How will you handle possible stop to elective surgery?

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dchz said:
I spent almost a year in ICUs in residency. Most residents out of my residency are very ICU competent.



Everyone is brain storming, but I don't see enough people mentioning hyperbaric chambers instead of vents. May be we don't get enough exposures to hyperbaric chambers in med school, but it's a legit solution to people with isolated hypoxia as a problem:

hyperbaric_chamber_inside_with_patients_1.ashx


That's a pic of it at Penn, I can easily cram 20 pts in there (assure they all have the same strain of the SARS-COV-2). Am i missing something?
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The cure for ARDS. In a post on SDN. What a world we live in.
 
SaltyDog said:
How are things in your neck of the woods anyways?
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Not much going on, i learned from the newspapers yesterday that ORs were to be shut down across the country but then this morning the hospital sends an email where it sounds like they would like for minor procedure on healthy patients to keep going...
A clinic i work at which has no ER or ICU will be working as usual (until further notice)
 
dannyboy1 said:
How would you go about proving where the infection originated?
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Prove is too strong a word, but there is a case to be made if someone is healthy, they come in for elective surgery, go home and essentially self quarantine already because they're recuperating, and then they fall sick with their only sick contact being someone in the perioperative setting.
 
It’s a great time to be a state or federal employee with guarantee paycheck (academic state hospital or federal hospital like VA or military) if case load is down. Sucks to be in private practice fee for service. AMC will still pay you in general so not as bad being employee. But this is gonna to be a weird 4-8 weeks coming up.
 
I'm an employee at a public hospital, I have no worries about getting paid ... so I can move on to worrying about not getting infected.
 
JobsFan said:
I'm an employee at a public hospital, I have no worries about getting paid ... so I can move on to worrying about not getting infected.
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I'm no hero - if I were some of you guys - I'd take a long vacation somewhere very remote
 
dchz said:
I spent almost a year in ICUs in residency. Most residents out of my residency are very ICU competent.



Everyone is brain storming, but I don't see enough people mentioning hyperbaric chambers instead of vents. May be we don't get enough exposures to hyperbaric chambers in med school, but it's a legit solution to people with isolated hypoxia as a problem:

hyperbaric_chamber_inside_with_patients_1.ashx


That's a pic of it at Penn, I can easily cram 20 pts in there (assure they all have the same strain of the SARS-COV-2). Am i missing something?
Click to expand...

Your average hyperbaric treatment has someone in the chamber for what, 2-3 hours? You going to send a team in there with some patients for a week or two without coming out? All the food, water, and toilet facilities built in with them? The longer you stay at "depth", the longer it takes to depressurize to avoid the bends on the way back out.

Also not sure this is a problem of just hypoxia, I assume they also get hypercarbic. And don't you need special ventilators to take into a chamber?
 
Mman said:
Your average hyperbaric treatment has someone in the chamber for what, 2-3 hours? You going to send a team in there with some patients for a week or two without coming out? All the food, water, and toilet facilities built in with them? The longer you stay at "depth", the longer it takes to depressurize to avoid the bends on the way back out.

Also not sure this is a problem of just hypoxia, I assume they also get hypercarbic. And don't you need special ventilators to take into a chamber?
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There's what, about nine of these things operational in North America? If it's even helpful, it's a curiosity, about as scalable as the Magic Johnson cure for AIDS discovered by the children from South Park.
 
pgg said:
There's what, about nine of these things operational in North America? If it's even helpful, it's a curiosity, about as scalable as the Magic Johnson cure for AIDS discovered by the children from South Park.
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There are lots of monoplace hyperbaric chambers which are basically small tubes that you put a single patient into to treat the bends from diving. It's the big multiplace chambers like shown in the picture that there are not many of where you can find 5-10 or more patients at a time. But like I mentioned, those are brief little treatment periods not sustained living at depth and I really don't think there are many ventilators capable of being in them and if a patient is that hypoxic it's not like you can go in and out of them you'd be stuck for a long time.
 
FFP said:
The grasshopper should do a CCM fellowship, to find out that high FiO2 (and probably pO2) worsens lung inflammation. That's one of the reasons why ARDS is so hard to treat.
Click to expand...
Hmmm, in a hyperbaric chamber you could lower FiO2 while theoretically improving PaO2.

(Physics argument, not a clinical one)
 
Mman said:
There are lots of monoplace hyperbaric chambers which are basically small tubes that you put a single patient into to treat the bends from diving. It's the big multiplace chambers like shown in the picture that there are not many of where you can find 5-10 or more patients at a time. But like I mentioned, those are brief little treatment periods not sustained living at depth and I really don't think there are many ventilators capable of being in them and if a patient is that hypoxic it's not like you can go in and out of them you'd be stuck for a long time.
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Right, that's what I meant. Big hyperbaric chambers one can conduct ICU level care in are rare.
 
CopaceticOne said:
Hmmm, in a hyperbaric chamber you could lower FiO2 while theoretically improving PaO2.

(Physics argument, not a clinical one)
Click to expand...
Physiology argument: I don't think the body cares about the FiO2, just about the total amount of O2 (as in molecules) it gets in contact with, i.e. PaO2.

Hyperbaric chambers are difficult to work in and expensive. Their main value is exactly to provide those very high pO2 levels, which would be toxic in ARDS. Otherwise one can just use an ETT, SV and PEEP, without a ventilator. Not that either the hyperbaric room or pure SV would work in severe ARDS, without a ventilator, due to the heavy inflamed lungs.

The treatment for ARDS is not high O2 levels, it's PEEP and positioning with as little PPV as one can get away with (ARDSnet). One just wants to avoid hypoxic organ injury (O2 sats of 88-94%) while waiting for the lungs to heal.
 
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Hyperbaric chamber, most stupid thing I have ever heard. Ignore most of what comes with ARDS and just try and fix the hypoxia.
 
All heart rooms will be ecmo centers.... cure for ARDS!! Listen I could do a decent job staffing an icu. But my malpractice, and family prefers I don’t do anything. I got a remote ranch in Idaho with plenty of guns, food, and firewood. I’ll be just fine. Alll Anes docs need 6 month emergency fund...
 
FFP said:
You almost sound like a CRNA. Go do that fellowship. 😛

I spent 5 months in the ICU, during residency, 3 of them MICU in internship (because I wanted to). I didn't learn sh-t in the SICU, because of all the scutwork. Ten years later, the current residents still don't learn much in the same academic SICU.

Most anesthesiologists spend 4 months in SICUs, with zero MICU exposure (or maybe a month). I wouldn't allow those guys to prescribe even the DVT prophylaxis for a MICU patient. Also, there is a HUGE difference between being in the ICU as a resident and as a fellow.

These will be sick medical patients. Non-intensivists should function as residents or fellows, depending on specialty and experience, definitely NOT as primary physicians (except for really good internists).
Click to expand...

Completely fair. However do you disagree most anesthesiologists would be better at ICU than most specialties?
 
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Ronin786 said:
The cure for ARDS. In a post on SDN. What a world we live in.
Click to expand...

dipriMAN said:
Hyperbaric chamber, most stupid thing I have ever heard. Ignore most of what comes with ARDS and just try and fix the hypoxia.
Click to expand...

Excellent discussion. Well said. I learned a lot 🙂

FFP said:
Physiology argument: I don't think the body cares about the FiO2, just about the total amount of O2 (as in molecules) it gets in contact with, i.e. PaO2.

Hyperbaric chambers are difficult to work in and expensive. Their main value is exactly to provide those very high pO2 levels, which would be toxic in ARDS. Otherwise one can just use an ETT, SV and PEEP, without a ventilator. Not that either the hyperbaric room or pure SV would work in severe ARDS, without a ventilator, due to the heavy inflamed lungs.

The treatment for ARDS is not high O2 levels, it's PEEP and positioning with as little PPV as one can get away with (ARDSnet). One just wants to avoid hypoxic organ injury (O2 sats of 88-94%) while waiting for the lungs to heal.
Click to expand...

I am very ignorant of hyperbaric chambers. Very true, hence why i questioned it and thought about it during brain storming. Let's learn about it with the guidance of our fellow CC attendings.

So let's examine this further. At the gas exchange physiology level is hyperbaric therapy drastically different than APRV? Is APRV superior to hyperbaric therapies? I have done some research and I have not found any evidence to support either direction.

Second, does hyberbaric oxygen cause ARDS? there seems to be some evidence that it does. however, the evidence is very iffy, a rare case report from Thailand: https://journal.chestnet.org/article/S0012-3692(19)30653-1/fulltext

Lastly, someone people already think this idea is so crazy that it's the "most stupid thing" ever heard. Has anyone used hyperbaric chamber to treat ARDS? well evidence is not strong either, but some people from Israel have claimed to do it:

www.ncbi.nlm.nih.gov

The life-saving effect of hyperbaric oxygenation during early-phase severe blunt chest injuries - PubMed

The effect of hyperbaric oxygenation (HBO2) on survival during the early phase of severe blunt chest injury (BChI) has not been elucidated. Our aim was to investigate this effect on human victims of BChI. We monitored cardiac index (CI), stroke volume index (SVI), PaO2 and PaO2/FiO2 in 18...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov


Conclusion: i'm not convinced that it will work. nor am i convinced it won't work. We certainly won't be putting anyone in a chamber if ECMO or a vent is available and will do the trick. But I would appreciate more evidence about HBOT and ARDS though. Just in case we run out of ECMO or Vents.
 
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dchz said:
Excellent discussion. Well said. I learned a lot 🙂



I am very ignorant of hyperbaric chambers. Very true, hence why i questioned it and thought about it during brain storming. Let's learn about it with the guidance of our fellow CC attendings.

So let's examine this further. At the gas exchange physiology level is hyperbaric therapy drastically different than APRV? Is APRV superior to hyperbaric therapies? I have done some research and I have not found any evidence to support either direction.

Second, does hyberbaric oxygen cause ARDS? there seems to be some evidence that it does. however, the evidence is very iffy, a rare case report from Thailand: https://journal.chestnet.org/article/S0012-3692(19)30653-1/fulltext

Lastly, someone people already think this idea is so crazy that it's the "most stupid thing" ever heard. Has anyone used hyperbaric chamber to treat ARDS? well evidence is not strong either, but some people from Israel have claimed to do it:

www.ncbi.nlm.nih.gov

The life-saving effect of hyperbaric oxygenation during early-phase severe blunt chest injuries - PubMed

The effect of hyperbaric oxygenation (HBO2) on survival during the early phase of severe blunt chest injury (BChI) has not been elucidated. Our aim was to investigate this effect on human victims of BChI. We monitored cardiac index (CI), stroke volume index (SVI), PaO2 and PaO2/FiO2 in 18...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Click to expand...
I am beginning to see what pisses some of your attendings off. 😀
 
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dchz said:
Completely fair. However do you disagree most anesthesiologists won't be better at ICU than most specialties?
Click to expand...
Most? Yes. They will also kill a number of patients if left unsupervised, because critical care is more than just resuscitation, and what's wise short-term in the OR may be dumb long-term in the ICU. Severe ARDS is not something anesthesiologists are trained in, neither are most SICU intensivists (though they will disagree, because many tend to confuse ARDS with other causes of hypoxia).
 
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SaltyDog said:
Hopefully less than orthopods or pathologists though.
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No doubt about that.

I know that some anesthesiologists think that critical care is piece of cake, and I am just trying to combat that idea. Medical critical care is anything but easy. We rarely see their sick patients in the OR and we are never the ones who fix them.
 
I'd rather have an anesthesiologist who hasn't left a GI surgicenter in 8 years manage my ventilator from the national stockpile that got stuffed in a tent in the parking lot, than just about any other non critical care trained doc.
 
pgg said:
I'd rather have an anesthesiologist who hasn't left a GI surgicenter in 8 years manage my ventilator from the national stockpile that got stuffed in a tent in the parking lot, than just about any other non critical care trained doc.
Click to expand...

Their ability to sign charts and sign out patients from recovery is unrivaled
 
dchz said:
So let's examine this further. At the gas exchange physiology level is hyperbaric therapy drastically different than APRV? Is APRV superior to hyperbaric therapies? I have done some research and I have not found any evidence to support either direction.
Click to expand...

That’s an interesting point.

It’s also worth mentioning that just because you’re in a hyperbaric chamber, doesn’t mean you have to be at an elevated FiO2.

To me the biggest problem with your proposal is that it attempts to alleviate the strain on a limited resource with an exponentially even more limited resource.
 
BLADEMDA said:
I'm expecting this to be a relative non event by May in my neck of the woods as the heat and humidity slow the spread of the virus. Second, I think the lessons learned from Singapore and South Korea will help us keep this contained.

In the grand scheme of things we all can withstand 4 weeks of lost wages or income if needed. I simply don't see the this pandemic getting out of control despite the dire warnings from the experts.

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I hope so, too. However, I cannot ignore what the Italians keep saying: don't be stupid like we were.

As I say to my ICU families and trainees: prepare for the worst, hope for the best. One thing will definitely not help: ignoring the potential black swan-level threat, like we did for 2 months.

Also, even if the weather helps, this will survive in the community until fall, when the weather will be against us. We won't be completely out of the woods for another 12 months or more, especially with no vaccine.
 
dchz said:
Completely fair. However do you disagree most anesthesiologists would be better at ICU than most specialties?
Click to expand...
I good anesthesiologist who is an expert at drinking coffee and chatting up the nurses is probably less harmfull ergo better than most ICU docs practicing at the top of their licence.
 
I stand by my statement .... hyperbaric chamber is a ridiculous idea. Sure, if you don’t have a ventilator I’m up for trying anything,but it’s not going to help the work if breathing or impending respiratory failure.
 
If there’s one thing this nation is good at (particularly referencing our military), it’s logistics. We have the ability to supply massive fighting forces at pretty much any location around the world including pop-up ICU’s, surgical suites, etc. Putting that to work domestically would alleviate the strain on civilian services if the need arose.
 
SaltyDog said:
If there’s one thing this nation is good at (particularly referencing our military), it’s logistics. We have the ability to supply massive fighting forces at pretty much any location around the world including pop-up ICU’s, surgical suites, etc. Putting that to work domestically would alleviate the strain on civilian services if the need arose.
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I’ve had the same thought and I’m not sure why they haven’t been mobilized in Seattle, San Francisco, Boston, NYC, etc already.
 
FFP said:
Most? Yes. They will also kill a number of patients if left unsupervised, because critical care is more than just resuscitation, and what's wise short-term in the OR may be dumb long-term in the ICU. Severe ARDS is not something anesthesiologists are trained in, neither are most SICU intensivists (though they will disagree, because many tend to confuse ARDS with other causes of hypoxia).
Click to expand...

The surgeon intensivists kill me.
“Urine output is down, give fluids” “base excess is up, give fluids”
The number of ”ARDS” diagnoses on patients whose weight is up 10-20kg that magically resolves with diuresis is too high! SICUs should not be managing ARDS or hypoxia or viral pneumonia.
 
MoMoGesiologist said:
The surgeon intensivists kill me.
“Urine output is down, give fluids” “base excess is up, give fluids”
The number of ”ARDS” diagnoses on patients whose weight is up 10-20kg that magically resolves with diuresis is too high! SICUs should not be managing ARDS or hypoxia or viral pneumonia.
Click to expand...
You've put your finger on it.

I've had multiple cases of pulmonary interstitial edema (from fluid overload) which my SICU-trained anesthesiologist-intensivist colleagues kept calling ARDS, just because the P/F ratio was low. That's why I don't trust most of them to treat severe ARDS.
 
SaltyDog said:
If there’s one thing this nation is good at (particularly referencing our military), it’s logistics. We have the ability to supply massive fighting forces at pretty much any location around the world including pop-up ICU’s, surgical suites, etc. Putting that to work domestically would alleviate the strain on civilian services if the need arose.
Click to expand...
As fate and coincidence would have it, I'm the officer-in-charge of one of those mobile surgical suites right now, in Italy. (A role 2 FRSS/STP for those who know what that is. We were here before any of this COVID-19 stuff started, completely different mission. We are not caring for any COVID-19 patients at this time.)

Couple issues -

1) We're supplied and equipped for trauma, not ongoing ICU care. And just initial resuscitation and damage control surgery at that, not comprehensive trauma care. Our holding time is limited by personnel, equipment, and consumable supplies - measured in hours, perhaps a day. But not weeks. We also have a substantial non-medical logistic tail that is rather cumbersome and inefficient if viewed in terms of cost/resources per unit of deliverable medical care.

2) An even larger issue is that just because COVID-19 is rearing its ugly head, doesn't mean our mission supporting warfighters goes away. Crises beget more crises, and the sort of world events that require people with guns to handle (with a FRSS/STP supporting them) are more likely now than they were three months ago. The military mission we're supporting isn't going to go away and free us up.

3) When the military deploys one of these things, they haul the roughly 40,000 pounds of tents and generators and all the other gear out of a warehouse where all the stuff is stockpiled ... but they haul the people (doctors, nurses, and techs) out of hospitals. At this point most of us anticipate that hospitals everywhere are likely to be overwhelmed, so it's probably best to leave the people there. Pull some vents out of a warehouse, convert some ward beds to ICU beds.

Our role here in Italy, should the actual brick & mortar hospital here be overwhelmed with COVID-19 patients, won't be to pop up our 4 tents and establish another facility. We'll just go to the hospital and work there. We have about a dozen portable ventilators but I'm not sure they're up to the task of being ICU vents keeping ARDS patients alive for a week or more. In theory we could convert some ward rooms to ICU beds but it's not like we brought along a fleet of ancillary services. We have an xray tech and a lab tech, and very limited lab capabilities and supplies (think transfusion and ER-level trauma labs). These patients require far more resources than just a ventilator.


If this was a geographically confined crisis, it would possibly make sense for the military to pull physicians, nurses, and other persons from military hospitals and send them to that region. We see this all the time for natural disasters. The tsunami, Haiti earthquake, hurricanes in the southeast USA. At the moment however, every US military hospital in the world is making plans to best manage an overwhelming number of patients at their own facilities. Shuffling people around and setting up tents may not be helpful in the big picture.
 
vector2 said:
No such thing as a ventilator shortage. Only a 'BVM/PEEP valve/family member who likes you enough' shortage.
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Hopefully the family member likes you enough to also massage your legs q15 minutes so you don't survive COVID-19 only to die of a PE 20 seconds after you move to get out of bed.
 
pgg said:
Hopefully the family member likes you enough to also massage your legs q15 minutes so you don't survive COVID-19 only to die of a PE 20 seconds after you move to get out of bed.
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We should be minimizing or not giving sedation so the pts are up moving themselves! Just need family members to hold you down!
 
FFP said:
Easiest thing in the world (it's time-based), as long as the patient is truly critical: CPT codes 99291 and 99292.

Understanding and coding for critical care services - www.hcpro.com

CMS defines critically ill and injured patients as those who are experiencing one or more vital organ failure(s) and who have a high probability of life threatening deterioration in their condition. Lois E. Mazza, CPC, PCA, helps clarify coding for critical care services and addresses how to...
www.hcpro.com
www.the-hospitalist.org

Report Critical Care - The Hospitalist

Strict guidelines and case detail must support these time-based codes
www.the-hospitalist.org www.the-hospitalist.org
www.the-hospitalist.org

How To Avoid Medicare Denials for Critical-Care Billing - The Hospitalist

The basic principles of documentation for services provided to critical-care and injured hospital patients
www.the-hospitalist.org www.the-hospitalist.org
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So as an Anesthesia group we probably have no contract with payers for these services, right? Basically would be pro bono care?
 
FFP said:
Most? Yes. They will also kill a number of patients if left unsupervised, because critical care is more than just resuscitation, and what's wise short-term in the OR may be dumb long-term in the ICU. Severe ARDS is not something anesthesiologists are trained in, neither are most SICU intensivists (though they will disagree, because many tend to confuse ARDS with other causes of hypoxia).
Click to expand...

Ten plus years ago I spent a few months in various ICUs. I would not do patients justice in that role now, without significant retraining.
That said, I guarantee I am a better option than most other specialties.

Any scenario that places me in charge of managing ICU patients long term is also a scenario where substandard care is the best one can hope for.
 
caligas said:
So as an Anesthesia group we probably have no contract with payers for these services, right? Basically would be pro bono care?
Click to expand...

you are correct that you won't have contracted rates for those services. But you can still submit bills to be paid. The fun part is, now you will be out of network for those services! It'll be great to tie all the OON surprise billing stuff to the Coronavirus outbreak.
 
Does anyone besides me think that one of the reasons Italy is having such a problem is that they also smoke like chimneys? That's the thing I hated most about my visit there a couple years ago.
 
jwk said:
Does anyone besides me think that one of the reasons Italy is having such a problem is that they also smoke like chimneys? That's the thing I hated most about my visit there a couple years ago.
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Europeans in general use mass transportation. It’s winter and everyone crowded together. Just like any flu season but obviously cornavirus strand more dangerous especially to Italy older population.

just the perfect storm. I don’t think it has to do with smoking
 
And here's the big one

www.bloomberg.com

N.Y. Hospitals Pitch Tents, Nix Surgeries to Gird for Influx

New York hospitals are pushing forward with emergency plans to make rooms and resources available for a surge in coronavirus cases that’s expected to place historic pressure on the region’s health-care system.
www.bloomberg.com www.bloomberg.com
 
jwk said:
Does anyone besides me think that one of the reasons Italy is having such a problem is that they also smoke like chimneys? That's the thing I hated most about my visit there a couple years ago.
Click to expand...

Yes, I completely believe that. Italy is one of the oldest (demographically) countries in the world. Their current smoking rate is almost double that of the United States. And you can bet that even a large number of these 70+ year old people who are current nonsmokers, were smokers for most of their lives. The chainsmoking culture is not quite as bad as southeast Asia, but it's bad.
 
aneftp said:
Europeans in general use mass transportation. It’s winter and everyone crowded together. Just like any flu season but obviously cornavirus strand more dangerous especially to Italy older population.

just the perfect storm. I don’t think it has to do with smoking
Click to expand...
Why wouldn’t it? What do COPDers tend to get? Exacerbations that land them in the hospitals/ERs because their lungs aren’t able to ward off viruses/bacteria as well as normal lungs that aren’t chronically inflamed and have normal cilia. Add that to the fact that they travel en mass and there you have it.
 
aneftp said:
Europeans in general use mass transportation. It’s winter and everyone crowded together. Just like any flu season but obviously cornavirus strand more dangerous especially to Italy older population.

just the perfect storm. I don’t think it has to do with smoking
Click to expand...
I would think smoking is a factor. Not the main factor, but definitely a factor in mortality. Not only do Europeans crowd more socially but they make more physical contact when greeting one another. Just based on observation. China and S. Korea also has a significant amount of smokers.
 
Twiggidy said:
I would think smoking is a factor. Not the main factor, but definitely a factor in mortality. Not only do Europeans crowd more socially but they make more physical contact when greeting one another. Just based on observation. China and S. Korea also has a significant amount of smokers.
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Smoking is a big deal, obviously, even before COPD, because it decreases lung defenses (e.g. impairs ciliary motility, increases secretions).

And, btw, any pre-existing lung disease, which decreases respiratory functional capacity (even obesity), matters in a bilateral pneumonia +/- ARDS.
 
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