Coding COVID patients

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Just because we are all supposedly vaccinated? Have plenty of partners and CRNAs who are all received three shots are out. Also a report of they only give monoclonal antibody to people who aren’t vaccinated.

The answer is FUK no…. You find me that N95 and gown before I will pop in to intubate. Has anyone actually saw someone with COVID that received CPR making it out without a pit stop by the morgue?
 
DrSnips said:
Was wondering if you guys have heard about the new AHA guidelines RE: coding COVID patients. Specifically where they say not to "delay chest compressions for provider PPE" if you are coding a COVID patient who has arrested. I thought I was hallucinating when I first read it:

AHA COVID code guidelines
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whats the point of coding someone who's lungs are fibrosed to hell

the AHA can eat a bag of d*cks on this one. I'm not gonna risk my health to do futile CPR.
 
bravotwozero said:
Eff those guys
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Remember when cardiologists wouldn't cath COVID+ patients who were having heart attacks at the beginning of the pandemic? Even though almost everyone in the cath lab is covered in a thick layer of PPE and lead?

But apparently now it's ok to rush in first, ask questions later.
 
I have mixed feelings on this. Unfotunately the powers that be seem unable or unwilling to differentiate between the confirmed covid+, suspected covid and the undifferentiated, instead lumping them all together in this document.

I don't think anyone should be obligated to provide care w/o appropriate PPE, especially if said care is likely futile. However, I also don't think that people should be forced to delay providing life-saving care in order to procure PPE, or penalized for doing so (by a forced leave for potential exposure). Perhaps my feelings are colored by the fact that I was written up a few months ago for intubating a teenager w/ a head bleed s/p MVA w/o a face shield on, as well as a case where I witnessed another physician allow an asthmatic to code through barring entry to the room until everyone had put on a PAPR.

Overall, I think policies like this and the recent CDC guidance about isolation time are part of the collective 'learning to live with covid'.
 
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If a physician wants to wear appropriate PPE during a viral respiratory pandemic during CPR!, they should never be penalized for it.

It should be the physician's responsibility to ask the hospital to provide and store the PPE in a spot easily accessible in the ER. The physician can't walk 100 yards away to another spot in the hospital to don the PPE.

To me this is a no brainer. We have to make sure we are safe taking care of dead people.
 
AHA has a shortsighted (moreso a one-sighted) view -- they are only concerned about quick compressions and quick defibrillation. Their statement has no concern for provider safety whatsoever.

Advocating not delaying CPR for PPE is like advocating not delaying resuscitative thoracotomy for you to don gloves or telling a paramedic it's ok to rush into a GSW scene without waiting for police. It's insanity, and AHA is out of touch with reality.
 
turkeyjerky said:
I have mixed feelings on this. Unfotunately the powers that be seem unable or unwilling to differentiate between the confirmed covid+, suspected covid and the undifferentiated, instead lumping them all together in this document.

I don't think anyone should be obligated to provide care w/o appropriate PPE, especially if said care is likely futile. However, I also don't think that people should be forced to delay providing life-saving care in order to procure PPE, or penalized for doing so (by a forced leave for potential exposure). Perhaps my feelings are colored by the fact that I was written up a few months ago for intubating a teenager w/ a head bleed s/p MVA w/o a face shield on, as well as a case where I witnessed another physician allow an asthmatic to code through barring entry to the room until everyone had put on a PAPR.

Overall, I think policies like this and the recent CDC guidance about isolation time are part of the collective 'learning to live with covid'.
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Agreed - allow clinicians to exercise JUDGEMENT
 
I'm in agreement with the tenor of this thread. AHA is out of touch (but we've known that since their stroke guidelines diverged with evidence in favor of industry).

That said, I want to point out how they're trying to thread a needle here:
The guidelines recommend not delaying NON AEROSOL GENERATING PROCEDURES (apparently CPR doesn't generate aerosol (which just defies common sense)) but the AGPs should await appropriate PPE.

OK, that is at least rational on it's face, but it's so out of touch with reality to be worse than useless.
 
My guess is we’re all thinking coding Covid pneumonia patient and AHA is thinking any Covid + patient who has arrested for another reason. I haven’t looked at the guidelines but definitely not a one size fits all policy.
 
DrSnips said:
...the new AHA guidelines RE: coding COVID patients. Specifically where they say not to "delay chest compressions for provider PPE" if you are coding a COVID patient ...
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Most of the time it's ER techs, nurses, EMS, med students, or residents doing the chest compressions, not cardiologists. I'm eagerly awaiting the new guidelines that require cardiologists to skip PPE before gaining vascular access.
 
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WilcoWorld said:
I'm in agreement with the tenor of this thread. AHA is out of touch (but we've known that since their stroke guidelines diverged with evidence in favor of industry).

That said, I want to point out how they're trying to thread a needle here:
The guidelines recommend not delaying NON AEROSOL GENERATING PROCEDURES (apparently CPR doesn't generate aerosol (which just defies common sense)) but the AGPs should await appropriate PPE.

OK, that is at least rational on it's face, but it's so out of touch with reality to be worse than useless.
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To be fair, COVID has been full of people talking about common sense and just being plain wrong. Remember when everyone was freaking out about how BiPAP and HFNC was going to aersolize and contaminate EVERYONE?

Yea... there were studies predating COVID that showed that non-invasive ventilation doesn't aersolize, but that didn't stop people from using "common sense" and not using modalities because of the lack of a negative pressure room (separate issue then the initial futility, chance of harm argument against. However that error was at least understandable when using influenza's course to guide treatment due to a lack of evidence).

Same with intubations... I'd take an intubation over an extubation any day of the week when it comes to aersolization. It's hard to aersolize after the roc goes in and the BiPAP doesn't come off until after the patient is paralyzed.
 
Siggy said:
To be fair, COVID has been full of people talking about common sense and just being plain wrong. Remember when everyone was freaking out about how BiPAP and HFNC was going to aersolize and contaminate EVERYONE?

Yea... there were studies predating COVID that showed that non-invasive ventilation doesn't aersolize, but that didn't stop people from using "common sense" and not using modalities because of the lack of a negative pressure room (separate issue then the initial futility, chance of harm argument against. However that error was at least understandable when using influenza's course to guide treatment due to a lack of evidence).

Same with intubations... I'd take an intubation over an extubation any day of the week when it comes to aersolization. It's hard to aersolize after the roc goes in and the BiPAP doesn't come off until after the patient is paralyzed.
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No doubt, common sense is often wrong. As am I.
 
thegenius said:
If they haven’t had treatment I would. It’s very likely hypoxic respiratory arrest and they need O2. However if they are full treatment like on a ventilator, and they code, then I would probably just call it.
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I heard an intensivist put this point very well "The purpose of CPR is to circulate oxygenated blood. This patient's blood can not be oxygenated, despite our best efforts, so we will not perform CPR to circulate deoxygenated blood."
 
Siggy said:
To be fair, COVID has been full of people talking about common sense and just being plain wrong. Remember when everyone was freaking out about how BiPAP and HFNC was going to aersolize and contaminate EVERYONE?

Yea... there were studies predating COVID that showed that non-invasive ventilation doesn't aersolize, but that didn't stop people from using "common sense" and not using modalities because of the lack of a negative pressure room (separate issue then the initial futility, chance of harm argument against. However that error was at least understandable when using influenza's course to guide treatment due to a lack of evidence).

Same with intubations... I'd take an intubation over an extubation any day of the week when it comes to aersolization. It's hard to aersolize after the roc goes in and the BiPAP doesn't come off until after the patient is paralyzed.
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Well, THE weakest form of evidence, by far, is "expert opinion".
 
Not an EM physician, just browsing the forums, but a family acquaintance in his 40s got COVID and coded in the icu while on a ventilator. Had cpr performed on him for over 10 mins, eventually left the icu largely neuro intact and able to spend more time with his kids even though his lungs are damaged . So it’s not entirely futile to code these patients, especially the younger ones.
 
AspiringDoc422 said:
Not an EM physician, just browsing the forums, but a family acquaintance in his 40s got COVID and coded in the icu while on a ventilator. Had cpr performed on him for over 10 mins, eventually left the icu largely neuro intact and able to spend more time with his kids even though his lungs are damaged . So it’s not entirely futile to code these patients, especially the younger ones.
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At this point, if you're coding on a ventilator due to covid it is pretty much entirely your fault and I don't feel any empathy for you.
 
Obviously a horse**** recommendation.

I had a more elaborate version of twitter,

But they basically are strictly defining DEFIBRILLATING and CHEST COMPRESSIONS as NON-AEROSOLIZING PROCEDURES, and leaning on the seconds-matter mantra regarding defib’ing Vfib and initiating chest compressions, and saying for those two things, one should NOT delay for ANY PPE. If you read the full text, they go into detail that it is totally fine to do two minutes of chest compressions with NO mask on (we aren’t talking a 5 minute delay for a PAPR and a bunny suit a la first wave).

This is idiocy, in my professional opinion.

Yes defibrillating is likely minimally aerosolizing. You could convince me to apply pads and shock x 1 @ 360J without PPE, assuming no PPE is in the neighborhood and somehow I have a defibrillator.

Chest compressions… they are relying on some very weak literature basically claiming the vast majority of people undergoing chest compressions where the airway ISN’T actively managed are occluding their airways and thus it isn’t aerosolizing.

So I have THREE separate issues with this—>
(1) What happened in the room for the 10 minutes prior to code? You think.. maybe they were coughing, struggling, tachypneic, tripodding, or generally spreading a vast lingering aerosol of Omicron in the little room? Ergo, even walking into said room you are in trouble if unmasked?
(2) If you’ve never seen someone getting chest compressions gurgling and foaming and leaking secretions from their face, you clearly haven’t been in enough codes.
(3) Lets pretend they just drop dead of Vfib suddenly, they are in a clean room, and that doing compressions really creates no aerosol. The unmasked first-response ring doing compressions… you think they are going to sprint out of the room when anesthesia starts playing with the airway, when RT shoves a BVM on the patient’s face, or when a resident throws an NRB on the mouth at flush rate 02? Naw, its chaos and they will get exposed as the rest of the code team comes in.


I appreciate their… sticking to the “science”. But its bad advice. Here is my draft version—>
Immediate defibrillation and chest compressions can save lives.
Both likely causes relatively minimal aerosolization versus airway management.
In the case of a witnessed arrest, attempt to provide defib and compressions as quickly as possible, with minimal delay to apply PPE.
We recommend just a mask/gloves or N95/gloves to speed the initiation of chest compressions and defib
AS SOON AS POSSIBLE, a relief code team with full PPE should take over.

Better?
 
GassYous said:
At this point, if you're coding on a ventilator due to covid it is pretty much entirely your fault and I don't feel any empathy for you.
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I share your frustration with the unvaccinated , but at my place about 1/4 of our admissions, 1/5 vents and 1/6 of deaths are fully vaccinated … I feel especially bad for those vaxxed folks who appear by time course to have caught covid in our waiting room and then do poorly 😕
 
AspiringDoc422 said:
This happened a number of months ago, your comment as a physician is disappointing nonetheless.
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Unfortunately, healthcare workers aren't bottomless wells of empathy and good will. We're human too, and we're tired of fighting this pandemic.

We're going into our 3rd year now of this **** and at this point, it's almost entirely made up of people who have refused to take proper care to prevent themselves from getting sick. And we're supposed to feel empathy for them when they burn through resources that we now have to deny other sick people? Eff that.
 
AspiringDoc422 said:
This happened a number of months ago, your comment as a physician is disappointing nonetheless.
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Vaccines were out a number of months ago, your opinion as a nonphysician is irrelevant nonetheless.

Spend months with a hospital entirely full of covid patients, risking your life everyday, hearing codes going off every hour and the majority of sick patients dropping dead no matter what you do. You have no idea what we've been through.
 
GassYous said:
Vaccines were out a number of months ago, your opinion as a nonphysician is irrelevant nonetheless.

Spend months with a hospital entirely full of covid patients, risking your life everyday, hearing codes going off every hour and the majority of sick patients dropping dead no matter what you do. You have no idea what we've been through.
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Just like the other poster have said….. this is the THIRD fuking wave. Second after the vaccines have been out. Out of three monoclonal antibodies only one work against omicron. I’ve heard there are some hospital systems restricting it to non-vaccinated patients only. WTH is this world coming to?

I am putting on proper PPE before I tube anyone, that’s all. Whoever want to write anything to the hospital administrator, I will ask them to present for the procedure without PPE with me.
 
AspiringDoc422 said:
Not an EM physician, just browsing the forums, but a family acquaintance in his 40s got COVID and coded in the icu while on a ventilator. Had cpr performed on him for over 10 mins, eventually left the icu largely neuro intact and able to spend more time with his kids even though his lungs are damaged . So it’s not entirely futile to code these patients, especially the younger ones.
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I was actually very excited when I read your account…. Then looked into it a little more, found out you aren’t even in med school yet. Don’t be offended when I say, I cannot accept your account of ICU events.

Good luck with your study and I hope you will keep your idealism when you’re my age.
 
GassYous said:
Vaccines were out a number of months ago, your opinion as a nonphysician is irrelevant nonetheless.

Spend months with a hospital entirely full of covid patients, risking your life everyday, hearing codes going off every hour and the majority of sick patients dropping dead no matter what you do. You have no idea what we've been through.
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Just because I’m not yet a physician doesn’t mean that I’m not aware of the realities associated with this pandemic. Many of my closest family members were on the frontlines of healthcare during the past two years, I personally spent hundreds of hours assisting in the ER in any way that I could, good to know that my efforts are considered “irrelevant” . Even though I certainly understand the frustration felt by those on the frontlines as a result of this pandemic, I find it concerning that some medical professionals have such disdain for certain patients as a result of their life choices. I wonder if this level of disdain would be tolerated if it were directed towards other patients that require advanced care as a result of their life choices? In any case I’m just happy that this acquaintance of my family, a hardworking father of two young girls, was able to return to his family, and that when it mattered most he was surrounded by medical professionals that cared.
 
IMGASMD said:
I was actually very excited when I read your account…. Then looked into it a little more, found out you aren’t even in med school yet. Don’t be offended when I say, I cannot accept your account of ICU events.

Good luck with your study and I hope you will keep your idealism when you’re my age.
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Part of his medical care was actually provided by a close family member, so this account of events is fairly trustworthy. I’m certainly not suggesting that this outcome can be expected of most COVID patients that get coded. In any case thanks for your well wishes, hope you guys can catch a break from this eventually.
 
Lexdiamondz said:
Unfortunately, healthcare workers aren't bottomless wells of empathy and good will. We're human too, and we're tired of fighting this pandemic.

We're going into our 3rd year now of this **** and at this point, it's almost entirely made up of people who have refused to take proper care to prevent themselves from getting sick. And we're supposed to feel empathy for them when they burn through resources that we now have to deny other sick people? Eff that.
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Exactly. Not only is it a pandemic of stupid at this point, but these people and their families are the most insufferable people to work with. They are demanding, unreasonable, litigious, and stupid. Ive had far too many for my liking. Just grateful I work pure nights and so rarely speak with em.
 
AspiringDoc422 said:
Just because I’m not yet a physician doesn’t mean that I’m not aware of the realities associated with this pandemic. Many of my closest family members were on the frontlines of healthcare during the past two years, I personally spent hundreds of hours assisting in the ER in any way that I could, good to know that my efforts are considered “irrelevant” . Even though I certainly understand the frustration felt by those on the frontlines as a result of this pandemic, I find it concerning that some medical professionals have such disdain for certain patients as a result of their life choices. I wonder if this level of disdain would be tolerated if it were directed towards other patients that require advanced care as a result of their life choices? In any case I’m just happy that this acquaintance of my family, a hardworking father of two young girls, was able to return to his family, and that when it mattered most he was surrounded by medical professionals that cared.
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Spoken like the inexperienced.
 
AspiringDoc422 said:
Just because I’m not yet a physician doesn’t mean that I’m not aware of the realities associated with this pandemic. Many of my closest family members were on the frontlines of healthcare during the past two years, I personally spent hundreds of hours assisting in the ER in any way that I could, good to know that my efforts are considered “irrelevant” . Even though I certainly understand the frustration felt by those on the frontlines as a result of this pandemic, I find it concerning that some medical professionals have such disdain for certain patients as a result of their life choices. I wonder if this level of disdain would be tolerated if it were directed towards other patients that require advanced care as a result of their life choices? In any case I’m just happy that this acquaintance of my family, a hardworking father of two young girls, was able to return to his family, and that when it mattered most he was surrounded by medical professionals that cared.
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A premed in the ed is about as useless as you can get. And maybe this hardworking father of two young girls should have just gotten the vaccine. Then I might care a little more.
 
GassYous said:
A premed in the ed is about as useless as you can get. And maybe this hardworking father of two young girls should have just gotten the vaccine. Then I might care a little more.
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I appreciate the premed insults, sometimes it’s the little “useless“ things like scribing, transporting patients to the CT scanner, running lab samples to pathology, and restocking medical supplies that help an already stressed department run just a little more smoothly throughout a shift. The remainder of your comment regarding your lack of concern for the suffering of a patient and his family speaks for itself.
 
AspiringDoc422 said:
This happened a number of months ago, your comment as a physician is disappointing nonetheless.
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<sigh>

I can understand why his comment might be jarring.

But I don't think you understand how bad the past 2 years have been for physicians. I'm tired and burnt out and I'm just primary care - not ICU or emergency medicine.

From having to work overtime because of staff shortages and high patient demand, to the debilitating fear of bringing COVID home to your family, to worries about your pay being cut because of falling revenues across all health systems - it was a lot. Added to that, many of us have children who couldn't be in school or daycare safely, but we had to keep working, so we patchworked together tenuous childcare options - for the past 2 years, it has felt like everything was on a knife edge but you couldn't let it come crashing down because if you did, who was going to see all these patients? Your overextended colleagues?

And now there's a way out with vaccines but patients don't want it. Worse, there are those who mock me or scream angrily at me because I encourage them to get the vaccine. That's ignoring those who told me that I was basically committing child abuse for getting vaccinated while pregnant.

I've been a physician for 12 years and, like all physicians, I have had my bad days and weeks. But I have never wanted to quit medicine entirely as much as I did over this past year. The reaction against the vaccine (which is literally lifesaving) has been utterly demoralizing.

I get while you might find his comment distasteful. But until you've experienced this pandemic in the shoes of a physician, I don't think you get to judge. And no, working as a healthcare worker and "seeing what goes on on the frontlines" isn't the same - clearly, as a mystifyingly high number of other healthcare workers are still NOT VACCINATED.
 
AspiringDoc422 said:
Part of his medical care was actually provided by a close family member, so this account of events is fairly trustworthy. I’m certainly not suggesting that this outcome can be expected of most COVID patients that get coded. In any case thanks for your well wishes, hope you guys can catch a break from this eventually.
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Unless you’re there, unless you can account for events lead to the arrest, whatever you report will be treated as an anecdote. But I am glad that he got discharged.


AspiringDoc422 said:
Just because I’m not yet a physician doesn’t mean that I’m not aware of the realities associated with this pandemic. Many of my closest family members were on the frontlines of healthcare during the past two years, I personally spent hundreds of hours assisting in the ER in any way that I could, good to know that my efforts are considered “irrelevant” . Even though I certainly understand the frustration felt by those on the frontlines as a result of this pandemic, I find it concerning that some medical professionals have such disdain for certain patients as a result of their life choices. I wonder if this level of disdain would be tolerated if it were directed towards other patients that require advanced care as a result of their life choices? In any case I’m just happy that this acquaintance of my family, a hardworking father of two young girls, was able to return to his family, and that when it mattered most he was surrounded by medical professionals that cared.
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Not when their choice affect everyone else. There are greater implications of their choices which they don’t see/care. Since they’re not vaccinated and end up in icu. They take away a bed for a mother of three, who suffered from a heart attack, that can “easily” be treated in the cath lab, but there are no icu bed, now has to be transferred 100 miles away. Missed the window.

We are all tired. We are all a lot older than you. Most of us have families, some of us have young kids too. When the patients “choose” not to get vaccinated, it’s a slap on our faces. “I” don’t have a choice, when this patient comes to my hospital, and needs medical care. Most of us have all “turn the other cheek” when it comes to unreasonable patient demands. But when they’re fuking with my family and kids because of a “choice”. No thank you.

Empathy and understanding have their places in medical practices, but not after two years of the nonsense and one year after vaccines being available.
 
AspiringDoc422 said:
Just because I’m not yet a physician doesn’t mean that I’m not aware of the realities associated with this pandemic. Many of my closest family members were on the frontlines of healthcare during the past two years, I personally spent hundreds of hours assisting in the ER in any way that I could, good to know that my efforts are considered “irrelevant” . Even though I certainly understand the frustration felt by those on the frontlines as a result of this pandemic, I find it concerning that some medical professionals have such disdain for certain patients as a result of their life choices. I wonder if this level of disdain would be tolerated if it were directed towards other patients that require advanced care as a result of their life choices? In any case I’m just happy that this acquaintance of my family, a hardworking father of two young girls, was able to return to his family, and that when it mattered most he was surrounded by medical professionals that cared.
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I have a few friends who served this country in Iraq and Afghanistan.

I would never go on a forum full of veterans and suggest that I understand what they went through because I have friends who are vets, and then turn around and chastise them for venting about their experiences.


Similarly, the fact that you are not a physician or nurse means on a fundamental level you are utterly unaware of the realities of what it means to provide care in this environment. The fact that you expect us to be superhuman and not have negative feelings towards people who belittled, demonized and then subsequently demanded everything of us shows that you have absolutely no clue what it's like.

You spending hours pushing people to CT is appreciated, but it in no way, shape or form gets you a seat at the table where people here spent hundreds of hours a week trying to keep dozens of patients alive, while trying not to get ourselves and our families sick, and simultaneously being spat on by our own admin and the public we serve.


I really suggest you turn tail and leave gracefully. This conversation isn't for you.
 
Some of the comments I read on here back when I made this account (name is now essentially a joke) made me sad.

Then I went into EM and now have been BC'd for a bit

Wrote up a long response to Aspiringdoc422 but deleted all of it after I remembered that

He'll see, guys

he'll see

he doesn't have to understand now
 
DrSnips said:
Was wondering if you guys have heard about the new AHA guidelines RE: coding COVID patients. Specifically where they say not to "delay chest compressions for provider PPE" if you are coding a COVID patient who has arrested. I thought I was hallucinating when I first read it:

AHA COVID code guidelines
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Posted by the NAEMSP President in our S&P listserv:

I had a great conversation with Comilla Sasson with AHA today who has assured me that by early next week there will be an update/revision to the October document that will re-assert the commitment to provider safety, explicitly state that PPE should be worn when providing CPR and offer some type of apology or acknowledgment of the potential for misunderstanding that this caused. It is my understanding that they plan to revise the figure in question.
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southerndoc said:
Posted by the NAEMSP President in our S&P listserv:
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“potential for misunderstanding that this caused”

I didn’t potentially misunderstand their message; they explicitly state you can do chest compressions without masks.

And for all the people who said the twitter/facebook/listserv/email firestorm this document created was silly/over-the-top… look, they are changing the written recommendation. Turns out PR debacles can help the cause.
 

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