Clinical Pearls Covid 19 for ER practitioners

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Eponymous
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In reply to Ag_of_08 • 10:53p, 3/25/20
Ag_of_08 said:
...The face shield frames are great if I could find clear lexan, I could make them by the dozen, but I dont have a source for the guard materials.

I will print anything that could be helpful at this point with the supplies I have *shrug*


Don't know if this will help, obviously much thinner than Lexan, but I had some laminate sheets *that had been through the laminator* and have been working at home on shaping them to be face guards.

At work I had to laminate papers and posters, and this is the parts of the laminate sheets that were cut off after laminating.

Extra pieces like that were common and thrown out. A private school if they are closed might be willing to donate to you for the purpose?
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vettmaster99
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In reply to mernaggie12 • 11:16p, 3/25/20
AG
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
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Reveille
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In reply to vettmaster99 • 11:21p, 3/25/20
AG
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
There is already significant resistance to azithromycin.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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elchucoag93
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11:25p, 3/25/20
AG
God be with you and your colleagues nawlinsag. Thank you
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JTA1029
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11:35p, 3/25/20
AG
You're awesome. God bless. Seriously, doctors and nurses and everyone on the front lines of this thing. Thank you.

I havent seen much said about asthma and if it's worse if you're an asthmatic. Can you talk to that, if you get time?

Nevermind I just saw it was answered on the previous page. Maybe I should work from home. I have pretty much all the "puts you at higher risk" boxes checked.
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KidDoc
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In reply to vettmaster99 • 11:37p, 3/25/20
AG
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
Yeah I have patients using the insurance company's teledoc who looks at their throat on video and says "that looks like strep here is a z-pack".

Wrong on every level and I would be penalized 4% of my income if I did the same thing but for some reason insurances love teledocs for this and do not penalize them.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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TexasAggieMike
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3:23a, 3/26/20
AG
Texas EM PA here. I'm so glad you took the time to rewrite this. Spreading it around to my circles. We know it's coming.
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Ag_of_08
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In reply to Eponymous • 3:31a, 3/26/20
AG
Eponymous said:
Ag_of_08 said:
...The face shield frames are great if I could find clear lexan, I could make them by the dozen, but I dont have a source for the guard materials.

I will print anything that could be helpful at this point with the supplies I have *shrug*


Don't know if this will help, obviously much thinner than Lexan, but I had some laminate sheets *that had been through the laminator* and have been working at home on shaping them to be face guards.

At work I had to laminate papers and posters, and this is the parts of the laminate sheets that were cut off after laminating.

Extra pieces like that were common and thrown out. A private school if they are closed might be willing to donate to you for the purpose?


I may be able to get donations through mom. Let me see what the next couple of days bring, I've got a request for a crapload of masks, and will probably be able to fit frames on the build plate to, I'm hoping by friday the printer is running pretty much 24/7
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Dr. Not Yet Dr. Ag
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In reply to Dr. Not Yet Dr. Ag • 4:33a, 3/26/20
Dr. Not Yet Dr. Ag said:
I've got several doc friends in NOLA that are giving identical stories. The kind of stuff you and they are talking about are things I'd never have expected to see as a physician. I went from seeing none of these patients, to 10 of them in the last 2 days. All of them so far mild. I'm sure that this will change in the next day or two. As i told some of my colleagues, based on the number of mild cases I'm seeing, **** is about to hit the fan.
Another day, another 5 seen, 2 are confirmed, the other 3 told they should assume they have it. Our hospital system is about to run out of rapid test kits and the local health department has asked us to no longer send them swabs from patients that are being discharged (that was apparently a thing for about 4 days before they were so inundated with swabs that they had to stop it).

All the cases so far have remained mild, thankfully, although I suspect most are early in the disease process. Ages range from 20-80+. Can't rely on the chief complaint to be the typical viral syndrome, as I have had one who came in for abdominal pain and another was an older gentleman with altered mental status. Many of them don't have fever. Several of them have pretty unremarkable lab work, although many have several of the typical lab or imaging abnormalities. Many of these patients are being seen by healthcare workers w/o proper PPE due to atypical complaints. One of the confirmed patients was brought in by EMS without any PPE on whatsoever, although I don't think they realized that this patient was at risk for having it. Unfortunately, after talking with some of my local EMS friends, they are getting absolutely no education regarding ways to protect themselves, and who they should suspect this in, at least according to them.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Reveille
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In reply to KidDoc • 6:37a, 3/26/20
AG
KidDoc said:
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
Yeah I have patients using the insurance company's teledoc who looks at their throat on video and says "that looks like strep here is a z-pack".

Wrong on every level and I would be penalized 4% of my income if I did the same thing but for some reason insurances love teledocs for this and do not penalize them.


Don't want to even get started on insurance companies teledoc! I personally think it is a conflict if interest having a physician who is essentially owned by the insurance company making decisions for patients.

Doctors should only have the patient in mind when treating the patient not what's the least expensive things we can do.

However, with many telemedicine restrictions listed hopefully that is one there few good things that will come out of this. Patients will call thier personal doctor for a televists instead of the insurance companies.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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KidDoc
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In reply to Reveille • 8:46a, 3/26/20
AG
Reveille said:
KidDoc said:
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
Yeah I have patients using the insurance company's teledoc who looks at their throat on video and says "that looks like strep here is a z-pack".

Wrong on every level and I would be penalized 4% of my income if I did the same thing but for some reason insurances love teledocs for this and do not penalize them.


Don't want to even get started on insurance companies teledoc! I personally think it is a conflict if interest having a physician who is essentially owned by the insurance company making decisions for patients.

Doctors should only have the patient in mind when treating the patient not what's the least expensive things we can do.

However, with many telemedicine restrictions listed hopefully that is one there few good things that will come out of this. Patients will call thier personal doctor for a televists instead of the insurance companies.
We are being told to put this statement in every single telephone visit we try to bill. The regs are so crazy!

The patient was seen today via Telemedicine by agreement and consent of patient in light of current COVID-19 pandemic. The visit was conducted by using the telephone. This patient encounter is appropriate and reasonable under the circumstances given the patient's particular presentation at this time. The patient has been advised of the potential risks and limitations of this mode of treatment (including but not limited to the absence of in-person examination) and has agreed to be treated in a remote fashion in spite of them. Any and all of the questions from the patient/patient's family on this issue have been answered and I have made no promises or guarantees to the patient. The patient has been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Granitestate
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9:34a, 3/26/20
I am not a doctor

I have been reading the medrxiv boards and found this (yet to be peer reviewed) report indicating blood type may play a factor. Not sure if it is useful but thought I would share.

https://www.medrxiv.org/content/10.1101/2020.03.11.20031096v1

Good luck and God speed!
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Reveille
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In reply to KidDoc • 10:48a, 3/26/20
AG
KidDoc said:
Reveille said:
KidDoc said:
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
Yeah I have patients using the insurance company's teledoc who looks at their throat on video and says "that looks like strep here is a z-pack".

Wrong on every level and I would be penalized 4% of my income if I did the same thing but for some reason insurances love teledocs for this and do not penalize them.


Don't want to even get started on insurance companies teledoc! I personally think it is a conflict if interest having a physician who is essentially owned by the insurance company making decisions for patients.

Doctors should only have the patient in mind when treating the patient not what's the least expensive things we can do.

However, with many telemedicine restrictions listed hopefully that is one there few good things that will come out of this. Patients will call thier personal doctor for a televists instead of the insurance companies.
We are being told to put this statement in every single telephone visit we try to bill. The regs are so crazy!

The patient was seen today via Telemedicine by agreement and consent of patient in light of current COVID-19 pandemic. The visit was conducted by using the telephone. This patient encounter is appropriate and reasonable under the circumstances given the patient's particular presentation at this time. The patient has been advised of the potential risks and limitations of this mode of treatment (including but not limited to the absence of in-person examination) and has agreed to be treated in a remote fashion in spite of them. Any and all of the questions from the patient/patient's family on this issue have been answered and I have made no promises or guarantees to the patient. The patient has been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.


Thanks kiddoc

I like that disclosure! I will probably use that too!
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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vettmaster99
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In reply to KidDoc • 11:10a, 3/26/20
AG
KidDoc said:
Reveille said:
KidDoc said:
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
Yeah I have patients using the insurance company's teledoc who looks at their throat on video and says "that looks like strep here is a z-pack".

Wrong on every level and I would be penalized 4% of my income if I did the same thing but for some reason insurances love teledocs for this and do not penalize them.


Don't want to even get started on insurance companies teledoc! I personally think it is a conflict if interest having a physician who is essentially owned by the insurance company making decisions for patients.

Doctors should only have the patient in mind when treating the patient not what's the least expensive things we can do.

However, with many telemedicine restrictions listed hopefully that is one there few good things that will come out of this. Patients will call thier personal doctor for a televists instead of the insurance companies.
We are being told to put this statement in every single telephone visit we try to bill. The regs are so crazy!

The patient was seen today via Telemedicine by agreement and consent of patient in light of current COVID-19 pandemic. The visit was conducted by using the telephone. This patient encounter is appropriate and reasonable under the circumstances given the patient's particular presentation at this time. The patient has been advised of the potential risks and limitations of this mode of treatment (including but not limited to the absence of in-person examination) and has agreed to be treated in a remote fashion in spite of them. Any and all of the questions from the patient/patient's family on this issue have been answered and I have made no promises or guarantees to the patient. The patient has been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.


This is a good disclosure. Do you have them sign/agreeing to the terms of service remotely or just obtaining verbal consent? It will be interesting to see if insurance companies will require their hired physicians to do prior authorizations.
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vettmaster99
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11:20a, 3/26/20
AG
On another note, I'm having to limit the quantity to dispense on certain inhalers and other maintenance medications for chronic conditions. We are having a lot of medications go on backorder and we just don't know when more will be coming. So you may see more drug change requests from pharmacy. Also, since a lot of physicians are on this thread just a heads up as of 3-20-2020:

1 TITLE 22 EXAMINING BOARDS
2 PART 15 TEXAS STATE BOARD OF PHARMACY
3 CHAPTER 291 PHARMACIES
4 SUBCHAPTER A ALL CLASSES OF PHARMACIES
5 291.30. Medication Limitations.
6 No prescription or medication order for chloroquine, hydroxychloroquine, mefloquine, or
7 azithromycin may be dispensed or distributed unless all the following apply:
8 (1) the prescription or medication order bears a written diagnosis from the prescriber consistent
9 with the evidence for its use;
10 (2) the prescription or medication order is limited to no more than a fourteen (14) day supply,
11 unless the patient was previously established on the medication prior to the effective date of this
12 rule; and
13 (3) no refills may be permitted unless a new prescription or medication order is furnished.

https://www.pharmacy.texas.gov/files_pdf/291.30.pdf

If you get a call about these medications from pharmacy this is why.
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Ag9701
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11:25a, 3/26/20
AG
I have a feeling insurance companies will try to push teledoc more citing this pandemic of how great it works.
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AggieTarheel
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11:39a, 3/26/20
AG
Not a medical professional...

However, I have had sinus issues for 25 years. When I get a sinus infection they used to immediately give a Zpac. Now not even HEB rediclinic wants to prescribe it for at least 10 years. I ask for it specifically because it's easy on the stomach and works for a simple sinus infection... until about 3 years ago. I get better but can't fully shake it. Each doctor says the same thing... zpacs are basically useless now.

TLDR... I'd be wary of any doctor prescribing a zpac.
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KidDoc
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In reply to vettmaster99 • 2:30p, 3/26/20
AG
vettmaster99 said:
KidDoc said:
Reveille said:
KidDoc said:
vettmaster99 said:
mernaggie12 said:
Azithromycin is used for its anti-inflammatory properties, including effects on IL-6, in other conditions. This may be the benefit of azithromycin in COVID-19.


Hopefully there isn't much indiscriminate use of azithromycin otherwise we may end up causing more bacterial resistance in the long run.
Yeah I have patients using the insurance company's teledoc who looks at their throat on video and says "that looks like strep here is a z-pack".

Wrong on every level and I would be penalized 4% of my income if I did the same thing but for some reason insurances love teledocs for this and do not penalize them.


Don't want to even get started on insurance companies teledoc! I personally think it is a conflict if interest having a physician who is essentially owned by the insurance company making decisions for patients.

Doctors should only have the patient in mind when treating the patient not what's the least expensive things we can do.

However, with many telemedicine restrictions listed hopefully that is one there few good things that will come out of this. Patients will call thier personal doctor for a televists instead of the insurance companies.
We are being told to put this statement in every single telephone visit we try to bill. The regs are so crazy!

The patient was seen today via Telemedicine by agreement and consent of patient in light of current COVID-19 pandemic. The visit was conducted by using the telephone. This patient encounter is appropriate and reasonable under the circumstances given the patient's particular presentation at this time. The patient has been advised of the potential risks and limitations of this mode of treatment (including but not limited to the absence of in-person examination) and has agreed to be treated in a remote fashion in spite of them. Any and all of the questions from the patient/patient's family on this issue have been answered and I have made no promises or guarantees to the patient. The patient has been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.


This is a good disclosure. Do you have them sign/agreeing to the terms of service remotely or just obtaining verbal consent? It will be interesting to see if insurance companies will require their hired physicians to do prior authorizations.
Verbal only. This is for established patients we are not doing it with new patients. I'm not really taking new patients anyway as I am already overloaded.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Pasquale Liucci
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In reply to Mthakral • 3:09p, 3/26/20
AG
Hey rook. Trying to source a story?
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Tailgate88
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In reply to nawlinsag • 3:15p, 3/26/20
AG
Nawlinsag, just want to let you know we have you and your team in our prayers. Stay strong!
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culdeus
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3:17p, 3/26/20
AG
Daily mail says NOLA is a budding hot spot. I know that site is hot garbage most of the time but I'm greatly worried for you. Please be safe and may you find peace when this is over.

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Mthakral
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In reply to Pasquale Liucci • 3:17p, 3/26/20
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.
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McInnis 03
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In reply to Mthakral • 3:21p, 3/26/20
AG
Mthakral said:
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.


I just searched Facebook using some of the lesser utilized vocab from doc's writeup. Omg, it's getting copied and pasted and shared like crazy, like 1000s and 1000s of people.
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ham98
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In reply to Mthakral • 3:26p, 3/26/20
Mthakral said:
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.
https://texags.com/forums/84/topics/3102278

This is what the site's ownership asked for to vet the original poster.
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Tabasco
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In reply to ham98 • 3:32p, 3/26/20
AG
ham98 said:
Mthakral said:
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.
https://texags.com/forums/84/topics/3102278

This is what the site's ownership asked for to vet the original poster.

Two things for rookies/visitors unfamiliar with Texags.

First, rookies only get five posts per day, but you can edit and add text multiple times until the next day. I forget how many posts gets you past rookie status, and that limitation goes away.

Second, if you found this thread via a link from someone else or using a keyword, there is a whole forum re: Coronavirus. Link below.

Coronavirus/COVID-19 News & Information
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Mthakral
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In reply to ham98 • 3:33p, 3/26/20
Thanks so much for the info!!
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Tabasco
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In reply to Tabasco • 3:36p, 3/26/20
AG
Tabasco said:
ham98 said:
Mthakral said:
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.
https://texags.com/forums/84/topics/3102278

This is what the site's ownership asked for to vet the original poster.

Two things for rookies/visitors unfamiliar with Texags.

First, rookies only get five posts per day, but you can edit and add text multiple times until the next day. I forget how many posts gets you past rookie status, and that limitation goes away.

Second, if you found this thread via a link from someone else or using a keyword, there is a whole forum re: Coronavirus. Link below (or you can click the link at the top of every page of every thread/topic in the forum)

Coronavirus/COVID-19 News & Information
ahhh, that was supposed to be an edit to my last post (to edit, click the pencil icon... lower right of your post), not a reply.
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FriscoKid
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In reply to McInnis 03 • 3:37p, 3/26/20
AG
McInnis 03 said:
Mthakral said:
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.


I just searched Facebook using some of the lesser utilized vocab from doc's writeup. Omg, it's getting copied and pasted and shared like crazy, like 1000s and 1000s of people.
This board might have gone nuclear.

I'm no lawyer, but I think the disclaimer for all the docs is a great idea.
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Thomas Ford 91
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3:44p, 3/26/20
AG
I saw it somewhere else and some of the comments said it was complete BS. The telltale clue...residents don't graduate in May.
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McInnis 03
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In reply to Thomas Ford 91 • 3:47p, 3/26/20
AG
Yeah, that was reddit. They called BS on the ferritin and il6 data in the ER too.
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KidDoc
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In reply to McInnis 03 • 3:50p, 3/26/20
AG
McInnis 03 said:
Mthakral said:
Sorry, I'm a nurse from Boston and a researcher, and found this post on fb. Is that not allowed? People are wanting to share this with administrators and were looking for some source verification.


I just searched Facebook using some of the lesser utilized vocab from doc's writeup. Omg, it's getting copied and pasted and shared like crazy, like 1000s and 1000s of people.
This is how pandemic viral spread works! R0 of his post is likely 10+

No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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ham98
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4:21p, 3/26/20
texags: Our doctors know stuff!
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Copperpot
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In reply to Mthakral • 4:23p, 3/26/20
AG
Mthakral said:
Thanks so much for the info!!
Gig'em!
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TexasAggieMike
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In reply to AggieTarheel • 5:08p, 3/26/20
AG
EM PA who sees azithromycin improperly prescribed allllll the time. Unless it's for chlamydia, pneumonia, or pertussis, the Zpak/azithromycin is often given by clinicians who have a hard time telling patients that their symptoms are likely viral... meaning they don't respond to antibiotics. There are other far better drugs for true bacterial sinus infections. May be best for you to talk to an ENT specialist to see if you really have sinus problems or something else.
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TelcoAg
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5:19p, 3/26/20
AG
Hello facebook and Reddit people. Please take the time to participate in our welcome center forum: https://texags.com/forums/16

If you find out you actually already have an account on this site, it's probably from the dermdoc days
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