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Posted by: Branos Posted on: 29.04.2020

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The flash player was unable to start. If you have a flash blocker then try unblocking the flash content - it should be visible below. In this episode I speak with Dr. Lower level of PPE. Providers wear N95 masks under a surgical mask with goggles, even if seeing ankle sprains or working at their desk.

In general, when not sure, wait, augment noninvasive therapies, and reassess. Many are reporting much better results using APRV instead of conventional modes of ventilation.

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As the epidemic worsens, your ability to do this diminishes. Pulmonary hypertension seems to play an important role in very ill COVID patients and there is some enthusiasm for using pulmonary vasodilators like inhaled nitric oxide or prostacyclin.

Prothrombosis is one of the many not-yet-understood but repeatedly observed cts of this disease. Many institutions are moving to aggressive anticoagulation practices in COVID patients, based on trending d-dimers. At a minimum, everyone admitted should probably be prophylaxed. Was it PE? Was it diffuse microthrombosis? Was it something else? Was it coincidence?

We have no idea.

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All sorts of chitchat on who should be resuscitated and how. If a patient is already intubated and receiving maximal therapies for COVID, and deteriorates and arrests, it does not seem appropriate to pursue further resuscitation, assuming no immediately reversible cause e. Undifferentiated patients arriving to the ED in cardiac arrest should, in my opinion, be managed like a patient arriving in cardiac arrest in normal times, with one exception: the patient should be assumed to have COVID, and appropriate measures should be taken to protect staff and other patients from aerosols generated during intubation and chest compressions.

See this impossibly well-produced video. Despite the media clickbait frenzy on this topic, to my knowledge there has been no need for any hospital to go on an allocation protocol, but that time may come. You do not want that time to come without a protocol that you have established and vetted.

Here is one protocol. At first, departments try to separate into hot and cold zones, but as the prevalence of COVID increases in the community, most of us have noticed that everyone presenting for any reason has evidence of COVID e. I have nothing to add to the national referendum on PPE other than to say that wearing PPE for the duration of an ED shift is difficult, and I think every ED worker in the city is now wearing a single full PPE getup for their entire shift, regardless of where they are in the department.

For example, is PPE allowed in the breakroom? What will you do with the food that is donated by the community, that your providers will really want to eat? Useful to designate a nonclinical, probably person to manage food and PPE donations. Non-COVID ED visits have dropped off precipitously, no one has any idea where all the strokes, heart attacks, intoxicated and withdrawing patients are. However the fraction of patients requiring admission has skyrocketed; the majority of people who arrive to the ED now require significant oxygen support and admission.

This is perhaps the greatest struggle in the latest stage of the epidemic in NYC: providing intensive care to 10x the number of patients the hospital is set up for. Plan to augment ward staff physicians, nurses, technicians, anyone to keep more eyes on these patients.

Any healthcare provider can do this. It is an awesome demonstration of our shared purpose and the petty illogic of our usual balkanized culture.

Hong kong dating - Men looking for a woman - Women looking for a man. Find a man in my area! Free to join to find a man and meet a man online who is single and hunt for you. How to get a good man. It is not easy for women to find a good man, and to be honest it . Use the links below to access anonymized patient-level data for patients seen in our COVID ICU. This data is ated in near real time. Because New York City has been seriously affected by COVID before most other cities, we have gained experience in managing many of these patients before severe cases have accumulated in other regions. reuben strayer is a member of Vimeo, the home for high quality videos and the people who love them.

People are ready to step up. Utilize them. This data is ated in near real time. Because New York City has been seriously affected by COVID before most other cities, we have gained experience in managing many of these patients before severe cases have accumulated in other regions. First sheet in each patient notebook is a summary; following sheets correspond to subsequent hospital days. Patients who are discharged or deceased are marked as such, unmarked patients are currently admitted.

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More patients are added daily. Credits: Daniel Dove, Ashley R. Patient 1 discharged. Patient 2 discharged. Patient 3 discharged.

Patient 4 discharged.

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Patient 5 deceased. Patient 6 deceased. Patient 7 deceased. Patient 8 discharged. Patient 9 deceased. Patient 10 discharged. Patient 11 discharged.

Aug 09,   After a long break, we are back with a heavy hitter: Dr. Reuben Strayer (@ emates).He is the author of mcauctionservicellc.com, a treasure trove of emergency medicine mcauctionservicellc.comghts include a set of genuinely useful checklists, many airway pearls, an approach to opioid misuse in the ED, and much much more. Dr. Strayer regularly speaks at national and international Missing: dating. In this episode I speak with Dr. Reuben Strayer, emergency physician at Maimonides Medical Center in Brooklyn, NY. The news is rife with reports of New York's escalating COVID cases and there are lessons we can learn from how they are mcauctionservicellc.comg: dating. Reuben Gray is single. He is not dating anyone currently. Reuben had at least 1 relationship in the past. Reuben Gray has not been previously engaged.

Patient Patient 13 deceased. Patient 14 deceased.

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Patient 15 deceased. Patient 16 deceased. Patient 17 deceased. Patient 18 discharged. Patient 20 discharged. Patient 22 deceased.

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Patient 24 deceased. Patient 25 deceased. Patient 26 deceased. We will continue to ate all these patents until disposition. Ventilator Allocation Protocol [google doc].

Below are points of clarification and explanation, most of this is just my opinion. Yes you can use the protocol however you want, you do not need to ask me or provide any attribution.

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Do everything feasible to not have to use an allocation protocol: reduce the burden of disease and increase capacity. Goal is saving the most lives, in accordance with important societal values such as protecting vulnerable populations.

You want to provide ventilator therapy to patients who are most likely to have their life saved by ventilator therapy, and remove ventilator therapy from patients who are unlikely to have their life saved by ventilatory therapy.

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Is that the right approach? But last week, when we were in intubate early mode, we intubated 7 patients in one shift and that is clearly not sustainable.

You need vents, beds, and people trained to provide critical care. As a routine, in normal times we operate near capacity on all three, especially beds. There are of course other critical supplies in addition to ventilators, like PPE, oxygen. The NYSTF calculated that in a severe influenza pandemic, about patients would require ventilators simultaneously, resulting in a shortfall of over 15, ventilators. The ventilator triage committee must know the status of ventilators and critical care availability in the hospital moment to moment.

We receive two reports per day. The triage committee should be identified well before they are needed, and the usual model would be that there is a single triage officer on duty at any given time, and that duty rotates among members of the committee.

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Three steps: 1. Apply exclusion criteria 2. Assess mortality risk 3. For intubated patients, perform protocolized interval reassessments 48h, h, and every subsequent 48h. The original document stipulates that based on the observed characteristics of a particular pandemic, 48 and h may not be an appropriate interval, and the intervals should be adjusted based on what is observed for a specific syndrome, so for example if we find that COVID patients all have high SOFA scores for 10 days and then recover, we should push the intervals out, and if we find that all patients who are doing poorly at 72h end up succumbing to the disease, we should pull the intervals in.

Age was rejected by the NYS task force as discriminatory - age of course indirectly contributes to exclusionary criteria and SOFA scores. The exception is children, based on strong societal preference. The Hopkins protocol does use age or what they call life cycle considerations as a secondary criterion. If you stipulate that being subject to the protocol is dependent on diagnosis, you will change diagnoses. Although all patients needing a ventilator are subject to the allocation protocol, I think an exception should be made for patients who are thought to require intubation temporarily for unrelated reasons, e.

SOFA is used as a proxy for mortality risk. Some experts disagree with this, suggesting that SOFA performs poorly as a mortality predictor in primary lung disease. Much better would be a disease-specific predictor of short-term mortality, which, for COVID, we may soon have.

And what that means is that you have to stratify every patient in the hospital on a vent as blue red yellow green, which in many centers will take a while, before you run out. Should family members be allowed to bag indefinitely? Also, it places a burden on the facility, compromising the care of others. Who takes over when the family has to pee?

Or when they pass out?

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Should we allow teams of family members to be at bedside, bagging, exposing them to all the sick patients on the ward, potentially making patients out of them? These family members will contract the illness and transmit it.

But I can see counter-arguments. See page 70 of the source document. Regional command centers seem crucial, so that resources like beds and ventilators can be shifted from places of surplus to places of shortage, and patients can be transferred to facilities that have capacity.

Withholding or withdrawing a life-sustaining therapy without the consent of patient or proxy is a profound, devastating decision that will severely affect some healthcare workers, and these consequences, along with the possible legal ramifications of these decisions, are partly why it is essential that they are undertaken according to an established protocol, ideally a protocol that is as objective as feasible.

As Dr. Reuben Strayer said in his SMACC talk on the topic: "Opioid misuse explodes in our face on nearly every shift, splattering the entire department with pain and suffering, and addiction and malingering and cursing and threats and hospital security, and miosis and apnea and naloxone and cardiac arrest.".

Should healthcare workers receive priority? There is a whole section on this and the task force decided no, and I agree. Do all technicians, janitorial staff qualify?

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What about a home health aid taking care of someone affected at home? There are actually so many healthcare workers in the community that in a shortage, only healthcare workers would get vents.

Also, the notion that we are more valuable to the community, even in a pandemic, is probably bunk. If all the doctors disappeared during this pandemic, there would be a lot of needless deaths, but it would be a lot worse if all the police officers, or all the sanitation workers disappeared.

Also it seems particularly self-serving to prioritize healthcare workers in a policy designed primarily by healthcare workers, and such a feature of the policy would erode public trust in the policy and in healthcare workers more generally. Emanuel et al take the opposite view in their NEJM essay.

The New York State guideline did not use functional status as an exclusion criterion to avoid judgments around quality of life. I am comfortable with such judgments though, especially when they include an objective criterion, which is why I included the ECOG scale criterion I used ECOG score of 4, some might say it should be 3.

However, these criterial e. There are more explicit criteria listed in the Hopkins documentunder Table 1. If a patient is intubated prior to the discovery of an exclusion criterion, ventilator therapy should be removed as soon as an exclusion criterion is known. It is reasonable to intubate DNR patients in a non-shortage, but not, in my opinion, in a shortage, though this stipulation is also open to challenge and diverges with the NYS guideline. But even if many ultimately require intubation, having an option for delaying intubation if ventilators are scarce is helpful.

This can be delivered using a dedicated device with humidified HFNC capacity. The advantage is that you can titrate FiO2 and flow rate independently. Alternatively, you can use a conventional nasal cannula at the highest rate tolerable to the patient.

Mildly ill with a little dyspnea, fever, malaise, and no hypoxia. Moderately ill with more significant dyspnea and hypoxia. These are first put on nasal cannula O2. Most are admitted, but some improve to the point of being able to go home in a few hours. In the ideal world, you would send them home on home O2.

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Severely ill patients clearly need to be intubated from the outset. He is surprised by how little PPE we have. It is astounding how quickly hospitals are getting to the point of needing to ration PPE to providers. Patient volumes are dramatically down.

They went from having access to no tests, to very limited tests, to plenty.

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When the testing capacity increased, they were testing lots of patients, and virtually all were coming back positive. Now they have reverted back to having limited if any tests. Currently, only people who are sick are tested, and with the high prevalence of COVID in the community, the results are almost always positive and rarely helpful. The question is how much COVID patients will be harmed by sharing a ventilator with another person vs. New York State has developed a ventilator allocation guideline which Strayer simplified and shared on his blog.

The blog also includes a comprehensive intubation checklist. The Ventilation Allocation Protocol has several steps:. This is based on a quantification of short term mortality using the SOFA score. It considers a series of organ systems and uses surrogates for organ dysfunction as a way of determining short term mortality. As you approach a potential scarcity of ventilators, you need to assess and triage the patients currently on ventilators to identify those who might need to be removed from them blue category patients in order to free up a ventilator for a triage category red or yellow patient.

When the number of red priority patients is greater than the number of ventilators available, ventilators are assigned by randomization or lottery. Physician judgement and other clinical factors are not used to further sub prioritize patients. How does Strayer anticipate his future shifts will look like in the next few weeks?

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He brings to Mount Sinai and New York an interest in procedural sedation and clinical decision making which began during his training in Texas and Montreal. Physicians and scientists on the faculty of the Icahn School of Medicine at Mount Sinai often interact with pharmaceutical, device and biotechnology companies to improve patient care, develop new therapies and achieve scientific breakthroughs. In order to promote an ethical and transparent environment for conducting research, providing clinical care and teaching, Mount Sinai requires that salaried faculty inform the School of their relationships with such companies.

Strayer has not yet completed reporting of Industry relationships. Mount Sinai's faculty policies relating to faculty collaboration with industry are posted on our website.



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