"many of the great medical advancements of the past would’ve never happened" like leeches on the body, drilling holes in skulls to let out demons, and the 1001 other horrible medical advances that occurred prior to evidence-based medicine? Or are you referring to a dozen advances that occurred in the past that you will now google and then reply with like you had them in mind all along? Thx, in advance.
But are there randomized prospective case controlled trials for ventilator use in COVID-19 confirming your statement? I have seen no such data.
Obviously this is a joke akin to the “testing parachute effectiveness” variety. But one could make a cogent argument that, say, hydroxychloroquine inhibits Sars-CoV2 in vitro and was effective in the original SARS and that people will die without it and there is anecdotal and smaller trial evidence of effectiveness and hence it should be the “standard of care” and not just an option for COVID-19. Yet we see people like Fauci every day disparage this form of therapy as “no evidence” on the basis of lack of multicenter double blind prospective randomized case controlled study. That same lack applies to ventilator use.
If you are in respiratory failure because you can't breathe on your own, you need a ventilator whether you got hydroxychloroquine or not. Hydoxychloroquine might prevent you from needing a ventilator. It might improve your chances of survival or getting off the ventilator sooner. But if you can't breathe, you need a ventilator. If you're hypoxic, you need supplemental oxygen. That is not an intelligence test that anyone should fail, but congratulations, I suppose.
So no, obviously we don't have those studies on ventilators in COVID-19, nor do we have evidence that people with COVID-19 should eat food, drink water, not dance around naked in the snow covered in apple sauce. On the other hand, we have plenty of evidence using them in people with respiratory failure from viral pneumonia, bacterial pneumonia, ARDS, etc. And if we don't give this treatment to people who need it, they would die. That is why it is the 'standard of care.'
Hydroxychloroquine has showed some surprising promise both in in vitro studies and some small studies in vivo. Some studies haven't shown any benefit, but that doesn't mean there is none. Unfortunately some of the preliminary data was with sloppy methodology and the data reported has a number of inconsistencies that reduce the confidence in those results. It requires further study.
**Hydroxychloroquine isn't magic. What dose do we give people to treat COVID-19? Nobody knows. How do we know hydroxychloroquine is more effective than the other drugs being studied? We don't. Should we give it to patients with azithromycin and risk fatal arrhythmias in some patients for a treatment that may not be very effective? Which patients should receive hydroxychloroquine? Should we give it to only the sickest patients who may be too far gone for it to make a difference? Should we give it to everyone who has symptoms? If 95% or more of those people are going to recover on their own, we might harm more people than we save.
So no, I don't think we should be automatically giving everyone hydroxychloroquine as the 'standard of care' because there is no 'standard' nor is there data to guide on how much to give and who to give it to and it may end up being inferior to some of the other drugs being studied. Given that we don't know these things, the decision to give it should be based on decision making between patients and their doctors. It shouldn't be made by governors, politicians and bureacrats. However, those holds were put in place not because everyone is so anti-Trump but because a number of irresponsible doctors not treating COVID patients, dentists, podiatrists, PAs started writing it for themselves and their friends and families in large quantities that would cause a drug shortage.
I do not think the drug should be restricted to clinical trials. But we do, in fact, need those trials to determine whether or not its effective at all.
You might not like it, but if you were in charge we would probably still be using leeches on patients.**
Not really. I’m a doc and I participate in clinical trials. Try not being so butthurt.
Hydroxychloroquine is a known medicine, not thalidomide, and we will be practicing battlefield medicine over the next 3 weeks. I’m glad if you don’t want it. I will offer to my patients and docs who deny it to patients when it might help are not doing their patients a service IMO. That’s what I mean when I say standard. It should be offered.
"Given that we don't know these things, the decision to give it should be based on decision making between patients and their doctors. It shouldn't be made by governors, politicians and bureaucrats."
Nowhere did I say it shouldn't be offered. It's also not an 'alternative' to someone who needs to be intubated.
You are right that I am unfairly taking out my downvotes on you. It's like I posted on r/politics. Before the ban from the governor, the ID docs here had been using it on some COVID patients.
There is certainly an alternative to try different forms of treatment earlier, to avoid the need to put people on ventilators.
You might as well say "leeching is the standard of care" as it once was. We are always learning and improving, and during a crisis we often do so more quickly than normal.
Since they are calling on Respiratory Therapist to help fight the Coronavirus, and I am a retired one, too old to work in a hospital setting, I'm going to share some common sense wisdom with those that have the virus and are trying to stay home. If my advice is followed as given, you will improve your chances of not ending up in the hospital on a ventilator. This applies to the otherwise generally healthy population, so use discretion.
Only high temperatures kill a virus, so let your fever run high. Tylenol will bring your fever down allowing the virus to live longer. They are saying that Ibuprofen, Advil, Aleve, Motrin, etc. will actually exacerbate the virus. Use common sense and don't let a fever go over 103 or 104, if you got the guts. If it gets higher than that, take your Tylenol, not Ibuprofen or Advil ( or any type of anti-inflammatory drugs ) to keep it regulated. It helps to keep your house warm and cover up with blankets so your body does not have to work so hard to generate the heat. It usually takes about 3 days of this to break the fever.
The body is going to dehydrate with the elevated temperature, so you must rehydrate yourself regularly, whether you like it or not. Gatorade with real sugar or Pedialyte with real sugar for kids works well. Why the sugar? Sugar will give your body back the energy it is using up to create the fever. The electrolytes and fluid you are losing will also be replenished by the Gatorade. If you don't do this and end up in the hospital they will start an IV and give you D5W ( sugar water ) and normal saline to replenish electrolytes. Gatorade is much cheaper, pain-free, and comes in an assortment of flavors.
You must keep your lungs moist. This is best done by taking long steamy showers on a regular basis. If you're wheezing or congested, use a real minty toothpaste and brush your teeth while taking the steamy shower and deep breaths through your mouth. This will provide some bronchial dialation and help loosen the phlegm. Force yourself to cough into a wet washcloth pressed firmly over your mouth and nose, which will cause greater pressure in your lungs forcing them to expand more and break loose more of the congestion.
Eat healthily and regularly. You've got to keep your strength up.
Once the fever breaks, start moving around to get the body back in shape and blood circulating.
Deep breathe on a regular basis, even when it hurts. If you don't, it becomes easy to develop pneumonia. Pursed lip breathing really helps. That's breathing in deep and slow, then exhaling through tight lips as if you're blowing out a candle. Blow until you have completely emptied your lungs and you will be able to breathe in an even deeper breath. This helps keep lungs expanded as well as increase your oxygen level.
Remember that every medication you take is merely relieving the symptoms, not making you well.
If you're still not improving, then go to the ER.
I've been doing these things for myself and my family for over 40 years and it has kept us out of the hospital. All are healthy and still living today.
Thank you for sharing this information. We have got to help one another right now.
Be advised, I am not hip to these things myself, but it seems this gentleman is pretty knowledgable on the subject, and my sister and niece are both Nurses and stated this was good advice, although they are not in the field he was in so they don't know about the letting the temps run up high.
100% of them would have died without a ventilator. If you are hypoxic, you need oxygen. If you can't breathe, you need a ventilator. If you're in cardiac arrest, you need CPR. Some posts here are arguing against the use of ventilators which is simultaneously retarded and nonsensical.
It's not...'we can give you the ventilator or we can give you hydroxychloroquine.' It's 'we can give you the ventilator if you need it and hopefully save your life or you can die without one' whether you received hydroxychloroquine or not.
Hh Did you even look at Dr. Slidell’s argument?
He says O2 is needed more than high pressure PEEP. He doesn’t say throw out the ventilators, just adjust them properly.
This is why they do clinical trials in the first place, to flush out any unintended consequences.....however, when you’re in the situation we are now, clinical trials are not expedient and need to be by-passed as best as possible
They need to do clinical trials to determine whether or not the drug is actually effective. They also need to know what dose regimen is optimal. Which patients are most likely to benefit from it (and later on they need to compare it to other drugs to determine if any one of them is superior). We have not convincingly arrived at the point where most practitioners accept it to be actually effective.
There are a lot of ongoing studies in different drugs. Who is to say that a study in only 20 people showed a benefit compared to not getting it because 4 of the people who got the drug only had a milder illness to begin with and it wasn't from an effect of the drug? Etc.
This idea is stupid. Most patients are already on 100% oxygen when they start increasing pressure (PEEP). You cant increase oxygen more than that. ARDS (from covid) causes the permeability of the aveoli in the lungs to change (alveoli are microscopic air pockets in the lung). This causes them to fill with water. Increasing pressure keeps fluid out, keeps patient from drowning and keeps the alveoli open. The increased pressure can cause damage, but they do things like decreasing volume and increasing rate of ventilation to try and mitigate it. But without the pressure patients will die much earlier.
Edit: If you have doctors who have no experience treating ARDS and they try increasing volume with high pressure then sure it can cause lots of damage. But still just increasing oxygen isnt enough
WuFlu's surface glycoproteins have been shown to possibly bind to heme, dissociating the iron from it. That would render the hemoglobin unable to transport o2 while simultaneously increasing the free iron in the blood.
It's not fluid in the alveoli causing ARDS, it's a reduced o2 capacity thanks to this effect on the hemoglobin. So no, ventilators will not help. Patients aren't 'tiring out', they are turning progressively hypoxic. Would you intubate a patient for carbon monoxide poisoning? Of course not.
You COULD use a hyperbaric chamber full of pure o2, at 2x, 3x, 4x atmospheres of pressure to help what's left of the functioning hemoglobin to keep carrying o2 to the organs. Even then you're just buying time in the hope the patient's immune system will finally overcome the virus.
I appreciate the thought, but all you have to do is look at the chest films of people coming in. It's multifocal pneumonia with completely opacified airspaces. That's not how carbon monoxide poisoning looks or altitude sickness.
Yes, and you usually, at least in my experience, start with the lowest PEEP possible; if you aren’t getting the result you want, then you increase. I doubt competent MDs would jump to high PEEP right away; if they are increasing peep, it’s probably because they aren’t oxygenating on lower peep & the lung damage is a trade off.
A little extra PEEP is fine with low driving pressure (Plateau - PEEP). It actually shows improved mortality in ARDS, but COVID-19 is atypical ARDS... more of an intravascular issue. Lung compliance is fairly normal with COVID-19, something you don't see with traditional ARDS.
I don't think the doctor in this video is suggesting that doctors just increase oxygen. He's suggesting that we need to fine tune the way ventilators are calibrated to treat the conditions associated with this particular illness.
You do that for every patient on a vent. Full featured vents let you dial in a number of different settings based on the patient. It is never one sized fits all.
LOW TIDAL VOLUME VENTILATION (LTVV): INITIAL SETTINGS
For patients with ARDS, we and others recommend LTVV (also known as lung protective ventilation; 4 to 8 mL/kg predicted body weight [PBW]) (table 1 and table 2). LTVV is typically performed using a volume-limited assist control mode, targets a plateau pressure (Pplat) ≤30 cm H2O, and applies positive end-expiratory pressure (PEEP) using a strategy outlined in the table (table 3). This approach is based upon several meta-analyses and randomized trials that report a mortality benefit from LTVV in patients with ARDS. It is thought that low tidal volumes (VT) mitigate alveolar overdistension induced by mechanical ventilation, which can cause additional lung injury and mortality in patients with ARDS. (See 'Efficacy and harm' below and "Ventilator-induced lung injury", section on 'Mechanisms'.).
It's because they read the original ARDSnet study and jerked off to the PEEP/FiO2 table that both groups got for standardization - but that study wasn't about PEEP. It was to figure out whether low or high volumes on a vent were better.
Since then, we have become a lot more advanced with specializing PEEP individually for patients. We can do esophageal manometry to estimate intrapleural pressure and counteract the distending force on the lungs with just the right amount of PEEP to maintain functional residual capacity.
Sounds like you are on the ball with this stuff. Medical professional? My cousin is a surgeon and has been talking about the risks of vents being used by medical professionals that don't have the expertise. She was especially worried about NYC because of the "all hands on deck" nature of the response to the virus.
Not true that people are already on 100% oxygen when they start increasing PEEP. If you follow ARDSNet protocol you don't reach 100% FiO2 until you have a PEEP of 18-24. Most critical care docs have been following ARDSNet protocol. That's why the doc in the video says we are doing it wrong.
But what we’ve been doing is trying to lower the FiO2 fairly soon after intubation and adjusting PEEP accordingly to maintain adequate oxygenation. This is across many different types of pathology. I’m curious as to what your specialty is and how often you are tubing and adjusting vent settings. EM here. Maybe we’re just trained differently
Edit: looking back I repeated what you said but my point is that we aren’t in general keeping ppl on 100% O2 for a prolonged period of time and PEEP tables are used broadly to make adjustments in tandem. So FiO2 is decreased and then adjusted with PEEP. Still curious as to your specialty and if you are managing vent settings.
True, but what a lot of the feedback I am reading about is people being put on vents and not CPAP/BiPAP (maybe to minimize aerosolizing virus or because they think the hypoxia is too much?) or they are starting them out on higher settings (PEEP of 10 or more which is was recommended by SCCM and European guidelines.
We start on low PEEP and high FiO2 and we try to increase the PEEP to reduce FiO2 to 60% or less. But if they don't respond to the higher PEEP or it adversely effects their hemodynamics, I don't keep it on. But from what I've seen with our patients is that they don't respond much to increasing the PEEP and we end up keeping high FiO2 with a PEEP of only 5-10.
We had a patient who recently got a PEEP of 14 and ended up with a pneumo. SCCM supports their 'high PEEP' based on data that was higher than that. Some of those PEEP #s I am seeing just seem crazy high to me.
I've seen some updates on the Pathophys but still no mention of that hemolgobin thing.
I work in emergency care and people don't go on vents unless it's absolutely needed. People on vents are generally very sick and can no longer breath on their own. Saying to simply switch them pure oxygen is at best an uneducated statement since most people would die shortly after being taken off a vent if their body has not recovered. Now there could certainly be future changes in the treatment protocols for hospitalized patients that are currently not sick enough to need a vent. Most of this seems to be related to mass hysteria and poor understanding of how the virus works as well as poor understanding of medical practices. Doctor's avoid the use vents as much as possible because it is risky and their ass is on the line for medical malpractice if your putting people on a vent that don't actually need it. Vents are the last line of defense for extremely sick patients and running out of vents in a "shit hits the fan scenario" could mean the number of fatalities greatly increases.
Original mantra with COVID-19 was to intubate early. If someone needed greater than 6L O2 via nasal cannula then the move was to intubate. We are now moving away from that given that we are running out of vents and learning that early intubation may not be the right answer
The standard of care is to start at the lowest pressure setting and you go up if if the patient needs more. That's why all the healthcare professionals watching this video are shaking their heads.
It's less of a COVID-19 specific problem than a respiratory failure secondary to severe pneumonia and ARDS problem. It's physiological.
I honestly think what he is getting at is that this may not end up being uniform lung pathology across patients. We’re adjusting the vent setting to get an oxygenation status we are comfortable with but ultimately we are causing lung damage in the process and making the patient’s problems worse
The official numbers are probably highly guarded, but 15% survival after going on a ventilator looks about right. Even if you do survive, you won't be the same again.
forces air or O2 into your lungs with pressure. The problem is that your lungs are weakened by the infection and even minimal pressure could do permanent damage.
It's also why you want to get on the drug cocktail ASAP if you have the Chinese virus. You can get off the ventilator, but it's a very traumatic experience for the patient. Also if you get to that point there is a good chance you have permanent lung damage even if you recover.
The people going on ventilators cannot breathe on their own, oxygen would simply not address the problem. You don’t know what the fuck you’re talking about.
People who are doing fine on oxygen don't need to be ventilated. People who are being ventilated start out on max oxygen and lowest pressure setting and the pressure only increases if it needs to be. People are kept on the minimal pressure needed. That's the standard of care everywhere.
That's why this video-guy doesn't make any sense. No one has any idea what he is talking about when he says 'high pressure.'
Well the video doctor should communicate what he is talking about to other doctors in the field and discuss what pressures he is talking about instead of posting vague nonsensical things on social media.
You are wise not to simply accept what people on TheDonald are telling you (including me), but you shouldn't just accept what someone in a video is telling you either.
There are roughly 300 medical centers in the world that can do ECMO.
This is mostly done in NICU patients. Doing it adults is rare. We are talking about less than 5000 adults in a year.
If full function ventilators are Porsche 911 then an adult ECMO is a bugatti veyron.
This is the main reason. There are 264 hospitals in the USA with Ecmo capability but many have only 1 unit.
Even if there are, say, 500 ECMO units in the USA, there may be 200,000 COVID patients who need assistance in oxygenation. It’s a drop in the bucket of need.
Not a doc, but I've wondered about this as well. I think the issues are realistic cost, availability, and trauma associated with whole process.
If you've got a pre-dementia 90 year old already dying of pancreatic cancer and a lung infection, it doesn't make sense to drop a million dollars on keeping them alive when the next flu season will probably take them out anyway.
That's just life. We don't have infinite resources.
So, for disclosure, I’m an anesthesiologist who has worked in a few ECMO capable ICU’s.
V-V ECMO (oxygenating the blood, not bypassing the heart) which is what would typically be needed in hypoxia respiratory failure is a massively invasive undertaking that is hugely fraught with both morbidity and mortality. First it almost always requires a mechanically ventilated patient to begin with, then it requires a huge catheter to be placed in the neck that effectively drains and returns blood from the patient. There are large infectious, inflammatory, and hemorrhagic/thrombotic risks associated with this. The decision to go on ECMO is also highly ethically charged, as there needs to be an end in sight. For V-V ECMO in these cases, you generally need to have a reasonable expectation of recovery but are failing mechanical ventilation. Putting someone on ECMO who will never recover is entirely unethical and should not be done.
In the ICU where I am working now, we will not consider putting a COVID patient on ECMO unless they has a clean bill of health prior to getting COVID, and are under 60 years old. Part of that is resource utilization, meaning we want to use ECMO for patients who have a high chance to recover and not waste it in terminal cases, but it is also the ethically correct thing to do.
In short, if putting someone in mechanical ventilation is like sewing up a skin laceration, putting someone on ECMO is like performing an amputation. It is orders of magnitude more complex and dangerous
That's crazy. I wish I would've archived it. It ended with some pro hydroxychloroquine info and "China is asshoe". I'm going to try and find that guy on Twitter and see if he posted his write up elsewhere.
Or it's actually -the worst- write up given that I don't see -anywhere- in the actual medical literature so far where this hypothesis is supported. I have no idea where this guy came up with this information and nor do I see him cite a single source.
Even if that were true (and I suspect it isn't), I don't know that it would lead to low oxygen readings on a pulse oximeter which would make it bupkiss. Pulse oximeters are actually measuring the ratio of oxygenated hemoglobin to de-oxygenated hemoglobin in your blood. If the Fe was removed from the porphyrin ring I'm not certain it would give you a 'low' reading (for example, in carbon monoxide poisoning, the reading is actually high or in the case of severe anemia where the oxygen content in the blood is very low but the reading is normal.
I also haven't seen evidence of either free or denatured hemoglobin or dysmorphic red cells in the actual coronavirus patients I've treated which would be expected if this were the case (and nothing in the medical literature supports that either but they do talk about white blood cell abnormalities occurring. You would think this hemoglobin thing would have come up).
In the absence of such, I would presume that the mechanism is (drum roll) just like any other coronavirus or even other respiratory viruses causing severe pneumonia from direct damage to the lung and widespread inflammation. It's a bad disease, but there's no reason to believe it has some magical powers that no other respiratory virus has (including other coronaviruses it is similar to which may be less contagious but have a higher fatality rate)
Citing 'high iron' being found in the blood is meaningless here because the transporter molecule for the storage form of iron (ferritin) is often present at high levels in inflammatory states and thus doesn't support his hypothesis at all.
The only paper I did find is what seems to be an unpublished paper from "liu wenzhong" where he discusses this could theoretically happen, but the article above goes far further.
I would love to know who the author of this paper is and how he 'knows' anything he claims.
The only literature I've seen that has anything like that write up is the unpublished paper you found too. My issue is that multiple docs in critical care are coming out and saying that this disease is not acting like ARDS in terms of lung compliance and response to ventilation treatments. Some liken it to HAPE but it doesn't explain it all. Listen to the latest podcasts by Scott Weingart on EMCrit or Rebel EM. There IS something we are missing here that isn't fully fleshed in the current literature. It's all anecdotal, but I'm just trying to make sense of it all as it doesn't completely fit the severe pneumonia and subsequent ARDS picture. We have to think outside of the box as mortality for intubated patients is 50-80%.
If you watch Weingart's latest video I'm sure you'll like the guy with an O2 sat reading of 1% (good waveform) who is still talking.
Here's some Italian observations by Gattinoni, well published in critical care and lung protective ventilation, expaining that COVID-19 is different from the usual ARDS. I think this is what OP's video was getting to. The following ventilatory recommendations are different from current ARDS recommendations. For those of us managing vents this can be super helpful which is why I thought it might be of interest to you and your colleagues. It's anecdotal but by the time you get a great study on this many of your patient's may have experienced a bad outcome.
Edit:
Here's another take on SARS-COV-2 attacking affecting hgb. More nuanced than the other take and only a suspicion but at least you have an MD name behind it and supposedly currently being researched. I think that hbg is affected in some way to decrease O2 carrying capacity but it's just my gut feeling.
If they'd warned families about the dangers of putting a loved one on a BiPAP mask, no one would use it. Compromised lungs don't get stronger on a BiPAP and the muscles weaken over time making the device medically necessary to sustain life. That is, only a small to moderate percentage of patients ever come off it and to do so takes a lot of therapy work.
When dad had enough of his pulmonary fibrosis and cancer, he lawyer filed his DNR, loaded himself up on morphine. He slipped his mask off and died.
The worst part about this is that they had to know. Medical agencies at very high levels pushed the use of ventilators to increase the damage. Disgusting, they should be ashamed.
People end up on ventilators because they go into respiratory failure and can no longer breathe on their own. The docs are making decisions to put people on vents and they do so based on individual patient cases. Also, this video is somewhat nonsense and not at all helpful.
When we put people on a ventilator, we start them at max oxygen and start at the lowest pressure setting. Pressure goes up only if they need more pressure. This is the standard of care everywhere. This guy is not making sense.
This is inaccurate and be very wary of any medical professional on social media saying they know of a secret that the medical community is holding back. Vent settings are complex and both pressure AND oxygen saturation have to be managed because different diseases require different settings. Every med student knows about barotrauma, the bursting of alveoli from overpressure. There's also toxicity from too much oxygen. This is not secret knowledge that doctors are all purposefully fucking up on.
Pneumonia from diseases like flu or covid are a pressure problem, not oxygenation. The problem is that in certain situations the pressure required to reopen alveoli could increase to the point of being higher than the pressure that could burst them. If you're on a ventilator for pneumonia vs things like throat closure or for surgical reasons, you're already in a fucked situation with a high mortality rate.
Can every pede w a twitter account go & @ Tucker, Laura Ingram, NIH, Don Jr, and all the R senators who care? Maybe if this gets talked abt more someone will start to pay attention?
In Wuhan they confirmed this early on in the outbreak, they found that if they put severe cases on ECMO instead of ventilators that the outcome was drastically improved. The issue with this disease is the effect it has on the blood to deliver oxygen and remove carbon dioxide, it's not just
pneumonia. Blood transfusions and ECMO is the way to go. It seems like the West is not learning from mistakes in China early on. Our focus should be on preventing people from getting sick enough to require life support, the majority of people that go on life support do not pull through.
What's up with these doctors looking like bums? Not helpful for your credibility. This guy and the Hydroxy guy need some help with their profile pictures.
Spread the word because people, even doctors still don’t understand COVID19. It affects blood cells, not lung capacity. Steady stream of unfiltered O2 is the answer, not increased pressure into the lungs.
No, don't spread the word. Doctors are looking at new and up to date information on a daily basis on how to treat COVID. I know because I do and all my colleagues do. And my colleagues also share new information multiple times a day.
People get put on vents either because they need to be on a vent or because less invasive ventilatory measures may be aerosolizing more of the virus and spreading it around. Doctors routinely avoid high pressure on vents. The doctors treating the patients understand the use of the ventilator better than you do so please stop driving more uninformed hysteria.
Every state, every county, every city/town is on its own Curve.
Because the federal government is a federal it looks at worst cases in large cities and treats the whole country the same way.
State governors do the same thing and treat the whole state like it is Chicago or NY.
This results in hospitals in places that have few cases being at 50% capacity while hospitals in big cities being maxed out. One size fits all does not make sense. We need to have county by county recommendations. Low, medium, high risk with different mitigation strategies for each.
We are also doing everything we can to keep beds available for when the peak does hit and only admit people who absolutely need to be admitted. A lot of people are afraid to come to the hospital at all and we aren't seeing patients. It may not hit everywhere evenly. The models could also be wrong and all the lockdowns and social distancing in place may prevent us from being overwhelmed but we are doing our best to be prepared in any case.
It's easy enough for a leftwing hospital admin to hit the "DIVERT" button in order to further the narrative. Let me know when you have video proof of overcrowded hospitals, because every overcrowded hospital I've seen reports about were quickly debunked by citizen journalists.
Appropriate government agencies will now review and advise on protocol change, expect answers early to mid 2021.
Yes. Maybe Fauci will conduct copious clinical trials until the entire population is wiped out.
Bureaucracy at its finest!
I've joked about Fauci's autistic "anecdotal" hcq statement with
Are ventilators double blind, randomized, placebo controlled clinical trial proven safe and effective for this particular covid 19 strain?
Food pyramid created by cereal manufacturers.
"many of the great medical advancements of the past would’ve never happened" like leeches on the body, drilling holes in skulls to let out demons, and the 1001 other horrible medical advances that occurred prior to evidence-based medicine? Or are you referring to a dozen advances that occurred in the past that you will now google and then reply with like you had them in mind all along? Thx, in advance.
Ventilators are the standard of care and the patients who end up on ventilators will die without them. There isn't an alternative.
But are there randomized prospective case controlled trials for ventilator use in COVID-19 confirming your statement? I have seen no such data.
Obviously this is a joke akin to the “testing parachute effectiveness” variety. But one could make a cogent argument that, say, hydroxychloroquine inhibits Sars-CoV2 in vitro and was effective in the original SARS and that people will die without it and there is anecdotal and smaller trial evidence of effectiveness and hence it should be the “standard of care” and not just an option for COVID-19. Yet we see people like Fauci every day disparage this form of therapy as “no evidence” on the basis of lack of multicenter double blind prospective randomized case controlled study. That same lack applies to ventilator use.
Here's a datum for you.
I've been in hospital since last Saturday with pneumonia, and probably should have gone in three days before that.
I've been on HCQ.
I'm still alive. I strongly suspect that I wouldn't be, were this not the case.
God bless you bro. Wishing you a speedy recovery!
Thank you, my friend.
Dr. Doom has entered the chat
If you are in respiratory failure because you can't breathe on your own, you need a ventilator whether you got hydroxychloroquine or not. Hydoxychloroquine might prevent you from needing a ventilator. It might improve your chances of survival or getting off the ventilator sooner. But if you can't breathe, you need a ventilator. If you're hypoxic, you need supplemental oxygen. That is not an intelligence test that anyone should fail, but congratulations, I suppose.
So no, obviously we don't have those studies on ventilators in COVID-19, nor do we have evidence that people with COVID-19 should eat food, drink water, not dance around naked in the snow covered in apple sauce. On the other hand, we have plenty of evidence using them in people with respiratory failure from viral pneumonia, bacterial pneumonia, ARDS, etc. And if we don't give this treatment to people who need it, they would die. That is why it is the 'standard of care.'
Hydroxychloroquine has showed some surprising promise both in in vitro studies and some small studies in vivo. Some studies haven't shown any benefit, but that doesn't mean there is none. Unfortunately some of the preliminary data was with sloppy methodology and the data reported has a number of inconsistencies that reduce the confidence in those results. It requires further study.
**Hydroxychloroquine isn't magic. What dose do we give people to treat COVID-19? Nobody knows. How do we know hydroxychloroquine is more effective than the other drugs being studied? We don't. Should we give it to patients with azithromycin and risk fatal arrhythmias in some patients for a treatment that may not be very effective? Which patients should receive hydroxychloroquine? Should we give it to only the sickest patients who may be too far gone for it to make a difference? Should we give it to everyone who has symptoms? If 95% or more of those people are going to recover on their own, we might harm more people than we save.
So no, I don't think we should be automatically giving everyone hydroxychloroquine as the 'standard of care' because there is no 'standard' nor is there data to guide on how much to give and who to give it to and it may end up being inferior to some of the other drugs being studied. Given that we don't know these things, the decision to give it should be based on decision making between patients and their doctors. It shouldn't be made by governors, politicians and bureacrats. However, those holds were put in place not because everyone is so anti-Trump but because a number of irresponsible doctors not treating COVID patients, dentists, podiatrists, PAs started writing it for themselves and their friends and families in large quantities that would cause a drug shortage.
I do not think the drug should be restricted to clinical trials. But we do, in fact, need those trials to determine whether or not its effective at all.
You might not like it, but if you were in charge we would probably still be using leeches on patients.**
Not really. I’m a doc and I participate in clinical trials. Try not being so butthurt.
Hydroxychloroquine is a known medicine, not thalidomide, and we will be practicing battlefield medicine over the next 3 weeks. I’m glad if you don’t want it. I will offer to my patients and docs who deny it to patients when it might help are not doing their patients a service IMO. That’s what I mean when I say standard. It should be offered.
Take my money. You deserve it.
"Given that we don't know these things, the decision to give it should be based on decision making between patients and their doctors. It shouldn't be made by governors, politicians and bureaucrats."
Nowhere did I say it shouldn't be offered. It's also not an 'alternative' to someone who needs to be intubated.
You are right that I am unfairly taking out my downvotes on you. It's like I posted on r/politics. Before the ban from the governor, the ID docs here had been using it on some COVID patients.
You should see someone about your anxiety.
There is certainly an alternative to try different forms of treatment earlier, to avoid the need to put people on ventilators.
You might as well say "leeching is the standard of care" as it once was. We are always learning and improving, and during a crisis we often do so more quickly than normal.
Good information from a respiratory therapist:
CORONA Common Sense
Since they are calling on Respiratory Therapist to help fight the Coronavirus, and I am a retired one, too old to work in a hospital setting, I'm going to share some common sense wisdom with those that have the virus and are trying to stay home. If my advice is followed as given, you will improve your chances of not ending up in the hospital on a ventilator. This applies to the otherwise generally healthy population, so use discretion.
Only high temperatures kill a virus, so let your fever run high. Tylenol will bring your fever down allowing the virus to live longer. They are saying that Ibuprofen, Advil, Aleve, Motrin, etc. will actually exacerbate the virus. Use common sense and don't let a fever go over 103 or 104, if you got the guts. If it gets higher than that, take your Tylenol, not Ibuprofen or Advil ( or any type of anti-inflammatory drugs ) to keep it regulated. It helps to keep your house warm and cover up with blankets so your body does not have to work so hard to generate the heat. It usually takes about 3 days of this to break the fever.
The body is going to dehydrate with the elevated temperature, so you must rehydrate yourself regularly, whether you like it or not. Gatorade with real sugar or Pedialyte with real sugar for kids works well. Why the sugar? Sugar will give your body back the energy it is using up to create the fever. The electrolytes and fluid you are losing will also be replenished by the Gatorade. If you don't do this and end up in the hospital they will start an IV and give you D5W ( sugar water ) and normal saline to replenish electrolytes. Gatorade is much cheaper, pain-free, and comes in an assortment of flavors.
You must keep your lungs moist. This is best done by taking long steamy showers on a regular basis. If you're wheezing or congested, use a real minty toothpaste and brush your teeth while taking the steamy shower and deep breaths through your mouth. This will provide some bronchial dialation and help loosen the phlegm. Force yourself to cough into a wet washcloth pressed firmly over your mouth and nose, which will cause greater pressure in your lungs forcing them to expand more and break loose more of the congestion.
Eat healthily and regularly. You've got to keep your strength up.
Once the fever breaks, start moving around to get the body back in shape and blood circulating.
Deep breathe on a regular basis, even when it hurts. If you don't, it becomes easy to develop pneumonia. Pursed lip breathing really helps. That's breathing in deep and slow, then exhaling through tight lips as if you're blowing out a candle. Blow until you have completely emptied your lungs and you will be able to breathe in an even deeper breath. This helps keep lungs expanded as well as increase your oxygen level.
Remember that every medication you take is merely relieving the symptoms, not making you well.
If you're still not improving, then go to the ER.
I've been doing these things for myself and my family for over 40 years and it has kept us out of the hospital. All are healthy and still living today.
Thank you for sharing this information. We have got to help one another right now.
Be advised, I am not hip to these things myself, but it seems this gentleman is pretty knowledgable on the subject, and my sister and niece are both Nurses and stated this was good advice, although they are not in the field he was in so they don't know about the letting the temps run up high.
This is great. Thank you.
YW
This should be it's own post. Thank you!
Excellent advice and transparently true even to layman!
Thanks, sure seems like good advice. I'm going to run it by a doctor friend as well
Let me know what he says.....
Number 1, about the Advil, has been walked back. The WHO is the one who said it would exacerbate it. They now say it's fine.
If you need to let the temps run then all would stop the healing by not allowing the fever to break sooner it seems.
100% of them would have died without a ventilator. If you are hypoxic, you need oxygen. If you can't breathe, you need a ventilator. If you're in cardiac arrest, you need CPR. Some posts here are arguing against the use of ventilators which is simultaneously retarded and nonsensical.
It's not...'we can give you the ventilator or we can give you hydroxychloroquine.' It's 'we can give you the ventilator if you need it and hopefully save your life or you can die without one' whether you received hydroxychloroquine or not.
Hh Did you even look at Dr. Slidell’s argument? He says O2 is needed more than high pressure PEEP. He doesn’t say throw out the ventilators, just adjust them properly.
This is why they do clinical trials in the first place, to flush out any unintended consequences.....however, when you’re in the situation we are now, clinical trials are not expedient and need to be by-passed as best as possible
Every war leads to advances in medicine.
And more efficient ways to kill.
They need to do clinical trials to determine whether or not the drug is actually effective. They also need to know what dose regimen is optimal. Which patients are most likely to benefit from it (and later on they need to compare it to other drugs to determine if any one of them is superior). We have not convincingly arrived at the point where most practitioners accept it to be actually effective.
There are a lot of ongoing studies in different drugs. Who is to say that a study in only 20 people showed a benefit compared to not getting it because 4 of the people who got the drug only had a milder illness to begin with and it wasn't from an effect of the drug? Etc.
Tony "copious clinical trials" Fauci.
If Trump hears about it he'll cut the red tape.
If you have a family member who gets sick, you might want to show the docs this video.
This idea is stupid. Most patients are already on 100% oxygen when they start increasing pressure (PEEP). You cant increase oxygen more than that. ARDS (from covid) causes the permeability of the aveoli in the lungs to change (alveoli are microscopic air pockets in the lung). This causes them to fill with water. Increasing pressure keeps fluid out, keeps patient from drowning and keeps the alveoli open. The increased pressure can cause damage, but they do things like decreasing volume and increasing rate of ventilation to try and mitigate it. But without the pressure patients will die much earlier.
Edit: If you have doctors who have no experience treating ARDS and they try increasing volume with high pressure then sure it can cause lots of damage. But still just increasing oxygen isnt enough
WuFlu's surface glycoproteins have been shown to possibly bind to heme, dissociating the iron from it. That would render the hemoglobin unable to transport o2 while simultaneously increasing the free iron in the blood.
It's not fluid in the alveoli causing ARDS, it's a reduced o2 capacity thanks to this effect on the hemoglobin. So no, ventilators will not help. Patients aren't 'tiring out', they are turning progressively hypoxic. Would you intubate a patient for carbon monoxide poisoning? Of course not.
You COULD use a hyperbaric chamber full of pure o2, at 2x, 3x, 4x atmospheres of pressure to help what's left of the functioning hemoglobin to keep carrying o2 to the organs. Even then you're just buying time in the hope the patient's immune system will finally overcome the virus.
If true, then perhaps explains severity for diabetics. The high sugar glyconation of hemoglobin may leave more vulnerable?
☝️this guy logics
The simple answer is that young healthy people have better immune systems.
Better every systems. They can tolerate physiologic extreme longer without dying.
pretty much, yeah. quicker response but they're still open to opportunistic infection while your immune system recovers
I appreciate the thought, but all you have to do is look at the chest films of people coming in. It's multifocal pneumonia with completely opacified airspaces. That's not how carbon monoxide poisoning looks or altitude sickness.
Might this also explain the higher death rate in northern Italy as it's a higher elevation?
Yes, and you usually, at least in my experience, start with the lowest PEEP possible; if you aren’t getting the result you want, then you increase. I doubt competent MDs would jump to high PEEP right away; if they are increasing peep, it’s probably because they aren’t oxygenating on lower peep & the lung damage is a trade off.
Indeed. Increase PEEP is generally the last lever you want to pull because of the trade offs.
A little extra PEEP is fine with low driving pressure (Plateau - PEEP). It actually shows improved mortality in ARDS, but COVID-19 is atypical ARDS... more of an intravascular issue. Lung compliance is fairly normal with COVID-19, something you don't see with traditional ARDS.
Yea PEEP is titrated to compliance and helps with oxygenation.
That is what we do as well. But it seems the European Society of Intensive Care Medicine and the Society of Critical Care Medicine COVID guidelines (https://www.esicm.org/wp-content/uploads/2020/03/SSC-COVID19-GUIDELINES.pdf) suggest using a 'high PEEP' strategy (page 23).
What is a high PEEP strategy? They don't know, but suggest >10cmH2O is high PEEP. 'Weak recommendation, low quality evidence.'
I don't think the doctor in this video is suggesting that doctors just increase oxygen. He's suggesting that we need to fine tune the way ventilators are calibrated to treat the conditions associated with this particular illness.
You do that for every patient on a vent. Full featured vents let you dial in a number of different settings based on the patient. It is never one sized fits all.
link to the ARDS vent guidelines
LOW TIDAL VOLUME VENTILATION (LTVV): INITIAL SETTINGS For patients with ARDS, we and others recommend LTVV (also known as lung protective ventilation; 4 to 8 mL/kg predicted body weight [PBW]) (table 1 and table 2). LTVV is typically performed using a volume-limited assist control mode, targets a plateau pressure (Pplat) ≤30 cm H2O, and applies positive end-expiratory pressure (PEEP) using a strategy outlined in the table (table 3). This approach is based upon several meta-analyses and randomized trials that report a mortality benefit from LTVV in patients with ARDS. It is thought that low tidal volumes (VT) mitigate alveolar overdistension induced by mechanical ventilation, which can cause additional lung injury and mortality in patients with ARDS. (See 'Efficacy and harm' below and "Ventilator-induced lung injury", section on 'Mechanisms'.).
TLDR high PEEP strategies for ARDS have not been preferred for a long time because of the risk of Ventilator-induced lung injury.
These experts who claim that ARDS is treated with a high PEEP strategy are at least 15 years behind the standard of care.
It's because they read the original ARDSnet study and jerked off to the PEEP/FiO2 table that both groups got for standardization - but that study wasn't about PEEP. It was to figure out whether low or high volumes on a vent were better.
Since then, we have become a lot more advanced with specializing PEEP individually for patients. We can do esophageal manometry to estimate intrapleural pressure and counteract the distending force on the lungs with just the right amount of PEEP to maintain functional residual capacity.
Sounds like you are on the ball with this stuff. Medical professional? My cousin is a surgeon and has been talking about the risks of vents being used by medical professionals that don't have the expertise. She was especially worried about NYC because of the "all hands on deck" nature of the response to the virus.
Not true that people are already on 100% oxygen when they start increasing PEEP. If you follow ARDSNet protocol you don't reach 100% FiO2 until you have a PEEP of 18-24. Most critical care docs have been following ARDSNet protocol. That's why the doc in the video says we are doing it wrong.
You are on 100% oxygen the moment you get intubated and then the oxygen is weaned and the PEEP adjusted accordingly.
But what we’ve been doing is trying to lower the FiO2 fairly soon after intubation and adjusting PEEP accordingly to maintain adequate oxygenation. This is across many different types of pathology. I’m curious as to what your specialty is and how often you are tubing and adjusting vent settings. EM here. Maybe we’re just trained differently
Edit: looking back I repeated what you said but my point is that we aren’t in general keeping ppl on 100% O2 for a prolonged period of time and PEEP tables are used broadly to make adjustments in tandem. So FiO2 is decreased and then adjusted with PEEP. Still curious as to your specialty and if you are managing vent settings.
True, but what a lot of the feedback I am reading about is people being put on vents and not CPAP/BiPAP (maybe to minimize aerosolizing virus or because they think the hypoxia is too much?) or they are starting them out on higher settings (PEEP of 10 or more which is was recommended by SCCM and European guidelines.
We start on low PEEP and high FiO2 and we try to increase the PEEP to reduce FiO2 to 60% or less. But if they don't respond to the higher PEEP or it adversely effects their hemodynamics, I don't keep it on. But from what I've seen with our patients is that they don't respond much to increasing the PEEP and we end up keeping high FiO2 with a PEEP of only 5-10.
We had a patient who recently got a PEEP of 14 and ended up with a pneumo. SCCM supports their 'high PEEP' based on data that was higher than that. Some of those PEEP #s I am seeing just seem crazy high to me.
I've seen some updates on the Pathophys but still no mention of that hemolgobin thing.
I work in emergency care and people don't go on vents unless it's absolutely needed. People on vents are generally very sick and can no longer breath on their own. Saying to simply switch them pure oxygen is at best an uneducated statement since most people would die shortly after being taken off a vent if their body has not recovered. Now there could certainly be future changes in the treatment protocols for hospitalized patients that are currently not sick enough to need a vent. Most of this seems to be related to mass hysteria and poor understanding of how the virus works as well as poor understanding of medical practices. Doctor's avoid the use vents as much as possible because it is risky and their ass is on the line for medical malpractice if your putting people on a vent that don't actually need it. Vents are the last line of defense for extremely sick patients and running out of vents in a "shit hits the fan scenario" could mean the number of fatalities greatly increases.
Original mantra with COVID-19 was to intubate early. If someone needed greater than 6L O2 via nasal cannula then the move was to intubate. We are now moving away from that given that we are running out of vents and learning that early intubation may not be the right answer
You always run a vent at the lowest pressure needed to sustain the patient. Each patient gets a custom setting tailored to their needs.
I think they're saying "tick up the pressure until the patient no longer is dying"
You start at some minimum and work your way up until the O2 stats get better.
Every patient is different, so there isn't really a "recommendation" beyond the minimum required.
The standard of care is to start at the lowest pressure setting and you go up if if the patient needs more. That's why all the healthcare professionals watching this video are shaking their heads.
It's less of a COVID-19 specific problem than a respiratory failure secondary to severe pneumonia and ARDS problem. It's physiological.
I honestly think what he is getting at is that this may not end up being uniform lung pathology across patients. We’re adjusting the vent setting to get an oxygenation status we are comfortable with but ultimately we are causing lung damage in the process and making the patient’s problems worse
This is exactly what my nurse sister-in-law told me. She said whatever you do don't let anyone put you on a ventilator.
Even just in general, once you get on a ventilator, you're very likely to be done. It's very hard to get off them.
The official numbers are probably highly guarded, but 15% survival after going on a ventilator looks about right. Even if you do survive, you won't be the same again.
In Wuhan it was 5%
Jesus thats a low percentage, what is this machine?! I thought it was a life saving device not a death machine :/
forces air or O2 into your lungs with pressure. The problem is that your lungs are weakened by the infection and even minimal pressure could do permanent damage.
Tht is what my SIL said
It's also why you want to get on the drug cocktail ASAP if you have the Chinese virus. You can get off the ventilator, but it's a very traumatic experience for the patient. Also if you get to that point there is a good chance you have permanent lung damage even if you recover.
Exactly, it looks like Brazil is taking this route and refusing to shut down. Bolsonaro could become a hero
The people going on ventilators cannot breathe on their own, oxygen would simply not address the problem. You don’t know what the fuck you’re talking about.
People who are doing fine on oxygen don't need to be ventilated. People who are being ventilated start out on max oxygen and lowest pressure setting and the pressure only increases if it needs to be. People are kept on the minimal pressure needed. That's the standard of care everywhere.
That's why this video-guy doesn't make any sense. No one has any idea what he is talking about when he says 'high pressure.'
Well the video doctor should communicate what he is talking about to other doctors in the field and discuss what pressures he is talking about instead of posting vague nonsensical things on social media.
You are wise not to simply accept what people on TheDonald are telling you (including me), but you shouldn't just accept what someone in a video is telling you either.
There are roughly 300 medical centers in the world that can do ECMO. This is mostly done in NICU patients. Doing it adults is rare. We are talking about less than 5000 adults in a year.
If full function ventilators are Porsche 911 then an adult ECMO is a bugatti veyron.
This is the main reason. There are 264 hospitals in the USA with Ecmo capability but many have only 1 unit.
Even if there are, say, 500 ECMO units in the USA, there may be 200,000 COVID patients who need assistance in oxygenation. It’s a drop in the bucket of need.
Not a doc, but I've wondered about this as well. I think the issues are realistic cost, availability, and trauma associated with whole process.
If you've got a pre-dementia 90 year old already dying of pancreatic cancer and a lung infection, it doesn't make sense to drop a million dollars on keeping them alive when the next flu season will probably take them out anyway.
That's just life. We don't have infinite resources.
So, for disclosure, I’m an anesthesiologist who has worked in a few ECMO capable ICU’s.
V-V ECMO (oxygenating the blood, not bypassing the heart) which is what would typically be needed in hypoxia respiratory failure is a massively invasive undertaking that is hugely fraught with both morbidity and mortality. First it almost always requires a mechanically ventilated patient to begin with, then it requires a huge catheter to be placed in the neck that effectively drains and returns blood from the patient. There are large infectious, inflammatory, and hemorrhagic/thrombotic risks associated with this. The decision to go on ECMO is also highly ethically charged, as there needs to be an end in sight. For V-V ECMO in these cases, you generally need to have a reasonable expectation of recovery but are failing mechanical ventilation. Putting someone on ECMO who will never recover is entirely unethical and should not be done.
In the ICU where I am working now, we will not consider putting a COVID patient on ECMO unless they has a clean bill of health prior to getting COVID, and are under 60 years old. Part of that is resource utilization, meaning we want to use ECMO for patients who have a high chance to recover and not waste it in terminal cases, but it is also the ethically correct thing to do.
In short, if putting someone in mechanical ventilation is like sewing up a skin laceration, putting someone on ECMO is like performing an amputation. It is orders of magnitude more complex and dangerous
Thanks for the reply, doc. Super informative, and it answered this long standing question of mine. :)
They have to reserve those for celebrities and ruling class.
Scuba diver here. Pure oxygen under pressure is toxic. O2, no pressure, is fine.
Went thru this doctor’s Twitter. Not a single mention of treatment. Quite a few anti-Trump doctors comments he posted in his feed as well.
Best write up I've seen so far in explaining how this coronvirus causes damage.
https://medium.com/@agaiziunas/covid-19-had-us-all-fooled-but-now-we-might-have-finally-found-its-secret-91182386efcb
WTH
"This account is under investigation or was found in violation of the Medium Rules."
That's crazy. I wish I would've archived it. It ended with some pro hydroxychloroquine info and "China is asshoe". I'm going to try and find that guy on Twitter and see if he posted his write up elsewhere.
Someone else did archive it.
http://archive.is/ONUmi
Thanks!
Or it's actually -the worst- write up given that I don't see -anywhere- in the actual medical literature so far where this hypothesis is supported. I have no idea where this guy came up with this information and nor do I see him cite a single source.
Even if that were true (and I suspect it isn't), I don't know that it would lead to low oxygen readings on a pulse oximeter which would make it bupkiss. Pulse oximeters are actually measuring the ratio of oxygenated hemoglobin to de-oxygenated hemoglobin in your blood. If the Fe was removed from the porphyrin ring I'm not certain it would give you a 'low' reading (for example, in carbon monoxide poisoning, the reading is actually high or in the case of severe anemia where the oxygen content in the blood is very low but the reading is normal.
I also haven't seen evidence of either free or denatured hemoglobin or dysmorphic red cells in the actual coronavirus patients I've treated which would be expected if this were the case (and nothing in the medical literature supports that either but they do talk about white blood cell abnormalities occurring. You would think this hemoglobin thing would have come up).
In the absence of such, I would presume that the mechanism is (drum roll) just like any other coronavirus or even other respiratory viruses causing severe pneumonia from direct damage to the lung and widespread inflammation. It's a bad disease, but there's no reason to believe it has some magical powers that no other respiratory virus has (including other coronaviruses it is similar to which may be less contagious but have a higher fatality rate)
Citing 'high iron' being found in the blood is meaningless here because the transporter molecule for the storage form of iron (ferritin) is often present at high levels in inflammatory states and thus doesn't support his hypothesis at all.
The only paper I did find is what seems to be an unpublished paper from "liu wenzhong" where he discusses this could theoretically happen, but the article above goes far further.
I would love to know who the author of this paper is and how he 'knows' anything he claims.
The only literature I've seen that has anything like that write up is the unpublished paper you found too. My issue is that multiple docs in critical care are coming out and saying that this disease is not acting like ARDS in terms of lung compliance and response to ventilation treatments. Some liken it to HAPE but it doesn't explain it all. Listen to the latest podcasts by Scott Weingart on EMCrit or Rebel EM. There IS something we are missing here that isn't fully fleshed in the current literature. It's all anecdotal, but I'm just trying to make sense of it all as it doesn't completely fit the severe pneumonia and subsequent ARDS picture. We have to think outside of the box as mortality for intubated patients is 50-80%.
If you watch Weingart's latest video I'm sure you'll like the guy with an O2 sat reading of 1% (good waveform) who is still talking.
Here's some Italian observations by Gattinoni, well published in critical care and lung protective ventilation, expaining that COVID-19 is different from the usual ARDS. I think this is what OP's video was getting to. The following ventilatory recommendations are different from current ARDS recommendations. For those of us managing vents this can be super helpful which is why I thought it might be of interest to you and your colleagues. It's anecdotal but by the time you get a great study on this many of your patient's may have experienced a bad outcome.
PRELIMINARY OBSERVATIONSON THE VENTILATORY MANAGEMENTOF ICU COVID-19 PATIENTS https://sfar.org/download/preliminary-observations-on-the-ventilatory-management-of-icu-covid-19-patients/?wpdmdl=25586&refresh=5e8ab4d54e10b1586148565
Gattinoni L et al. COVID-19 Does not Lead to a “Typical” Acute Respiratory Distress Syndrome. ATS 2020. [Epub Ahead of Print] https://www.ncbi.nlm.nih.gov/pubmed/?term=gattinoni+covid-19
Edit: Here's another take on SARS-COV-2 attacking affecting hgb. More nuanced than the other take and only a suspicion but at least you have an MD name behind it and supposedly currently being researched. I think that hbg is affected in some way to decrease O2 carrying capacity but it's just my gut feeling.
https://threadreaderapp.com/thread/1245846222969147392.html
TY for sharing! I would think that there may be mitochondrial dysfunction as in other forms of sepsis. But certainly interesting to explore.
If they'd warned families about the dangers of putting a loved one on a BiPAP mask, no one would use it. Compromised lungs don't get stronger on a BiPAP and the muscles weaken over time making the device medically necessary to sustain life. That is, only a small to moderate percentage of patients ever come off it and to do so takes a lot of therapy work.
When dad had enough of his pulmonary fibrosis and cancer, he lawyer filed his DNR, loaded himself up on morphine. He slipped his mask off and died.
He hated that fucking machine.
BiPAP and CPAP also aerosolize a significant amount. That’s why the doctors I know are either using just oxygen, or intubation.
Source: NYC 911 EMT
The worst part about this is that they had to know. Medical agencies at very high levels pushed the use of ventilators to increase the damage. Disgusting, they should be ashamed.
People end up on ventilators because they go into respiratory failure and can no longer breathe on their own. The docs are making decisions to put people on vents and they do so based on individual patient cases. Also, this video is somewhat nonsense and not at all helpful.
If he has a suggestion of what upper limit pressure level to set, he should have said that value.
Why would doctors put someone on ventilators when the person can breathe on his own?
What about operating like a baby vent. Lots of low pressure cycles?
(a sincere question, I am not in the medical field.)
When we put people on a ventilator, we start them at max oxygen and start at the lowest pressure setting. Pressure goes up only if they need more pressure. This is the standard of care everywhere. This guy is not making sense.
And this, is why its called Practicing Medicine. These guys are doing as great as theyre able to.
Saw this on youtube last night and was hoping someone had posted it here.
All I've got to say is, this explains the propagandists' absolute obsession with ventilators and their daily haranguing of the President about them.
They genuinely want more people to die.
"It's like the first time we've actually had to use medicine."
This is inaccurate and be very wary of any medical professional on social media saying they know of a secret that the medical community is holding back. Vent settings are complex and both pressure AND oxygen saturation have to be managed because different diseases require different settings. Every med student knows about barotrauma, the bursting of alveoli from overpressure. There's also toxicity from too much oxygen. This is not secret knowledge that doctors are all purposefully fucking up on.
Pneumonia from diseases like flu or covid are a pressure problem, not oxygenation. The problem is that in certain situations the pressure required to reopen alveoli could increase to the point of being higher than the pressure that could burst them. If you're on a ventilator for pneumonia vs things like throat closure or for surgical reasons, you're already in a fucked situation with a high mortality rate.
Can every pede w a twitter account go & @ Tucker, Laura Ingram, NIH, Don Jr, and all the R senators who care? Maybe if this gets talked abt more someone will start to pay attention?
In Wuhan they confirmed this early on in the outbreak, they found that if they put severe cases on ECMO instead of ventilators that the outcome was drastically improved. The issue with this disease is the effect it has on the blood to deliver oxygen and remove carbon dioxide, it's not just pneumonia. Blood transfusions and ECMO is the way to go. It seems like the West is not learning from mistakes in China early on. Our focus should be on preventing people from getting sick enough to require life support, the majority of people that go on life support do not pull through.
...or avoid the vent altogether by using the cure before COVID patients get too sick.
Yeah but deaths are what the CDC and WHO want, sooooo....
What's up with these doctors looking like bums? Not helpful for your credibility. This guy and the Hydroxy guy need some help with their profile pictures.
Still arguing about what kind of drug to give.... for the next couple of months.
Too much red tapes and middlemen to ask for a quick change.
Im starting to wonder if this is part of the reason (among others) that there is such a high death rate.
He looks half dead
This is a fascinating and enlightening article that all should take the time to read.
Spread the word because people, even doctors still don’t understand COVID19. It affects blood cells, not lung capacity. Steady stream of unfiltered O2 is the answer, not increased pressure into the lungs.
No, don't spread the word. Doctors are looking at new and up to date information on a daily basis on how to treat COVID. I know because I do and all my colleagues do. And my colleagues also share new information multiple times a day.
People get put on vents either because they need to be on a vent or because less invasive ventilatory measures may be aerosolizing more of the virus and spreading it around. Doctors routinely avoid high pressure on vents. The doctors treating the patients understand the use of the ventilator better than you do so please stop driving more uninformed hysteria.
So if you’re a doctor, explain the empty hospitals
Every state, every county, every city/town is on its own Curve. Because the federal government is a federal it looks at worst cases in large cities and treats the whole country the same way.
State governors do the same thing and treat the whole state like it is Chicago or NY.
This results in hospitals in places that have few cases being at 50% capacity while hospitals in big cities being maxed out. One size fits all does not make sense. We need to have county by county recommendations. Low, medium, high risk with different mitigation strategies for each.
Which hospital is maxed out?
It hasn't peaked everywhere yet. But in the NY and NJ hospitals are filling up.
https://www.nj.com/coronavirus/2020/04/coronavirus-update-the-surge-is-beginning-7-nj-hospitals-temporarily-hit-capacity-in-1-day-official-says.html
We are also doing everything we can to keep beds available for when the peak does hit and only admit people who absolutely need to be admitted. A lot of people are afraid to come to the hospital at all and we aren't seeing patients. It may not hit everywhere evenly. The models could also be wrong and all the lockdowns and social distancing in place may prevent us from being overwhelmed but we are doing our best to be prepared in any case.
It's easy enough for a leftwing hospital admin to hit the "DIVERT" button in order to further the narrative. Let me know when you have video proof of overcrowded hospitals, because every overcrowded hospital I've seen reports about were quickly debunked by citizen journalists.
pumping air into someone pressurizes the lungs? im not a medical expert but im pretty sure pure O2 kills you AND is also a gas thus makes pressure.