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In my 7 days on one of our (now 12!) non ICU #COVID19 units, I admitted 58 patients for COVID rule out, of whom 50 tested positive. Two died (DNR), 2 went to hospice, and 5 went to the ICU. That is… not my typical gen med service week. Following, some clinical observations.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
My experience perfectly matched published reports. Procal universally low. Ferritin, CRP, d-dimer elevated. Lymphopenia prominent. Patchy infiltrates on CXR. Diarrhea common. So, I want to share some other things I haven’t seen talked about as much.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
1st, I was shocked by the persistence of fevers. My patients had fevers every day, often all day, often >39, for days on end, not especially Tylenol responsive. And they had all had several days fevers before admission.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
2nd, the fevers did not seem particularly related to outcome. In fact most of my ICU transfers did not have persistent fever. They did, however, make patients miserable.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
3rd, this is not your usual sepsis picture. NONE of my patients, even the deaths/ICUs, developed meaningful AKI or liver failure (most had trivial transaminitis). There is no multiorgan failure. Just respiratory failure (I know reported later cardiac; I didn’t see those).— Leora Horwitz (@leorahorwitzmd) March 31, 2020
4th I did have a bunch of mild troponin elevations, but mostly demand ischemia. No EKGs c/w myocarditis. Suspect too late a complication for me to see.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
5rd, as noted by others, just about all of my patients had had symptoms for 7-10 days before needing admit for O2. This posed a conundrum for the few who were admitted with <5d sx (all on RA) – keep to await nadir? Can’t afford the beds. Had to discharge with warning.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
6th, I found CRP and ferritin often to move in opposite directions (usually CRP ↘️while ferritin still ↗️; CRP leading indicator?). This was confusing. Moreover, I had patients with ferritin >3,000 who did well and others with <800 who struggled. So, not universally helpful.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
7th, as noted by others, these patients deteriorate fast. Really fast. I started calling ICU for any patient who went from RA to 6L in <24 hours; nearly all wound up at least on 100% NRB or high flow if not intubation.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
8th I kept underestimating their exertional hypoxia. Learned my lesson when I transferred one pt to lower acuity floor and he had a syncopal event getting from wheelchair to new bed. Walked all patients with pulse ox prior to d/c.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
9th On the topic of syncope, I admitted 3-4 COVID+ patients with presenting complaint of syncope (2 with head lacs), all early in course, with orthostatic hypotension without significant antecedent fevers. Could COVID be having some effect on autonomic system?— Leora Horwitz (@leorahorwitzmd) March 31, 2020
10th Our standard protocol right now is azithro/hydroxychloroquine/zinc but I have little faith in efficacy. For the patients I really worried about (fast O2 requirement rise, high inflammatory markers) I gave tocilizumab off label. Clinical trial of sarilumab starting this week.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
11th Proning is now standard in our ICU and I tried hard to get my sicker patients to do it too to head off intubation. This is much harder than it sounds. Most patients couldn’t get into position on their own, found it uncomfortable (back pain), refused.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
12th Most of my patients didn’t eat anything. Partly lack of taste/smell, partly misery with fever, partly hypoxia with exertion, partly lack of visitors/staff in room to encourage and help. Several asked me for soft diet to reduce effort of chewing. Must attend to nutrition.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
13th Lastly, one of the biggest concerns for non-critically ill patients was persistent painful cough. Most had paroxysmal dry, wheezy coughing spasms, often precipitating desaturations. Tried cough syrup, albuterol MDI with spacer (avoiding nebs), codeine, with little effect.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
Our ICU team has been pushing hard for us to do it on floors - anything to reduce intubation risk. Makes sense. My younger/thinner patients could do it. Very tough for the others especially without staff able to spend long periods at bedside to help.— Leora Horwitz (@leorahorwitzmd) March 31, 2020
Yesterday, I donned up and entered a patient's room. He was COVID+, and he was decompensating rapidly. His breathing was shallow on 100% NRB, and he was minimally rousable. This was expected - but it was still shocking.— Arnav Agarwal (@iArnavAgarwal) April 18, 2020
I switched on the iPad and started the video call. [THREAD]
[2/ ] His wife popped up on the screen first. She let out a huge sigh of relief to have connected through. Her eyes looked tired.— Arnav Agarwal (@iArnavAgarwal) April 18, 2020
Then others started popping up. I asked for her permission to add them in - she nodded. First one family member, then another - then 15 others.
[3/ ] I was amazed. It had been only 10 minutes since I had gotten the video call arranged. People from across the world had found a way to share this moment with us.— Arnav Agarwal (@iArnavAgarwal) April 18, 2020
I tried to put myself in their shoes and imagine how it must feel. I stopped myself short.
[4/ ] I switched screens so they could see him. I stood there for 15 minutes as some remembered the special moments they shared with him, some begged him not to leave, some moaned in grieving, and some offered prayers for peace and comfort.— Arnav Agarwal (@iArnavAgarwal) April 18, 2020
My eyes filled up.
[5/ ] It was among the heaviest moments I've encountered in my short clinical career so far. It is difficult enough to encounter death and lose a loved one - it is exponentially more difficult to see them suffer alone, and to say goodbye through a video chat.— Arnav Agarwal (@iArnavAgarwal) April 18, 2020
[6/ ] Once every family member on the call had a chance to express their words and wishes - I moved away, expressed my condolences, and thanked them.— Arnav Agarwal (@iArnavAgarwal) April 18, 2020
I switched the video call off, doffed, and left the room. Then I took some time on a busy Friday to cry.
That was tough.
Nas últimas décadas, tem vindo a aumentar a evidência científica de boa qualidade que demonstra a eficácia de algumas medidas terapêuticas não farmacológicas em várias áreas da Medicina. Contudo, os manuais de intervenção terapêutica, também designados por formulários terapêuticos ou farmacopeias, normalmente só encontramos as medidas farmacológicas. Neste contexto, um conjunto de médicos de família australianos, coordenados por Paul Glasziou, iniciou o projeto HANDI - Handbook of Non-Drug Interventions.
Com base na ideia das farmacopeias modernas, cada entrada do HANDI inclui a descrição da intervenção, as suas indicações, contraindicações e efeitos adversos, entre outros. Segundo os autores, o objetivo é tornar a "prescrição" de uma terapia não farmacológica tão fácil quanto a prescrição de um medicamento. A metodologia de construção deste manual é rigorosa e transparente. Por exemplo, um dos critérios para que uma intervenção seja incluída no formulário HANDI passa pela existência de pelo menos dois ensaios clínicos randomizados de boa qualidade e com marcadores de resultado orientados para o paciente.
No seu formato atual, o Manual HANDI dispõe de intervenções agrupadas em 6 secções: cardiovascular, Pediatria, Saúde Mental. Músculo-esquelética, Nutrição e “Outras”. Uma ferramenta muito útil!
Thomas Felix Kaye
GP, NHS Greater Glasgow and Clyde, Waverley Park Medical Practice, Glasgow, UK. Email:firstname.lastname@example.org