2021 all over again

[Nephro critical care]

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I had a 95 year old with COVID. Unvaccinated and never had COVID before. Extremely sick with CT looking like COVID. Daughter did not want her to get vaccinated. Doesn’t want RDV because of risk of AKI. OK with toci. Full code but intubation only last resort. I was having a deja vu moment.

I am sure tomorrow she will ask for Ivermectin.

 

[SurfingDoctor]

I had a 95 year old with COVID. Unvaccinated and never had COVID before. Extremely sick with CT looking like COVID. Daughter did not want her to get vaccinated. Doesn’t want RDV because of risk of AKI. OK with toci. Full code but intubation only last resort. I was having a deja vu moment.

I am sure tomorrow she will ask for Ivermectin.

Tell her it only works rectally and has to be inserted by next of kin.

 

[sylvanthus]

I had a 95 year old with COVID. Unvaccinated and never had COVID before. Extremely sick with CT looking like COVID. Daughter did not want her to get vaccinated. Doesn’t want RDV because of risk of AKI. OK with toci. Full code but intubation only last resort. I was having a deja vu moment.

I am sure tomorrow she will ask for Ivermectin.

We just got an 85 yo unvaccinated covid, hard DNR/DNI at least.

 

[Nephro critical care]

I don’t they where these people read this up but the demographics and the beliefs are very similar. White people. Militantly anti vaccine , strong belief that Remdesivir is bad because of AKI, Ok with steroids and toci. Intubation is last resort but totally impervious to goals of care discussions. Want all medications cleared by them.

 

[SurfingDoctor]

I don’t they where these people read this up but the demographics and the beliefs are very similar. White people. Militantly anti vaccine , strong belief that Remdesivir is bad because of AKI, Ok with steroids and toci. Intubation is last resort but totally impervious to goals of care discussions. Want all medications cleared by them.

Well, COVID doesn’t care about their beliefs so oh well.

 

[chessknt]

I don’t they where these people read this up but the demographics and the beliefs are very similar. White people. Militantly anti vaccine , strong belief that Remdesivir is bad because of AKI, Ok with steroids and toci. Intubation is last resort but totally impervious to goals of care discussions. Want all medications cleared by them.

Nah. Tell them if there are specific medications disallowed due to the patients faith then they need to provide that list otherwise you'll be using all other medications you would normally use for someone who wants every measure taken except for any EUA meds or where there is uncertain risk:benefit ratio. They are free to review the medications on a daily basis with the medical records department on their own time and can bring up concerns if there are any when they get updated. If they disagree then you inform them that they can request a transfer of care to another hospital at their personal expense because it is inappropriate for them to be involved to that degree. You have to lay down boundaries with people like this because they will push to micromanage something they don't know **** about, giving in to them is always the wrong move.

There was a lady who didn't want us to give heparin because she was worried it would cause blood clots because her mother died of a covid blood clot and she was on heparin. I told her that was inappropriate and I wouldn't be following that request.

 

[Hernandez]

Want all medications cleared by them.

Most time I get by just fine with hard no's. The last family I had like that was refusing blood for hgb 3.5, refusing glucose for sugars of 60, refused to place lines then refuse to pull them, didn't want us to wake pt up to liberate because it was uncomfortable. They called the CEO and then a senator on my not capitulating on basically everything.

 

[FutureInternist]

When someone like me is being given emergency privileges (again), you know its bad 🤦‍♂️.

I have been braver (stupider) about telling off families about their idiocy regarding vaccines, remdesivir, ivermectin etc…. And have been turning off the TV whenever I come in (cos its almost always on one particular channel) and telling them, THIS is why you are here.

Lets see how long before I get in trouble. 🤞

 

[BicepsTriceps]

Most time I get by just fine with hard no's. The last family I had like that was refusing blood for hgb 3.5, refusing glucose for sugars of 60, refused to place lines then refuse to pull them, didn't want us to wake pt up to liberate because it was uncomfortable. They called the CEO and then a senator on my not capitulating on basically everything.

How do you deal with these families?

Can you fire them as a patient because of their obstruction of care and nope out?

Get a court order?

They're clearly endangering their patient's life.

 

[chessknt]

How do you deal with these families?

Can you fire them as a patient because of their obstruction of care and nope out?

Get a court order?

They're clearly endangering their patient's life.

I mean at that point you inform them that if comfort is the number one priority they are going to be transitioned to comfort care only.

 

[Hernandez]

How do you deal with these families?

Can you fire them as a patient because of their obstruction of care and nope out?

Get a court order?

They're clearly endangering their patient's life.

You can't fire an in patient without finding an accepting service, due to by laws my group would have had to be involved anyways. I tried to move him to his specialist at another hospital and was told "we're not a higher level of care". I just counted down the days until my week was over.

 

[FutureInternist]

Most time I get by just fine with hard no's. The last family I had like that was refusing blood for hgb 3.5, refusing glucose for sugars of 60, refused to place lines then refuse to pull them, didn't want us to wake pt up to liberate because it was uncomfortable. They called the CEO and then a senator on my not capitulating on basically everything.

Probably have these kind of issues all the time as an ICU doc… just make sure to have a nurse present for all family interactions (for witness purposes), and document “family continues to decline…” to show that you discussed it on an ongoing basis.

A few of the malpractices cases I reviewed had this issue where it was one doc vs 3 family members word, while another was a “We said No once but Dr X didn’t tell us that he still needed Y since he never brought it up again”

Both went 6-0 for the doctor (3 lawyers, 3 docs), but a hassle nonetheless

 

[Nephro critical care]

COVID seems to have slowed down again but have an unvaccinated patient who was on the ventilator for COVID in December. Got better and was on room air however this month again febrile hypoxic with new bilateral infiltrates. COVID is negative but CRP LDH and D-dimers are high. Work-up for bacterial/viral/fungal infection is so far unrevealing on a bronchoscopy.

Behaving just like a COVID player just it does not make sense that she had COVID last month. Anybody had this type of patient and what would you do ?

 

[Radetzky]

Had several types of these patients with an organizing pneumonia that required high dose steroids. After infection sufficiently ruled out etc.

 

[Nephro critical care]

Is there a dose that most people would use. I have been using 60 mg q12h. Are there some people who are using higher doses ?

 

[chessknt]

Is there a dose that most people would use. I have been using 60 mg q12h. Are there some people who are using higher doses ?

If they're sick on a vent go bigger imo. 125 q6h for a few days see if it does anything and back off if it doesn't.

 

[Nephro critical care]

Another case recently had me scratching my head. Double vaccinated and boosted older 80 yr old not immunocompromised. Relatively asymptomatic COVID a month back for which did not need hospitalization. Now presented with bilateral infiltrates and hypoxia. COVID -ve on PCR. Developed acute kidney injury with mild transamintis. I intubated and did bronch/BAL. Nothing on bacterial / fungal cx and viral respiratory panel. I started solumedrol 60 mg q12hrs. Got better and extubated to RA. Follow up CT showed improved infiltrates.
However next day LDH and D-dimer skyrocketed. I shipped out to quaternary center. They stopped steroids. Rapidly went into multi-organ failure on 4 pressors and died. Just like a gram -ve septic shock with delayed abx. Funny thing is that had been on abx all along.
Was acting like a cytokine storm we used to see in 3rd week of COVID but odd thing is one and a half months out from an asymptomatic COVID infection. Also vaccinated and boosted. I haven't seen this in a boosted population. I don't know if this patient had the bivalent booster though.
I was wondering whether COVID IgM/IgG testing would be helpful in patients' with -ve COVID antigen by PCR presenting as a MIS-A syndrome ?

 

[SurfingDoctor]

Another case recently had me scratching my head. Double vaccinated and boosted older 80 yr old not immunocompromised. Relatively asymptomatic COVID a month back for which did not need hospitalization. Now presented with bilateral infiltrates and hypoxia. COVID -ve on PCR. Developed acute kidney injury with mild transamintis. I intubated and did bronch/BAL. Nothing on bacterial / fungal cx and viral respiratory panel. I started solumedrol 60 mg q12hrs. Got better and extubated to RA. Follow up CT showed improved infiltrates.
However next day LDH and D-dimer skyrocketed. I shipped out to quaternary center. They stopped steroids. Rapidly went into multi-organ failure on 4 pressors and died. Just like a gram -ve septic shock with delayed abx. Funny thing is that had been on abx all along.
Was acting like a cytokine storm we used to see in 3rd week of COVID but odd thing is one and a half months out from an asymptomatic COVID infection. Also vaccinated and boosted. I haven't seen this in a boosted population. I don't know if this patient had the bivalent booster though.
I was wondering whether COVID IgM/IgG testing would be helpful in patients' with -ve COVID antigen by PCR presenting as a MIS-A syndrome ?

Not IgG. Everyone is positive at this point. But we used to routinely send for IgM titers back in the hay day of MIS-C. I’ve definitely seen it in the vaccinated population too. Don’t know about boosters, but then again, I treat children and they are resilient by design.

Also, you guys don’t do IVIG for myocarditis? The older European studies showed equal efficacy between IVIG + steroids versus IVIG alone for MIS-C.

 

[Nephro critical care]

Not IgG. Everyone is positive at this point. But we used to routinely send for IgM titers back in the hay day of MIS-C. I’ve definitely seen it in the vaccinated population too. Don’t know about boosters, but then again, I treat children and they are resilient by design.

Also, you guys don’t do IVIG for myocarditis? The older European studies showed equal efficacy between IVIG + steroids versus IVIG alone for MIS-C.

Unfortunately it is hard to get IgM serology for COVID. It seems like no one doing it anymore. Only IgG.

 

[chessknt]

Not IgG. Everyone is positive at this point. But we used to routinely send for IgM titers back in the hay day of MIS-C. I’ve definitely seen it in the vaccinated population too. Don’t know about boosters, but then again, I treat children and they are resilient by design.

Also, you guys don’t do IVIG for myocarditis? The older European studies showed equal efficacy between IVIG + steroids versus IVIG alone for MIS-C.

No there is functionally no useful data for viral myocarditis in adults so they just get treated like every other chf pt--usual medical therapies->pressors/inotropes->mechanical support->death or transplant.

 

[SurfingDoctor]

No there is functionally no useful data for viral myocarditis in adults so they just get treated like every other chf pt--usual medical therapies->pressors/inotropes->mechanical support->death or transplant.

Hmm… interesting.