A rough week......

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Marcus Aurelius
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10:26a, 1/28/21
AG
I hate to be negative, but sometimes I find this board to be cathartic and necessary to vent, and I am curious to other inpt docs as to current experience. I am about to lose my 4th covid pt in 3 days. Including a 51 y/o father of 4, husband and pastor. All our pts are getting the aggressive drug regimens we have been doing for months. It just feels like for the sick ones who hit the ICU, nothing touches them. Worse than the summer? I am numb. After one dies another is wheeled into the room.

I consulted CTS for ECMO on my 51 y/o the day before he passed. He said "let's try a bumex GTT." A day went by. No response. Sats 75%. He OKd ECMO in am and OR called for him. He coded and died before he made it down.

It seems as if anyone who has renal failure who requires RRT mortality near 100%.

My hospital is questioning monoclonal ab use with dex. So we have to choose and I am reluctant to stop dex.

Anyway. Sorry to rant. Appreciate other's experience now.
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Charpie
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In reply to Marcus Aurelius • 10:43a, 1/28/21
AG
I'm so sorry.
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JSCDO
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11:02a, 1/28/21
can only speak from outpatient experience but I too have noted that my patients with CKD and patients with DM requiring insulin do very poorly. Of course a large portion of DM patients have associated Nephropathy. That seems to be key, CKD=poor outcome.
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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In reply to JSCDO • 11:15a, 1/28/21
3rd Generation Ag
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11:22a, 1/28/21
AG
Not a doctor, but just learned that a family friend is having kidney failure as part of his covid situation and was offered pallitive care rather than stay on oxygen support. He is cognizant and his children are leaving the decision in his hands. I really did not know covid could hit the kidneys. His wife, a dear friend to many of us died yesterday in the same hospital..she was in better shape, then suddently faded fast. Both in late 70s but both also lean and in shape for their age.
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Capitol Ag
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11:37a, 1/28/21
AG
I know the Dr. is busy, but can someone translate a few of the abbreviations for us that aren't well versed in medical terminology?

Hope things take a better turn for you Doc. Know that we are all praying for you guys and your patients.
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In reply to Capitol Ag • 11:46a, 1/28/21
MiMi
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11:48a, 1/28/21
S
CTS - cardiothoracic surgery
ECMO - extracorporeal membrane oxygenation
bumex GTT - bumetanide drip or infusion
CKD - chronic kidney disease
DM - diabetes mellitus
RRT - renal replacement therapy
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plain_o_llama
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11:49a, 1/28/21
not a doc but I suspect these are some of the acronyms


CKD - chronic kidney disease
RRT - renal replacement therapy
ECMO - extracorporeal membrane oxygen https://www.mayoclinic.org/tests-procedures/ecmo/about/pac-20484615

and two beat me to it. :-)


<edit to remove mistake>
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Windy City Ag
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In reply to JSCDO • 11:50a, 1/28/21
AG
Quote:
patients with DM requiring insulin do very poorly
I have read incredibly deeply on this as I have a child with Type 1. Almost everything says that the insulin requirement itself has zero correlation with severity of disease. It is the toll of poor glycemic control over longer periods and the resulting impact on the body that is the culprit per most of the endos I have talked to.

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Windy City Ag
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In reply to plain_o_llama • 11:58a, 1/28/21
AG
Quote:
not a doc but I suspect these are some of the acronyms

DM - Type 1 diabetes
And this is not correct. Diabetes Mellitus is the umbrella term for both Type 1 and Type 2.

Type 1 DM is the result of an gentic autoimmune reaction that causes a specific set of antibodies for some reason to attack and kill the islet cells in your pancreas and turn off insulin production in the process.

Type 2 DM is somewhat related but has to do with the body's insulin production dropping off and your cells interaction with insulin chaning resulting in a degraded burning of glucose and elevated blood sugars. While there is no clear understanding as to how it happens, it is generally thought to be a lifestyle related disease that can be managed effectively through lifestyle changes like not being an alcoholic, couch dwelling fat#ss.

Both have the same concern of ketoacidosis (hyperglycemia), which is the result of the body burning fat rather than sugar for energy which results in an acidic effect on your bloodstream that in turn has longer term complications for vision, nueropathy, and a few other factors.

Type 1s have the added problem of hypoglycemia, which means your blood sugar drops far too low which can result in coma or even death.

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plain_o_llama
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In reply to Windy City Ag • 12:04p, 1/28/21
Thanks, I will remove it.
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Windy City Ag
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In reply to plain_o_llama • 12:05p, 1/28/21
AG
No worries. . . .I had to get all deep into this thing due to my family so I probably talk too much about it.
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JSCDO
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12:18p, 1/28/21
I should have said my Type II diabetics requiring insulin do poorly. My Type I diabetics have done fine. Type II diabetics tend to be obese, have had DM for a long time and have more DM complications like diabetic nephropathy. Covid seems to attack attack pre existing weakness in the body. As I said, my perspective is an outpatient perspective as I no longer do Hospital work but I do see what happens to my patients who are hospitalized.
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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hsvag
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12:20p, 1/28/21
Marcus
Your note provides the first (albeit discouraging) information I've seen after I posted awhile back on COVID treatment results. I have been searching for (local/U.S./whatever) data on the trends over the last 11 months on treatment results for COVID-19 patients admitted to hospitals (yes, I know there are many variables). In other words, are we demonstrating improved success in treating COVID patients as time goes on, and if so, what treatment protocols appear to be driving this success? If there has been little or no change, the public, I believe, would like to know that. Failing to get any information locally I have sent a query to the CDC, who should be collecting this data. No response yet.
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Windy City Ag
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In reply to JSCDO • 12:22p, 1/28/21
AG
Quote:
My Type I diabetics have done fine.
I have to admit I have been stunned by the unbelievable discipline and self control of older Type 1s who have maintained tight time in range and A1Cs. The disease forces you think about your lifestyle choices on a hourly basis in most cases and you get near cyborg levels of self control in these folks. They get incredibly attuned to minor shifts in their bodily processes as well. They have this advanced spider sense of something not quite being right.

I wouldn't wish it on anyone but it does result in amazing expressions of the human will and has prepared most of them to be in tip top shape to fight illnesses like this one.
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AggieBiker
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12:25p, 1/28/21
AG
Not a doc and my experience is strictly anecdotal. My 84 year old mother had kidney failure and was on dialysis for 1+ year along with being a type 2 diabetic, hypertension and dementia when she developed CV. She got over the virus but died from all the rest. Also had a healthy friend in his late 50s get sick from an overseas business trip. After many weeks in ICU he had renal failure and soon died. So there seems to be some correlation but it also seems nothing is absolute with this disease.
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Marcus Aurelius
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In reply to hsvag • 12:30p, 1/28/21
AG
hsvag said:
Marcus
Your note provides the first (albeit discouraging) information I've seen after I posted awhile back on COVID treatment results. I have been searching for (local/U.S./whatever) data on the trends over the last 11 months on treatment results for COVID-19 patients admitted to hospitals (yes, I know there are many variables). In other words, are we demonstrating improved success in treating COVID patients as time goes on, and if so, what treatment protocols appear to be driving this success? If there has been little or no change, the public, I believe, would like to know that. Failing to get any information locally I have sent a query to the CDC, who should be collecting this data. No response yet.
Looking at the Hopkins data, the deaths/wk continue to climb dramatically. I have referral bias as I see the sickest of the sick. There are a subset that hit the ICU that are destined to die, no matter what you do. Unfortunately that is a significant portion of the ICU pts. So - compared to March 2020 I'd say we are better at taking care of the ICU pts. Compared to last summer - no.

To me the key now is treating the sicker ones before they reach day 7. Ab infusions etc. There comes a point at which the cat is loose and you can only stand back and do your best.
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Kay's Lounge
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1:00p, 1/28/21
AG
Hang in there, Marcus. Prayers for strength for you and your staff.
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aggieduke
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1:16p, 1/28/21
AG
Marcus,
I follow this board(probably more than I should) and feel as if I know you personally just from reading your post. You have answered a couple of my questions and many others through this crazy ordeal. We all appreciate you more than you know.

My 3 boys and I will send up some words for you tonite to the Big Man. You have and will continue to be in our prayers.

Ay God bless you.
Philippians 4:13
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Capitol Ag
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1:39p, 1/28/21
AG
Thank you all for the definitions. Extremely informative and interesting.
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Born&Raised
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2:00p, 1/28/21
Any chance this is from new strains causing 'more' issues?

Do y'all send any samples out for tests?

These new variants have me thinking about previous COVID exposure and herd immunity.

Do you see people getting tested for strains? UK or SA?

I have seen many reports that antibodies and vaccines are having, on some cases NO effect or have a reduced effect.

Logic says that if antibody transfusions are having less effect - then previous COVID exposure would be the same... no?

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proc
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In reply to Windy City Ag • 2:05p, 1/28/21
AG
Windy City Ag said:
Quote:
My Type I diabetics have done fine.
I have to admit I have been stunned by the unbelievable discipline and self control of older Type 1s who have maintained tight time in range and A1Cs. The disease forces you think about your lifestyle choices on a hourly basis in most cases and you get near cyborg levels of self control in these folks. They get incredibly attuned to minor shifts in their bodily processes as well. They have this advanced spider sense of something not quite being right.

I wouldn't wish it on anyone but it does result in amazing expressions of the human will and has prepared most of them to be in tip top shape to fight illnesses like this one.
Not meaning to argue or add any gloom, my MIL was one of these vigilant older Type 1s, near cyborg. We really thought she could defeat Covid like we did. In the end Covid killed her, but it wasn't her kidneys. It was her lungs. Former smoker. This disease is an opportunistic *******.
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Jock 07
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In reply to JSCDO • 2:10p, 1/28/21
AG
JSCDO said:
I should have said my Type II diabetics requiring insulin do poorly. My Type I diabetics have done fine. Type II diabetics tend to be obese, have had DM for a long time and have more DM complications like diabetic nephropathy. Covid seems to attack attack pre existing weakness in the body. As I said, my perspective is an outpatient perspective as I no longer do Hospital work but I do see what happens to my patients who are hospitalized.

This is a relief to read. Wife is type 1 and manages her sugars well. She's always been worried about being hospitalized and nurses not monitoring her numbers as well as she does. Luckily she just got her first shot so hopefully we're close to being in the clear on in this regard.
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Kool
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2:18p, 1/28/21
AG
That's awful, Marcus. I'm hoping that between natural herd immunity and increasing vaccination (with the J&J vaccine being one-dose and not being subject to stringent shipping and storage constraints), this nightmare ends soon.
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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czechy91
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2:21p, 1/28/21
AG
So apparently only Type II diabetes kicks a person into the Phase 1B category is that correct? I have a couple of friends with Type 1 that are very concerned. No additional risk with a mere Phase I?
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Quinn
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In reply to czechy91 • 2:48p, 1/28/21
AG
czechy91 said:
So apparently only Type II diabetes kicks a person into the Phase 1B category is that correct? I have a couple of friends with Type 1 that are very concerned. No additional risk with a mere Phase I?
That is correct that Type II is only in the 1B grouping. JDRF (type 1 org) and ADA are trying to get this changed, though who knows if that will happen. There does seems to be an similar risk to type 1 and type 2 from what I've seen.

https://www.jdrf.org/blog/2021/01/22/answering-your-questions-about-the-covid-19-vaccines/
https://care.diabetesjournals.org/content/early/2020/12/01/dc20-2260?_ga=2.233907419.452101857.1611866727-1199587203.1609860892

As for type 1 in general, as Windy said, it does take a lot of discipline. I've been type 1 for 22 years and it's something I think about on an almost minute by minute basis. All the good decisions you've made can be undone by one stupid decision. Being regimented helps a ton and can take away some of the variability.

/end thread derail
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Nephron_Ag
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3:37p, 1/28/21
AG
I'm a nephrologist. I had more deaths last week than any other inpatient week in my career. Once they develop renal failure requiring dialysis in the ICU I've seen very few survive, but the kidneys are the canary in the coal mine. I think they're just a marker for catastrophic multisystem organ failure. I am not impressed with any of the COVID specific treatments thus far. I was hopeful for remdesevir but that busted.
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Marcus Aurelius
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In reply to Nephron_Ag • 3:40p, 1/28/21
AG
Agree. Renal failure is just a marker of the severity.
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bay fan
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In reply to Marcus Aurelius • 4:03p, 1/28/21
S
So sorry Doc. One of the hardest things about this is seeing how hard it is on doctors, nurses and all health care workers. What you are experiencing is terrible and I am sorry for what your days have turned into. I hope the vaccine distribution begins to positively effect your days. Thank you very much for your efforts!
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Vascular Ag
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4:04p, 1/28/21
AG
Marcus,

I haven't been involved in the care of a ton of COVID patients but here is what our experience has been from a vascular standpoint. Many patients are being prophylactically anticoagulated to try to avoid the complications of the hypercoagulable state associated with COVID. For those patients who develop thrombosis despite anticoagulation, there is absolutely no answer. We have not successfully salvaged a limb yet. In addition, the mortality of these patients is approaching 100%. I suspect that the thrombosis is a marker for the inflammatory system being completely out of control.

We have tried open surgical thrombectomy as well as thrombolysis. With the thrombosis being recognized acutely (usually less than 6-12 hours), it should be very responsive to thrombolysis but it is not. I reached out to some of my vascular surgery colleagues elsewhere to see if they had any success. Their reply was that their one successful case was that they had salvaged a patient that was going to require a hip disarticulation to only an above knee amputation

Like I said, I haven't dealt with the quantity of patients as you have but have certainly felt your frustrations and feelings of helplessness in the severe cases
Vascular Ag '95
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Marcus Aurelius
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In reply to Vascular Ag • 4:08p, 1/28/21
AG
Wow. Thx for response. We are anticoagulating still for those with elevated d dimers and the sick icu pts. Havent seen limb ischemia. Have seen alot of PE DVT and strokes. Unfortunately also seen alot of bleeding complications for the very sick anticoagulated. We had one on ecmo last week bleed out and die from a massive GI bleed.
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DCAggie13y
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In reply to Marcus Aurelius • 4:33p, 1/28/21
AG
Sorry to hear that you are continuing to deal with these challenges. This disease feels like a distant war to so many people. You are on the front line every day fighting and most of us don't experience the battle. Fortunately everyone i know who got COVID has had a mild or asymptomatic case with no hospitalizations. I think you are seeing the worst of the worst situations.

Good news is most of my older friends and relatives have already received the 1st shot of the vaccine. Hopefully that slows this down for you. Hospitalizations and cases are dropping across the country. I hope your ICU starts to drop soon as a result.
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Sq 17
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6:11p, 1/28/21
I am a nobody non MD Texas poster but IMO

Marcus Aurelius and the other Docs fighting this every day never need to apologize for anything

If reaching out/ranting On this board is helpful please by all means go right ahead
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2PacShakur
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6:45p, 1/28/21
AG
https://www.nytimes.com/2021/01/26/well/mind/doctors-facing-burnout-turn-to-self-care.html?surface=home-discovery-vi-prg&fellback=false&req_id=363917&algo=identity&variant=no-exp&imp_id=404572122&action=click&module=Science%20%20Technology&pgtype=Homepage
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