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

[Apollyon]

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

Had an old lady who broke her hip. Gave 1 of Dilaudid. Sat dips for a moment to 91. 2L NC takes care of it. Admitting med (family med, in this case) sends her from the floor for CT. Bilat PE, with saddle.

No SOB for me, no complaint of CP or dyspnea, nothing. Just a really painful broken hip! (Of course, the admitting doc sent it to peer review.)

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[bravotwozero]

Had an old lady who broke her hip. Gave 1 of Dilaudid. Sat dips for a moment to 91. 2L NC takes care of it. Admitting med (family med, in this case) sends her from the floor for CT. Bilat PE, with saddle.

No SOB for me, no complaint of CP or dyspnea, nothing. Just a really painful broken hip! (Of course, the admitting doc sent it to peer review.)

I’ve been shocked by the number of saddle PEs ive seen that have normal/near normal vitals.

 

[Siggy]

(Of course, the admitting doc sent it to peer review.)

I honestly don't get this. On one hand, I've seen plenty of BS things that should have gone to peer review (I honestly don't understand how a hematologist doesn't see low platelets, anemia, schistocytes and doesn't think TTP... especially after they gave platelets and everything got significantly worse). However peer review always seems like mutually assured destruction where the only winning move is not to play.

At the same time it's really easy to take pot shots at EM as EM doesn't really have the ammo to fire back... where as all of the bad calls end up finding their way to the unit.

 

[southerndoc]

I’ve been shocked by the number of saddle PEs ive seen that have normal/near normal vitals.

14 of the 46 PE's we diagnosed and admitted last quarter were either saddle PE's or bilateral main pulmonary artery PE's. That's 30% of all PE's that were admitted. A large number of these had near-normal vitals (not terribly tachy, hypotensive, etc.). Two had sPESI's of 0!

 

[thegenius]

Had an old lady who broke her hip. Gave 1 of Dilaudid. Sat dips for a moment to 91. 2L NC takes care of it. Admitting med (family med, in this case) sends her from the floor for CT. Bilat PE, with saddle.

No SOB for me, no complaint of CP or dyspnea, nothing. Just a really painful broken hip! (Of course, the admitting doc sent it to peer review.)

So the dilaudid caused her to have a PE?
😂

 

[thegenius]

14 of the 46 PE's we diagnosed and admitted last quarter were either saddle PE's or bilateral main pulmonary artery PE's. That's 30% of all PE's that were admitted. A large number of these had near-normal vitals (not terribly tachy, hypotensive, etc.). Two had sPESI's of 0!

Theoretical question: if someone has normal hemodynamics, low risk Wells and 8/8 PERC indicating no need to further workup PE, and a calculated PESI of 0 if they had a PE, why does it matter if they have a saddle or not? I may not even order a PE study depending on how they look. Especially if they have no respiratory distress.

We probably have all sent home undiagnosed saddles in our lifetime and the patient did fine (I think)

 

[AlmostAnMD]

My hot take:

If it's missed and it's a big left and right main it's only a matter of time until it coagulates further into a massive life ending PE

I cannot prove what I just said with science, I just feel like small PE's in periphery might infarct/disappear but it seems like a near saddle probably wouldn't?

 

[Rekt]

My hot take:

If it's missed and it's a big left and right main it's only a matter of time until it coagulates further into a massive life ending PE

I cannot prove what I just said with science, I just feel like small PE's in periphery might infarct/disappear but it seems like a near saddle probably wouldn't?

Agree. Or the rest of the clot from the leg or elsewhere embolizes and propagates the burden. Or we help prevent pulmonary hypertension from a saddle breaking up into a bunch of clots and hanging around too long.

 

[Birdstrike]

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.

You make some excellent points. The problem is, the "ponderous old bureaucracies" are almost always the ones that persecute the "crazy Semmelweiss's" for no better reason than they're a threat to their power. So much so, that this many years later we're still calling him "crazy" Semmelweiss, when in fact he was much smarter than the "ponderous old bureaucracies" who are the ones we should be calling crazy.

Why aren't we calling the old bureaucracy "crazy" and stupid? After all, they're the ones whose actions resulted in the killing of laboring mothers by infecting them, all because the alternative ideas were a threat to their power and image.

 

[WorkNoteEmergency]

I generally CT Covid patients, as another poster mentioned, who have hypoxia out of proportion to CXR findings or other classic findings that would make me consider PE. Besides the cost and normal burden of getting a CT scan, in a small shop with one scanner, a Covid pneumonia patient is going to shut the scanner down for a prolonged time while it gets disinfected.

If the patient is hemodynamically stable and just hypoxia, unlikely they would get an intervention like EKOS anyway, so you can just anticoagulate

 

[Birdstrike]

CDC: Natural immunity stronger than vaccines alone during delta wave​

 

[thegenius]

CDC: Natural immunity stronger than vaccines alone during delta wave​

I'm sorry I can't read that small, unbolded font. Can you make it much larger for all of us to read?

 

[Siggy]

CDC: Natural immunity stronger than vaccines alone during delta wave​

I fail to see the point… as I’ll point out again that the side effects of obtaining natural immunity are significantly worse than the side effects of the vaccine.


“Initial infection among unvaccinated persons increases risk for serious illness, hospitalization, long-term sequelae, and death; by November 30, 2021, approximately 130,781 residents of California and New York had died from COVID-19. Thus, vaccination remains the safest and primary strategy to prevent SARS-CoV-2 infections, associated complications, and onward transmission.”

From the actual study….

 

[deleted1114045]

I fail to see the point… as I’ll point out again that the side effects of obtaining natural immunity are significantly worse than the side effects of the vaccine.

That vaccine mandates for people who have documented previous infection are pointless?

 

[Birdstrike]

I fail to see the point…

The point is, that the people who said "vaccine based immunity is better than naturally acquired immunity" were wrong. That was unquestionable dogma early in this pandemic. But it made no sense, came out of nowhere and was pushed so strongly, it was bizarre. Historically, naturally acquired immunity has always been better than vaccine induced and was always accepted as such. It never made sense that immunity from one part of a virus (spike protein) was superior to immunity from that part of the virus and every other part of the virus. I think the super aggressive approach on everything covid related, shares a lot of the blame for the backlash against vaccination, masking and other mitigation strategies.

The point is not to say that if you've had previous infection, you shouldn't consider vaccination. That series also shows that hybrid immunity (tax + natural) is the best of all.

 

[Birdstrike]

I'm sorry I can't read that small, unbolded font. Can you make it much larger for all of us to read?

Yes, I'm cooking up some super explosive large/bold font in my lab, right now. But it won't be ready for a while. So, be patient. No, but seriously. The weird font came from the fact that I copied and pasted the headline from the article so it took the font with it. My bad. Didn't mean to insult the visually challenged (Lol!)

 

[maxxor]

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

What would your preference be? No contrast? If you are giving contrast, might as well get it protocoled as a CT PE. It's only *slightly* more expensive than a CT with contrast as it's technically a CTA.

 

[thegenius]

What would your preference be? No contrast? If you are giving contrast, might as well get it protocoled as a CT PE. It's only *slightly* more expensive than a CT with contrast as it's technically a CTA.

There really isn't a reason to give contrast on Chest CT's unless it's trauma, PE or dissection.
Usually the decision is "we are going to CT for some reason so give contrast to r/o PE while you are at it".

 

[WildEMDoc]

One of my previous sites had ?arbitrary? (never seen it in the literature, doesn't mean it doesn't exist) cut offs. D-Dimer every COVID pt we admit. We scanned who we needed to but otherwise it was this.

<1000 = PPX
1000-2500 = Treatment dose lovenox/hep and dc on oral anticoag on discharge from hospital
2500< = CT PE

Not sure any of that was based on anything good, but didn't seem like we were missing anything significant at least.

 

[Angry Birds]

That vaccine mandates for people who have documented previous infection are pointless?

1. Are they actually pointless though? That's a strong claim. In order to prove that ("pointless"), you would need to compare the immunity between someone who (a) had COVID and is also vaccinated with (b) someone who only had COVID.

2. If you are implementing a policy across the board, how do you ensure that someone indeed had COVID? You could certainly mandate that they show a positive test result or antibodies... but we certainly can't take the word of those people who are anti-vaxx given that they in general are unreliable and untrustworthy...

3. Are we "rewarding" people who go out and get COVID?

4. The point is to maximize your chance of a good immune response so that you don't take up a hospital bed. In that sense, being vaccinated makes sense, even if you already had COVID.

 

[Angry Birds]

The point is, that the people who said "vaccine based immunity is better than naturally acquired immunity" were wrong. That was unquestionable dogma early in this pandemic. But it made no sense, came out of nowhere and was pushed so strongly, it was bizarre. Historically, naturally acquired immunity has always been better than vaccine induced and was always accepted as such. It never made sense that immunity from one part of a virus (spike protein) was superior to immunity from that part of the virus and every other part of the virus. I think the super aggressive approach on everything covid related, shares a lot of the blame for the backlash against vaccination, masking and other mitigation strategies.

The point is not to say that if you've had previous infection, you shouldn't consider vaccination. That series also shows that hybrid immunity (tax + natural) is the best of all.

If we're speaking about "dogma early in this pandemic," weren't you part of the crew here that was saying that COVID is just like the flu?

You say that "a lot of the blame for the backlash against vaccination, masking and other mitigation strategies" is on those who spread such "dogma." What about the anti-science perspective being pushed by one political party and its leaders, including their don, etc.? How about the conspiracy theories and the politicization of public health measures? Nothing to do with that, right?

 

[deleted1114045]

1. Are they actually pointless though? That's a strong claim. In order to prove that ("pointless"), you would need to compare the immunity between someone who (a) had COVID and is also vaccinated with (b) someone who only had COVID.

2. If you are implementing a policy across the board, how do you ensure that someone indeed had COVID? You could certainly mandate that they show a positive test result or antibodies... but we certainly can't take the word of those people who are anti-vaxx given that they in general are unreliable and untrustworthy...

3. Are we "rewarding" people who go out and get COVID?

4. The point is to maximize your chance of a good immune response so that you don't take up a hospital bed. In that sense, being vaccinated makes sense, even if you already had COVID.

1. At this point, numerous countries and states have given up on vaccine mandates, masking requirements, and authoritarian attempts to quarantine COVID patients. Anybody who hasn't got a vaccine yet is never going to. Never. You can't reason with them. Omicron is literally ubiquitous. Several people in my household had symptoms and my son tested positive in the past 2 weeks. The case numbers are being vastly undercounted. I don't know a single household in the past 3 weeks that hasn't had COVID. Are we really, with a straight face, going to tell people that we are going to fire them if they don't get vaccinated when they have had positive, documented COVID infection? I just had a patient who has got COVID three different times! I know a family whose mom decided to not get vaccinated and nearly died. Three months later, she got COVID again. She was much less symptomatic the second time. How does it make sense, from an employer or from a governmental standpoint to try to force people in this situation to get vaccinated? Certainly not in the 6-12 months after being infected. We have no reliable long term data (over 12 months) on the duration of immunity after infection from delta. We are in the midst of the omicron wave. These waves only last 8 months or so, and then, we are on to the next global variant, with unique infectiousness and unique case fatality rates. Any policy action is not going to be based on reliable, actionable, definitive data in the midst of such variable situation. How can we, with a straight face, insist that people have to get a vaccine that is designed for a variant of the virus that is 1.5 years old? Look at the monoclonal antibody situation... the virus is changing too fast for them to be effective. The vaccines have proved utterly futile at stopping the spread of infection. It is airborne. It is unstoppable. It is now a lot less severe. Why insist on the use of old, outdated vaccines?

2. It is rational to have a yearly documented COVID test or proof of antibodies to COVID from a reputable lab count en lieu of a vaccine requirement. As for the unreliable comment, that is just stoking the irrational hatred of the different vaccine religions... That is the attitude that leads to civil war and civil disobedience. Very counter-productive.

3. We certainly shouldn't reward people who are vaccinated. All that nonsense a few months ago, that the unvaccinated could walk around without masks and congregate was complete BS! I'm vaccinated, all my kids are. I have been a great advocate for vaccines. I was a staunch pro-vaccine religionist this last summer, dueling it out with anti-vaxxer friends and family during the delta wave. I had numerous fights with friends and family on social media and through phone conversations and text messages. Do you know how many people I convinced to get vaccinated? One. He only believed me because he reached out to me first, asking me my opinion. Do you know how many relationships I've destroyed over the vaccine question? Several. Not worth it anymore, especially over omicron.

4. Good point. How soon after Omicron should people get vaccinated? what does the data say? Not there. Can't be. We are in the midst of Omicron, so, by definition, there is no data on natural immunity specific to omicron.

 

[GassYous]

It is now a lot less severe but your friend's mom almost died
uh ok

 

[Angry Birds]

1. At this point, numerous countries and states have given up on vaccine mandates, masking requirements, and authoritarian attempts to quarantine COVID patients. Anybody who hasn't got a vaccine yet is never going to. Never. You can't reason with them. Omicron is literally ubiquitous. Several people in my household had symptoms and my son tested positive in the past 2 weeks. The case numbers are being vastly undercounted. I don't know a single household in the past 3 weeks that hasn't had COVID. Are we really, with a straight face, going to tell people that we are going to fire them if they don't get vaccinated when they have had positive, documented COVID infection? I just had a patient who has got COVID three different times! I know a family whose mom decided to not get vaccinated and nearly died. Three months later, she got COVID again. She was much less symptomatic the second time. How does it make sense, from an employer or from a governmental standpoint to try to force people in this situation to get vaccinated? Certainly not in the 6-12 months after being infected. We have no reliable long term data (over 12 months) on the duration of immunity after infection from delta. We are in the midst of the omicron wave. These waves only last 8 months or so, and then, we are on to the next global variant, with unique infectiousness and unique case fatality rates. Any policy action is not going to be based on reliable, actionable, definitive data in the midst of such variable situation. How can we, with a straight face, insist that people have to get a vaccine that is designed for a variant of the virus that is 1.5 years old? Look at the monoclonal antibody situation... the virus is changing too fast for them to be effective. The vaccines have proved utterly futile at stopping the spread of infection. It is airborne. It is unstoppable. It is now a lot less severe. Why insist on the use of old, outdated vaccines?

2. It is rational to have a yearly documented COVID test or proof of antibodies to COVID from a reputable lab count en lieu of a vaccine requirement. As for the unreliable comment, that is just stoking the irrational hatred of the different vaccine religions... That is the attitude that leads to civil war and civil disobedience. Very counter-productive.

3. We certainly shouldn't reward people who are vaccinated. All that nonsense a few months ago, that the unvaccinated could walk around without masks and congregate was complete BS! I'm vaccinated, all my kids are. I have been a great advocate for vaccines. I was a staunch pro-vaccine religionist this last summer, dueling it out with anti-vaxxer friends and family during the delta wave. I had numerous fights with friends and family on social media and through phone conversations and text messages. Do you know how many people I convinced to get vaccinated? One. He only believed me because he reached out to me first, asking me my opinion. Do you know how many relationships I've destroyed over the vaccine question? Several. Not worth it anymore, especially over omicron.

4. Good point. How soon after Omicron should people get vaccinated? what does the data say? Not there. Can't be. We are in the midst of Omicron, so, by definition, there is no data on natural immunity specific to omicron.

I'm OK with reassessing strategy going forward. What I am protesting, however, is the reverse blame game going on, whereby the blame for the "civil war and civil disobedience" is foisted on one side whereas the actual "civil war and civil disobedience" rhetoric is coming from the other, including its leaders.

As for your discussions with anti-vaxxers, I am not surprised. However, the only way to deal with them is by having indirect penalties for their non-compliance, i.e. no-fly without vaccination, employer mandates, etc. But alas, one side opposes that due to the insane politicization of this issue.

Finally, I don't see anything changing the fact that the sick patients we are seeing are the unvaccinated, which again, reinforces the point that vaccination was indeed an important prong to the overall strategy... even if I agree that perhaps the focus needs to be expanded beyond that and towards a more multi-pronged approach.

 

[deleted1114045]

It is now a lot less severe but your friend's mom almost died
uh ok

Yes, delta was a much more severe variant. My hospital doesn’t have a single intubated COVID patient right now. Omicron is much less severe.

 

[deleted1114045]

I'm OK with reassessing strategy going forward. What I am protesting, however, is the reverse blame game going on, whereby the blame for the "civil war and civil disobedience" is foisted on one side whereas the actual "civil war and civil disobedience" rhetoric is coming from the other, including its leaders.

As for your discussions with anti-vaxxers, I am not surprised. However, the only way to deal with them is by having indirect penalties for their non-compliance, i.e. no-fly without vaccination, employer mandates, etc. But alas, one side opposes that due to the insane politicization of this issue.

Finally, I don't see anything changing the fact that the sick patients we are seeing are the unvaccinated, which again, reinforces the point that vaccination was indeed an important prong to the overall strategy... even if I agree that perhaps the focus needs to be expanded beyond that and towards a more multi-pronged approach.

Both sides have shown egregious idiocy and criminally bad leadership. We are in a really bad place. We can't even have a conversation about the medical treatment of a disease without inserting politics unnecessarily. The mods on the forum constantly plead with us to tone down the rhetoric. Still, those whose religion is their political party can't help but inject politics into unrelated topics, deifying their political leaders and demonizing the opposition. In 1994 and 2017, the Pew Research Center polled America. In 1994, most people prided themselves on being moderates, and there was much in common in the rhetoric of the two political parties. This research showed that people were becoming politically and ethnically polarized. A poll conducted by the Public Religion Research Institute revealed some disturbing trends in American society in 2019:

Nearly half of all Democrats (45 percent) and more than a third of Republicans (35 percent) say they would be unhappy if their child married someone from the opposite political party. A stark gap has emerged on this question over time: in 1960 only four percent of Democrats or Republicans said they would be displeased if their son or daughter married someone of the opposite party. Americans Deeply Divided by Party on Ideals of Religious and Ethnic Pluralism - PRRI

They were not the only researchers to witness these disturbing trends. 42% of people in each political party viewed the opposition as “downright evil.” Around 20% of people believed that the opposing party “lack the traits to be considered fully human — they behave like animals.” Thomas B. Edsall, from “The New York Times” wrote:

Some 20 percent of Democrats (that translates to 12.6 million voters) and 16 percent of Republicans (or 7.9 million voters) do think on occasion that the country would be better off if large numbers of the opposition died. Opinion | No Hate Left Behind (Published 2019)

We’re not finished: “What if the opposing party wins the 2020 presidential election. How much do you feel violence would be justified then?” 18.3 percent of Democrats and 13.8 percent of Republicans said violence would be justified on a scale ranging from “a little” to “a lot.”

The answer is to forgive the opposing political party and do your best to reform your own. We need to de-escalate. Why? Because these problems have been worsened ten fold by the pandemic. Epidemics divide us. History tells us epidemics are followed by huge civil unrest for these three reasons

Academics have warned that the level of social unrest around the world may spike once the COVID-19 pandemic is over, for three reasons.

"To different degrees, most of the great epidemics of the past appear to have been incubators of social unrest," Massimo Morelli, professor of political science at Bocconi University, and Roberto Censolo, associate professor in the department of economics and management at Italy's University of Ferrara, wrote in the journal Peace Economics, Peace Science and Public Policy.

The pair reviewed evidence on protests and unrest around the time of 57 epidemics between the Black Death in the 1300s and the Spanish Flu pandemic of 1918, finding only four occasions where revolts were not clearly connected with the respective outbreaks.

 

[Dr Mantis Toboggan]

Yes, delta was a much more severe variant. My hospital doesn’t have a single intubated COVID patient right now. Omicron is much less severe.

The old/unhealthy and unvacc’d patients I’m seeing now look exactly the same as they did in summer/fall.

I’d swear by now everyone in those categories around here would’ve gotten it by now or gotten vaccinated but nope, every shift they keep coming and coming…

 

[Angry Birds]

Both sides have shown egregious idiocy and criminally bad leadership. We are in a really bad place. We can't even have a conversation about the medical treatment of a disease without inserting politics unnecessarily. The mods on the forum constantly plead with us to tone down the rhetoric. Still, those whose religion is their political party can't help but inject politics into unrelated topics, deifying their political leaders and demonizing the opposition. In 1994 and 2017, the Pew Research Center polled America. In 1994, most people prided themselves on being moderates, and there was much in common in the rhetoric of the two political parties. This research showed that people were becoming politically and ethnically polarized. A poll conducted by the Public Religion Research Institute revealed some disturbing trends in American society in 2019:

Nearly half of all Democrats (45 percent) and more than a third of Republicans (35 percent) say they would be unhappy if their child married someone from the opposite political party. A stark gap has emerged on this question over time: in 1960 only four percent of Democrats or Republicans said they would be displeased if their son or daughter married someone of the opposite party. Americans Deeply Divided by Party on Ideals of Religious and Ethnic Pluralism - PRRI



Some 20 percent of Democrats (that translates to 12.6 million voters) and 16 percent of Republicans (or 7.9 million voters) do think on occasion that the country would be better off if large numbers of the opposition died. Opinion | No Hate Left Behind (Published 2019)



The answer is to forgive the opposing political party and do your best to reform your own. We need to de-escalate. Why? Because these problems have been worsened ten fold by the pandemic. Epidemics divide us. History tells us epidemics are followed by huge civil unrest for these three reasons

I'm going to let your post be the last one on this so it doesn't just keep going tit-for-tat, but I'll just say: I am not really a Democrat (although I very grudgingly registered as one just in the last election) nor do I see political moderation as a virtue, although I agree that medical and health issues be taken out of the political arena.