downplays the loss of life caused by covid-19 and/or the damage it does to acute care and critical care infrastructure across the board. However an honest discussion of the risks of continued economic shutdown that doesn't rely on falsehoods is a welcome change.
  7. Cowboyardee

    Kern County ER Docs C-19

    1. Wait, what? I only got involved in this conversation when you claimed (entirely without evidence) that healthcare is not overwhelmed in NYC or anywhere in particular, implying that hospitals are fine and handling the crisis well. I then presented you with a first-hand account of what "not overwhelmed" and "fine" actually mean to those trying to fight this disease... You then have the nerve to tell me I have no evidence as though seeing patients suffer and/or die of inadequate care first-hand and talking friends and relatives suffering from inadequate medical resources in NYC through their ordeal couldn't possibly compete with 'facts' you pulled out of thin air, about a real life crisis and tragedy you haven't seen or taken part in, to make blustery, tone-deaf arguments on the internet. Seriously, check yourself. This is real life, not some keyboard warrior pissing contest. As for numbers 2-7: Completely, 100% irrelevent to anything I actually said. If the rest of your argument hinges on your fantasyland head-in-the-sand nonsense about hospitals coping perfectly well with the crisis and patients not suffering at all for the chaos, then you should definitely reconsider your entire case. But I haven't particularly taken a side on economic shutdowns and mass quarantines and I don't know why you're wasting most of your post lecturing me about it. It's still early on. The peer reviewed meta-analyses will come later. For now, best you can do is actually listen to accounts from the front lines rather than pretending you know what's going on when you clearly don't at all.
  8. Cowboyardee

    Kern County ER Docs C-19

    For whatever it's worth, I'm not particularly arguing about whether the country should open back up. There are far too many considerations to that kind of decision for me to pretend I know what's best. But on the subject of NYC or any other hot spot... Nope. You're just plain wrong. Why are you just reiterating the same incorrect talking points I responded to in your last post? You clearly aren't on the front lines and clearly don't understand the challenges we face. You clearly have little idea of what's gone on in NYC or any other hot spot. Please have a little humility. Read my post again if you need to. The problem wasn't and isn't the number of beds. It's the need for trained personnel. Critical care has been overwhelmed in many areas and still is, and many patients are dying not only of the disease but of inadequate medical care for that reason. You may not read about it in political op-ed pieces, but that doesn't make it any less true. If you want to learn whats going on with critically ill patients, talk to people who work in the field rather than searching out whichever talking heads most closely agree with the conclusions you've already made.
  9. The first video linked is about reasonable topics, but seems to be disappointingly devoid of actual clinical evidence. Of course, at this point, clinical evidence is hard to come by, since this is a new phenomenon. But I dont think they should take it as a given that early intubation wprsens outcomes. That is pure conjecture at this point. Likewise, it seems they are underestimating the severity of the consequences of a genuine lack of well trained critical care personnel. You can't apply protocols developed and tested in an environment with plenty of staff (e.g. proning by a 1:1 ICU trained nurse) and expect the benefits of that therapy to hold up when enacted in a completely different environment (5:1 ratio, nurses minimally trained in ICU care, etc.) They seem to lack the perspective of people involved first hand in the crisis. The second video linked is sensationalized garbage posted by a nurse who lacks even a cursory knowledge of critical care and who should not be informing anyone. Virtually nothing she said is useful or reliable. There are plenty of good, important conversations to be had about hospitals pushing suboptimal protocols, or the ethical issues involved in providing medical care without our normal ratios of skilled staff. This kind of trash doesn't lead to those conversations.
  10. Your wife has exited the realm of rural and/or conservative individuals who are honestly engaged with the world and has drifted into a kind of right wingnut culture cult. Normal people can realise that CNN is occasionally full of **** without buying into worldwide conspiracy theories. Whenever someone tells you that everyone else - the whole world - is lying to you and that the only people who will speak the truth is themselves and their narrow band of likeminded individuals... there's a word for that. It's called brainwashing. Sounds like your wife has been listening to some brainwashers. Good luck de-programming her.
  11. Cowboyardee

    COVID-19 and extinction of human species

    I'm suspecting there's a bit of an echo chamber ongoing where people are repeating the (comforting) thought that since there are surely way more cases than we know of, the case fatality rate must be much lower than reported. What that line of thinking leaves out is the very likely possibility that the number of deaths attributed to covid19 is lower than the actual number. For one, many patients die without getting tested, either due to code status or disease progression. For another, it would not have been uncommon even up to a few weeks ago for patients presenting with covid along with some other illness not to be worked up or even suspected. And of course a substantial number of the patients currently positive for covid19 will in fact die from it but merely haven't yet. Lets a assume a 1% case fatality rate, for the sake of argument. That would mean every covid19 fatality missed from the official count would balance off 100 undiagnosed cases. The problem with assuming that the case fatality rate is actually 10 times lower than what has been measured so far is that to make that assumption, we have to estimate not only that theres 10 times more cases than we know about (which isn't entirely unlikely) but also that the numerator of the case fatality equation is accurate as reported. Unfortunately, it isn't.
  12. Cowboyardee

    How are you testing for covid right now?

    Hi all. I'm wondering how covid testing is being performed in your area currently. Where I am (hospital, ICU, mid atlantic state), I'm seeing tests being ordered from either the state health dept or quest diagnostics. Cases are being tested on the basis of severe (critical) illness with symptoms consistent with covid19. 1st order exposures are also being tested I think (like, spouse of someone covid +). I think that likely exposures with likely symptoms are being tested too. I'm not sure beyond that. We are doing a single nasal pharyngeal swabs sent for PCR in most cases, I believe. There is some reason to worry about the possibility of false negatives with nasal pharyngeal PCR swabs - best data I can find is that the sensitivity of the test is only 75% (emcrit's covid19 page discusses this and cites the study they used to estimate this figure), though I would welcome better or updated data if anyone can offer any. So I'm wondering if other states are routinely sending 2 swabs to double check or have some other procedure. As is, it appears there could be could be one covid + patient whose test was erroneously negative for every 3 patients who actually test positive, which potentially has some very concerning consequences. However, I'd love to hear that my thinking is wrong on this matter or be directed to better information. What are you seeing?
  13. Cowboyardee

    COVID-19 and extinction of human species

    I'm probably more pessimistic than many epidemiologists seem to be about the effects of covid19 - I doubt the real case fatality rate is below 1%, though many seem to be banking on this; I doubt a vaccine will be ready soon or possibly even that an effective one can be developed at all given difficulties vaccinating against the most similar known corona viruses; I hope we develop some kind of effective treatment that severely mitigates the illness soon, but I dont see any of the ones being touted so far as that miracle RX; I personally believe that the 100k-300k figures being thrown around as a likely death toll in the US are probably a best case scenario right now. But with all that said, you would have to make certain assumptions to conclude this could be a serious threat to our species, and I doubt those assumptions as well. Namely you'd have to believe that people can readily be reinfected after illness and repeated illness, and that doesnt appear to be true from what we see so far. Theres probably at least temporary immunity, and lasting immunity is unknown, but reasonably likely. Youd have to assume that no effective treatment will be discovered for several or many years while this rages - I dont know about a quick fix, but given time, we do pretty well against infectious diseases. Youd probably have to assume that the virus gets worse in terms of case fatality either as time passes or as people get it repeatedly, and there's no good reason to think that AFAIK. And you'd have to assume that changing conditions among our virus-ravaged society won't be enough to bring the infectious rate below 1 spread per new case. Given the success of China and Korea in controlling spread, that's probably unlikely. All of these things would have to be true for this to be as apocalyptic as you're worried. Probably none of them are true. Still, its going to be plenty bad, best I can tell.
  14. Cowboyardee

    Am I a coward for going on FMLA due to COVID?

    Ill offer a dissenting opinion, but its not really directed at the OP, who has risk factors that I dont share - I'm in no position to judge such a hard decision about someone else's life. Here goes You don't owe this to your employer or the administrators at your hospital. You don't even owe this to those of your coworkers who are sticking in there. You did not sign up for this. Disaster nursing, sure maybe. Pandemic without PPE? Not so much. Many levels of society, political leadership, and healthcare administration have failed leading up to this. Forget about owing anyone anything. But... Here's the thing. I'm following projections of this virus and I'm watching the ICU I work in slowly get overrun, even in an area thats not yet considered a hot spot. And I'm pretty sure there will come a time (and soon) when every patient I treat, more or less, will be one more patient that wouldn't get treated if I wasnt there. It's not about what I signed up for. Instead, I have a skill set that is desperately needed right now. Eventually, every day I'm working at risk to myself and my family is also a chance to save lives in a system that will save that many fewer without me. And each of us has to decide how much risk to ourselves is too much to bear for that opportunity, not worth the lives of our neighbors. The risk to yourself is real and substantial. I can't make that decision for anyone else. But please don't make it casually or bitterly or to spite those who have failed us. This virus has proven many of our bean counters and administrators wrong - youre not just a cog in a system, replaceable by a fresh new recruit in the same color scrubs for a small cost and a little orientation. But of course, the problem with being irreplaceable is that you won't be replaced. Best wishes to everyone making hard decisions, and not taking them lightly.
  15. Courage isn't the absence of fear; it's doing the best you can even though you're afraid. I think a lot of us are about to find out we're braver than we thought and stronger than we realized. You're not alone in your thoughts and fears, OP. Best wishes to you and yours.
  16. Cowboyardee

    Why is BSN required for CRNA?

    Assuming I'm understanding you correctly and you're comparing the BSN curriculum to the ADN or diploma RN curricula, that's not really true. There's no additional pathophysiology at all, and additional education in either assessment or research (statistics class notwithstanding) tends to be incredibly basic. If the BSN offered substantially improved education in these areas over the ADN and diploma, I'd be much happier with it and the push to make it the entry-level degree for RNs.