COVID/Omicron - What's your treatment protocol now?

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thegenius said:
Why would an SSRI help with a viral infection?
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Because you become depressed when you find out you have COVID.
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Angry Birds said:
Because you become depressed when you find out you have COVID.
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Really? I thought it's a badge of courage "hey look i got covid and i'm still alive it is nothing but a cold". Except for all those *******es dying on a vent I suppose
 
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thegenius said:
Why would an SSRI help with a viral infection?
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That is the million dollar question. Why all this drug repurposing stuff? I could be wrong about this, but I think the root of it is the anti-vaccine movement. There are an enormous number of doctors producing shoddy research, rolling the dice with non-randomized, non-placebo controlled studies that get random, seemingly promising results. Many of these anti-vaccine people want the government and drug companies to focus on therapeutics, so that nobody would tell them that they needed to get vaccinated. The naturopathic type physicians at Home | America's Frontline Doctors and Home - FLCCC | Front Line COVID-19 Critical Care Alliance are putting out a massive amount of disinformation which is heavily influencing crunchy hippy type people, anti-vaccine, and anti-government folks, who bristle at vaccine mandates. For example, Robert Malone is a strange character who is employed by a private company to head up research, hoping to repurpose medications to be used against COVID and other diseases. They use in vitro methodology among other things. This guy, Robert Malone gave an interview on Joe Rogan, where he claimed to be using computer modeling to find drugs that would bind to various parts of a virus to inactivate it. We know that in vitro has no bearing often on clinical medicine. I would imagine that computer modeling would be way worse.

RM: once before I was infected at the end of February because I was attending a MIT conference on drug discovery and artificial intelligence so this is pre-lockdown February 20. but it goes back further than that um there's a CIA agent that I've co-published with in the past named Michael Callahan he was in Wuhan in the fourth quarter of 2019 he called me from Wuhan on January 4th I was currently managing a team that was focusing on drug discovery for organophosphate poisoning ergo nerve agents for DTRA, defense threat reduction agency, involving high-performing computing and biorobot screening um high-end stuff and he told me Robert you got to get your team spun up because we got a problem with this new virus I worked with him through prior outbreaks and so it was then that I turned my attention to this started modeling um a key protein a protease inhibitor of this virus when the sequence was released on January 11th as the Wuhan seafood market virus and I've been pretty much going non-stop ever since. I was self-treating myself after I got infected with agents that we'd identified through the computer modeling.
JR: so February of 2020 you get infected and how bad is your case
RM: bad I thought I was going to die you got to remember I was up up up on all the latest information from china and everywhere else I knew all about this virus I knew you know I I've been watching the videos of people dropping in the street my lungs were burning until I took famotidine and that relieved that
JR: and what is famotidine?
RM: it's otherwise known as pepcid so just to on this tangent since I've said it um I've got some good news to announce um first time here uh today we believe we should have the first patient enrolled in our clinical trials of the combination of monitoring and celecoxib for treatingSARS-CoV-2. This is trials being run by the company lidos which is one of my clients that I've helped design that's based on my discoveries they're funded by a defense threat reduction agency so this is another drug combination now I work with all these folks like Peter and Pierre um that I know you know
JR: Peter Mccullough, Pierre Cory
RM: but I haven't pushed this drug combination I just felt it was inappropriate until we got the trials running but they're now open and we've passed through the FDA screening process by the way we tried to get we had data showing that adding ivermectin further improve the combination but the FDA created such enormous roadblocks to us doing an ivermectin arm that we had to drop it and by we what I'm saying is the FDA created so much grief that the DOD decided it the juice wasn't worth the squeeze and they just dropped that arm
JR: why do you think that is what do you think is going on with the pushback on ivermectin
RM: So it's not just ivermectin, its hydroxychloroquine and just to put a marker on that there are good modeling studies that probably half a million excess deaths have happened in the United States through the intentional blockade of early treatment by the U.S. government that is familiar
JR: half a million
RM: half a million that is a well-documented number okay and it's the combination of hydroxychloroquine and ivermectin now when you ask me why you're asking me to get into somebody's head what I can say as a scientist is what I observe um the behaviors, the actions, the correspondence, these bizarre things like uh you know don't you know it's a horse drug y'all right which is amazingly pejorative I live in virginia okay I can tell you the people around me I live in a rural county and I raise horses um that was deeply offensive um to use that language in that way um but there's clearly been an intentional push and Zeb Zelenko who's a buddy the guy that came out with the original protocol zlanco protocol and was the one by the way that wrote the letter to um to trump advocating for hydroxychloroquine okay kind of important to put that together he's put together a great little video clip in which he clearly documents the conspiracy between Janet Woodcock and Rick Bright to make it so that physicians could not administer hydroxychloroquine outside of the hospital
JR: and who is Janet Woodcock and who's Rick Bright
RM: rick bright was the head of BARDA the biomedical advanced research director which is thegroup that for instance funded the JNJ vaccine and operational warp speed etc so they're thebig-ticket funder in health and human service of biodefense products
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RonWeezy said:
That is the million dollar question. Why all this drug repurposing stuff? I could be wrong about this, but I think the root of it is the anti-vaccine movement. There are an enormous number of doctors producing shoddy research, rolling the dice with non-randomized, non-placebo controlled studies that get random, seemingly promising results. Many of these anti-vaccine people want the government and drug companies to focus on therapeutics, so that nobody would tell them that they needed to get vaccinated. The naturopathic type physicians at Home | America's Frontline Doctors and Home - FLCCC | Front Line COVID-19 Critical Care Alliance are putting out a massive amount of disinformation which is heavily influencing crunchy hippy type people, anti-vaccine, and anti-government folks, who bristle at vaccine mandates. For example, Robert Malone is a strange character who is employed by a private company to head up research, hoping to repurpose medications to be used against COVID and other diseases. They use in vitro methodology among other things. This guy, Robert Malone gave an interview on Joe Rogan, where he claimed to be using computer modeling to find drugs that would bind to various parts of a virus to inactivate it. We know that in vitro has no bearing often on clinical medicine. I would imagine that computer modeling would be way worse.
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What is at the root of drug repurposing, like most things, is money.
 
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RonWeezy said:
That is the million dollar question. Why all this drug repurposing stuff? I could be wrong about this, but I think the root of it is the anti-vaccine movement. There are an enormous number of doctors producing shoddy research, rolling the dice with non-randomized, non-placebo controlled studies that get random, seemingly promising results. Many of these anti-vaccine people want the government and drug companies to focus on therapeutics, so that nobody would tell them that they needed to get vaccinated. The naturopathic type physicians at Home | America's Frontline Doctors and Home - FLCCC | Front Line COVID-19 Critical Care Alliance are putting out a massive amount of disinformation which is heavily influencing crunchy hippy type people, anti-vaccine, and anti-government folks, who bristle at vaccine mandates. For example, Robert Malone is a strange character who is employed by a private company to head up research, hoping to repurpose medications to be used against COVID and other diseases. They use in vitro methodology among other things. This guy, Robert Malone gave an interview on Joe Rogan, where he claimed to be using computer modeling to find drugs that would bind to various parts of a virus to inactivate it. We know that in vitro has no bearing often on clinical medicine. I would imagine that computer modeling would be way worse.
Click to expand...

For the reputable people looking at drug repurposing it’s because it’s lower clearance to wide use because safety trials are largely done.

It’s really hard to do a high quality trial during a pandemic, but there’s no excuse for the crap some people have put out. What I’d like to see is that we learn from this and have some standardized designs ready to go if we’re ever in this situation again, and some reputable centers and researchers/teams designated to do certain studies so it’s not some international free for all with some efforts being duplicated and some important stuff not being done right away.
 
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thegenius said:
Why would an SSRI help with a viral infection?
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Maybe it's an effect on platelet function. We know COVID can cause hypercoagulability. SSRI's can inhibit platelet function (platelets need serotonin to fully function), so maybe they decrease coagulopathy?

NB: The above was brought to you by my imagination.
 
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wholeheartedly said:
For the reputable people looking at drug repurposing it’s because it’s lower clearance to wide use because safety trials are largely done.

It’s really hard to do a high quality trial during a pandemic, but there’s no excuse for the crap some people have put out. What I’d like to see is that we learn from this and have some standardized designs ready to go if we’re ever in this situation again, and some reputable centers and researchers/teams designated to do certain studies so it’s not some international free for all with some efforts being duplicated and some important stuff not being done right away.
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I mean we still have the RECOVERY Trial that has been consistently doing much of the work since 2020. If we stick to that trial and ignore crappy prospective studies elsewhere, that should be more than plenty
 
I think there was a trial on fluvoxamine done in the US that was stopped early for futility. Would be nice if the authors published their data.
 
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Today I got my first patient that was prescribed ivermectin by a legit physician. Like 20 pill of ivermectin a day for 2 weeks, the FLCCC protocol.

Out of morbid curiosity I did check out their website what the cool kids are doing these days

The prevention regimen seems to be ivermetin two times a week (you can substitute black cumin seed), antiseptic mouthwash gargle 2x daily, vitamin cocktail of D3, C, Quercetin, Zinc, Melatonin,

Early treatment protocol seems to bump ivermectin to daily + nitazoxanide, Mouthwash is 3x daily now + iodine nasal spray. Add aspirin 325 to the vitamin cocktail. Second line agents here includes double anti-androgen therapy (spironolactone + dutasteride), fluvoxamine (but you can substite fluoxetine), and MAB goes here too.


For me, it seems to be easier to just get the vaccine then this pretty complicated (and obviously very effective) protocols. There's also a Long Hauler protocol.
 
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pkwraith said:
Today I got my first patient that was prescribed ivermectin by a legit physician. Like 20 pill of ivermectin a day for 2 weeks, the FLCCC protocol.

Out of morbid curiosity I did check out their website what the cool kids are doing these days

The prevention regimen seems to be ivermetin two times a week (you can substitute black cumin seed), antiseptic mouthwash gargle 2x daily, vitamin cocktail of D3, C, Quercetin, Zinc, Melatonin,

Early treatment protocol seems to bump ivermectin to daily + nitazoxanide, Mouthwash is 3x daily now + iodine nasal spray. Add aspirin 325 to the vitamin cocktail. Second line agents here includes double anti-androgen therapy (spironolactone + dutasteride), fluvoxamine (but you can substite fluoxetine), and MAB goes here too.


For me, it seems to be easier to just get the vaccine then this pretty complicated (and obviously very effective) protocols. There's also a Long Hauler protocol.
Click to expand...

FLCCC?
 
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pkwraith said:
Today I got my first patient that was prescribed ivermectin by a legit physician. Like 20 pill of ivermectin a day for 2 weeks, the FLCCC protocol.

Out of morbid curiosity I did check out their website what the cool kids are doing these days

The prevention regimen seems to be ivermetin two times a week (you can substitute black cumin seed), antiseptic mouthwash gargle 2x daily, vitamin cocktail of D3, C, Quercetin, Zinc, Melatonin,

Early treatment protocol seems to bump ivermectin to daily + nitazoxanide, Mouthwash is 3x daily now + iodine nasal spray. Add aspirin 325 to the vitamin cocktail. Second line agents here includes double anti-androgen therapy (spironolactone + dutasteride), fluvoxamine (but you can substite fluoxetine), and MAB goes here too.


For me, it seems to be easier to just get the vaccine then this pretty complicated (and obviously very effective) protocols. There's also a Long Hauler protocol.
Click to expand...
Aspirin is probably doing all the work here...
 
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pkwraith said:
Today I got my first patient that was prescribed ivermectin by a legit physician. Like 20 pill of ivermectin a day for 2 weeks, the FLCCC protocol.

Out of morbid curiosity I did check out their website what the cool kids are doing these days

The prevention regimen seems to be ivermetin two times a week (you can substitute black cumin seed), antiseptic mouthwash gargle 2x daily, vitamin cocktail of D3, C, Quercetin, Zinc, Melatonin,

Early treatment protocol seems to bump ivermectin to daily + nitazoxanide, Mouthwash is 3x daily now + iodine nasal spray. Add aspirin 325 to the vitamin cocktail. Second line agents here includes double anti-androgen therapy (spironolactone + dutasteride), fluvoxamine (but you can substite fluoxetine), and MAB goes here too.


For me, it seems to be easier to just get the vaccine then this pretty complicated (and obviously very effective) protocols. There's also a Long Hauler protocol.
Click to expand...

At first I thought this was a funny joke but now I'm concerned that this is an actual protocol that people are doing
 
RustedFox said:
FLCCC?
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The Front Line Covid-19 Critical Care Alliance, the group that has been suing hospitals to administer ivermectin. Their webpage and all their various "protocols" Home - FLCCC | Front Line COVID-19 Critical Care Alliance

Although I will note that this family medicine doctor who wrote this prescription didn't seem to be following the "FLCCC protocol" she cited. As she wrote for 14 days of ivemerctin overdose instead of the recommended "5 days". I don't think I have ever written for ivermectin and have written for nitazoxanide maybe one time (for HIV cryptosporidium diarrhea). But I have a philosophy. If I am thinking about writing for 12 tablets of ANYTHING as a single dose (let along for 2 weeks), maybe don't write that prescription.
Protip to patients: if your doctor writes you to take 12 tablets of anything, he may be trying to murder you.

Also, the indication on the prescription seems to be "cough", so I'm not sure any pharmacy would actually fill that out.
 
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Found this gem:

"Detainees at an Arkansas jail who had Covid-19 were unknowingly treated by the detention center’s doctor with ivermectin, a drug that health officials have continually said is dangerous and should not be used to treat or prevent a coronavirus infection, according to a federal lawsuit filed by the American Civil Liberties Union on behalf of four detainees."

"The lawsuit says the men “ingested incredibly high doses” of the drug while sick with Covid, causing some to experience diarrhea, bloody stools, stomach cramps and issues with their vision."

"She added that after the American Civil Liberties Union began to raise questions about the practice last year, the jail tried to get inmates to sign forms saying that they retroactively consented to the treatments."

www.nytimes.com

Detainees Sue Arkansas Jail That Gave Them Ivermectin to Treat Covid

For months, the jail’s doctor has promoted the drug, which health experts say should not be used to treat or prevent Covid-19.
www.nytimes.com www.nytimes.com



Warning for those of you prescribing drugs for "off-label" use. Not a bad practice per se . Just better make sure your patients are signing consents specifically stating the medication is off-label, non-fda approved for the condition and you LIST all the side effects. Any bad outcome otherwise and you're on the hook.
 
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pkwraith said:
The Front Line Covid-19 Critical Care Alliance, the group that has been suing hospitals to administer ivermectin. Their webpage and all their various "protocols" Home - FLCCC | Front Line COVID-19 Critical Care Alliance

Although I will note that this family medicine doctor who wrote this prescription didn't seem to be following the "FLCCC protocol" she cited. As she wrote for 14 days of ivemerctin overdose instead of the recommended "5 days". I don't think I have ever written for ivermectin and have written for nitazoxanide maybe one time (for HIV cryptosporidium diarrhea). But I have a philosophy. If I am thinking about writing for 12 tablets of ANYTHING as a single dose (let along for 2 weeks), maybe don't write that prescription.
Protip to patients: if your doctor writes you to take 12 tablets of anything, he may be trying to murder you.

Also, the indication on the prescription seems to be "cough", so I'm not sure any pharmacy would actually fill that out.
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I still always thinks its weird to be taking 5-8 methotrexate pills/week for RA even though I know better.

I've written ivermectin here and there for headlice. Its .4mg/kg, two doses spaced a week apart. That's also the highest dose you see, most parasites are .2mg/kg and almost always as a single dose.

The FLCCC "doctors" are using .6mg/kg every day for 5 days straight. So 50% higher dose and for multiple days in a row. What could go wrong?
 
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Add me to the "CTA every hypoxic covid patient" regardless of the d-dimer. I can't tell you how many PEs I've found. Perhaps it's excessive, but at least our hospitalists are great at accepting the patient prior to the CTA result being back, to which they follow up on results.

With the current medicolegal environment, and without evidence-based "guidelines" on how to clinically rule out PEs in hypoxic COVID patients, I personally think an EP is taking on a ton of risk by not approaching it this way.
 
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Kryptocoin said:
Warning for those of you prescribing drugs for "off-label" use. Not a bad practice per se . Just better make sure your patients are signing consents specifically stating the medication is off-label, non-fda approved for the condition and you LIST all the side effects. Any bad outcome otherwise and you're on the hook.
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A very sizable portion, if not a majority, of medications dispensed every day in the United States are for "off-label" use.

As just one example, gabapentin is only approved for postherpetic neuralgia and as an adjunctive therapy in the treatment of a subset of partial onset seizures. However, I would be shocked if that amounted to even 5% of the amount actually prescribed.

No one is getting specialized consent for "off label" use.

The problem in the linked article was not "off label" use of ivermectin in the jail, it was apparently the lack of any consent at all. Even if the FDA did provide approval for that indication, the underlying problem would remain. He could have slipped acetaminophen in their applesauce and it would have been the same issue.
 
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Vandalia said:
A very sizable portion, if not a majority, of medications dispensed every day in the United States are for "off-label" use.

As just one example, gabapentin is only approved for postherpetic neuralgia and as an adjunctive therapy in the treatment of a subset of partial onset seizures. However, I would be shocked if that amounted to even 5% of the amount actually prescribed.

No one is getting specialized consent for "off label" use.
Click to expand...

I do. I have a small concierge practice and I have a specialized consent forms for off label medications I frequently write for ( just three medications but they are sensitive medications).

Does not matter how many doctors are doing it. If you're prescribing a medication for a non-FDA approved condition and not consenting your patients for it including side effects, you open yourself to liability if there's a bad outcome. It's just good medicine.

.There was a local doctor here in town that was treating patients with off-label peptides. One of them had an MI and the wife sued. "Didn't tell me this can cause MI". Doctor settled.
 
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Kryptocoin said:
I do. I have a small concierge practice and I have a specialized consent forms for off label medications I frequently write for ( just three medications but they are sensitive medications).

Does not matter how many doctors are doing it. If you're prescribing a medication for a non-FDA approved condition and not consenting your patients for it including side effects, you open yourself to liability if there's a bad outcome. It's just good medicine.

.There was a local doctor here in town that was treating patients with off-label peptides. One of them had an MI and the wife sued. "Didn't tell me this can cause MI". Doctor settled.
Click to expand...
You do that for all off-label meds?
 
VA Hopeful Dr said:
You do that for all off-label meds?
Click to expand...

If they have the potential for badness or are sensitive drugs, then yes, I'll have them sign the consent and initial next to each side effect. Low risk medication? Probably just a verbal consent and document it.
 
Kryptocoin said:
If they have the potential for badness or are sensitive drugs, then yes, I'll have them sign the consent and initial next to each side effect. Low risk medication? Probably just a verbal consent and document it.
Click to expand...
I haven't heard of anyone doing this before. Would you mind sharing the meds and indication you do this for?
 
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Kryptocoin said:
I do. I have a small concierge practice and I have a specialized consent forms for off label medications I frequently write for ( just three medications but they are sensitive medications).

Does not matter how many doctors are doing it. If you're prescribing a medication for a non-FDA approved condition and not consenting your patients for it including side effects, you open yourself to liability if there's a bad outcome. It's just good medicine.

.There was a local doctor here in town that was treating patients with off-label peptides. One of them had an MI and the wife sued. "Didn't tell me this can cause MI". Doctor settled.
Click to expand...
Do you (or would you) use propranolol for thyroid storm or hepatic portal hypertension?

Do you use colchicine for pericarditis?

Do you use high dose albuterol for hyperkalemia?

Do you use erythromycin to improve gastric emptying (for example, prior to EGDs)?

Do you infuse albumin at 1.5 mg/Kg within 6 hours of DX and 1 mg/Kg at day 3 for SBP patients with renal failure? (AASLD class 2a, level B recommendation)

Do you use 4 factor PCC (KCentra) for severe bleeding with DOACs?

Do you use TXA for severe post partum bleeding (WOMAN trial), non-neurological major trauma (CRASH-2), neurological trauma (CRASH-3), or based on TEG/ROTEM results?


So you're prepared to discuss the risks of off label uses for these medications... or not use them at all then?

Just because it isn't in the label doesn't mean it also can't be a part of the standard of care.
 
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HemorrhagicShock said:
Add me to the "CTA every hypoxic covid patient" regardless of the d-dimer. I can't tell you how many PEs I've found. Perhaps it's excessive, but at least our hospitalists are great at accepting the patient prior to the CTA result being back, to which they follow up on results.

With the current medicolegal environment, and without evidence-based "guidelines" on how to clinically rule out PEs in hypoxic COVID patients, I personally think an EP is taking on a ton of risk by not approaching it this way.
Click to expand...

The question is who dies or suffers permanent chronic sequelae from untreated thromboembolism in COVID patients?

Maybe the long haulers who have like 6 months of dyspnea actually had PE initially and never got treated.

Interesting concept and idea.

It's literally daft to scan 1/2 the population over a 2 month surge looking for PE when there is at least an equally more likely (and profoundly more likely) explanation for their hypoxia.
 
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Kryptocoin said:
.There was a local doctor here in town that was treating patients with off-label peptides. One of them had an MI and the wife sued. "Didn't tell me this can cause MI". Doctor settled.
Click to expand...

What ever happened to proof beyond a reasonable doubt? Or even just probably so?

Our legal system is f'ed up too.
 
Kryptocoin said:
If they have the potential for badness or are sensitive drugs, then yes, I'll have them sign the consent and initial next to each side effect. Low risk medication? Probably just a verbal consent and document it.
Click to expand...

The question is whether all the extra work properly shields you in a worst case scenario.

"If there is a bad outcome, a lawyer will find blame whether it's there or not."
 
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Kryptocoin said:
I do. I have a small concierge practice and I have a specialized consent forms for off label medications I frequently write for ( just three medications but they are sensitive medications).

Does not matter how many doctors are doing it. If you're prescribing a medication for a non-FDA approved condition and not consenting your patients for it including side effects, you open yourself to liability if there's a bad outcome. It's just good medicine.

.There was a local doctor here in town that was treating patients with off-label peptides. One of them had an MI and the wife sued. "Didn't tell me this can cause MI". Doctor settled.
Click to expand...
There is a very good chance that you are increasing your malpractice risk, not reducing it.
 
Kryptocoin said:
Found this gem:

"Detainees at an Arkansas jail who had Covid-19 were unknowingly treated by the detention center’s doctor with ivermectin, a drug that health officials have continually said is dangerous and should not be used to treat or prevent a coronavirus infection, according to a federal lawsuit filed by the American Civil Liberties Union on behalf of four detainees."

"The lawsuit says the men “ingested incredibly high doses” of the drug while sick with Covid, causing some to experience diarrhea, bloody stools, stomach cramps and issues with their vision."

"She added that after the American Civil Liberties Union began to raise questions about the practice last year, the jail tried to get inmates to sign forms saying that they retroactively consented to the treatments."

www.nytimes.com

Detainees Sue Arkansas Jail That Gave Them Ivermectin to Treat Covid

For months, the jail’s doctor has promoted the drug, which health experts say should not be used to treat or prevent Covid-19.
www.nytimes.com www.nytimes.com



Warning for those of you prescribing drugs for "off-label" use. Not a bad practice per se . Just better make sure your patients are signing consents specifically stating the medication is off-label, non-fda approved for the condition and you LIST all the side effects. Any bad outcome otherwise and you're on the hook.
Click to expand...
That seems like a leap. There's quite a gulf between a common off label use for a civilian who fills the Rx and takes it at home vs surreptitiously giving a rogue med to people who have been stripped of their freedom.

When I give a ventilated patient fentanyl, it's off label and they don't consent. But this story describes shenanigans reminiscent of Tuskegee.
 
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Siggy said:
Do you (or would you) use propranolol for thyroid storm or hepatic portal hypertension?

Do you use colchicine for pericarditis?

Do you use high dose albuterol for hyperkalemia?

Do you use erythromycin to improve gastric emptying (for example, prior to EGDs)?

Do you infuse albumin at 1.5 mg/Kg within 6 hours of DX and 1 mg/Kg at day 3 for SBP patients with renal failure? (AASLD class 2a, level B recommendation)

Do you use 4 factor PCC (KCentra) for severe bleeding with DOACs?

Do you use TXA for severe post partum bleeding (WOMAN trial), non-neurological major trauma (CRASH-2), neurological trauma (CRASH-3), or based on TEG/ROTEM results?


So you're prepared to discuss the risks of off label uses for these medications... or not use them at all then?

Just because it isn't in the label doesn't mean it also can't be a part of the standard of care.
Click to expand...

That's the key phrase. Most of what you listed have already been institutionalized and also under the agency of critical care. Most of critical care is resuscitating and stabilizing. Treat first and ask questions later. No one will fault you for trying to save a life.

Prescribing ivermectin off-label in an outpt setting is not in the same category.
 
thegenius said:
The question is whether all the extra work properly shields you in a worst case scenario.

"If there is a bad outcome, a lawyer will find blame whether it's there or not."
Click to expand...

I'm actually not too worried about lawyers. You know what's scarier? State medical boards. These are typically retired old male doctors, not versed in current literature. Lack of consent , improper consent or poor documentation is their favorite clutch. I took some medmal/risk mgmt CMEs during pandemic last year that were pretty eye-opening.
 
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We are finding lots of PEs on admitted COVID. My practice is adjusting to CTA anyone with ddimer over age adjusted level - which unfortunately is a lot. The hospitalist accepts them with the CTA pending.
 
GonnaBeADoc2222 said:
We are finding lots of PEs on admitted COVID. My practice is adjusting to CTA anyone with ddimer over age adjusted level - which unfortunately is a lot. The hospitalist accepts them with the CTA pending.
Click to expand...

See…I might consider doing this if I could order the CT and just hand it off to the hospitalist, but I still think it’s daft to scan all Covid patients . Frankly hypoxia should be irrevelant. If you have pleuritic chest pain, you should get a CT
 
In Medicine, it's better to be wrong and in the herd, than correct and apart from the herd.

In Medicine, you are punished for thinking and acting outside the box. This is not art, music, entrepreneurship or creative writing, where those things new, risky, edgy and against the grain are prized. If you act outside the accepted norm, you're more likely to be punished, than not. It doesn't matter if you turn out to be right, in the end. You'll be punished in the meantime and without apology. It's even codified into law: "THE. STANDARD. OF. CARE."

What if the standard of care turns out to be wrong and you were right? Nothing, other than you'll be punished for "violating the standard" when it was standard. "Standard of care" in medicine turns out to be wrong, and changes, so often, you could almost consider it being wrong and eventually changing, the norm. You'll never receive and apology letter after the fact saying, "Sorry, all of Medicine was wrong. But you were right. Good job." The last thing you want to be in Medicine is the guy that's right, before everyone else is. The only thing nerds hate more than someone that thinks they're smarter than them, is someone that is smarter and not afraid to show it.
 
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thegenius said:
Regeneron (casirivimab and imdevimab) and Eli Lilly (bamlanivimab) are not effective against Omicron. And right now I'm assuming everybody has Omicron because it's penetrance is like 85-90% last I checked.

There is very little treatment, if any, that I offer. My workflow:

Code: 
if (symptoms sound like COVID) {
   if (SpO2 > 90% RA or if borderline, exertional SpO2 > 90% RA) {
      // there is basically nothing I do for definitive treatment in this group, e.g. no MABs
      // 99 of 100 people in this group get discharged, and the one that doesn't must fight to be admitted

      - reciteShpeel("there is nothing to do.  Hope you don't get sick.  
        You are putting up the good fight.  COVID is at least 10x worse than flu.  
        You are going to do fine.  Don't see Grandma or Grandpa over the next week.  
        No, you can't have ivermectin.");
  
      if (random number between 1-100 is > 3) {
         - reciteShpeel("Please consider getting vaccinated after you recover from this.");
      }

      // however there are special subpopulations that I might do something:
  
      if (vitals are out of whack for routine COVID infection) {
         - they still prob. have COVID, but I consider PE, bacterial PNA, etc.  workup accordingly
      }
      else if (age > 70ish) {
         - I usually send CXR and basic labs, but mostly for show. People can't fathom 
         - going to the doctor and doing nothing.  I still don't treat though.
      }
      else if (super demented or bedbound w/ poor protoplasm) {
         - send basic labs and CXR
         - reciteShpeel("Oh your demented, mute mother is dehydrated!");
         - give 1L LR
         - give ofirmev
      }

      - send COVID Rapig Ag test
      - +/- supportive care meds (Toradol, tylenol, zofran, promethazine, etc).
      - discharge immediately, callback if (+), do not callback if (-).  
   }
   else {
      // here SpO2 < 90%
      // you get admitted
  
      - BMP, Mg, CBC, LFTs, Lactate, BCx x2, Ferritin, C-RP
      - CXR
      - COVID PCR test
      - supportive care meds if needed
      - ADMIT
   }
}
Click to expand...
This might be the greatest post on SDN yet. I'm just sad that 3% of patients don't get the Shpeel on vaccination.
 
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GonnaBeADoc2222 said:
We are finding lots of PEs on admitted COVID. My practice is adjusting to CTA anyone with ddimer over age adjusted level - which unfortunately is a lot. The hospitalist accepts them with the CTA pending.
Click to expand...
I'd be interested to know what the approximate yield on this practice is. I don't think it's necessarily wrong, as long as radiology can accommodate it. Especially if the hospitalist is accepting the patient with the scan pending. (From their perspective, I can see why they would want everyone scanned off the bat. It can be a pita to get people scanned from the floor and it can really help differentiate things if/when the patient decompensates, esp in a situation when you're covering too many patients to be able to reevaluate them frequently.)

Personally, I would say that I scan most ICU level covid patients, as well as admitted patients who have hypoxia out of proportion to their CXR findings or tachycardia out of proportion to their fever or general level of illness. I generally find myself surprised at how few actually seem to have PE.

I'd be even more interested to see how many patients, whom you would otherwise be sending home, have a PE on routine CT scanning.
 
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I would say there is definately confirmation bias with covid-19 and PE. When we looked at our local PE prevalence pattern even in admitted patients, it is magnitude lower than what some of the papers are describing. Routine scanning of all patient in the ED is a complete waste of time.
 
pkwraith said:
I would say there is definately confirmation bias with covid-19 and PE. When we looked at our local PE prevalence pattern even in admitted patients, it is magnitude lower than what some of the papers are describing. Routine scanning of all patient in the ED is a complete waste of time.
Click to expand...
This has been my experience as well. Very few hypoxic covid patients have ended up having PE for me. I generally don't pursue CTA unless they are stepdown level to begin with or clinically worsening on steroids.
 
pkwraith said:
I would say there is definately confirmation bias with covid-19 and PE. When we looked at our local PE prevalence pattern even in admitted patients, it is magnitude lower than what some of the papers are describing. Routine scanning of all patient in the ED is a complete waste of time.
Click to expand...
I am overseeing our PE discharge protocol and pull all PE diagnosis made every 30 days (for both admission and discharge). I also check every CTA PE protocol ordered. Out of my random sampling of the CTA PE orders, the positivity rate is no more with Covid patients than it is with non-Covid patients. I have been checking Covid status (when known) for all charts I've reviewed. The vast majority of Covid patients that are hypoxemic with non-impressive chest x-rays usually have multifocal pneumonia as the cause of their hypoxemia.
 
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southerndoc said:
I am overseeing our PE discharge protocol and pull all PE diagnosis made every 30 days (for both admission and discharge). I also check every CTA PE protocol ordered. Out of my random sampling of the CTA PE orders, the positivity rate is no more with Covid patients than it is with non-Covid patients. I have been checking Covid status (when known) for all charts I've reviewed. The vast majority of Covid patients that are hypoxemic with non-impressive chest x-rays usually have multifocal pneumonia as the cause of their hypoxemia.
Click to expand...
Every bit of the literature reports what you have seen, unless you think they have a PE don’t scan them. +\- COVID
 
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southerndoc said:
I am overseeing our PE discharge protocol and pull all PE diagnosis made every 30 days (for both admission and discharge). I also check every CTA PE protocol ordered. Out of my random sampling of the CTA PE orders, the positivity rate is no more with Covid patients than it is with non-Covid patients. I have been checking Covid status (when known) for all charts I've reviewed. The vast majority of Covid patients that are hypoxemic with non-impressive chest x-rays usually have multifocal pneumonia as the cause of their hypoxemia.
Click to expand...

What percentage of all PE studies ordered result in + PE?
 
Birdstrike said:
In Medicine, it's better to be wrong and in the herd, than correct and apart from the herd.

In Medicine, you are punished for thinking and acting outside the box. This is not art, music, entrepreneurship or creative writing, where those things new, risky, edgy and against the grain are prized. If you act outside the accepted norm, you're more likely to be punished, than not. It doesn't matter if you turn out to be right, in the end. You'll be punished in the meantime and without apology. It's even codified into law: "THE. STANDARD. OF. CARE."

What if the standard of care turns out to be wrong and you were right? Nothing, other than you'll be punished for "violating the standard" when it was standard. "Standard of care" in medicine turns out to be wrong, and changes, so often, you could almost consider it being wrong and eventually changing, the norm. You'll never receive and apology letter after the fact saying, "Sorry, all of Medicine was wrong. But you were right. Good job." The last thing you want to be in Medicine is the guy that's right, before everyone else is. The only thing nerds hate more than someone that thinks they're smarter than them, is someone that is smarter and not afraid to show it.
Click to expand...
I just can’t wrap my mind around fluvoxamine. I think I wouldn’t believe evidence, even if it were presented to me about it. I feel the same way about Ivermectin. At least Hydroxychloroquine had some anti-inflammatory effects that made some physiological sense. I think we sometimes believe certain studies and adopt certain practices because they make us feel more wise than our peers. “I am practicing cutting edge medicine!” But, when we see somebody else practice on the fringe, we think “what in the hell is that wack job doing?”

The mainstream of academic thought is a good place to be. If one were to attempt to base your current practice on only the latest evidence-based medicine, you would zig-zag all over tarnation, chasing random fads.

Having said that, dissonant voices in medicine are critically needed. The story of Semmelweiss is instructive. After witnessing much greater mortality among the patients of physicians as opposed to midwifes, he correctly deduced that the physicians were introducing infectious materials from their autopsies to their laboring patients. After introducing handwashing, he dramatically cut the rate of puerperal fever. He became obsessed with the idea and preached far and wide the practice of hand washing. His fellow physicians refused to believe him. This frustrated him so much that he became quite adamant, leading to him being placed in an insane asylum. He was beaten into submission and died a few days later. Ironically, he died of infected wounds. Perhaps genius and schizophrenia aren’t all that far apart. When a person believes things that nobody else does, despite being told they are wrong, we call them delusional. If they are proven right, we call them geniuses. Only a small percentage of the population has the desire or ability to investigate the difference.

As a direct result of political polarization, increasing numbers of physicians view themselves as geniuses, smarter than governmental regulatory bodies. There is a fracturing of our medical practices that I can’t remember seeing 20 years ago when I was in medical school. I see a disturbing trend today, of certain groups of physicians and medical workers refusing to trust governmental regulatory bodies and institutions. They trust isolated small studies that amount to no more than large amounts of anecdotal information more than a body of wise, well-chosen professionals who have the larger picture in mind. (Obviously, contributing to this process is the increasing tendency of our Universities to produce large amounts of absolute garbage.) Look at the average Emergency Medicine academic magazine. More than 90% utter nonsense is being published by our Emergency Medicine residency programs. Trust in organizations like the CDC is waning as their decisions, because of their inherently political nature, sometimes aren't rational to an outside observer.

We need to embrace both the crazy Semmelweiss’s of medicine, as well as the ponderous old bureaucracies that keep medicine on an even keel. Both are needed. But both are increasingly acting more and more antagonistic towards each other.
 
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I think the following articles shed light on the increasing distrust that the public and professionals have in our public institutions:

Why most published research findings are false - PubMed
There is increasing concern that most current published research findings are false. The probability that a research claim is true may depend on study power and bias, the number of other studies on the same question, and, importantly, the ratio of true to no relationships among the relationships probed in each scientific field. In this framework, a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance. Simulations show that for most study designs and settings, it is more likely for a research claim to be false than true. Moreover, for many current scientific fields, claimed research findings may often be simply accurate measures of the prevailing bias. In this essay, I discuss the implications of these problems for the conduct and interpretation of research.

Amazon product
Charles J. Sykes points out the fact that the vast majority of professors contribute little to nothing to the overall body of scientific knowledge. Because there is such an emphasis on publication, professors tend to churn out large volumes of research papers with very little original or useful information. He describes a “tidal wave of unread, unreadable junk scholarship that fills library shelves but adds little to the sum of human knowledge." Ninety percent of studies are never cited by any other author, proving their irrelevance to the overall body of knowledge.

It's Surprisingly Easy to Get a Fake Study Published in an Academic Journal
There are many investigators who have deliberately submitted overtly silly and nonsensical articles and gotten them published. In 2013, for example, John Bohannon submitted an academic study to 304 peer-reviewed journals and 157 of the journals accepted it. Despite the fact that he was just a journalist and that he made ludicrous claims of being able to cure cancer with a molecule extracted from a lichen, the majority of reviewers fell for his ruse.

What an Audacious Hoax Reveals About Academia
A group of three left leaning academics, Helen Pluckrose, James A. Lindsay and Peter Boghossian, became concerned about the lack of scientific rigor in many academic journals. They went about intentionally writing obscenely stupid academic papers and submitting them to journals. To their simultaneous amusement and horror, only 6 out of 20 papers were rejected.

Feminist Journal Accepted Hoax Anti-Male Re-Write of 'Mein Kampf' | Breitbart
Among many other strangely reasoned articles, they copied a large passage of Mien Kampf, and substituted the vocabulary to argue for “intersectional feminism.” The paper was accepted into one of the most prestigious feminist journals despite its encouragement for government to abandon freedom for its citizens.

From dog rape to white men in chains: We fooled the biased academic left with fake studies

It’s difficult to know whether the correct response here is to laugh or cry. Either way, we believe we’ve uncovered evidence that points to a significant cultural problem that starts with scholarship and extends far beyond the academy. This is because what’s taking place within certain university disciplines is a kind of idea laundering. Under these circumstances, aggrieved academics can put broken, biased, and even openly racist and sexist ideas through the peer-review process, and have them come out the other side legitimized as though they are established knowledge…

So far, this process has been going on within certain politicized corners of the university without adequate checks and balances for decades. As a result, many of these broken and hurtful ideas have seeped out of the university and become part of our everyday lives.

How and why elite colleges should pass the buck on social justice

Truth vs. Social Justice
 
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southerndoc said:
I randomly sample patients, so not statistically significant. Somewhere around 10% with a positive D-dimer and less than that without.
Click to expand...

One time at work I was killing time with nothing to do…and I pulled up the last 50 CT PE studies ordered by ER physicians. Knew nothing about the cases, whether a ddimer was even run, it’s result, etc. 49 / 50 were negative.
 
thegenius said:
One time at work I was killing time with nothing to do…and I pulled up the last 50 CT PE studies ordered by ER physicians. Knew nothing about the cases, whether a ddimer was even run, it’s result, etc. 49 / 50 were negative.
Click to expand...
I think without a d-dimer it's like 5% are positive. I'll have to look at the numbers.
 
southerndoc said:
I think without a d-dimer it's like 5% are positive. I'll have to look at the numbers.
Click to expand...

I was surprised at how low our PE percentage was when I looked into it. Problem is most of the thoracic imaging we do is often just protocoled for PE (whether it’s needed or not) “just so we can rule it out” and make the hospitalists happier.

Most of the time if we scan the chest, we protocol it for PE. In my opinion it’s sloppy, bad medicine
 
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