You can indulge your curiosity about the significance of low diastolic blood pressure (DBP) in ICU patients.
Did you know that DBP rises to its peak at age 55 and then declines?
“Perhaps the most concerning statistic regarding mental health problems relates to suicide. Those with mental illnesses have much higher suicide rates, and suicide is often considered a mental health disorder in its own right. Given this, recent statistics show that the rate of suicide in the U.S. exceeds 11 for every 100,000 people. This is so significant that suicide represents the 10th leading cause of death among all ages. Among those between 18 and 65, suicide is the fourth leading cause of death. In other words, suicide as a cause of death ranks higher than diabetes, stroke, homicide, and HIV infections. From every epidemiological perspective, mental illness represents a serious and devastating group of health disorders.”
Well, it’s been awhile, as they say. I’ve been away from the internet since March; although I do really wonder if we can ever fully get away. It wasn’t a happy vacation, mind you. The pandemic continues to loom large in my mind, and even though cases of covid19 have slowed (and nearly stopped) in my ICU doesn’t mean it hasn’t been busy. There is just as much normal heartbreak, death and disease to be found at my hospital as ever–if not more. And my colleagues are getting restless, wanting life to return to normal and travel the world again; they’re getting burnt out and in desperate need of whatever they call rest. The hospital is tallying it’s “losses” from last year and trying to squeeze the staffing and supplies to make up some deficit.
It has been a long few months of near hopelessness. What can be changed to make things better? What will normal look like? What is even the point?
But I’m back to try again, to think about this messy world I inhabit–on the edge of life and death, between the sick and the living. To make meaning out of this whole thing, healthcare, the pandemic, life, health, humanity. I’ll start again today in earnest.
I have gone back over a few “drafts” I’d saved while in hibernation and published them. I can’t claim quality. But, it is what it is. I’m sure I’ll be in this position again, so forgive me. And join me. Below are some links I’ve accumulated in the past week, and I knew that the urgency I felt when saving these links meant I was ready to start writing again…
At about 8:20 a.m., 94-year-old Leo Hainzl, took what would be his last walk with his dog, Rip, to Glen Canyon. He crossed paths with a man who’d slept on the streets of the neighborhood for years and had often menaced passersby through a fog of mental illness. Police said Peter Rocha, now 54, attacked Hainzl with a stick, causing him to fall, hit his head and die within hours at a hospital.
Read more at SF Chronicle: “San Francisco’s Mental Healthcare System Fails Two Men”
Another instance when a homeless person, Rocha, who lived in Glen Canyon for reportedly more than a dozen years cannot be helped by police–because he can simply refuse medical care. And so he was left on the streets, where his mental illness deteriorated and left untreated led to the psychosis that caused him to kill someone. A very sad case.
Homelessness is a public health problem. Mental illness is a public health problem. If we don’t find systematic ways to treat these problems, we will never help the people suffering from these conditions.
The crisis teams were created as part of Mental Health SF, a major initiative to reform the city’s care system, which is often understaffed and overwhelmed. But Mental Health SF has struggled to get off the ground during the pandemic.
Supervisor Hillary Ronen, one of the architects of Mental Health SF, said the crisis response teams look like “a promising program.” But to be successful, she said, the city must increase its long-term care options, from case managers to residential treatment programs.
According to city data, 9% of the street crisis teams’ encounters have ended in a 5150, an involuntary mental health hold for those who are a danger to themselves or others. Meanwhile, 18% were transported to a hospital and 18% to a program such as residential care or drug treatment.
The majority of the crises are resolved on scene, which means the person is left where found. But it is unclear what happens to people after the team leaves.
Read more at “S.F. finally has a new mental health team to respond to homeless people in distress. Is it helping?” on SF Chronicle
Jeannette Shields, 70, broke her hip while she was at the Cumberland Infirmary in Carlisle, North West England, where she was being treated for gall stones, BBC News reported. While she was in the hospital she buzzed for help to go to the restroom, but went by herself when she got no answer, and she fell and broke her hip after she got dizzy, her husband, John Shields, told the broadcaster.
She then had surgery to fix her broken hip, and the hospital told her husband that the procedure had gone to plan but “unfortunately they dropped her off the operating [table] after the surgery.”
John Shields, 78, said: “She had a great big bump on the back of her head and she just deteriorated and then she just passed away, just died… I’m really shocked.”
Read more at Newsweek, “Woman Dies After Being ‘Dropped’ on Floor Following Surgery”
A plastic surgeon wants to go back to basics, the very culture that is built into medicine during training, to address our healthcare system’s problems:
“Many factors contribute to our nation’s soaring medical costs, flagging clinical quality and the rising dissatisfaction of both doctors and patients. The one problem we continually overlook with tragic consequences is the flawed culture of medicine.”
–Read more “Op-Ed: How doctor culture sinks U.S. healthcare” at LA Times
“Doctors are supposed to be trusted authorities, a patient’s primary gateway to healing. But for fat people, they are a source of unique and persistent trauma. No matter what you go in for or how much you’re hurting, the first thing you will be told is that it would all get better if you could just put down the Cheetos.”
–Read the full article “Everything You Know About Obesity Is Wrong” at Highline (Huffington Post)
Do you want to know what the medical director of my unit says about “obese” patients, often unconscious and critically ill in the ICU– he says to calorie restrict them to 1,200kc a day and that at least they’ll lose weight in the hospital. I don’t even think I can fully explain how cruel this is. The patients are critically ill and it is hard to even get 1,200 calories into an unconscious person via tube feedings. The tubes can be tricky to get in the right place, the bowels often are not properly functioning so we don’t know what is even being absorbed, and tube feed is notorious for causing copious diarrhea. Which takes all the nutrients and additionally much of the water out of your body. Conscious patients who are able to eat often are so exhausted that they just can’t, not to even mention the frequent periods when patients can’t eat before tests or procedures. Even food brought from home, which I highly encourage, is often left untouched.
But fat shaming, per se, doesn’t happen as much in the inpatient hospital setting. It’s at the doctor’s office, the lab, the radiology department. Its at the OB-GYN’s office when you’re told that maybe if you had weight loss surgery, the heavy menstrual bleeding you’ve been experiencing continuously for over 6 months might get better. Or at the neurologist’s office when you’re told that a brain condition nobody understands might be caused by being fat but that, again, nobody understands why. Or at your primary care physician’s office, when you go in with your first ever joint problem (a sprained knee, it turns out, basically nothing, fine in a week), you are first (FIRST) even before the physical exam of your knee, told that if you weighed less, you’d hurt yourself less. And then the same doctor says later in the appointment, “I don’t want to be the asshole doctor that weight shames you.” Too late, doc, too fucking late.
If you hadn’t noticed, I am the fat person here. I am one of us, a person traumatized and triggered by the very industry that I work in. I have more to say about this, but the words evade me now.
“And starting this weekend, at least one Toronto-area hospital will begin training physician volunteers so they can help critical care nurses in the ICU, as a way to immediately add more staff to keep up with a flood of severely ill COVID-19 patients.”
I had to laugh about this one. The medical residents, aka “baby doctors,” barely know how to do anything. I’ve had to teach doctors how to place an IV line, how to reduce a prolapsed rectum, how to talk to patients about death. And there’s no way they’ve ever considered giving IV antibiotics or other medications. Talk about chaos in the ICU.
I couldn’t find the original news article. See video report on Global News
I don’t want to say I’ve seen every.single.one of these things happen. But I’ve seen A LOT OF THINGS. It’s kind of funny, but only because it’s true. Sad face.
— Read on www.buzzfeed.com/ehisosifo1/doctors-sharing-mistakes-made-by-other-doctors
As much as I want to ignore hysterical news coverage, I still cannot tune out covid stories. Even though I try not to open the news app on my phone, I find myself jolting into full consciousness after scrolling for who-knows-how-long and wincing as I realize that I’m reading yet another covid story. By that point, I’m halfway to bookmarking it to share with y’all later or reading it aloud to my sister. Because you know the old adage– misery loves company. With that depressing introduction, here’s three stories that caught my interest so far this week…
Organ transplant patient dies when they receive (unknown) covid lungs. You have to keep doing transplants during a pandemic because people are still dying waiting for them… and when an organ becomes available, you have a VERY limited amount of time to utilize it. But there is really such a short window of time in which the whole process occurs, sometimes 1 day. A person can test negative for covid but actually be positive in that time. So sad that someone got new lungs, only to get covid also.
Dr. Scott Kobner is the chief emergency room resident at the Los Angeles County-USC Medical Center and an amateur photographer. He photo-documented covid as it occurred at his hospital in stunning black and white.
Even the headline on this piece made my blood run cold and my heart shutter a little as I remember all the pregnant women in the ICU in 2009, the year we fought H1N1: “Russia tells WHO it has detected first case of avian flu strain in humans.” My first thought: pandemic on top of pandemic??? NOOOO!!!!!! But it turns out the headline is a little misleading because although 2 people have indeed been diagnosed with H1N8, a new bird flu to transmit to humans, it was from direct bird contact and has not passed from human to human. But, you know, we might want to insert the word “yet” in the previous sentence so it reads “it has not YET passed from human to human.” Don’t all the viruses seem to go that way eventually?
When you say you’ve found something fishy at the nurses’ station…
I have been lax in writing lately. Maybe my posts about mental health have given you a small clue about why? Not so subtle hint… In the background, I’m still reading some news and research, but most of the links I find interesting just end up in a notes file loosely titled “pandemic.” Today, I decided that I could at least go back and share the stories I’ve found interesting enough to save over the last month. Some might be a little out of date, but I know you’ll excuse me.
Most recently, the CDC annouced some shocking news (to me!) about masking. According to this NPR article, “Double Masking Offers More Protection,” with the most common combo being a cloth mask over a disposable (paper) surgical mask. This apparently helps the masks fit tightly and seal any holes that might exist to keep out any stray aerosols. When both people in an “exposure” during research wore their mask according to newly recommended CDC standards, transmissions of covid was reduced by 95%. This is AS EFFECTIVE AS THE VACCINE.
So, wear a mask, or even better TWO MASKS!
Monday, January 25, a group of scientists from UCSF announced promising research into the cancer drug Aplidin, currently only approved in Australian to treat multiple myeloma, but currently on limited trial in Spain for covid19. The anti-viral drug is 30 times more potent that the current standard treatment remdesivir. Aplidin, generic name plitidepsin, was discovered in a sea squirt called Aplidium albicans off the coast of Ibiza, Spain but is not commercially available in most of the world.
Read more about the research at “The UCSF-led team racing to find a COVID cure may have found a promising candidate“
This is the question Emma Gray Ellis asks for Wired Magazine in the article “The Lasting Impact of Covid-19 on Homelessness in the US.” She explores programs like California’s Project Roomkey, which utilized unused hotel rooms to house homeless people to curb the spread of covid among the homeless population by simply getting them off the street. And then the how the plan has transitioned to Project Homekey, which is attempting to turn these places into permanent housing for the homeless. Will attempts across the country to prevent widespread covid in the homeless population actually result in long-lasting change and housing? I really hope so, and some signs point to yes.
Its only February and yet January seems years away. It was a horrible post-holiday surge, and in the Bay Area, Santa Clara County was one of the hardest hit–as it was at the very beginning of the pandemic as well. This article about what it’s like inside the ICUs during the surge is fascinating reading, if you’re into that kind of thing.
Work has been shit lately. Covid is still surging in my ICU, and we’re busy with other things too.
Last week was an especially difficult week for our heart failure service, as every patient on service was deemed “not a candidate” for advanced heart failure treatment. Bottom line: this is end-stage heart failure and hospice is the next step. For many patients, this means removing a piece of equipment that’s been helping their heart do it’s job (like an intra-aortic balloon pump, or an Impella). This can mean almost immediate death, but many patients do go home from the ICU to die there. It’s emotionally exhausting but incredibly important work.
And it’s so important to spend some quality time with these patients. Last week, I helped a gentleman who was just days away from getting his Impella out to go home on hospice. He was itchy from laying in bed. I washed his back with real soap and water and washcloths. The put on lotion with a little massage. 20 minutes including gathering supplies. And it made his day! We chatted about traveling and life’s simple pleasures. These are the important moments at the end of life, and I was so happy to be there for him.
But despite that part of my job being so meaningful, there are other parts that are nearly unbearable. There is a day shift charge nurse who is mad at me no matter what I do, and who demands a ridiculous amount of report on our patients. She wants a full head to toe but the 90 second version. Do you know how long it takes me to prepare a cohesive and comprehensive 90 second head to toe report that also includes the plan and updates from when she was last on shift??? It takes about 5 hours to do it for 30-36 patients. And when I don’t give her all the info she wants, she asks for it in aggressive tones. If I don’t know the answers, she will eye roll, sigh and slam turn the pages of her printout. Actually, she does that sometimes anyways if she’s annoyed by something, anything.
I find this to create a workplace so toxic that it gives me panic attacks. I dread giving her report. I get short of breath talking to her. I often cry after interactions with her.
So what do I do when I tell my managers about this and nothing changes? That is the million dollar question facing me right now.
Oh, I almost forgot my dream. I had a left ventricular assist device (LVAD) in my dream, but it became dislodged internally. FYI, I’ve never ever seen this happen in real life… I was bleeding to death, surrounded by work mates. They could do nothing. And finally, as I was about to die, one of the help pressure on the bleeding spot as the warm feeling spread through my chest and I lost consciousness.
Whoa. Is that symbolic? I hope not.