Fear and Loathing, a Rat Flu Odyssey

[pureantigravity]

Before I read #hostilegary's rude post, I actually came to ask this question. So here it is for anyone that is knowledgeable in medicine:

As per "A plea for avoiding systematic intubation in severely hypoxemic patients with COVID-19-associated respiratory failure
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03063-6"

Is intubation a killer and/or is providing more Oxygen without intubation actually better?

Say they wanted to intubate yoi or your mom/pop, under what circumstances should you agree to this or instead ask for a different therapy?

[garyfromterrace]

THIS MESSAGE IS HIDDEN BECAUSE PUREGRAVITY IS ON YOUR IGNORE LIST.
What?

[old goat]

Before I read #hostilegary's rude post, I actually came to ask this question. So here it is for anyone that is knowledgeable in medicine:

As per "A plea for avoiding systematic intubation in severely hypoxemic patients with COVID-19-associated respiratory failure
https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03063-6"

Is intubation a killer and/or is providing more Oxygen without intubation actually better?

Say they wanted to intubate yoi or your mom/pop, under what circumstances should you agree to this or instead ask for a different therapy?

I am not knowledgeable in this area of medicine but there certainly is a school of thought that the complications of intubation--which requires prolonged heavy sedation in order to keep patients from breathing against the ventilator--outweigh the benefits. There are newer methods--high flow nasal cannula oxygen and proning (placing the patient on their stomach) that didn't exist when I was actively managing patients with respiratory failure that seem to be able to deliver as much oxygen and raise the oxygen level in the blood as well or nearly as well as a ventilator, and people without coronary artery disease seem to be able to tolerate lower oxygen saturations in the blood than previously thought. Patients can also receive mechanical ventilatory support by mask although not as effectively as through an endotracheal tube I believe. The best indication for supporting someone with mechanical ventilation is that they cannot sustain the physical work of breathing well enough to keep the CO2 in their blood from continuing to rise.

Just heavily sedating someone has ill effects--it becomes much more difficult to mobilize them which is necessary to expand all parts of the lungs and prevent blood clots among other things.

There are things a mechanical ventilator can do that nasal 02 cannot, primarily maintain a constant positive pressure in the airways which helps keep all parts of the lungs fully expanded. In the past this has been felt necessary to treat what is called ARDS--adult respiratory distress syndrome, of which SARS 1 and 2 and MERS are felt to be variants. I don't know what the current thinking is on this.

I've given a fair amount of thought to what I would do and I would personally want to avoid ventilation unless I was physically struggling to breath despite the high flow nasal oxygen and proning. My recent personal experience is as a patient--after 14 rib fractures and again after heart surgery I was walking around with oxygen saturations in the 80's, didn't feel short of breath and didn't seem to have any negative consequences from it, other than they wouldn't let me go home until my saturation improved. When I did feel short of breath in bed, it seemed to be due to anxiety and they had me breath in through the nose and out through the mouth--or maybe it was the other way around, not sure it matters, the main thing is it controlled my anxiety.

There are certainly people posting in this thread who have personal experience treating Covid who can answer your question better. Particularly--is the opinion expressed in the letter the majority or minority opinion these days.

One thing that concerns me is that decisions regarding intubation seem to be frequently be made in the ER--by ER docs and not by the lung and intensive care specialists who will be managing the case. How well versed the ER docs are in the most up-to-date ideas in managing Covid I think will depend on the hospital and on the quality of communication between ICU and ER docs. Also, as cases surge and ERs start to get overwhelmed, immediately intubating may necessary to stabilize someone who might be able to do ok off the ventilator if the ER wasn't so busy and the docs and nurses had more time to work with them.

As a (retired) HCW the idea that patients would be intubated primarily to protect the people caring for them rather than for the patient's benefit disturbs me. Maybe that would not have been thought necessary if we had adequate supplies of PPE. Just one more way in which our govt and our health care system has failed us, despite being the most expensive in the world. When my wife broke her ankle in April she was intubated and ventilated for the operation in order to protect the anesthesiologist just in case she had Covid and she had complications from the intubation. Normally she would have been masked and breathing spontaneously for the operation.

[bennymac]

another factor to consider is people needing to be transported (by ambulance or air) from a smaller community to a larger hospital that has an ICU and lung doctors etc - a flight paramedic (or even a doctor) - no matter how highly trained, is not gonna want to switch a person onto a ventilator via intubation in the back of the ambulance or plane. Sure it happens but it's gonna be far from ideal situation.

So the somewhat unstable covid (or whatever) patient who needs to get to that ICU you are talking about ends up being intubated for travel - better that is done in the hospital versus in a cramped paramedic plane.

[wkd-rdr]

Dexamethasone, asymptomatic vs symptomatic, and antibody lifespan

[CantDog]

Is intubation a killer and/or is providing more Oxygen without intubation actually better?

Say they wanted to intubate yoi or your mom/pop, under what circumstances should you agree to this or instead ask for a different therapy?

So fairly quickly we learned that if you could delay intubation than you should, but it wasnt like everyone was waltzing into the hospital stone cold normal except for a low oxygen reading. There are multiple reasons someone winds up getting intubated, its a bit of the final pathway in critical care. Certainly by mid april things like hi-flow nasal canula were being used in the ICU. At least at the two hospitals I was at they were not using other noninvasive ventilatory apparatuses like bipap and cpap as they aerosolized quite a bit. The fancy helmet things you saw in Italy werent used because you had to be able to take them off, and most patients were incredibly weak, confused, etc and not able to do that.

Maybe with a wave of younger patients in the South some of these other things could be used more, but so many of the early admissions and deaths were from older, frail, diminished functional status and cognitively impaired. In those cases, hi flo NC , self proning, etc dont work because the person pulls at it, or is unable to prone.

It's disingenuous to say that everyone was immediately intubated. The majority of patients I saw started on HFNC and became intubated. Proning is a great idea, but was not tolerated by many. If it was, I also saw a lot of pressure wounds develop from proning.

Without being in the ICU, it is hard to fully gauge just how sick the patients were there. You would have a person in bed, with fluids, typically 1-2 medications needed to keep their blood pressure up going, a line in their neck to monitor blood pressure, a tube in their throat, a catheter, an extra IV or two in their arms, devices on their legs squeezing to prevent blood clots, another cuff on their arm for blood pressure. They were intubated for a while so they also needed a tube down their nose to provide food. With all this going on they also had to be sedated, and sometimes paralyzed(especially when proned and intubated), so that is another few medications hanging and being delivered. Oh, and they were often really swollen because of the medications needed to support their blood pressure, not moving, and just how sick they were.

Finally, I would say that even for the older patients who were very sick, but did not need to be intubated, they frequently did not do well. COVID-19 was in many instances 'the straw that broke the camel's back'. It often felt like a terrible game of which was going to happen first--their breathing would improve, or they would simply just become so exhausted from the increased work of breathing that they would decompensate and die. Sadly, for the folks who didn't want intubation this was the daily game that was played.

[Benny Profane]

So fairly quickly we learned that if you could delay intubation than you should, but it wasnt like everyone was waltzing into the hospital stone cold normal except for a low oxygen reading. There are multiple reasons someone winds up getting intubated, its a bit of the final pathway in critical care. Certainly by mid april things like hi-flow nasal canula were being used in the ICU. At least at the two hospitals I was at they were not using other noninvasive ventilatory apparatuses like bipap and cpap as they aerosolized quite a bit. The fancy helmet things you saw in Italy werent used because you had to be able to take them off, and most patients were incredibly weak, confused, etc and not able to do that.

Maybe with a wave of younger patients in the South some of these other things could be used more, but so many of the early admissions and deaths were from older, frail, diminished functional status and cognitively impaired. In those cases, hi flo NC , self proning, etc dont work because the person pulls at it, or is unable to prone.

It's disingenuous to say that everyone was immediately intubated. The majority of patients I saw started on HFNC and became intubated. Proning is a great idea, but was not tolerated by many. If it was, I also saw a lot of pressure wounds develop from proning.

Without being in the ICU, it is hard to fully gauge just how sick the patients were there. You would have a person in bed, with fluids, typically 1-2 medications needed to keep their blood pressure up going, a line in their neck to monitor blood pressure, a tube in their throat, a catheter, an extra IV or two in their arms, devices on their legs squeezing to prevent blood clots, another cuff on their arm for blood pressure. They were intubated for a while so they also needed a tube down their nose to provide food. With all this going on they also had to be sedated, and sometimes paralyzed(especially when proned and intubated), so that is another few medications hanging and being delivered. Oh, and they were often really swollen because of the medications needed to support their blood pressure, not moving, and just how sick they were.

Finally, I would say that even for the older patients who were very sick, but did not need to be intubated, they frequently did not do well. COVID-19 was in many instances 'the straw that broke the camel's back'. It often felt like a terrible game of which was going to happen first--their breathing would improve, or they would simply just become so exhausted from the increased work of breathing that they would decompensate and die. Sadly, for the folks who didn't want intubation this was the daily game that was played.

Yeah, it was absurd to hear Pence talk about our great success providing ventilators the other day, when pretty much a few months ago the medical community realized that they weren't really all that critical anymore because, well, at least in NY, something like 85 percent of covid patients who were intubated died anyway. Note how you haven't heard about the need for ventilators since.

[Deebased]

Although her husband may have guns these women usually have shrinking violets for husbands. She's beaten him down over the years and he's probably embarrassed but unwilling to speak out since we've seen how she reacts.

Great stereotyping. That must work wonderfully on your non-white friends.

[Name Redacted]

Shit is getting real for Karen and Chad:

https://www.yahoo.com/huffpost/coupl...072204408.html

[oftpiste]

Curly or straight?

Curly. Gets in the way of everything.

[huckbucket]

Shit is getting real for Karen and Chad:

https://www.yahoo.com/huffpost/coupl...072204408.html

How'd we land on those names anyway?

[Cono Este]

Let me tell you what I think is fucked up about the masks.

I’m a social distancing first person. And people with masks, who presumably wear them first for their own protection, have no problem walking right up to me.

I just picked up a check from my bank, and the guy dons a mask, comes outside, and walks to within 12 inches of me. I put up my hand, and it makes no difference.

Happened at the post office too.




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[simple]

How'd we land on those names anyway?

Reddit

[westoxified]

And people with masks, who presumably wear them first for their own protection

Let me tell you something about your presumption

[Name Redacted]

How'd we land on those names anyway?

They just seem to play into a certain stereotype. Sorry if your name is Chad,,,,,or Karen.

[Cono Este]

Let me tell you something about your presumption

Why the fuck do they ignore social distancing then? At the post office, there are x’s on the floor telling you where to stand. Put on a mask, I guess they could give a fuck.

That’s the problem with America. People just give a fuck about themselves. There are no real, centralized, instructions coming from health departments. Put a mask on everyone, and we’re still fucked.




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[The AD]

Let me tell you what I think is fucked up about the masks.

I’m a social distancing first person. And people with masks, who presumably wear them first for their own protection, have no problem walking right up to me.

I think there are people who respect social distancing, and people who do not. I don't really expect mask wearing enters into it, but I'd certainly rather have someone wearing a mask enter my personal space than someone who's not.

[westoxified]

tough questions but it won't be long now before they tear us to shreds

[Deebased]

How'd we land on those names anyway?

Gotta have racist stereotypes to perpetuate.

Because racists are going to racist.

Those who haven't/won't succeed need to feel validated. It used to be obtaining money, power, hot girlfriend, lots of friends now its virtue signaling.

The same clowns who thought N* jokes were funny a decade ago are adding a new racist stereotype to their trope.

[old goat]

The masks don't make people stupid. They were stupid to begin with.
I agree--distancing whenever possible, a mask when it's not and at all times indoors. It's not either or.

Re: intubation for ambulance transfer. One more reason you are better off being in a big city if you have the Covid or think you have it. You want to be cared for at a hospital with a lot of Covid experience and you don't want to be transferred if you can help it.

[Ted Striker]

@ cono, I'm seeing some of that too - although many more are respecting everyone's space. I'd submit that most of them are just dumb. Without specific knowledge/expertise, most people are terrible at discerning between perceived risk and actual risk.

[buttahflake]

There is not enough lsd being consumed these days.

[east or bust]

Shit is getting real for Karen and Chad:

https://www.yahoo.com/huffpost/coupl...072204408.html

Wrong thread

[old goat]

Wrong thread

It's real easy to forget whether you're in the America Burning thread or the bat flu thread. All the usual suspects posting all the usual shit in both. (Guilty as charged.)

[simple]

Did deebased just equate Karen to the N word?

See that is how we know it is working to piss off entitled white people.

Oh how the right wing have turned into the snowflakes they claimed the rest of us to be. Probably my favorite thing of 2020