Thread by @GuerinGreen

National Critical Care Rounds tweetstorm
Haven’t been on the calls since before the holidays
It was one of the more depressing calls to date. Volume of very sick #COVID patients and changing disease course /1

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Presenting on today’s call: Harry Sibold- MT emergency doctor on loan in Odessa TX
Oren Freidman- Cedars Sinai LA and Marina - ICU director/Pulmonary doc /4

Freidman: COVID cases have taken over all of the ICUs- pediatric, surgical, cardiac

Smaller hospital- 12 ICU beds without dedicated intensvists. Create tele-ICU to guide hospitalists
Not enough, moonlighting intensivists overnighting at affiliate hospital. /5

Any transfers in LA County?- process gummed up, very hard.Created strict criteria about who we are going to bring in.

Send the sickest or the busiest patients? Move the patient that is most salvageable. /6

People are dying left and right. People intubate for 2-3 weeks with no improvement.

Steroids are working to suppress cytokine storms. But replaced by superimposed bacteria infections. Steroids causing tissue breakdowns? /7

Extubating people left and right? No. It feels worse (this surge).
Hard to separate out the effect of the surge… from the change in treatment on mortality
(overwhelmed and stretched staff & resources could be contributing to mortality) /8

Harry Sibold, MD - Texas Response
I’ll let Dr. Freidman jump in too, but here we aggressively wean O2 as we can. Hyperoxia is damaging, especially in the face of cytokine storm or increased systemic inflamation. If peak pressures are unacceptably high, /9

...then you have to wean peep to avoid the damage and risks of pneumothorax. It is a balancing act either way. /10

FEMA regional response in West Texas. Emergency doc… offload some of an intensivist’s workload.
Something else going on with lung physiology. Evolution of severly ill patients, new subtleties on the disease process.
Something else going on with lung physiology. /11

...Evolution of severely ill patients, new subtleties on the disease process.
Pneumothorax and Pneumomediastinum in both of intubated and non-intubated patients - the issue of the fall, according Freidman /12

Freidman:
Crisis care (rationing): really stuck to withholding futile treatment. Be more thoughtful and appropriate instead leaving it to the family.
Allowed the intensivists to be the allocators of resources. /13

Ethics (department) available 24 hours a day
Limiting things that we don’t think will work.
NYC had hard age cutoffs… /14

Somebody gets the resource and somebody doesn’t. Happening more frequently now. Month, two months on ECMO. Stricter and stricter on using it.
(ECMO is a heart-lung machine) /15

Comment: If the public could understand what crisis care means and how it may impact them & their families, they may change behaviors. As a public health person, we don’t like to use fear, but colleagues we are there. /16

Esp in LA where I have family and friends. We must make the case public ally. Its hard to do that but we must ! /17

back to Freidman: No longer work with unlimited resources- must be used with those with “meaningful chance of survival” get the resources they need. /18

ECMO most limited resource. 60% survival (according to retrospective) but “much less than that”
20 days plus on ECMO. “This disease doesn’t respond well or quickly” /19

On LA's exploding case count: A couple of superspreader events… increase in community positivity then an explosion -Freidman /20

Overall takeaways... the changing disease course, perhaps in response to treatments (steroids) is very disheartening.
We have had a failure in translational medicine and public health, despite heroic efforts in supportive care & on the vaccine side 21/21