Pop quiz: Stat intubation, covid +, no PPE
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Arch Guillotti
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Do the best you can. Don't do it without proper PPE though. Do anything but rush in without wearing proper PPE.
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2 residents have passed away in their 20s, don't do it without proper PPE, period.
So sad.... Will not do it without PPE.
Arch Guillotti
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link?
This isn’t even a question. Even for a code, we’re not going in until we’re dressed.
Yes but what if no supplies at all? Is this not a problem anymore? Is there enough PPE to last?
I guess I can’t speak for everyone, but at my two hospitals, we have enough, and the supply chain, particularly for n95 and face shields, has improved quite a lot. One of our orthopedic surgeons (actually, two brothers), are 3D printing face shields for us. Science!
hasn't been published yet, but have been told through academic channels that it has happened in both NYC and Detroit. please just take your own protection very seriously, we need you around for the next sick patient that needs your help.
there are rumors of this spreading in nyc. have not seen any source other than twitter/instagram...
meanwhile
few weeks ago. called me stat to ED to intubate patient in covid unit . SaO2 reading <60. Of course they did not have PPE ready for me when i got there. ED staff yelling, HURRY HE NEEDS TO BE INTUBATED. I told them not until i get my PPE.
Arch Guillotti
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My question is why are you going to the ED to intubate a patient? Can't they do it themselves? Or do you have a COVID "intubation team"?
it was a reintubation. ED previously intubated patient and took 3 attempts, so they decided to call anesthesiology
Just because you are in your 20s, doesnt mean you dont have risk factors. We had an OMS 2 pass away last year who had longstanding IDDM. Obesity seems to be a risk factor also. We have more than a few students with BMI 30 or much higher.
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Here's a reddit link...
Most of it seems like heard from a friend of a friend but the first comment has the name of the Detroit resident.
I haven't seen anything official but I know my wife told me that it was being discussed on the Lives of Doctors Wives Facebook group.
a lot of places are discussing. none have provided a credible source. not saying it's not true, but we havent seen any credible source.
Hard policy for our anesthesia department with hospital in full agreement - full PROPER PPE before we go in the room. Particularly for the known Covid + patients or PUI, that means gown, double gloves, N95, ortho hood or full face protection, etc. The hospital staff has been terrible about having everything ready for intubations - so we're bringing all of OUR supplies with us - but they have to have suction all hooked up, vent ready, etc. For codes - again, full PPE is mandatory before we go in the room. Clearly stated hospital policy is chest compressions only till airway is secure. We have a designated intubation team that has practiced with getting ready quickly. They got PAPR training yesterday. Unless the intubation team is already occupied, the rest of us do not go to codes or intubations out of the OR so that we can minimize exposing additional personnel unnecessarily.
Purellbath
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We have around 80 intubated covid-19 patients where I work. Almost all are obese. I don’t have the exact number but probably half are morbidly obese. I live in a city with lots of obesity though. Are people in thinner cities also finding your severe covid patients are mostly obese?
The info we really need is what percent of patients that get coded walk out of the hospital? If it's zero you could save a bunch of PPE.
Edit. posted before I saw the question about obesity but that would be good info too. What percent of morbidly obese survive intubation to walk out of the hospital?
Edit. posted before I saw the question about obesity but that would be good info too. What percent of morbidly obese survive intubation to walk out of the hospital?
Arch Guillotti
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Fair enough. I would take as much time as I needed though. I ain't no hero.
Have your department make up bags of proper ppe that you can grab and bring with you to stat intubations. You shouldn't depend on the nursing staff to gather up everything for you. I doubt they will have enough and most of them won't even care if you're properly protected.
yes we literally did this later during the day. it was early and i dont think hospital/department was prepared yet for the covid unfortunately
Why is New Orleans' coronavirus death rate twice New York's? Obesity is a factor
The coronavirus has been a far deadlier threat in New Orleans than the rest of the United States, with a per-capita death rate twice that of New York City. Doctors, public health officials and available data say the Big Easy's high levels of obesity and related ailments...
Nope. 6th year resident in Detroit. Oral surgery. Didn't necessarily get it from a patient, but definitely and unfortunately dead.
this isn't an ethical quandary nor do you need a official policy - do nothing without PPE. the PPE is to keep you around for future patients not just THIS one - whether you're out because covid makes you sick or it kills you; even if you're someone so altruistic you'd forgo your own health (which I am not) to "save" one person, what of all the patients you have yet to care for?
that one is confirmed. but nyc ones are not
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Personally, I like to intubate patients with my wiener hanging out. Under the circumstances though, I'd have to oblige to wearing proper PPE prior to doing an aerosolizing procedure.
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deleted162650
Re: the OP question -
I’ve thought about this quite a bit. There’s near 80% mortality for CoV patients requiring intubation. Me running in to get CoV from a patient that’s (statistically) likely to die isn’t the best use of my skill set. I’m sure there are ethical and legal issues I haven’t considered; I’m interested to see how the tort claims from the CoV era settle out.
As noted legal scholar & pandemic specialist Ice Cube once said: “I’d rather be judged by 12 than carried by 6”.
I’ve thought about this quite a bit. There’s near 80% mortality for CoV patients requiring intubation. Me running in to get CoV from a patient that’s (statistically) likely to die isn’t the best use of my skill set. I’m sure there are ethical and legal issues I haven’t considered; I’m interested to see how the tort claims from the CoV era settle out.
As noted legal scholar & pandemic specialist Ice Cube once said: “I’d rather be judged by 12 than carried by 6”.
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deleted87051
Step 1. Find PPE
That's going to be very interesting. As terrible as this sounds, if there's nobody around to see what's happening, who's going to raise a lawsuit? Staff? The dead patient?
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deleted171991
There will be a lot of medical records subpoenaed after all this is over. Families will want to know the story of their loved ones. If nurse writes "anesthesia refused to intubate patient, patient coded etc.", good luck.
My advice is to document the hell out of every situation like this. "Called to intubate. Unable to enter room due to lack of PPE (specifically A, B, C). Alternatives such as D, E, or F not available either. Discussed with Dr X, nurse Y, nurse supervisor Z."
I'm starting to equate these situations as though the patients were covered in plutonium that had leaked from a faulty nuclear reactor. Would you go into the room to treat the burns without a radiation suit?
Nobody is getting anything until the PPE fairy arrives with my PAPR, gown and gloves. Sorry if it’s not in time. They should have called earlier.
The majority of extremely ill Covid 19 patients are going to die. In particular, the ones with low Sats, Fat with DM or Prediabetic. We know their mortality is over 80%.
So, why risk the health of your FAMILY and you in that situation? Perhaps, Prayer as you don your PPE would be the most appropriate course of action. Even if you don't get sick personally you may infect your wife or relative. You could end up self-quarantined for 2 weeks unable to work.
At a minimum you need good eye protection, N95 mask, face shield, shoe covers, gown, gloves x 2 (double glove) and maybe even some duct tape.
The only part I would be willing to "skip" is the duct tape.
So, why risk the health of your FAMILY and you in that situation? Perhaps, Prayer as you don your PPE would be the most appropriate course of action. Even if you don't get sick personally you may infect your wife or relative. You could end up self-quarantined for 2 weeks unable to work.
At a minimum you need good eye protection, N95 mask, face shield, shoe covers, gown, gloves x 2 (double glove) and maybe even some duct tape.
The only part I would be willing to "skip" is the duct tape.
There are zero legal issues as far as I am concerned. The mortality rate is so high that legal action is unlikely and even more unlikely to be successful. Of course, you should document the availability of PPE on the chart.
Remember that your viral dose as a healthcare worker without proper PPE will be much larger than that of the average dude who gets a mild case and just shrugs the illness off. Maybe through treating hundreds of patients you will get exposed to more than one strain during the incubation stage, which will make the job that much harder for your immune system. On top of all that, you are probably overworked, getting poor sleep, and stressed out. Due to the nature of the work, we are playing this game on extra hard difficulty, and this may or may not outweigh you not being that fat or that old. It's no joke. As a resident there is not much I can do but to walk into the reactor core if told to by admin and hope my body can take it, but as an attending you can at least quit if the risks placed on your health and life outweigh the temporary loss of income.
agree 100%. Obesity has been a unifying characteristic in our sicker cohort.
Just wanted to point out that as a resident you fall under the category of “ethically vulnerable” individuals, which is why you might feel helpless to resist self-endangerment orders (it feels like your job and future depend on compliance). I want to urge you to stand up for yourself. In the end it will not go well for program directors who have to defend endangering their charges. At the very least, a residency that places no value on your personal safety is not a residency worth completing. Remember, you can’t be a good anesthesiologist if you are dead.
Listen to this guy dude/dudette. I'm a resident too (an Army resident too no less) and I feel your pain, but DO NOT subject yourself to potential death just because a superior told you to. I know as **** that's easier said than done, but you still NEED to stand up for yourself. Your program director themselves should be on this **** and stating in no plain terms that you ARE NOT to sacrifice yourself because someone else told you to. Our program director has been pretty damn specific in telling us to report any of that sort of behavior to him.
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At our hospital we have a designated Covid intubation team made up of two anesthesiologists. They line the patient up after intubation. This is to offload the Intensivists and limit cxr’s. Hospital policy is no covid or pui is to be intubated by anyone but this team - no exceptions, even code.
Already had one instance where er tubed a pui because team was occupied (actually pt likely could have waited anyway). CMO came down hard on the doc.
At first there was a lot of people stating they wouldn’t standby and let someone die if they could step in and intervene. I think after the last week everyone has come around.
Already had one instance where er tubed a pui because team was occupied (actually pt likely could have waited anyway). CMO came down hard on the doc.
At first there was a lot of people stating they wouldn’t standby and let someone die if they could step in and intervene. I think after the last week everyone has come around.
As a resident you all need to band together and stand up for yourselves. You have rights but it would be more difficult to go at it alone. Not that you can’t, but you shouldn’t put yourself in danger because some administrators in an office say so.
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I suspect survivability of cardiac arrest in Covid patient is 0.0%
Wow, this pop quiz is easy - no intubation. Next!
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deleted697535
Yeah Na. Like what's the point tubing em even, if no one has ppe? Whatever about us not having ppe, but no nurse even? Forget it. I might tube em but I'm sure as **** not staying in the room for longer than 50 seconds.
I put ketofolurounium into a 30ml syringe syringe so you could just give that to the nurse to push. Run in the room at 50 seconds and snorkel em. That's some pretty good cough syrup
I put ketofolurounium into a 30ml syringe syringe so you could just give that to the nurse to push. Run in the room at 50 seconds and snorkel em. That's some pretty good cough syrup
