Recruiting Forum Football Talk II

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#125,452
#125,452
sutro said:
That's the frustrating reality of this, and is why I've been wearing an N95 mask and eye protection for my entire shift for the last few months. It is an alternate reality where nothing works and nothing makes any clinical sense. We've had patients present complaining only of worsening depression requesting psychiatric evaluation, only to crash and get intubated due to what turns out to be COVID a few hours later. A patient with a couple weeks of worsening cough/fever/shortness of breath - and family members living in the same household who tested positive for COVID - who had bilateral multifocal pneumonias, all the right serum lab abnormalities and died after testing negative multiple times as a COVID-negative death.
It turns everything you ever learned about hypoxia and ventilator management on its head. People with oxygen saturations of <80% can be chatting on cellphones. I think that the decreased ventilator usage in NY is at least in part due to behavior change by physicians, as the initial forecasts were likely based on an "early intubation" strategy with a trigger based on oxygen saturation and oxygen requirement. That has significantly changed in the last few weeks, and more people are being given high-flow nasal cannula oxygen or CPAP/BIPAP with a more permissive view of hypoxia and a focus on avoiding excessive fluids or high CPAP pressures. HFNC and CPAP were initially avoided due to increased risk of aerosolization, but that risk can be mitigated by staying in full PPE all the time, and some people can avoid intubation/mechanical ventilation using this strategy.
The nasal swabs are universally awful in terms of false negatives - the Chinese have published data that show ~65% sensitivity (positive test if disease is present) for nasopharyngeal swabs compared to CT and clinical diagnosis. That has been my experience. The tests themselves are great if virus is present at a certain threshold level in the sample - that's how they're validated, and they have to have >95% sensitivity (most are higher than this). The problem is that you have to get a threshold level of virus on the swab to come up with a positive result. You can sample perfectly and still come up with nothing, even in someone critically ill with COVID. It's unclear why this is the case.
I had high hopes for widespread antibody testing to clear things up, (and am personally curious about my status) but thus far, the test characteristics here seem underwhelming as well. Hopefully, a reliable, reproducible test will eventually emerge, but as of now, this is looking more like another confusing mess that doesn't move us forward much, if at all.
We've been locked down here in CA since mid-March. Our rate of growth has significantly decreased, but we're still seeing positives frequently. I have to assume that's due to continued asymptomatic spread, as people have become hypervigilant about avoiding anyone who looks like they could even harbor a thought about being sick. Now the South Koreans are talking about reinfections/reactivation in previously recovered patients. Sigh.
TL;DR version. Squirrely virus is VERY squirrely. We are still feeling our way toward optimal management strategies and have only reasonable theories of underlying pathophysiology of both more severe disease and reasons behind testing challenges. Humbling. Frustrating.
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Thanks for bringing info. Mostly went over my head, but it still sounds shizzy. If reinfection is real...just wtf?
 
#125,453
#125,453
Pepe said:
You bring up something it has been on my mind over the last 35 years. A family member was in a condition where he was put on long-term intubated good laser therapy.it seemed to me while it was going on that the lunhswere being inflated far more than one does in a normal resting breathing cycle. To make a very long story short he essentially died from having burst blood vessels in his lungs. In my opinion, ventilator therapy is far from being an exact science.
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Damn autocorrect, and this thing won't let me edit. It finally let me edit so it's good now
 
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#125,454
#125,454
Ron Swanson said:
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giphy.gif
 
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#125,456
#125,456
Bassmaster_Vol said:
Absolutely. Keep social distancing for a while if it helps, but let us go back to work. People are working every day in manufacturing and there aren't breakouts of co-vid happening all over the country. Most states have very few cases at all.
Click to expand...

Been working everyday. My company furloughed some wonderful people. A few that were at risk but there is no guarantee it picks back up enough to call those folks back, and for a few of them that will be tough. I am blessed and thankful to still have my job but I do believe it's time. I'm not even guaranteed a full check. Sorry about your wife's job. One thing I do hope after all this is all those "non essentials" can stay home. Traffic is much better for me haha.
 
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#125,458
#125,458
sutro said:
That's the frustrating reality of this, and is why I've been wearing an N95 mask and eye protection for my entire shift for the last few months. It is an alternate reality where nothing works and nothing makes any clinical sense. We've had patients present complaining only of worsening depression requesting psychiatric evaluation, only to crash and get intubated due to what turns out to be COVID a few hours later. A patient with a couple weeks of worsening cough/fever/shortness of breath - and family members living in the same household who tested positive for COVID - who had bilateral multifocal pneumonias, all the right serum lab abnormalities and died after testing negative multiple times as a COVID-negative death.
It turns everything you ever learned about hypoxia and ventilator management on its head. People with oxygen saturations of <80% can be chatting on cellphones. I think that the decreased ventilator usage in NY is at least in part due to behavior change by physicians, as the initial forecasts were likely based on an "early intubation" strategy with a trigger based on oxygen saturation and oxygen requirement. That has significantly changed in the last few weeks, and more people are being given high-flow nasal cannula oxygen or CPAP/BIPAP with a more permissive view of hypoxia and a focus on avoiding excessive fluids or high CPAP pressures. HFNC and CPAP were initially avoided due to increased risk of aerosolization, but that risk can be mitigated by staying in full PPE all the time, and some people can avoid intubation/mechanical ventilation using this strategy.
The nasal swabs are universally awful in terms of false negatives - the Chinese have published data that show ~65% sensitivity (positive test if disease is present) for nasopharyngeal swabs compared to CT and clinical diagnosis. That has been my experience. The tests themselves are great if virus is present at a certain threshold level in the sample - that's how they're validated, and they have to have >95% sensitivity (most are higher than this). The problem is that you have to get a threshold level of virus on the swab to come up with a positive result. You can sample perfectly and still come up with nothing, even in someone critically ill with COVID. It's unclear why this is the case.
I had high hopes for widespread antibody testing to clear things up, (and am personally curious about my status) but thus far, the test characteristics here seem underwhelming as well. Hopefully, a reliable, reproducible test will eventually emerge, but as of now, this is looking more like another confusing mess that doesn't move us forward much, if at all.
We've been locked down here in CA since mid-March. Our rate of growth has significantly decreased, but we're still seeing positives frequently. I have to assume that's due to continued asymptomatic spread, as people have become hypervigilant about avoiding anyone who looks like they could even harbor a thought about being sick. Now the South Koreans are talking about reinfections/reactivation in previously recovered patients. Sigh.
TL;DR version. Squirrely virus is VERY squirrely. We are still feeling our way toward optimal management strategies and have only reasonable theories of underlying pathophysiology of both more severe disease and reasons behind testing challenges. Humbling. Frustrating.
Click to expand...

I've read similar problems with antibody tests from other sources. This is discouraging. Hopefully, it will turn around.

The re-positives are frustrating as well. Again, I hope it's just a testing problem. Or it could be screwey immune systems. Either way, the hope is that it's very small in number.
 
#125,462
#125,462
Pepe said:
Damn autocorrect, and this thing won't let me edit
Click to expand...
There's a toxic effect on lung tissue from too-high oxygen concentrations. There are also pressure-related effects - barotrauma - related to over distention of alveoli. There is a well-recognized best way to manage ARDS - acute respiratory distress syndrome - that is what we typically see with severe pneumonia or lung injury. it involves lower oxygen concentrations and low tidal volumes (breath size) to minimize both the toxic effects of highly concentrated oxygen and barotrauma from over distention. Alveoli are kept open by increasing levels of PEEP - basically the machine keeping some pressure against expiration to keep diseased alveoli from collapsing with each breath. Once they collapse, they are much more difficult to reopen and O2/CO2 exchange suffers.
With COVID, the CT scans and x-rays look just like ARDS, but the clinical syndrome seems different. High levels of oxygen seem to work better despite the possible toxic effect. High PEEP seems to be detrimental. Most are switching to ventilator modes to try to encourage the patient breathing on their own (negative pressure supported by one form or another of CPAP) as opposed to breathing for them (positive pressure). Again, everything on its head.

As for your relative, they were probably treated before ARDSnet "lung-protective" protocols became a thing in the late 90s/early 2000s. Barotrauma or toxic effects of high oxygen concentrations certainly could have caused injury.
 
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#125,463
#125,463
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#125,465
#125,465
sutro said:
There's a toxic effect on lung tissue from too-high oxygen concentrations. There are also pressure-related effects - barotrauma - related to over distention of alveoli. There is a well-recognized best way to manage ARDS - acute respiratory distress syndrome - that is what we typically see with severe pneumonia or lung injury. it involves lower oxygen concentrations and low tidal volumes (breath size) to minimize both the toxic effects of highly concentrated oxygen and barotrauma from over distention. Alveoli are kept open by increasing levels of PEEP - basically the machine keeping some pressure against expiration to keep diseased alveoli from collapsing with each breath. Once they collapse, they are much more difficult to reopen and O2/CO2 exchange suffers.
With COVID, the CT scans and x-rays look just like ARDS, but the clinical syndrome seems different. High levels of oxygen seem to work better despite the possible toxic effect. High PEEP seems to be detrimental. Most are switching to ventilator modes to try to encourage the patient breathing on their own (negative pressure supported by one form or another of CPAP) as opposed to breathing for them (positive pressure). Again, everything on its head.

As for your relative, they were probably treated before ARDSnet "lung-protective" protocols became a thing in the late 90s/early 2000s. Barotrauma or toxic effects of high oxygen concentrations certainly could have caused injury.
Click to expand...
I am certain that he was getting the most up-to-date care that was available in 1984. It was in what many consider to be the best hospital in the world (MD Anderson). But the knowledge doesn't allay the nightmarish effect endured by my family.
 
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#125,469
#125,469
Devo182 said:
Yeah they will try to go off 2018 first. Not filing yet should not be a problem IF your 2018 return qualifies. If not, could be a waiting game. Think I am in the same boat as y'all. Filed last week...but they work SLOWLY.

Last year when they (irs) didn't apply our payment correctly and had to fix it...they said wait 6 weeks to see the change reflected 🤣
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Everything I’ve read says the government will first look at your 2019 return to determine your eligibility. If you have not filed your 2019 return, then they will look at your 2018 tax return.
 
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