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polarbebe

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About polarbebe

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  1. Names of healthcare workers that have passed. Several PAs are listed. https://www.medscape.com/viewarticle/927976 May they never be forgotten.
  2. I have been working in critical care for 9 years in a major metropolitan hospital “the epicenter”. Everything that is reported in mainstream media regarding the surge in patients is accurate. I have seen healthy 40 year olds intubated in my ICU, spoken to intensivists working at a sister hospital caring for 20 year olds intubated. Several ER staff at my hospital system are also intubated. So far two (as far as I know) PAs have passed, as of last week at least 41 doctors in Italy have passed. James Cai the first N.J. COVID case and a PA-C, as of last week was home on O2 after developing pulmonary fibrosis from ARDS. Heard recently though a fellow ICU PA colleague, a healthy 29 y/o female passed last week. I have read of a physician camping in the garage away from his family. Also heard of hospital workers living together away from their family. Yes, I have taken precautions. Perhaps extreme... Currently I am living away from my family and will continue do so as long as feasible due to possible asymptomatic spread. Stay safe.
  3. https://www.stripes.com/news/us/new-jersey-national-guard-member-is-first-coronavirus-death-in-the-military-1.624269 A NJ PA.
  4. Please lets avoid sarcasm and personal attacks during this crisis which will likely significantly impact some provider you know or family/friend during this pandemic (40% of hospitalized COVID-19 patients are 20-54 years old in the US). Preliminary data from China shows some patients with lowered lung function 1 month after acute lung injury with significant decreased exercise tolerance (unclear if this will resolve over a longer period of time). What kind of precautions having you been taking when you get home to avoid potentially transmitting it to your family? I have been taking off all my external clothes, showering immediately , wiping down surfaces after touching and quarantined myself in the bedroom of my apartment away from my family. Also looking to sublet a studio but prices in the metro area are ridiculous.
  5. After this statement I find it more difficult to objectively take your opinion/argument seriously when lavishing such praise on our President. Your argument that comparing government response of South Korea (or even Taiwan) to the USA is “disingenuous” as you say. Granted this is not a great comparison given the differences between countries as you noted. How about let’s compare India (another democracy) to the US response? India has FOUR times the population of the US and a far less developed medical system, less infrastructure, massive slums and with a far higher poverty rate but through very early and aggressive interventions (despite close geographic distance and huge amount of commerce/travel between the countries) has so far greatly minimized the number of cases (remains to be seen if this holds but due to reasons above is at higher risk for catastrophic spread). Objectively the President has done a few things early and aggressively (shutting down travel from China) but the prior two months he spent downplaying the then epidemic (“This is their new hoax” and on, Feb. 24 (tweet): "The Coronavirus is very much under control in the USA. … Stock Market starting to look very good to me!") with FOX news relay his talking points to half the nation (misinforming the public it is less serious than the flu)... CDC with botched roll out of tests and strict guidelines of not doing community testing early on hampering mitigation efforts, Bolton disbanding pandemic team. No doubt this crisis would be a challenge for any administration (with multiple missteps by anyone) but to say no leader is doing a better job... I respectfully disagree. At the major metropolitan hospital system where I work in the ICU everyone gets plaquenil after discussion with ID.
  6. NY state has guidelines of allocation of ventilators: https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf SCCM have made their Fundamentals of Disaster Management modules for free. Highly encourage everyone to watch them: https://www.sccm.org/disaster
  7. Got this email. Looks like their healthcare system is overwhelmed and likely significant staff quarantined. MAPA has received a request for PAs to help in both Washington State and San Carlos, CA Please send ALL inquires directly to atarianna.furr@ami.health for more information DO NOT CONTACT MAPA Please see below the details for AMI’s response in Kirkland, Washington this upcoming Monday 15th. AMI is looking for U.S. based Nurse Practitioners (NP), Physicians Assistants (PA) and Registered Nurses (RN) to join our team for an IMMEDIATE response effort in support of COVID-19. The response team will be deployed to Kirkland, Washington on the 15th of March. The team will consist of 30 registered nurses and 6 PAs/NPs. This response is in support of current efforts at the Life Care Center facility providing medical care to individuals with COVID-19 and those exposed to COVID-19. All Personal Protective Equipment (PPE) per the CDC standards will be provided. This project will be a minimum of 14 workdays. Personnel will be AMI contracted consultants under a contract AMI has with the Department of Health and Human Services. HHS already has staff onsite that will provide a handoff to our staff. Location: Life Care Center in Kirkland, Washington. Deployment date: March 15th, 2020. Positions available: 3 Three shifts a day, each shift is 8 hours. Shifts will be 10 RNs and 2 PAs/NPs on at a time. Travel and accommodation are covered by AMI. Accommodation in the form of hotel rooms. Please see the rates below to share with any RN, PA, NP connections you may have. Please have them contact me directly atarianna.furr@ami.health for more information. Visit us online at ami.health
  8. polarbebe

    COVID-19

    I can not verify the authenticity of the below post but it was forwarded by an ICU PA I know and reportedly posted by an intensivist in Seattle: “Intensivist front line in Seattle” * we have 21 pts and 11 deaths since 2/28. * we are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen. * US has been past containment since January * Currently, all of ICU is for critically ill COVIDs, all of floor medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New resp-sx pts Pulmonary Clinic offshoot is open * CDC is no longer imposing home quarantine on providers who were wearing only droplet iso PPE when intubating, suctioning, bronching, and in one case doing bloody neurosurgery. Expect when it comes to your place you may initially have staff home-quarantined. Plan for this NOW. Consider wearing airborne iso PPE for aerosol-generating procedures in ANY pt in whom you suspect COVID, just to prevent the mass quarantines. * we ran out of N95s (thanks, Costco hoarders) and are bleaching and re-using PAPRs, which is not the manufacturer's recommendation. Not surprised on N95s as we use mostly CAPRs anyway, but still. *terminal cleans (inc UV light) for ER COVID rooms are taking forever, Enviro Services is overwhelmed. Bad as pts are stuck coughing in the waiting room. Rec planning now for Enviro upstaffing, or having a plan for sick pts to wait in their cars (that is not legal here, sadly). * CLINICAL INFO based on our cases and info from CDC conf call today with other COVID providers in US: * the Chinese data on 80% mildly ill, 14% hospital-ill, 6-8% critically ill are generally on the mark. Data very skewed by late and very limited testing, and the number of our elderly pts going to comfort care. - being young & healthy (zero medical problems) does not rule out becoming vented or dead - probably the time course to developing significant lower resp sx is about a week or longer (which also fits with timing of sick cases we started seeing here, after we all assumed it was endemic as of late Jan/early Feb). - based on our hospitalized cases (including the not formally diagnosed ones who are obviously COVID - it is quite clinically unique) about 1/3 have mild lower resp sx, need 1-5L NC. 1/3 are sicker, FM or NRB. 1/3 tubed with ARDS. Thus far, everyone is seeing: - nl WBC. Almost always lymphopenic, occasionally poly-predominant but with nl total WBC. Doesn't change, even 10days in. - BAL lymphocytic despite blood lymphopenic (try not to bronch these pts; this data is from pre-testing time when we had several idiopathic ARDS cases) - fevers, often high, may be intermittent; persistently febrile, often for >10d. It isn't the dexmed, it's the SARS2. - low ProCalc; may be useful to check initially for later trending if later concern for VAP etc. - up AST/ALT, sometimes alk phos. Usually in 70-100 range. No fulminant hepatitis. Notably, in our small sample, higher transaminitis at admit (150-200) correlates with clinical deterioration and progression to ARDS. LFTs typically begin to bump in 2nd week of clinical course. - mild AKI (Cr <2). Uncertain if direct viral effect, but notably SARS2 RNA fragments have been identified in liver, kidneys, heart, and blood. * characteristic CXR always bilateral patchy or reticular infiltrates, sometimes perihilar despite nl EF and volume down at presentation. At time of presentation may be subtle, but always present, even in our pts on chronic high dose steroids. NO effusions. CT is as expected, rarely mild mediastinal LAD, occ small effusions late in course which might be related to volume status/cap leak. * Note - China is CT'ing everyone, even outpts, as a primarily diagnostic modality. However, in US/Europe, CT is rare, since findings are nonspecific, would not change management, and the ENTIRE scanner and room have to terminal-cleaned, which is just impossible in a busy hospital. Also, transport in PAPRs. Etc. 2 of our pts had CTs for idiopathic ARDS in the pre-test era; they looked like the CTs in the journal articles. Not more helpful than CXR. - when resp failure occurs, it is RAPID (likely 7-10d out from sx onset, but rapid progression from hospital admit). Common scenario for our pts is, admit 1L NC. Next 12hrs -> NPPV. Next 12-24hrs -> vent/proned/Flolan. - interestingly, despite some needing Flolan, the hypoxia is not as refractory as with H1N1. Quite different, and quite unique. Odd enough that you'd notice and say hmmm. - thus far many are dying of cardiac arrest rather than inability to ventilate/oxygenate. - given the inevitable rapid progression to ETT once resp decompensation begins, we and other hosps, including Wuhan, are doing early intubation. Facemask is fine, but if needing HFNC or NPPV just tube them. They definitely will need a tube anyway, & no point risking the aerosols. - no MOSF. There's the mild AST/ALT elevation, maybe a small Cr bump, but no florid failure. except cardiomyopathy. - multiple pts here have had nl EF on formal Echo or POCUS at time of admit (or in a couple of cases EF 40ish, chronically). Also nl Tpn from ED. Then they get the horrible resp failure, sans sepsis or shock. Then they turn the corner, off Flolan, supined, vent weaning, looking good, never any pressor requirement. Then over 12hrs, newly cold, clamped, multiple-pressor shock that looks cardiogenic, EF 10% or less, then either VT->VF-> dead or PEA-> asystole in less than a day. Needless to say this is awful for families who had started to have hope. - We have actually had more asystole than VT, other facilities report more VT/VF, but same time course, a few days or a week after admit, around the time they're turning the corner. This occurs on med-surg pts too; one today who is elderly and chronically ill but baseline EF preserved, newly hypoTN overnight, EF<10. Already no escalation, has since passed, So presumably there is a viral CM aspect, which presents later in the course of dz. - of note, no WMAs on Echo, RV preserved, Tpns don't bump. Could be unrelated, but I've never seen anything like it before, esp in a pt who had been HD stable without sepsis. Treatment - *Remdesivir might work, some hosps have seen improvement with it quite rapidly, marked improvement in 1-3 days. ARDS trajectory is impressive with it, pts improve much more rapidly than expected in usual ARDS. *Recommended course is 10d, but due to scarcity all hosps have stopped it when pt clinically out of the woods - none have continued >5d. It might cause LFT bump, but interestingly seem to bump (200s-ish) for a day or 2 after starting then rapidly back to normal - suggests not a primary toxic hepatitis. *unfortunately, the Gilead compassionate use and trial programs require AST/ALT <5x normal, which is pretty much almost no actual COVID pts. Also CrCl>30, which is fine. CDC is working with Gilead to get LFT reqs changed now that we know this is a mild viral hepatitis. -currently the Gilead trial is wrapping up, NIH trial still enrolling, some new trial soon to begin can't remember where. *steroids are up in the air. In China usual clinical practice for all ARDS is high dose methylpred. Thus, ALL of their pts have had high dose methylpred. Some question whether this practice increases mortality. *it is likely that it increases seconday VAP/HAP. China has had a high rate of drug resistant GNR HAP/VAP and fungal pna in these pts, with resulting increases mortality. We have seen none, even in the earlier pts who were vented for >10d before being bronched (prior to test availability, again it is not a great idea to bronch these pts now). - unclear whether VAP-prevention strategies are also different, but wouldn't think so? - Hong Kong is currently running an uncontrolled trial of HC 100IV Q8. - general consensus here (in US among docs who have cared for COVID pts) is that steroids will do more harm than good, unless needed for other indications. - many of our pts have COPD on ICS. Current consensus at Evergreen, after some observation & some clinical judgment, is to stop ICS if able, based on known data with other viral pneumonias and increased susceptibility to HAP. Thus far pts are tolerating that, no major issues with ventilating them that can't be managed with vent changes. We also have quite a few on AE-COPD/asthma doses of methylpred, so will be interesting to see how they do. -name removed per their request.
  9. This. Without testing and appropriate surveillance (those with risk factors) you can’t quarantine, make policies effectively, deploy resources most efficiently. Need to “flatten the curve”. South Korea was able to limit the spread by performing over 220,000 tests. The US? As of 3/10 performed about 11,000 tests. CDC really screwed up. Italian intensivists have run out of ventilators (making decisions on allocations of limited resources such as vents, basically mass casualty triage in the ICU) and are treating ICU patients in the corridors. Basically what happened also at ground zero (Wuhan). https://www.google.com/amp/s/www.euronews.com/amp/2020/03/12/coronavirus-italy-doctors-forced-to-prioritise-icu-care-for-patients-with-best-chance-of-s I read a post from an intensivist from Seattle that one ICU is only COVID-19 patients and med/surg for stable COVID-19 and end of life care. Haven’t been able to confirm this from other sources though. The same post also said most death from cardiac arrest not hypoxia/ARDS... ? Due to possible sepsis cardiomyopathy or viral myocarditis with normal EF reduced to ~10% several days later. Mixed shock states of sepsis plus cardiogenic = death. NY state has guidelines of allocation of ventilators: https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf SCCM have made their Fundamentals of Disaster Management modules for free. Highly encourage everyone to watch them: https://www.sccm.org/disaster Lastly, I recommend everyone get their affairs in order and make sure your family is taken care of in case something happens to you... A NJ PA is on high-flow NC due to COVID-19 (you can google him, he has been all over the press). Stay safe.
  10. I work in a state where a masters is not required. Experience counts more than a masters in PA studies. If you plan to make yourself more marketable and want to have more doors opened for you later in your career do yourself a favor and skip a masters in PA studies (adds nothing clinically and does not help with management) but get a MBA or MPH so you can climb the hospital administration ladder (chief PA, director, etc).
  11. Has anybody found any literature on this topic? The only article we found so far: "Professional Advancement for Advanced Practice Clinicians" found in JNP, Journal for Nurse Practitioners, Volume 14, Issue 1, January 2018 Authored by: Carmel McComiskey, CPNP-AC/PC, Shari Simone, DNP, CPNP-AC, Deborah Schofield, DNP, ANP-BC, Karen McQuillan, MS, CNS-BC, RN, Brooke Andersen, M Thanks in advance.
  12. Congratulations on accepting the offer. Working with the sickest and most complex patients will make you a better clinician and help you get noticed if/when you move on (generally easier to move down in patient acuity then up). I agree hospitals can pay whatever they want but I disagree that working in a higher level acuity (critical care) does not demand higher compensation than a hospitalist AP. Intensivists are paid higher than hospitalists for a reason (more training required and sicker patients with far less room for error). Hospital will find retaining highly trained and experienced PAs to run an ICU very challenging without appropriate high level compensation as approximately 1% of PAs are in critical care... and the difference in care between a PA with 2-3 years of experience is very different from > 8-10+ years in a emergent life threatening scenario. PAs are trained in primary care. A new grad PA has to learn internal medicine then build upon that foundation to practice critical care. In general critical care is one of the top 5 paying specialities.
  13. So after half a year, several committees have been formed with the mission to “standardize, engage, professionally develops PAs into leadership, education, research or clinical expert role to promote job satisfaction, retention which will turn into best practice and improved patient outcomes” If you know of any systems or institutions that have implemented any type of structure (successful or unsuccessful) I would really like to learn from it and how you thought it may or may not have benefitted any APPs Thank you in advance.
  14. HR 70s on presentation argues against acute pericardial tamponade or other causes of acute obstructive shock; however could have a chronic compensated obstructive process (quick POCUS to help evaluate undifferentiated shock may be helpful to r/o tamponade but studies shown that it doesn’t improve mortality...though there are many potential holes in this study) https://journalfeed.org/article-a-day/2018/pocus-for-shock-dont-be-shoc-ed Definitely agree given hypothermia (without environmental exposure factors) is most likely septic shock until proven otherwise. TSH is extremely reasonable given hypothermia, hypotension, AMS... Procalcitonin has not been validated for screening for sepsis as it has a low sensitivity (~80%) in a pathology with a high mortality (~18-29% from the PROMISE , ARISE and PROCESS trials). It it has been validated for the de-escalation of antibiotics in patients that have a clinical picture not suggestive of a bacterial infection. It also can be used to trend and can shorten the duration of inpatient antibiotics without mortality difference. In the inexperienced provider due to the low sensitivity it may sway clinical decision making against antibiotics which would be VERY worrisome. ICU/ER PA
  15. https://www.beckershospitalreview.com/quality/care-concerns-emerge-from-missouri-s-assistant-physician-licensure-program.html
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