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  • #16
    My virus test was negative so here we go. Just got a text that someone, they just intubated 3 folks. I think the next few days are going to be busy. Be careful folks.

    Comment


    • #17
      Thank you. Have a buddy to check on making sure you and other put on and take off PPE per guidelines to minimize your risk contamination/infection. Tough situation. Sorry to hear about the rising number of cases. Hoping we don't become the next "Italy" and have to decide who to intubate and who not to intubate because of limited resources.

      Comment


      • #18
        We are all going to be involved in this in some way. I really appreciate, though don't envy, the docs on the frontlines in the ERs and ICUs. I'm hoping that my hospital doesn't get hit in a way that brings me directly into the fight, but if it does, my group is ready. All there is to managing a vent is the on/off switch, right?

        It will be hard to remember this when things get really rough, but YOUR health is more important than the patient. Sad to say, but your life saves dozens or more, theirs does not (until we are the ones on the vents). To that end be especially diligent with PPE and hand washing. Good luck, be safe, and keep us updated!

        Comment


        • #19
          Originally posted by StarTrekDoc View Post
          TY.

          Doing the next right thing - https://www.youtube.com/watch?v=w6g1yQV0dIY

          edit: make sure that N95 is fitted right.
          Lol, I tweeted that this weekend. weird times.

          Comment


          • #20
            Originally posted by pulmccMD View Post
            in addition to PPE/N95s, use VL instead of direct laryngoscopy, paralzye them so as to limit coughing, use a viral filter on your Ambu Bag, and even don't bag at all if you can get away with it.
            This. Just got our viral filters for our bags. Nobody intubated for this in my EDs yet, but we've had positives.
            Helping those who wear the white coat get a fair shake on Wall Street since 2011

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            • #21
              Thank you for volunteering.

              I reached out to my former chief yesterday and told him I'm not looking for work and I hope they won''t need additional help, but that I would be willing to step up and serve if my services are required.

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              • #22
                Originally posted by PhysicianOnFIRE View Post
                Thank you for volunteering.

                I reached out to my former chief yesterday and told him I'm not looking for work and I hope they won''t need additional help, but that I would be willing to step up and serve if my services are required.
                Wow! I was actually wondering about you. I hope you are doing OK. I would imagine this might be an emotional roller coaster for you. I am 1-5 years from being done myself and you are sort of a hero of mine. I think being close to FI has helped me feel good about work and what I do and don't do. Some days I really feel important (doing pediatric cases or cardiac cases,) but other days I feel like I am doing mostly charting and trying to stay alert in an OR.
                This thing actually scares me badly, but it also makes me feel like I am really doing work that matters. Hang in there POF and be safe!
                Also, on a financial note: From a newly retired guy, are you OK? Sequence of return risk?
                Any lessons learned or wisdom for us? (feel free to link to a post)
                I am planning on staying flexible and shooting for a FAT fire situation with a gradual part time descent into retirement. I imagine you have a little money coming in form the blog / website and that might help but still seems kinda tough for the market to tank on you soon after you stopped clinical work (if I remember right). Anyway, I am not surprised at all that you volunteered to help out if they needed you. I know you have done some mission work. This might be like mission work in the USA, but man, I sure hope not. Hang in there!

                Comment


                • #23
                  Originally posted by Tangler View Post

                  Yes I am thinking 100% VL, proxygenate as much as possible, small hypnotic (I prefer ketamine or prop with phenylephrine ) large dose of roc, tube quickly with no bag mask ventilation unless essential. Get tube in fast after RSI but prepare Slow and careful with emergency drugs and equipment ready. Some might need norepi infusion started prior etc etc
                  Will also need to be careful to decontaminate after. keep fighting the good fight!
                  How do you dose prop with phenylephrine? Have never used that before

                  Comment


                  • #24
                    Originally posted by Tangler View Post

                    Wow! I was actually wondering about you. I hope you are doing OK. I would imagine this might be an emotional roller coaster for you. I am 1-5 years from being done myself and you are sort of a hero of mine. I think being close to FI has helped me feel good about work and what I do and don't do. Some days I really feel important (doing pediatric cases or cardiac cases,) but other days I feel like I am doing mostly charting and trying to stay alert in an OR.
                    This thing actually scares me badly, but it also makes me feel like I am really doing work that matters. Hang in there POF and be safe!
                    Also, on a financial note: From a newly retired guy, are you OK? Sequence of return risk?
                    Any lessons learned or wisdom for us? (feel free to link to a post)
                    I am planning on staying flexible and shooting for a FAT fire situation with a gradual part time descent into retirement. I imagine you have a little money coming in form the blog / website and that might help but still seems kinda tough for the market to tank on you soon after you stopped clinical work (if I remember right). Anyway, I am not surprised at all that you volunteered to help out if they needed you. I know you have done some mission work. This might be like mission work in the USA, but man, I sure hope not. Hang in there!
                    Regarding the financial side, we'll be fine. We started with a portfolio that could support an initial withdrawal rate of 2% but I'm not yet relying on the portfolio as we do have online income. It doesn't match my old physician income, but it is enough to support our annual spending, even after donating half of those profits. So I'm not thrilled about the bear market, but many people have more legitimate worries than my 7-figure drop in net worth.

                    Yesterday, I granted $1,000 each to the COVID-19 funds of WHO/UN, the CDC, Meals on Wheels, Feeding America, and the Red Cross. If I don't end up back on the front lines, I'll feel like I contributed somehow. I asked my wife to look into local charities that we can also support.

                    Thanks again for the heroic efforts as part of the intubation team. That's some very important work, and I hope it doesn't come to that everywhere.

                    Comment


                    • #25
                      Hats of to you Tangler . Go to war. This virus is akin to World War 3. Some like yourself (& many many others) have to save the planet.
                      $1 saved = >$1 earned. ✓

                      Comment


                      • #26
                        Originally posted by PedsCCM View Post

                        How do you dose prop with phenylephrine? Have never used that before
                        Almost every day, usually Multiple times a day. Almost every time I use prop in an old sick adult I bolus around 1mcg/kg neo with the prop.
                        The phenylephrine Counters the decrease in SVR and bp stays beautiful and coronary perfusion pressure stays up. Great in old adults. I have done this, since around 2003.
                        If you are an old guy with cad etc then a stable bp after a bolus of prop is a nice thing. The reflex Brady is also fine in an old patient, longer diastolic perfusion time.
                        Prop lowers SVR, decreases contractility and lowers bp (mostly by lowering SVR). The phenylephrine counters this loss in svr. I add phenylephrine
                        or a little ephedrine or (if really Sick some epi, or a norepi drip, or some vasopressin, 1-2 units) (call it proplyephrine, joke)
                        This is NOT medical advice. Don’t change your practice based on an anonymous post. Send me a pm and I’ll give you my cell and we can talk if you want but don’t do “new to you” stuff without some careful consideration.
                        Also, be careful with phenylephrine in small kids. Not great in infants, or neonates, they like their fast heart rate. If they have congenital heart disease or are really sick I favor ketamine. but again, be careful out there. With a really sick kid start an epi or dopamine drip, see a response to said drip, then induce, would be my approach. But, again, this is just my opinion.
                        Think of it like this: you know propofol drops SVR, increases venous capacitance and thus lowers preload and it lowers contractility a little, so bp drops. Most wait and treat after bp has dropped. I avoid the drop altogether by adding phenylephrine, or _____( insert vasopressor of choice).
                        Last edited by Tangler; 03-19-2020, 02:58 AM.

                        Comment


                        • #27
                          Originally posted by Tangler View Post

                          Wow! I was actually wondering about you. I hope you are doing OK. I would imagine this might be an emotional roller coaster for you. I am 1-5 years from being done myself and you are sort of a hero of mine. I think being close to FI has helped me feel good about work and what I do and don't do. Some days I really feel important (doing pediatric cases or cardiac cases,) but other days I feel like I am doing mostly charting and trying to stay alert in an OR.
                          This thing actually scares me badly, but it also makes me feel like I am really doing work that matters. Hang in there POF and be safe!
                          Also, on a financial note: From a newly retired guy, are you OK? Sequence of return risk?
                          Any lessons learned or wisdom for us? (feel free to link to a post)
                          I am planning on staying flexible and shooting for a FAT fire situation with a gradual part time descent into retirement. I imagine you have a little money coming in form the blog / website and that might help but still seems kinda tough for the market to tank on you soon after you stopped clinical work (if I remember right). Anyway, I am not surprised at all that you volunteered to help out if they needed you. I know you have done some mission work. This might be like mission work in the USA, but man, I sure hope not. Hang in there!
                          I retired in July. The reason I am not freaking out is I have several years of expenses in MMFs. This drop is exactly why cash is a necessary asset class as you get close to retirement. The carry forward tax losses will allow me to do some "free" Roth conversions. Gotts look for the silver lining!!!!

                          Comment


                          • #28
                            Food for thought, since hypoxia may be severe and refractory to preoxygenation without NPPV, I have been considering pushing sedation/paralytics and immediately placing intubating LMA apparatus and connecting to vent. If you pre-seat an ETT in the intubating LMA with a bronch adapter with side ventilating port on ETT, you could ventilate directly on the vent with closed circuit through side port, get oxygen up, then drive a fiberoptic scope down to secure the ETT. I would only do this with a fiberoptic connected to video screen and not one you have to put your eye on the eye piece.

                            Comment


                            • #29
                              Originally posted by Tangler View Post

                              Almost every day, usually Multiple times a day. Almost every time I use prop in an old sick adult I bolus around 1mcg/kg neo with the prop.
                              The phenylephrine Counters the decrease in SVR and bp stays beautiful and coronary perfusion pressure stays up. Great in old adults. I have done this, since around 2003.
                              If you are an old guy with cad etc then a stable bp after a bolus of prop is a nice thing. The reflex Brady is also fine in an old patient, longer diastolic perfusion time.
                              Prop lowers SVR, decreases contractility and lowers bp (mostly by lowering SVR). The phenylephrine counters this loss in svr. I add phenylephrine
                              or a little ephedrine or (if really Sick some epi, or a norepi drip, or some vasopressin, 1-2 units) (call it proplyephrine, joke)
                              This is NOT medical advice. Don’t change your practice based on an anonymous post. Send me a pm and I’ll give you my cell and we can talk if you want but don’t do “new to you” stuff without some careful consideration.
                              Also, be careful with phenylephrine in small kids. Not great in infants, or neonates, they like their fast heart rate. If they have congenital heart disease or are really sick I favor ketamine. but again, be careful out there. With a really sick kid start an epi or dopamine drip, see a response to said drip, then induce, would be my approach. But, again, this is just my opinion.
                              Think of it like this: you know propofol drops SVR, increases venous capacitance and thus lowers preload and it lowers contractility a little, so bp drops. Most wait and treat after bp has dropped. I avoid the drop altogether by adding phenylephrine, or _____( insert vasopressor of choice).
                              Fascinating. Makes perfect sense. In our PICU we almost always use 1-2mg/kg of ketamine to induce, or 3-5 mcg/kg of fentanyl if we want to avoid the catechol bump. Everyone worries about PIS so we don't use propofol unless we're forced to. Any of my kids who is hemodynamically tenuous already has an epi or NE drip hanging if possible but we use push rescue epi 0.001 mg/kg/mL for acute hemodynamic problems bc as you alluded to, they're dependent on HR for CO. We almost never have to worry about the increase in myocardial oxygen demand because they're kids. Will definitely keep the phenylephrine in my back pocket for those rare dynamic LVOFT obstructions or if God forbid I'm asked to care for older adults. (I found a couple articles describing it so it's not getting medical advice from unknown internet anesthesiologists

                              Thank you for the work you're doing. Saw an article today citing 2600+ healthcare workers in Italy with coronavirus representing 8.2% of all cases at that time... Surely having the best people intubate will help lower this risk!

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