Out of the frying pan…

and back to the COVID-19 unit. If it seems these COVID posts are coming closer together, you’re probably right.

We rotate therapy staff through there and the speed at which we rotate depends on how many of us are there at once. Last week there were three COVID Occupational Therapists all week, four on Monday. Once upon a time, there was one therapist for ½ days.

Instead of starting my week there, I ended it there. Saturday I saw three COVID patients. Two were incidental findings in patients admitted for traumatic injuries. All patients are tested on admission and isolated until a negative result comes back. These two were positive but asymptomatic. The third was sick enough to be admitted but breathing on their own on the third day and may be going home this afternoon (Saturday).

Saturday, January 8

Recommendations are in flux once again. When the delta variant blew through, I saw young, previously healthy, unvaccinated, and very sick people. Those who survived were here for weeks or months. Now numbers are up but severity is down. We got new recommendations last night.

PPE from “strongest” to “weakest”:
–For COVID+ patients, I wear a PAPR (Powered Air-Purifying Respirator), gown, and gloves. The PAPR sucks in room air, runs it through a filter, then delivers it to my hood. The filter is self-monitoring to let me know when it needs to be changed.
–I have the option of wearing a fit-tested N-95 respirator with a face shield instead of a PAPR. “Fit-tested” means I wore that mask, a hood was placed over my head, and a bitter-tasting substance was injected into the hood multiple times under varying conditions (standing still, moving around, shaking my head, bending over, etc). If I never tasted the bitter substance, I was now “fit-tested”. Any detection of the taste would mean starting the test over with a different mask model.
–For COVID- (negative) patients, I now wear a “well-fitting” mask. That essentially means an N-95 mask that has not been fit-tested but fits tightly and has no apparent leakage. (Why this? Because we just got a new model of N-95 that is way more comfortable than the one I was fit-tested for. No one has yet been fit-tested for this model but it looks promising. The mask I was first fit-tested for 20 years ago was not an option this time, though is now back in stock and less uncomfortable than my current fit-tested model. We are supposed to be fit-tested annually. I was fitted at the beginning of the pandemic and fitting should be available again soon. [Two years is better than 20 anyway.]) It is also “strongly recommended” that I wear an eye shield, so I do. A mask and face shield makes it hard for patients to hear me. The eye shield doesn’t have that effect. The N-95 is fluid-resistant anyway, so the shield is overkill for non-COVID patients unless you try to wear the same mask for a long time (as we did earlier in the pandemic when supplies were short).
–A standard “barrier mask” (surgical mask) is no longer considered adequate for any patient contact and some are saying only appropriate in your own office. As of today, that’s what I wear to enter the building.We’ll see how that changes on Monday.
–A cloth mask has not been acceptable for many months. We used to wear them in all parts of the hospital except patient rooms.

I’ve seen a bunch of anti-vax memes. Today I saw a batch of pro-vax memes. I couldn’t resist.

From Reddit via The Daily Kos
From Reddit via The Daily Kos

Thursday, January 13

An interesting week so far. The hospital gods must be on my side. I have seen several trauma patients with incidental COVID+ findings, so I feel at home. I’ve also seen patients whose trauma may have been a result of their COVID confusion; there’s really no way to know for sure. Tuesday I saw a young and otherwise healthy person who was sedated due to extreme agitation due to COVID. Wednesday that person looked great, except for the need for CPAP. (Continuous Positive Airway Pressure, which feels sort of like a powerful fan being blown into your mouth and nose at all times. It makes it hard to exhale.) They were up and around the room. We stood and looked out the window together. Thursday they were intubated and moved to the ICU. I’ve seen multiple people with brain bleeds – from major trauma, minor trauma, no known trauma. I saw them after a decompressive craniectomy (in which a chunk of skull is removed to allow the brain to swell, the skin is closed over it, and the bone flap is stored to put back later).

We are too busy to keep up. I have 15 patients per day. I can’t see that many. On Tuesday I had 12 newly-diagnosed patients. Most of them I passed on to a Therapy Assistant to see Wednesday, so I could see a dozen more new folks. Today I had a few that I had to leave until tomorrow. The eight hour day is not really an option; nor is seeing everyone who should be seen. Each day is a compromise. “Triage” is my middle name.

Today a bunch of suits came through the unit, led by the Director of Nursing. They stood by the nursing station to hear tales from the front. As I walked by, I heard the word “burnout” and the phrase “we can’t keep up” more than once.

Friday, January 14

One in every five patients in the hospital are now COVID+. We have the incidental finding (here for some apparently unrelated reason, asymtomatic, but COVID+), the here because of severe COVID infection, and the grey area in between. The person who fainted “for no reason” but is COVID+ may have fainted due to weakness from the infection. Do we know for sure? The person who had the ischemic stroke could be coagulopathic from COVID infection, but possibly just happened to have a stroke while COVID+. The person with bleeding on the brain after falling – did the COVID infection lead to the fall? The people with what we call “failure to thrive” (general malaise, lack of appetite, unable to care for themselves) and COVID-19 probably are failing to thrive due to COVID, or it may just be what pushed a borderline functional person over the edge.

At any rate, my COVID caseload keeps growing. It shrunk by two during the course of today. One went home, one died.

I’m not on Facebook, so count on others to read it for me and tell me of the stupidity therein. I’ve seen a lot from people posting anti-vax and COVID-denying memes that stop the day they are admitted. Then their posts are about how miserable they are. And then comes the inevitable post from someone else about the GoFundMe campaign to support all the children this person left behind.

I saw the posts from a person who refused the vaccine because its development involved a fetal stem cell line, then demanded treatment with monoclonal antibodies which were developed using that same stem cell line.

Another series involved people claiming that hospitals are paid a bonus for killing people with COVID treatments, so you should refuse to go to the hospital…then those people show up at the hospital only when at death’s door and wonder why the hospital didn’t save them – probably because they failed to use the proper doses of dewormer and bleach. There are those who seek attorneys to help them sue the hospital for failing to provide them with unproven and unapproved treatments they read about on Facebook. Yet another involved people telling their friend to refuse remdesivir because it kills people (and is one of the ways hospitals claim their bonus). Yes, some people treated with remdesivir die; but at a lower rate than those who don’t get the treatment. So if you show up at the verge of death, the hospital tries everything and you still die, was it the disease or the treatment that killed you? Why is that even a question?

I could argue with equal accuracy that you should refuse to drink water, as 100% of people who drink water die. (Not right away – that’s what makes it so insidious.) I could argue that, if you get pregnant, you should demand an abortion rather than being forced to bring a child into the world. We know that 100% of those who are born die – many only after a lifetime of suffering. Is it more humane to sentence one to a life of suffering, or to save it from birth in the first place?

Saturday, January 15

My eight day COVID week has come to an end. I’ve got nothing to say, but it’s okay (how’s your boy been?). (20)

Shredding a Life

Mortality is on my mind. So is storage space in my basement. I have a 3 drawer file cabinet that is hard to stuff more into. I decided it was time to make room.

I started with old check stubs and check registers. I had saved them forever. I had tax returns starting with the first year I paid taxes. I saved that one, but the rest of the last century (and some of this one) were not necessary.

Work and school-related stuff came next. I had course notes that I’ve never looked at. In round one I saved my Anatomy and Physiology drawings because they were the first evidence that I could draw something representational. (They got tossed today.) Anybody need a bunch of 3-ring binders? I don’t plan to be working much longer so a lot of work stuff went; much of it was outdated anyway.

I found reference letters people wrote for a job I didn’t get 25+ years ago. Reading them brought a tear to my eye and made me wonder how anyone could not hire that guy. I found the Strong Interest Survey that I completed during a job search 30 years ago. It told me I had very little in common with people who chose careers in sales or the military. Was I surprised?

There is stuff from an organization I helped start nearly 50 years ago. I already lent it to them to scan on their 40th anniversary, so the original paper may not be necessary. I trimmed that file but couldn’t part with all of it.

Bonus! Shredded paper is compostable. If your compost is mostly vegetable scraps, paper adds needed carbon. Compostable materials are thought of as green (e.g. vegetable scraps) and brown (e.g. dried and shredded leaves). Most of us have too much green in our compost. Paper adds some brown.

Doing this helps me let go of my identity as a worker. I can admit that I will be retiring soon and don’t need that stuff. It helps me realize that life is unpredictable. Any of us can die at any time. None of us are getting younger, so the probability of death increases. Do I want to make my kids sort through this? Might what I choose to save have meaning to them?

On the other hand, I found my book of county road maps, useful for planning bike rides. It is old, but town roads and county highways tend not to change much. I kept it. I have route maps and cue sheets for dozens of bike rides. I didn’t try to cull those.

Since we were talking about mortality, I received an indirect death threat for a recent COVID-19 post. I had already blocked the commenter, so the comment went to my trash file, but it warned me to delete this blog “before the villagers with pitchforks and torches head towards your house.” I thought that was all I as going to say about that. I was wrong. Hang onto your hats…

Stroke Week

Since we raised the topic, let’s talk about COVID-19. Many of you read these posts before the comments appear so won’t have seen the exchange I had with the person who calls themself “covidpilot”. They referred to the vaccine as the “COVID clotshot”. Ironic, then, that my move from the ICU back to the intermediate and general care COVID units this week brought me face-to-face with a bunch of young (as in, young enough to be my children) people with strokes.

Mostly, the COVID posts herein have been to highlight the personal experience of working with the COVID-19 population. Since misinformation in the name of “following the science” has reared its ugly head here, we will delve a little more deeply into the literature. (For each journal article I have noted the source and year of publication. Full citations available on request. Since this is not a scholarly article, I don’t want to take up a lot of space with citations.)

Strokes in people that young aren’t unheard of, and the journal Stroke (2020) lists a number of risk factors for stroke in the young. Stroke occurs in about 0.01% of the population under 40 in the US (Vascular Health Risk Management, 2015). So it could be merely coincidental that I saw several young people with strokes this week, way more than I ever saw when I worked on a neurology unit regularly. But I don’t think so.

“Just the facts, ma’am”

The International Journal of Stroke (2021) published a meta-analysis of 61 studies of COVID and stroke. The articles were all before the advent of the Delta variant, which has, at least anecdotally, affected younger people more than the earlier variants. Even before the Delta variant, the meta-analysis concluded that “individuals with COVID-19 who developed stroke were significantly younger” [than non-COVID patients with stroke]. [Emphasis added] They found that “pooled results…suggest a particular profile of COVID-19-associated strokes, characterized clinically by severe NIHSS [National Institutes of Health Stroke Score] and poor outcome and radiologically by large artery occlusion and multiple arterial territory involvement. ” In plain English, COVID patients are younger and have more severe strokes than non-COVID patients. It cannot be conclusively proven, at this time, that COVID caused the strokes, but the high correlation “suggests a causal relationship.”

covidpilot referred to the vaccine as the “COVID clotshot”. A search of PubMed for data re: risk of clotting after vaccination vs after infection revealed “The risks of most of these events were substantially higher and more prolonged after SARS-CoV-2 infection than after vaccination in the same population.” [Emphasis added] (BMJ, 2020). The European Medicines Agency (referenced in Saudi Medical Journal, 2021) found “the number of observed thromboembolic events in vaccinated patients are much lower than expected as calculated in comparison to the incidence of events in general population.” [Emphasis added] In other words, while some people had strokes after the vaccine, the numbers are lower than would be expected in the general population – so the vaccine does not appear to be a factor. Taquet, et al (2021) looked at the relative risk of clot after: 1) COVID infection, 2) mRNA COVID vaccination, and 3) influenza infection. They examined over 500,000 cases and found the chances of serious clotting (they looked at CVT – cerebral venous thrombosis – as this is one of the adverse vaccine effects that has been reported anecdotally, and PVT – portal vein thrombosis) were 6.67 times greater from the disease than from the vaccine (for CVT) and 7.4 times greater from the disease than from the vaccine (for PVT). Patone, et al in Nature Medicine (2021) found: “In summary, although we find an increased risk of neurological complications in those who received COVID-19 vaccines, the risk of these complications is greater following a positive SARS-CoV-2 test.” [Emphasis added]

So yes, covidpilot is correct that there are reports of neurological and clotting complications following COVID vaccination. Most of the papers reporting those complications are case reports – reports of a single person having a complication temporally related to the vaccine. No causal relationship is demonstrated, though occasionally implied, and sometimes claimed (though more often by readers than writers). The papers claiming increased risk showed a much greater risk from the Astra-Zeneca vaccine than from the mRNA vaccines more common in the US. The papers which compare the relative risks from the vaccine vs the infection universally find that the illness carries greater risk of complication than the vaccine.

For those who missed the prior exchange, here it is:

thecovidpilotsays:m
In the news…Covid clotshot kills covid cult cardiologist who said that he would shed no tears for the selfish unvaccinated at their funerals. Poignant irony

thecovidpilotsays:
I follow the science, not the pharma narrative. Antwerp ICU covid patients are all vaccinated.

halffastcyclingclubsays:
Not sure where you’re going with this. It appears that you are calling the vaccine the “COVID clotshot”, while also claiming (in your next comment) to “follow the science”. If you can show us science that shows risk of death from the vaccine to be greater than the risk of death from the virus (even if you limit it to the relative risk of death from clotting disorders) I would be more inclined to take you seriously.

thecovidpilotsays:m
if you could show good science that the risk of death from the virus is greater than the risk of death from the clotshot, I might stop needling you. Of course, then you’d have to actually have some autopsy sampling of VAERS covid vaccine death reports by the CDC, but they don’t seem very interested in doing actual science that might question their narrative that vaccines are “safe and effective.”Hence, we don’t know much about the actual risk of clotshots. It looks like VAERS reports are the best science we have. Accordingly, we should use it.It looks like adverse event underreporting runs about 30x actual reports (1). Let’s use the CDC figure of 9,367 covid vaccine VAERS death reports. So it looks like there have been about 270,000 covid vaccine deaths, which is a small fraction of total vaccinations.As of now, the risk of death from covid is tiny for two reasons. First, it looks like we may have achieved herd immunity in the US. Second, the risk of death is small when antiviral treatment is used–20% of baseline. So my plan requires that early antiviral be given to high risk patients. Maybe 1% of the US population is actually at high risk from covid. But probably 90% of that group has some sort of immunity to covid. So we are talking 0.1% of the US population being seriously at risk. But antiviral cocktails given early–yes, I am assuming early treatment–will reduce covid mortality by 80%. So that looks like maybe 25,000 deaths from covid per year, which is in the range of flu. The clotshot so far this year has racked up 270,000 deaths, based on our estimates.It looks like continual boosters would be required if we followed your plan–with the undiminished risk for each booster–resulting in continual, straight-line vaccine deaths in all age groups.So, now, the risk from vaccination looks to be far higher than the risk from covid–especially for younger cohorts.(1) https://academic.oup.com/cid/article/61/6/864/451758?login=true

halffastcyclingclubsays:
To thecovidpilot:Your “science” is lacking. First, the VAERS system is notoriously unreliable. In their own words: “Reports may include incomplete, inaccurate, coincidental and unverified information. The number of reports alone cannot be interpreted or used to reach conclusions about the existence, severity, frequency, or rates of problems associated with vaccines.”

Second, the citation you offer does not support your conclusion of underreporting by a factor of 30, nor do the underlying articles cited in that source.

Third, even the data you cite are not specific to your assertion that the risk of death from clotting disorder is greater from the vaccine than from the disease.

Fourth, correlation does not equal causation. In randomized, double-blind, placebo-controlled trials, adverse reactions to the placebo are reported routinely.

Fifth, the article you cite is from before the COVID vaccine. There are clearly political factors at play here that were not at play during the period studied. There is a large and vocal anti-vaccine group, much more so than with any single prior vaccine. That group has a vested interest in reporting adverse effects. One could assert that there are those with an interest in falsifying reports of adverse effects for political gain. One cannot ignore that public health officials have received death threats for their work.

Sixth, as Stephen Wright told us, “42.7% of all statistics are made up on the spot.” I have seen no evidence to support your dual assertions that only 1% of the US population is at high risk and that 90% of that group has “some sort of immunity” to COVID. This leads to your next false assertion.

Seventh, you assert (due to your “calculation” above) that 0.1% of the US population is “seriously at risk” from COVID-19, though the death rate to date is already 2.5 times that.

Eighth, Johns Hopkins has confirmed 762,972 deaths from COVID-19 in the US as of 11/13/2021. They have confirmed 47,050,502 cases of COVID, for a death rate of 1.62% The reported (unconfirmed, and subject to the biases VAERS cites) deaths attributed to the vaccine total 7793, while 439,034,461 doses of the vaccine have been administered. This yields a death rate of 0.002%. Even if you limit the count to those fully vaccinated (which would eliminate anyone allegedly killed by the first dose and anyone who chose not to get the second dose due to an alleged adverse reaction to the first dose), the death rate is 0.004%. Thus the risk of dying from the virus is at least 400 times greater than that of dying from the vaccine, and probably considerably higher than that. [emphasis added]

Ninth, since this is my blog, this is the end of this discussion. If you would like to continue to spread misinformation, disinformation, or misleading conclusions from incomplete information, you are free to do so on your own site.

I left out a few points from that exchange. covidpilot asserts that we “may have achieved herd immunity”, yet still expects 25,000 deaths per year into the future. cp wrongly equates this to the number of deaths from influenza, a disease for which no one asserts we have herd immunity. covidpilot has a “plan” to give early antiviral treatment to high risk patients, though their own numbers show that all high risk patients are already dead two and a half times over.

Since the people I have seen the past two weeks have not been in cp’s “high risk” category (unless the anti-vaccine covidpilot considers unvaccinated people to be high risk) they would not qualify for cp’s early intervention. Since the set of people who oppose the vaccine and the set of people who don’t take this disease seriously appear to have a high degree of overlap, and have historically avoided presenting to hospitals until near death (or post-stroke), the proposed “early treatment” would likely not reach those people.

Nonetheless, I have decided to give covidpilot the last word. Here is their last message, the one that I blocked:

“You might want to shut down your blog before the villagers with pitchforks and torches head towards your house. People are VERY angry about all this and they are waking up.

COVID ICU

It’s time for my next round on a COVID-19 floor. This time it’s the ICU. I have been on General and Intermediate Care on my previous tours. ICU is for the sickest of the sick. My patients are on ECMO (Extra-Corporeal Membrane Oxygenation). This isn’t merely a ventilator that assists you to breathe or breathes for you. This is an artificial lung. Your blood leaves your body via a ½ inch or so diameter line, runs through a machine to remove CO2 and add O2, then sends it back into your body via another line. (That’s what “extra-corporeal” means – outside the body.) One line comes out of your neck and the other your groin. Mobilization is a bit tricky. You don’t want any leaks.

Ready for action as soon as you add gown and gloves. The conehead look isn’t the most comfy, but it’s cheaper than the 3M PAPR (Powered Air-Purifying Respirator). There is no patient information on the wall behind me.

Some of these folks have been in this hospital for two months. They came from smaller hospitals that didn’t have the means to provide the treatment they need, after exhausting all options available to them. At least one has been sick since August – 3 months and counting. They are young and unvaccinated. Will they survive? Beats me. Are they anti-vaxxers? Beats me. My job is to help them, not to second-guess them.

(But since you ask, let’s just say that, if I were a betting man, my money would be on “yes” to surviving. As to whether they are anti-vaxxers or just think they are immortal, that one’s a tossup. This batch of patients are young enough to be my children and have survived two months in the ICU.)

A friend and spouse are vaccinated. One of their two adult children is vaccinated. The other is not, along with spouse and kids. We’ll call my friend Vac and the child Not. Vac was at Not’s house and Not confessed (after several hours together) to feeling ill. Vac had a home COVID test handy – Not was positive, confirmed by another test the next day in a health care facility. Not’s spouse and children are all sick. Vac remains well and has tested negative twice since that exposure. Vac’s spouse and other child are also fine. Do you think maybe the vaccine works?

One of the anti-vaccine arguments is based on “natural immunity”. People want their own immune systems to fight it out with the novel coronavirus. Note that name: novel. Our immune systems work by developing antibodies against invaders. If an invader is known, we have the means to develop a specific defense rapidly. If the invader is unknown (novel), we toss stuff at it while we try to figure out what to do. If the virus is strong enough, we may die first. (Or, in the case of the polio virus, just some motor neurons die. If enough die, we die. If we’re lucky, we’re paralyzed.)

What does a vaccine do? It enables our body to recognize the invader and develop specific antibodies. If we then come in contact with the disease, our immune system is up to the task. The vaccine enables our natural defenses to work.

Did you go to public school? You probably had a bunch of vaccines before you were allowed to attend. We don’t want you to come into close quarters with others and infect them with measles, mumps, rubella, diphtheria, pertussis, poliomyelitis, etc. It’s what we call Public Health. That’s why you should get the COVID-19 vaccine. On one level, I don’t care whether you get the disease. You are “free” to get sick and die if you so choose. Should you also be free to infect others or use scarce resources by running to the hospital when you get sick? Should you be free to demand that said hospital treat you with horse dewormer or a “cleaning” with an injection of a disinfectant like bleach?

Don’t tell me you “did your own research“, like a certain professional football player. Those of us who use research in our lives know that research involves experimentally testing a hypothesis. Before you do your research, you do a literature review, to see what has already been done. Is that what you did? A lit review? Did you actually read the literature, or just listen to a talk radio host talking about the literature? When you do a critical review of the literature, you appraise it against a set of criteria. There are what we call “levels of evidence”. Some evidence is better than others. No study is worth a lot before it has been replicated by someone else. Did you believe one person who runs counter to the mainstream because they say they are a doctor?

If you’re against vaccines (or at least this one) because they’re “unnatural”, are you against soap and water or antibiotic ointment if you get a cut? Why not just let your body’s natural defenses go to work? Maybe you’ll live, maybe you’ll die. Maybe that cut finger will result in being faced with the choice of death or amputating the arm. Amputation is unnatural. Death is completely natural. Decision made.

After all, life is 100% fatal. Why wait?

[Editor’s note: Sorry, it has been a rough week at the hospital. The writer apologizes to those who do take care of themselves and others and is not wishing an early and painful death on anyone. He is tired of reading about people refusing help until it is too late and then demanding their own particular choice of help. He is tired of reading about people looking for lawyers to sue hospitals for employing the standard of care instead of listening to their half-baked theories. He is tired of reading about people who refuse to take action to protect themselves and others, then beg for your prayers and money for funerals and to raise the children of stupid people who refuse the vaccine, refuse to wear masks, and think they are standing up for freedom. He is sick and tired in general this week – and he hasn’t even finished the first week of this rotation.]

Eyes of a Painter

Every picture tells a story, as Ronnie Wood and Rod Stewart told us 50 years ago.

I was advised, when I started this blog, that pictures were essential. Words would not be enough. Since it’s about riding a bike, that meant phone pictures for the most part. With a “real” camera, composition includes choosing the right lens, getting the light right, and using aperture and shutter speed to control depth of field and motion. A phone limits those choices and a camera and lenses are too heavy to carry.

What my eye sees and what my phone shows you don’t always match. The weakness is on both sides – me and the phone. Another blogger I follow is a writer (novelist, poet, former English teacher) and a painter. On the ride that spawned the picture below, I though about Martha – writer and painter – and whether the picture in the phone would really show you what I saw.

Ken Burns tries to capture that in his films. It has been named “The Ken Burns Effect”. My eye saw that truck a lot more clearly than you probably see it in the picture. To get closer to the truck with a digital zoom loses the sharpness and the buildings on the horizon. The colors seem less vibrant here than out there. Digital enhancement (at least with the built-in phone software) makes it look fake. While Martha has the eyes of a painter, this is my kind of music, not hers. She’s a punk. I mean that in the nicest way.

Since Martha is a punk, The Stranglers may be more to her liking. I was never a Stranglers fan, but heard them on the way to meeting some folks for a ride. They were being interviewed by Lulu Garcia-Navarro, and played this:

It is from the album “Dark Matters”, their first in nearly 10 years, and contains the last recorded work of their keyboardist, Dave Greenfield, who died of COVID-19 during its recording. Nothing punk about that song (or a lot of their other work), but as we approach 70 (or pass it) my friends and I talk about aging more. Some friends no longer ride with us, having gotten old. Some have slowed down. Some wonder how long we will feel this good. I can ride 100 miles now, but for how much longer? I will enjoy it while it’s here. There are no guarantees.

Last Wednesday Night Ride

It is October. It is supposed to be getting cold and dark after work. 77 degrees and sunny. A quick 17 miles and I’ll be home in time to cook dinner. Soon there will not be enough daylight to ride after work. The fall color ride is just around the corner, and that will mark the end of recreational riding until the New Year Ride (unless it just stays too nice to resist).