ZDoggMD Interviews Intensivist Dr Herbert Patrick on #COVID19 Critical Care #Coronavirus

The tube in the mouth goes down into the lungs. The actual ventilator machine is out of the picture. You have to be heavily sedated to tolerate this 

I am not an intensivist, a physician that works full-time in critical care units, aka ICUs. Although I’m a hospitalist, I don’t do much work at all in the ICU. Intensivists are usually pulmonologists although I think more recently there are fellowship programs that bypass typical pulmonology training and go straight to critical care.

Anyway, if this Coronavirus pandemic really takes off in my area, I may have to start impersonating an intensivist because there may not be enough to go around.

Local TV news last night mentioned that the Feds are re-opening a hospital in Phoenix that closed down last fall—Phoenix St Luke’s—to provide 340 ICU beds. I swear that’s what I heard—340 ICU beds. Where will they get the staff: intensivists, respiratory therapists, ICU nurses??? My hospital has 8–10 ICU beds. Sometimes a bed is available, but no nurse to staff it. So the bed is useless. Be aware that ICU nursing is a specialty; you can’t just take any nurse and throw him in there.

The video below will be unintelligible to you unless you are a hospital-based physician, respiratory therapist, or nurse. So move along. Dr Z interviews Philadelphia intensivist Dr Herbert Patrick, who’s had experience with critically ill COVID-19 patients.

A few of my personal notes, “just in case.” These may not be accurate because Dr Patrick’s voice recording was sub-optimal.

  • his ICU patient are in “airborne isolation” negative pressure rooms
  • since Dr Patrick didn’t want to shave his beard, he uses a PAPR (powered air-purifying respirator)
  • some physicians are buying their own PAPRs for $1500-3000 (they are in short supply
  • providers not using PAPRs are covering the N95 masks with a “paper mask” (a surgical mask, I assume)
  • he advocates everyone in the hospital wear a surgical mask all the time (?)
  • don’t assume shock is always due to virus; search for bacteria and you will find
  • most COVID-19 ICU admits get an arterial line and central venous catheter, certainly if going on a vent
  • proning (prone body position)  is helpful: 4 hours prone, 4 hours on back or side, alternating every 4 hours
  • Ventilators: Start with PEEP of 8. 100% O2 at first, as usual. Tidal volume depends on plateau pressures during inhalation (keep under 30 cm H2O). A “weanable” patient should have FIO2 down to 50% and PEEP around 8.
  • permissive hypercapnia OK if needed; prevent or treat the associated acidosis with enteral bicitra via ore-gastric tube
  • don’t use so much PEEP that you interfere with cardiac output
  • if central venous O2 saturation is under 60-70, your PEEP may be impairing cardiac output, try to back off PEEP
  • he mentions external cardiac output measurement devices, which I’m not familiar with
  • the Impella device may help support cardiac output in selected cases; sounds like he prefers it over IAPB when available

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

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