gotmuddy Posted March 30, 2020 Posted March 30, 2020 Harbor freight hand tools are serviceable. I used them for years before going to snap on. all my stuff is snap on now. Terrierman 1 everything in this post is purely opinion and is said to annoy you.
jdmidwest Posted March 31, 2020 Posted March 31, 2020 On 3/29/2020 at 9:49 AM, N9BOW said: If you have family members who are Doctors this may be of some help. I'm editing the medical terminology based on google searches so check back and look for green ("definitions")....Google it yourself to make sure I have it right ER doctor offers lessons on treating Covid-19 patients… Cheat Sheet for Physicians (excellent read)… Posted by Kane on March 29, 2020 1:50 am Categories: Breaking https://www.citizenfreepress.com/breaking/er-doctor-offers-lessons-on-treating-covid-19-patients-cheat-sheet-for-physicians-excellent-read/ “I am an Emergency Room MD in New Orleans, UNC class of ’98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know. Clinical course is predictable. 2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias (back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell and taste, anorexia, fatigue. Day 5 of symptoms- increased SOB (Shortness Of Breath), and bilateral viral pneumonia from direct viral damage to lung parenchyma. Day 10- Cytokine storm (A potentially fatal hyperrelease of inflammatory mediators in response to stimulation of T cells and macrophages by pathogens and immune insultsTriggers Graft versus host disease, adult respiratory distress syndrome, sepsis, avian influenza, and systemic inflammatory response syndrome) leading to acute ARDS (Acute Respiory Distress Syndrom) and multiorgan failure. You can literally watch it happen in a matter of hours. 81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical. Patient presentation is varied. Patients are coming in hypoxic (diminished availability of oxygen to the body tissues) (even 75%) without dyspnea (Shortness of Breath). I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA (Diabetic ketoacidosis). I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT’s of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town. China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF (Congestive Heart Failure) and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA (Tissue plasminogen activator?) in the ED and rescue PCI (Percutaneous coronary intervention) at 60 minutes only if TPA fails. Diagnostic CXR (chest X-ray)- bilateral interstitial pneumonia (anecdotally starts most often in the RLL (right lower lobe) so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox. Labs- WBC (White Blood cells) low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95% CRP (C-reactive protein) and Ferritin (the complex of iron and apoferritin, a major form in which iron is stored in the body.)elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated. Notice D-Dimer- I would be very careful about CT (Computed tomography) PE (Pulmonary Embolism) these patients for their hypoxia (diminished availability of oxygen to the body tissues). The patients receiving IV contrast are going into renal failure and on the vent sooner. Basically, if you have a bilateral pneumonia with normal to low WBC (White Blood cells), lymphopenia, normal procalcitonin, elevated CRP (C-reactive protein) and ferritin (the complex of iron and apoferritin, a major form in which iron is stored in the body.)- you have covid-19 and do not need a nasal swab to tell you that. A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation. An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes. Other factors that appear to be predictive of poor outcomes are thrombocytopenia (Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots) and LFTs (Liver Function Test???) 5x upper limit of normal. Disposition I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won’t make it back. We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation. Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the “lockdown”, our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020. Treatment Worldwide 86% of covid-19 patients that go on a ventilator die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle. Plaquenil (hydroxy-chloroquine) which has weak ACE2 blockade doesn’t appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil’s potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post. We are also using Azithromycin. Do not give these patient’s standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA (Diabetic ketoacidosis) and renal failure dehydration, leave them dry. Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps. Vent settings- Usual ARDS (Acute Respiory Distress Syndrom) stuff, low volume, permissive hypercapnia (An abnormally high concentration of carbon dioxide in the blood, usually caused by acute respiratory failure from conditions such as asthma and obstructive pulmonary disease. It can lead to seizures and death if acute and untreated.), etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed. Do not use Bipap (Bilevel positive airway pressure, commonly referred to by the trademarked names BiPAP and BIPAP, is a form of non-invasive mechanical pressure support ventilation that uses a time-cycled or flow-cycled change between two different applied levels of positive airway pressure)- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours. The same goes for nebulizer treatments. Use MDI (metered-dose inhaler). you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn’t often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room. Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis (Upper respiratory infection,). We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads. One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI (Body Mass Index - She's not overweight) is out with the symptoms and an SaO2 of 92%. She will be the first of many. I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.” Anybody digging a hole in the back yard to bury our carcasses?? Funerals are shut down. Since we are all sitting around waiting to die, maybe build a box and dig a hole to help out the cause. "Life has become immeasurably better since I have been forced to stop taking it seriously." — Hunter S. Thompson
fishinwrench Posted March 31, 2020 Posted March 31, 2020 Supposedly the cure (a combination of 2 antibiotics) awaits approval. wily and N9BOW 2
N9BOW Posted March 31, 2020 Author Posted March 31, 2020 31 minutes ago, jdmidwest said: Anybody digging a hole in the back yard to bury our carcasses?? Funerals are shut down. Since we are all sitting around waiting to die, maybe build a box and dig a hole to help out the cause. Not here.....! Been getting lots done. Garden well under way, Tiller fired up, ground is drying out, seeds are germinating, been reading my Kent Rollins Cowboy cookbook and making plans to make every dish in it. Have the bread and pasta machines all ready to make stuff that we can enjoy and if things get real bad help out a neighbor or three. all set up to can this summers crop of three sisters... (providing Iowa weather dont chuck a bunch of hail at the wrong time). A great time to be alive! and Be Smart! Besides holes in the yard are frowned upon in by our HOA wily and BilletHead 2
jdmidwest Posted March 31, 2020 Posted March 31, 2020 32 minutes ago, fishinwrench said: Supposedly the cure (a combination of 2 antibiotics) awaits approval. Was that the guy in California that died sniffing aquarium chemicals?? Its a virus, Azithromycin antibiotic would only help a bacterial infection, secondary infection. Quinine is being studied, it killed malaria, a mosquito born parasitic disease. But the only real cure to a virus is to get it and live thru it, then you will be immune. Vaccine creates immunity to prevent. Several compounds have been found to lessen the effects of a virus, but never a cure. Don't get it and wait for a vaccine, or get it and get over it. "Life has become immeasurably better since I have been forced to stop taking it seriously." — Hunter S. Thompson
fishinwrench Posted March 31, 2020 Posted March 31, 2020 14 minutes ago, jdmidwest said: Was that the guy in California that died sniffing aquarium chemicals?? Its a virus, Azithromycin antibiotic would only help a bacterial infection, secondary infection. Quinine is being studied, it killed malaria, a mosquito born parasitic disease. But the only real cure to a virus is to get it and live thru it, then you will be immune. Vaccine creates immunity to prevent. Several compounds have been found to lessen the effects of a virus, but never a cure. Don't get it and wait for a vaccine, or get it and get over it. Yeah I dunno, but allegedly they have eliminated all traces of COVID19 within 4-5 days in 30+ people by giving them the combination of those 2 drugs. It has worked on everyone they tried it on so far. He acknowledged that "aintibiotics aren't recommended for viruses".....but then said "whatever... it's working!" Supposedly some retinal damage may come from the treatment, but that is reversable.
jdmidwest Posted March 31, 2020 Posted March 31, 2020 46 minutes ago, N9BOW said: Besides holes in the yard are frowned upon in by our HOA I dig holes all of the time, keeps the neighbors on their toes... I used to bury the fish carcasses that I filleted in the garden for fertilize. But then I realized that their dogs like to roll in them and learned they keep them out of my yard for a while. I usually leave dead carcasses out on top of the ground now and enjoy the thoughts of bowser or fluffy coming in smelling nice and ripe. Even have pics on the game cam of them making rounds. Its the little things in life that cheer you up. N9BOW, MOPanfisher, BilletHead and 1 other 4 "Life has become immeasurably better since I have been forced to stop taking it seriously." — Hunter S. Thompson
oneshot 1 Posted March 31, 2020 Posted March 31, 2020 I was told today they have came up with reducing flem by gargling, drinking warm liquids and wash everything with Soap. I said to them seems like people dealing with normal allergies are subseptable to the virus? They agreed but people with Allergies are already doing what they can to ease things. oneshot
Mitch f Posted March 31, 2020 Posted March 31, 2020 Getting close to home nomolites 1 "Honor is a man's gift to himself" Rob Roy McGregor
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