- 18 Aug 2021 20:25
#15186173
I don't think it is quite that simple. What I have seen with covid is not so much an overwhelming rate of admission, but rather a very slow and smoldering one. The issue is, unlike the many other reasons for admission, the covid patient ends up using a lot more resources. Take for instance the typical decompensated heart failure. We admit on monday, give high doses of diuretics on monday, tuesday, and wednesday morning they can leave either home or to a nursing facility/rehab depending on their functional status. The covid patient when they are "less sick" ends up staying in the hospital 5 days minimum due to the treatment being 5 days, then... if we are lucky, we can send them home on oxygen if they are young. However, if they are older and/or weak many facilities won't take them for many more days until they either test negative or until after 10+ days of being diagnosed... so they end up in the hospital a long time.
Then lets talk about ICU. Prior to covid, my typical ICU patient was either a DKA, a stroke patient, or someone that had undergone cardiac surgery. With the exception of large strokes, vast majority of these patients would stay 2-3 days then go to regular floor.
COVID patients in the ICU are requiring maximum treatment.
Do you know what goes into a covid patient?
So they get intubated, so that is a tube down their trachea to give air to their lungs.
They get a nasogastric tube, this is a small plastic tube that is inserted inside the nose and goes all the way to the stomach to provide nutrition.
Most often than not, they also need a central line, this is a plastic catheter (tube) that is about the thickness of an iphone charger cable. It is usually inserted in the neck's vein, but sometimes it can be done in the chest or in the groin.
Then there is the foley catheter, it is inserted inside the urethra, which is the small hole in the penis (for males) or in women just above the vagina.
For feces, we have 2 widely used options. There are rectal tubes, or there is the option of just letting the patient shit on themselves and then clean them. In the case of covid, since they are intubated for such a long time, usually they get a rectal tube. And it is exactly what it sounds like, a tube that is inserted inside your rectum to evaquate your poop.
Most patient with COVID, at some point are in "shock", meaning their blood pressure is too low. This happens when your regulatory system is overwhelmed due to severe infection, this happens when you get a superimposed infection, this happens when your heart gets weak, this happens when you get a large pulmonary embolus/lung disease. Or sometimes it is just the sedatives that make your blood pressure low. Either way, most of these patients end up getting an "arterial line" which is similar to an IV, but insted of being inserted into a vein, it goes into an artery (way more painful) so that we can measure your blood pressure accurately.
Now... that is "standard" for 90%+ of covid patients.
Then we have the "extras". For instance... there is pronation therapy. In which the patient is flipped over either manually or with a machine. Pronation is oftentimes necesary because covid patients do better, oxygen requirements wise, when they are flipped and lie on their abdomens. The problem with this, is that all those cables and tubes in your face tend to put pressure on your skin, so you get nasty ulcers if the nurses are not on top of their shit (which is not rare, given that they are understaffed. Sometimes pronation is done with a super bulky and expensive machine that hospital rent out.
Then we got dialysis. Many patients in the ICU with covid end up requiring dialysis at some point. Medications that we give for covid and/or bacterial superinfections are nephrotoxic, and if your blood pressure drops (e.g. a code) this can also damage your kidneys, not to mention potentially using contrast to look for PEs. As a result, kidney failure is fairly common. Dialysis means putting a catheter in you, getting a bunch of your blood out of your body, passing it through a filter and then putting it back into your body.
THen we have ECMO. At this point you are "sick as shit", your lungs, your heart, or both are fucked up. The ICU doctor doesn't know what the fuck else to do, asks a vascular surgeon to put 2x large hose-sized tubes on you (usually groin, sometimes neck) so we can get your blood out of your body and into a machine that will do your heart and lung's work. At this point, your chances of survival are dismal at best. Perhaps you'd be one of the "lucky ones" that go for a lung transplant. This is fucked up, because lungs are notoriously hard to keep after transplant. I am not a lung transplant specialists but my understanding is that nearly 100% of them will be rejected and the real question is how lung you can survive with it.
late wrote:This is triage, not ethics. The makeup of the rules of triage incorporate ethical considerations, but triage is about making the best of a bad situation.
I don't think it is quite that simple. What I have seen with covid is not so much an overwhelming rate of admission, but rather a very slow and smoldering one. The issue is, unlike the many other reasons for admission, the covid patient ends up using a lot more resources. Take for instance the typical decompensated heart failure. We admit on monday, give high doses of diuretics on monday, tuesday, and wednesday morning they can leave either home or to a nursing facility/rehab depending on their functional status. The covid patient when they are "less sick" ends up staying in the hospital 5 days minimum due to the treatment being 5 days, then... if we are lucky, we can send them home on oxygen if they are young. However, if they are older and/or weak many facilities won't take them for many more days until they either test negative or until after 10+ days of being diagnosed... so they end up in the hospital a long time.
Then lets talk about ICU. Prior to covid, my typical ICU patient was either a DKA, a stroke patient, or someone that had undergone cardiac surgery. With the exception of large strokes, vast majority of these patients would stay 2-3 days then go to regular floor.
COVID patients in the ICU are requiring maximum treatment.
Do you know what goes into a covid patient?
So they get intubated, so that is a tube down their trachea to give air to their lungs.
They get a nasogastric tube, this is a small plastic tube that is inserted inside the nose and goes all the way to the stomach to provide nutrition.
Most often than not, they also need a central line, this is a plastic catheter (tube) that is about the thickness of an iphone charger cable. It is usually inserted in the neck's vein, but sometimes it can be done in the chest or in the groin.
Then there is the foley catheter, it is inserted inside the urethra, which is the small hole in the penis (for males) or in women just above the vagina.
For feces, we have 2 widely used options. There are rectal tubes, or there is the option of just letting the patient shit on themselves and then clean them. In the case of covid, since they are intubated for such a long time, usually they get a rectal tube. And it is exactly what it sounds like, a tube that is inserted inside your rectum to evaquate your poop.
Most patient with COVID, at some point are in "shock", meaning their blood pressure is too low. This happens when your regulatory system is overwhelmed due to severe infection, this happens when you get a superimposed infection, this happens when your heart gets weak, this happens when you get a large pulmonary embolus/lung disease. Or sometimes it is just the sedatives that make your blood pressure low. Either way, most of these patients end up getting an "arterial line" which is similar to an IV, but insted of being inserted into a vein, it goes into an artery (way more painful) so that we can measure your blood pressure accurately.
Now... that is "standard" for 90%+ of covid patients.
Then we have the "extras". For instance... there is pronation therapy. In which the patient is flipped over either manually or with a machine. Pronation is oftentimes necesary because covid patients do better, oxygen requirements wise, when they are flipped and lie on their abdomens. The problem with this, is that all those cables and tubes in your face tend to put pressure on your skin, so you get nasty ulcers if the nurses are not on top of their shit (which is not rare, given that they are understaffed. Sometimes pronation is done with a super bulky and expensive machine that hospital rent out.
Then we got dialysis. Many patients in the ICU with covid end up requiring dialysis at some point. Medications that we give for covid and/or bacterial superinfections are nephrotoxic, and if your blood pressure drops (e.g. a code) this can also damage your kidneys, not to mention potentially using contrast to look for PEs. As a result, kidney failure is fairly common. Dialysis means putting a catheter in you, getting a bunch of your blood out of your body, passing it through a filter and then putting it back into your body.
THen we have ECMO. At this point you are "sick as shit", your lungs, your heart, or both are fucked up. The ICU doctor doesn't know what the fuck else to do, asks a vascular surgeon to put 2x large hose-sized tubes on you (usually groin, sometimes neck) so we can get your blood out of your body and into a machine that will do your heart and lung's work. At this point, your chances of survival are dismal at best. Perhaps you'd be one of the "lucky ones" that go for a lung transplant. This is fucked up, because lungs are notoriously hard to keep after transplant. I am not a lung transplant specialists but my understanding is that nearly 100% of them will be rejected and the real question is how lung you can survive with it.