Adaptive Curmudgeon at Middle Of the Right blog asks, Do They Really Need ICU?
Fair question, and I assume he's genuinely asking it.*
And thank a merciful deity, what I'm describing below was mostly how it was where I am last February, Not how it is is where I am , now. Yet. At least most nights. But sometimes, it is.
But it may be exactly what's going on in Florida or the Gulf Coast states today, or anywhere where things are getting congested.
What follows, it needs to be said for the small-minded, is not me bragging nor complaining. I knew the job was tough when I took it, I'm damned good at it (after 20 years, I'm starting to get the hang of it) and I sincerely love what I do, just as much as Lebron loves dunking, or a fighter pilot loves sending his opponent down in streamers of flames. (Now see if you can guess, when busybody lackwit 40-IQ governors want to prevent me from doing that job, in order to get injected infected with the poison not-a-vaxx, why I want to give them a few hundred raps to the forehead with a 12-pound sledgehammer, to jar their heads out of their own rectal exhaust pipes. I may or may not be speaking metaphorically.) But what I'm telling you here, and why I'm telling you, is for the benefit of those who have no wild idea, how it simply is. Neither more nor less.
Yes, they really need an ICU bed.
I’ve been a nurse for 25 years, 20 of them in Emergency, and not just “I don’t feel good” Emergency, but the busiest trauma centers and mega-hospitals in not just Califrutopia, but the busiest ERs in the entire civilized world, in the most densely populated region of the United States. Depending on where you ask, between 10-15% of the entire US lives in my county or the bordering ones.
120 hospitals in L.A. and Orange County. Almost as many as there are in the entire states of Oregon, Nevada, New Mexico, and Utah, combined.
What happens to that system which usually runs right on the ragged edge of capacity 24/7/365 in normal times, when you throw a pandemic at them?
In the ICU, they have an intensivist MD right there, most of the time. (The floors seldom have a doctor anywhere, for anything.) The patients are either 1:1, or 1:2, which means the nurse can handle 1 patient, and at most 2, at once. I do 4 in the ER normally.
But If I have ICU patients, and there’s no bed for them there, I can now only do 1 or 2 as well.
I had one last month, who was on 7 different medication drips, which all had to be titrated multiple times per hour to fine tune keeping the patient alive, and in certain parameters of vital signs.
I set my monitors to go off on the dot on the hour, and at :15, :30, and :45.
On the hour, I logged my vital signs. Then began doing the literally 57 things for that one patient I needed to be doing. Including not just doing everything I had to do, but charting that it was done. Picture Han Solo flying the Millenium Falcon through an asteroid field. Blindfolded. By the time I was finished, it was usually :50 minutes past the hour, or more. Meaning I had 2-10 entire minutes to do all the less-than-immediate tasks for that one patient that needed doing. Then it was top of the hour, and start all over again. Lather, rinse, repeat.
For an entire shift.
I wasn’t the only nurse so burdened with ICU patients who couldn’t get to the ICU. Which means if anything happens (like someone’s heart stops) there’s no one free to help anyone else. (A cardiac arrest or a major trauma can suck in 3-6 staff members just from the nursing staff alone, for an hour or more). But with all of us being ad hoc ICU nurses, that ain’t happening.
So a nurse is supposed to bag the patient, do chest compressions, start an IV, pull meds, give them, record all the interventions, all simultaneously and single-handedly? Sh’yeah, when monkeys fly outta my butt. That patient? They came in dead, and they’re going to stay that way. And even if, by some miracle, you get a pulse back, that’s another ICU patient, which you don’t have a bed for, or a nurse for, who’s shortly going to be on 2-7 medication drips, and on a ventilator, leaving the nurse scrambling to keep up the rest of the night…stop me if you’ve heard this one.
Which means my other 3 beds were empty, because there was no one to staff them. That turns a 32-bed ER into an 8 bed ER.
Which closes the hospital to ambulances.
Which sends the ambulances to other hospitals, which closes them.
You understand how one overload takes out a sector of the power grid, which can cascade into taking out an entire region over multiple states, right?
So now, imagine that with sick and injured people.
Except now, a blackout means people die waiting for care they cannot get.
And makes people wait in the waiting room until they’re literally trying very hard to die too, just to get into a bed.
If you’ve just sunk the Titanic or anything like it, and you have lifeboats for 2000 people, but 3500 on the ship, at least 1500 are going to die. But if, each time a lifeboat gets overloaded, all those people swim to the next lifeboat, you swamp each next boat in turn, and everyone dies.
That’s where we were headed when the last COVID wave broke, just about exactly 3 weeks after people all got together for New Year’s Eve and New Year’s Day get-togethers, and until they started acting like maybe we weren’t fooling about this thing being a problem.
And with my decades of ER experience, I’m a critical care nurse. I don’t like ICU, but I can pull it off, rough around the edges (meaning it isn’t pretty, but I don’t kill anyone or let them die through negligence or inexperience), for a shift or three.
But there were ICU patients on telemetry floors ( a lot less intense than the ED, and two levels of severity below the ICU). And ICU patients on Med/Surg floors (three levels below ICU). Where nurses never titrate a single drip, let alone 7 simultaneously, for an entire shift. And almost never manage ventilator patients in any way. They literally don’t know what they don’t know. Because they’re not supposed to be doing the most critical patients in the entire hospital on the least severe wing of the hospital, with the newest nurses.
Some of those nurses were freshly graduated nurses weeks before COVID kicked into high gear last fall.
And they normally handle 6 or 8 far less serious patients, not 4, 2, or 1.
So now their 40-bed floor ward can handle 5 patients. That means you’ve just wiped 80% of the hospital’s capacity on those floors out, from the get-go.
1,000 beds is now 200 beds.
200 beds is now 40 beds.
And it’s put the most seriously ill, critical patients, into the hands of the least-experienced nurses in the hospital.
Imagine throwing 5 year-olds into the 40-foot waves on Oahu’s North Shore with a pool noodle, and you’re not too far off.
Now see if you can figure out why some of those 600,000 people died from COVID in the last 18 months or so.
The nurses who regularly care for the sickest ICU patients are freaking rock stars, and they can only handle at most, 2 at once.
In the last serious COVID wave, from about Labor Day to the end of last February, half the nurses who worked in our ICU said “F**k it, I’m out!“. Forever. Burned out by 1 or 2 mega-critical patients like I had, every shift, every day, for weeks and weeks on end, understaffed, under-equipped, and under-supplied with basic equipment and supplies. No lunches, no breaks, just a 12-hour endless slog from 7 to 7, every day or night, and the same thing tomorrow, and the next day, and the next day, ad infinitum.
The ER and other floors lost upwards of 1/3 of our staff, for the same reasons.
Replacements can’t be whistled up, and they can’t be trained in less than years, to a minimum level of competence.
So hell yes, people die because we’re out of beds, out of supplies for the patients, out of PPE for the staff, and out of the staff to even show up.
In simple terms: how many games are the Dodgers or Yankees going to win in a season if they can only put 6 or 4 players on the field?
And what you’re asking, I assume legitimately, is “But do they really need 9 guys on the field? Do they really have to be major league players? Can’t the kids from Little League, high school, or maybe even Single-A suck it up and pull the load instead?”
So, my sincere question back to you is, what do you think the answer to that question is?
{And I didn't send this to my reply at that site, but I forgot to mention: In the ER, as in the ICU, I have a critical care monitor over nearly every patient bed in the department, so I (and others) can see my patient's heart beat, oxygen level, blood pressure, and respirations instantly, in real time. The telemetry floors are only monitored at the main nursing station, NOT the bed side. The Med/Surg floors have no monitoring anywhere, just portable vital signs machines, usually 2-4 for 40 beds. That's flying a plane at night, without any instruments installed, in the mountains. With a student pilot. You guess where the pitfalls in that approach are, and how well it's going to work, and for how long.}
*But I was wrong: he was just being a jackass, and virtue-signalling his Dunning-Kruger credentials.
Here's his reply to the above at his site:
Aesop: I let this get posted so others would understand why I hold you in such contempt.
You told us all how important you were, and how much smarter and better trained than everyone else but you really didn’t say all that much.
Nor did you really answer my question.
But hey, you got to blow your own horn again, so I guess you made yourself feel special.
Please, next time you comment, let it be either in answer to the post, a useful comment to the post, but please not so self serving, MMKAY?
No, I told you about 40 different ways that the patients who need ICU are sick as hell, and need the specialized care that only the ICU, and nurses trained to operate there regularly, can provide, which AIN'T ME, and that this is already kicking THEIR asses. But Reality doesn't comport with your ignorance or prejudices, so you honked your own horn and blew all that information right out your ass. Which was why I didn't wait for your gracious permission, and posted it myself.
Your disingenuousness is noted.
Don't waste time asking rhetorical questions you're manifestly too stupid to process when you get the answers. And good luck with that plan for the rest of your life. Like with undertakers, and for the same reason, that sort of intelligence is why I've been fully employed for 25 years, and people like you are my best customers.
Sorry to disturb your navel-gazing with the answers you couldn't handle. Go back to your beer and chemtrail websites. And by all means, don't wear a mask, lick the handrails, and pee on the electric fence. What could go wrong with that life plan?
Thanks again for reminding me why dealing with you honestly and giving you the benefit of any doubt is a complete waste of time, except as an object lesson to others.
Not having learned his lesson, and after getting picked on in Comments, he now doubles down, and takes another swing:
So far, Aesop’s record is slightly poorer than Fauci and the CDC. Remember the Ebola thing? And many other of his predictions?
I mean, he makes a TV weatherman look like a prophet…
You mean, when Fauci and the head of the CDC both said Ebola would never get here, and I said it would?
When Fauci and the head of the CDC said we had protocols that would deal with it, and I said we didn’t?
When Fauci and the head of the CDC said our first world medicine would triumph and stop it cold, and I said it wouldn’t?
When Fauci and the head of the CDC told you any hospital could handle Ebola, and I said that only the four BL-IV hospitals were trained or equipped to handle it?
You mean when, after they were both 100% wrong, and I was 100% right, on every one of those predictions, and Ebola in a Dallas ICU, using the CDC’s protocols, multiplied at the exact same rate it does in the wild, with no precautions, they ended up moving every Ebola patient in America – including the two ICU nurses they managed to infect with it in exactly 21 days, just like it multiples in the wild – into those exact BL-IV beds, taking up all but one of the only 11 such beds in North America, leaving us a red hair away from becoming West Africa?
Yeah, I remember that pretty well, since you mention it.
Everything I posted then (summer to winter 2014) is still up on my blog, in case you care to check it.
Now, tell me about your local weatherman with a 100% accuracy rate on his predictions and prophecies.
I haven’t made many predictions, as such. But the ones I have have panned out pure gold.
Please, B, for the love of God, stop stomping on your own junk with sharp cleats on.
and where is the national guard/military field hospitals and docs,nurses medics.
ReplyDeleteWe can deploy them throughout the Stans and latin america and africa. Are the effing Feds that incompetent or "out of chaos comes federal order". They have only had 2 years to ramp up production of biosuits and full facemask bipap. Doesnt really matter-----Marburg is next and its really good.
I have to say it now, after reading this, and say 'Thank you, Aesop." You and all the other nurses working their asses off for people who often taken them for granted.
ReplyDeleteI've an aunt and several cousins who're nurses, one an ER-- similar to you, I imagine, but on a much smaller scale-- and we talked quite a bit when I was going for my EMT-R. Hats off to them.
But mostly, I have to say that until I had a heart attack and spent 8 weeks recovering, I'd never fully realized how wonderful nurses are-- and especially those who can put up with an ass like me.(I think curmudgeon was coined for me.)
So, for you, and all those who work the medical field-- Thank You. God bless you all and keep you safe and healthy. (Now I can quit being sappy and return to grumpy self.)
And how many of those patients can be kept OUT of the ICU with cheap meds that the Establishment™ have deemed verboten for reasons no one can discern? Meds that, in one case, have safety profiles better than aspirin?
ReplyDeleteHas your hospital started using Ivermectin or HCQ early, when symptoms first present in a patient? If not, WHY NOT?
Funny how all the "official" HCQ studies tried it on patients were either on the verge of a vent, or on one already. It doesn't do shit for those patients, everyone knew that already. Those studies were tanked intentionally.
Ultimately it doesn't matter what the chair bound dipshits at CDC and NIH say, though, as word is getting out, and IVM is starting to be adopted more and more world wide, with great results. MATH protocol from FLCCC should be the standard of care, everywhere.
The burn out is going on here in Oklahoma also. Inside information has been "nurses resigning in droves". Haven't been able to transfer from our tiny rural hospital to ICUs past several weeks. "DKA with large anion gap - sorry but no room. Have to look else where.
ReplyDeleteTake care of them the best you can until you find a place." Sent a patient to a state 3 states away who needed an ICU. 1000 miles by plane. In the past we've occasionally sent patients to the city 60 miles away rather than the close city 30 miles away. Never sent them out of state.
And then one of our brilliant hospital systems administration team mandated the vaccine and promptly got several hundred nurses to resign right away. Looks like these administrators are willing to kill patients with their rigid vaccine rules.
Now is not the time to get sick and need an ICU. Not in Oklahoma and sounds like not in California either.
Imagine how far past fucked we'd be if it had turned into a real nasty pandemic with 10+ CFR and a real high RO...
ReplyDeleteHeck, it is in some spots and families.
Thanks for the look inside. I'll just note that around here, the ICU beds are near 90% utilization, but only 10%-15% for the 'Rona. I have no idea what normal utilization rates are, but folks from the hospital seem awfully tired. I do know EMS has done a record number of runs, but few are COVID-related.
ReplyDeleteAn older sister tapped out last year. She had retired from the AF and gone back into civilian nursing, but retired for good last year. She simply wasn't able to handle 12s 7 days a week any more, and the hospital was demanding that she keep up the pace.
ReplyDeleteI understand their side. She had the training and experience that was needed. But my sister is 67. She simply cannot do 80+ hour weeks back to back any longer. She tried, and it was breaking her. She has her .mil pension, so she really didn't need the job. The hospital wouldn't give her a less demanding schedule, so she quit. She's letting her quals lapse, so she cannot easily be voluntold. Done.
@Ang(1-7)Mas,
ReplyDeletePulling NG docs and nurses? Do you think their day jobs are bussing tables or changing tires? Just like something above 90% of MPs are civilian cops, pulling NG docs and nurses just robs civilian facilities of those same assets. Or d'ya figure we should be like China, and just draft a million people to fill sandbags every time there's a flood too, and tell everyone in the city to grab a shovel and report to the People's Glorious Worker Collective for duty? The only assets the .Gov really owns are active duty staff, which then takes them out of those units and commands too. Who are also dealing with the exact same pandemic problem set.
@Unknownsailor,
I have no idea. That's a problem for primary care doctors to be addressing at their offices. People don't come to the hospital early, and if they did, they'd be wasting our time. We're too effing busy with patients who are sick as hell to piddle around with people who should be going to Doc Jones' office, or the UrgentCare doc-in-the-box at 9AM, not the ER at 4 am.
By the time someone is sick enough to need the ICU, the time for coulda/woulda/shoulda is long past.
Yes, standard therapies that don't make a shitton of money for Big Pharma would be great, but the patients at issue already missed that bus two-three weeks before I even see them in the ER, and some of them become ICU patients within minutes to hours of arrival at the hospital.
@Harbinger62,
Yeah, that's about to be me and lot of nurses in CA too. We've had a nursing shortage in this country my entire adult life, and now they want to play political games, and lose 25-40% of the nurses they do have to try and force us to get the not-a-vaxx.
I can work in Vegas or Phoenix in about a minute, and if they get stupid there too, I'm still not getting that shit injected in me. Too many unknowns, and too many bad knowns.
And when it starts becoming a problem in a few years because of side effects, and the nurses who got the jab can't work, who're they going to be begging and pleading with to come back to work for them?
They can eat me, and even if I do come back, then, they'll be paying me brain surgeon rates. "Eff me? No, Eff YOU, genius political hacks."
Well said!!
ReplyDeleteReplied there myself.
I do believe Home Depot, Lowe's and other such have an adequate suppry of shovels and materials for pine boxes, should staffing and other problems adversely affect ICUs. Indeed entrenching tools could prove quite handy, and can be had at sporting goods and military surplus stores and also of course from Jeff Bezos et cetera.
ReplyDeleteThere are a number of conditions that may present with non-threatening symptoms and kill a person at short order. As in the case of folks who present to the ED after drinking a gallon of antacid and swallowing a bottle's worth of H2 blockers with Q waves across the precordium; the person who has a bellyache being discharged with exacerbation of recurrent "kidney stones" who gets syncopal when transferred from bed to wheelchair - and dies in the OR from a AAA.
Different groups have different perspectives. Office-based primary care providers have a "health maintenance" perspective: the presumption is that the patient is well unhil proven ill, and then mildly ill until proven seriously ill. Emergency and ICU staff see the patient as seriously ill until proven not-so-ill. The proof may not need a mega-workup; a careful history may be enough.
Not really.
ReplyDeleteIn the ER, we figure 7 times out of 10, you should have gone to Urgent Care, or your own doctor's office, but you're either not that bright, don't have insurance, or you think you're too special to make an appointment to see them, because you want the world on a velvet cushion, now.
The other three times, we work you up, because there's a good chance you're really sick.
In the ICU, they know every swinging Richard they get is sick as hell, because if you're not, you don't get an ICU bed.
People in the hospital know this without being told, and people whose entire medical training was staying in a Holiday Inn Express once, or watching a couple of episodes of Scrubs or Grey's Anatomy, don't.
That's why they ask if we're just randomly sending not-sick people to the ICU, just to jack up the bill, which is about as likely as McDonald's serving you ground tri-tip and filet mignon burgers, for the same reason.
It's on par with asking a pilot if the airplane really needs wings.
Which, of course, they don't - unless you expect them to fly anywhere.
Great respect given. What harbinger above said is true for the same reason you stated. The all mighty dollar reigns supreme. The industry over the years has become for profit and the campaign contributions follow. Just another way to steal from the masses.
ReplyDeleteDaughter recovered well from brain surgery for a tumor Jan. 2020. She had to withdraw from nursing school the previous fall. Went back fall 2021 and still couldn't pass muster and withdrew. All the stories like this over the last 18 months may be one of those, things happen for a reason, moment for me I don't know.
Good luck and God bless Aesop.
ReplyDeleteFrom a South Florida Hospitalist
Just finished an eleven day stretch as a hospital physician in the Tampa Bay area. We are getting hit hard. However, the hospital I am at is very well run and so there is no sense of being overwhelmed or even significant anxiety(except from administrators as lack of quick bed turn over causes decreased profits). ICU beds are full but our COVID nurses are awesome and have no problems managing BiPAPs, and maxed out high flow oxygen patients on the floors. The nurses have our personal cell phone numbers making instantaneous communication the norm. IMHO this has lead to improved patient care/outcomes.
I've only had one death so far and that patient had significant underlying medical conditions including a very weak heart with an EF of less than 10%.
One death from a service with many 80 and 90 year olds as well as a 101 year old that came off BiPAP, and is set to be discharged home.
Administration at all four hospitals I round at kept sending the same emails about the COVID crisis. They all say the same exact thing, using nearly the exact same words (very creepy)
"Our inpatients are well over 90% unvaccinated"
Then they all go on to write the same plea to all the unvaccinated to get vaccinated. They even add where and when you can go get the shot for yourself, your family and the community.
Problem. My numbers don't match up with the numbers provided by the specific hospital I am rounding at.
On any given day, I'm covering 20-25% of total hospitalized COVID patients and my numbers are showing 75% vaccinated
and 25% unvaccinated. I had one unknown but his delirium cleared and he denied getting the vaccine.
When I discussed this with a fellow hospitalist (from a different group) she stated that her much smaller sample size was running 50/50 vaccinated vs unvaccinated. Again, numbers don't match the 'official ones'
She actually reached out to administration with this discrepancy and asked if they could provide the Medical Staff with the actual breakdown of vaccinated vs unvaccinated.
She showed me the email she got in response. It was condescending and dismissive. She was told that there was no need for her to have that information and that she should just focus on her own patients.
Incredible. Worse part is that nearly all of my colleges are repeating the false administration narrative. Even after I show them my real life numbers and the math showing this can't be true. Very disturbing.
What is keeping me up at night is how this phenomenon of infected, but vaccinated may be the human version of Marek's disease in chickens (see study below).
From the Abstract:
"Marek's disease (MD), caused by Marek's disease virus (MDV), is a commercially important neoplastic disease of poultry which is only controlled by mass vaccination. Importantly, vaccines that can provide sterile immunity and inhibit virus transmission are lacking; such that vaccines are only capable of preventing neuropathy, oncogenic disease and immunosuppression, but are unable to prevent MDV transmission or infection, leading to emergence of increasingly virulent pathotypes. "
Read that again and let it sink in.
Are the vaccinated spreading more virulent COVID to the unvaccinated?
I don't know but it is a legitimate question with a real world example, confirming that it is a possible consequence of mass vaccination that allows the vaccinated to get sick.
When I asked one of my outpatient doctor friends (in Florida) what percentage of unvaccinated vs vaccinated patients he was seeing, he answered 100%. I was afraid to ask, but I had to...100% of his COVID positive patients were VACCINATED.
I sent him the Marek chicken study.
'Oh shit' was his reply...
Marek's disease in chickens: a review with focus on immunology
Nitish Boodhoo 1 , Angila Gurung 1 , Shayan Sharif 2 , Shahriar Behboudi 3
Affiliations expand
PMID: 27894330 PMCID: PMC5127044 DOI: 10.1186/s13567-016-0404-3
Thanks, Doc.
ReplyDeleteMy own census hereabouts is running just about 50/50. And the current COVID wave here in SoCal is a blip: they're maybe 10% of the ED intake now, vs. 80-90% in December/January/February. Our problem is the long-term loss of half our ICU staff, which they haven't yet replaced. That's impacting our regular traumas and ICU admits. Best wishes with things where you are. I hope they never get as bad there as they were for us 7-8 months ago here.
At least the manglement (not a typo) here isn't putting out happygas CDC talking points. Yet.
Boldly lying through one's teeth about the CoViD-19 rates in vaxxed vs. unvaxxed is a recipe for disaster; and ominously the same behavior is increasingly habitual in all aspects of society... a veritable witches' brew.
ReplyDeleteAesop - Thank you for sharing. My dad was in the ICU for a 10 day stretch this year (Not The Plague but a stroke). All the nurses were very helpful in giving us updates - we tried to space them out to morning and evening to not be a bother.
ReplyDeleteIt bothers me that there is a disconnect in the data. Eventually this completely undermines all trust in all data, which is not going to do anyone any good in the long run.
The way you say that - it’s almost like you think they care if it helps or hurts. All that matters is if it advances the ‘agenda’. 😕
DeleteBrian - I am bothered by it. I work in a health related industry and any compromising of data - lying, mis-reporting, outright making it up - is subject to any sort of things up to and including fines and prison. Perhaps it is a case of the rules apply to some, but not to all. None the less, I am bothered by it.
ReplyDeleteBelow is my pending comment at his post.
ReplyDelete---
KBYN
on 08/21/2021 at 08:12 said:
Your comment is awaiting moderation.
Aesop pointed out why a rush on ICU beds cascades downward to the ER and to the med/surg floors. Didn’t you read it?
When you fill the ICU and are forced to turn the ER and the med/surg floors into jury-rigged ICUs, you necessarily reduce the number of patients that a nurse in those units can keep alive.
That cuts the capacity of those ER and med/surg units, forcing incoming patients to bounce to the next hospital, which then fills up rapidly in the same way. Don’t you see the pattern?
Don’t you understand why ER & med/surg nurses can’t maintain an ICU level of performance when they haven’t got ICU equipment, ICU experience, or even ICU training? Don’t you understand that even some ICU nurses can’t maintain their performance for months on end when the ICU is swamped 24/7?
Thanks for trying.
ReplyDelete"You can't argue someone out of a position using facts and logic, that he didn't get himself into using facts and logic."
And if you don't go onto EPIC and document it all, your hospital might be charged with Medicare fraud.
ReplyDeleteClick all day, that's what matters!
Most dispiriting part of the day. All day.
God bless the nurses. After a year and a half of self sacrifice, our hospitals are telling us, "Thanks, but get the shot or get the F out."
I do not feel like my autonomy is being respected. So I will be fired in 2 months. For not accepting an experimental treatment to a disease I have recovered from.