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What doctors have learned (and you need to know) about mechanical ventilators

vetilator optIn early March, when the COVID-19 outbreak reached pandemic status, anguished cries wen up about critical shortages of mechanical ventilators at hospitals.

In the two months from early March to early May, two things have changed: First hospitals quickly received a surplus of ventilators. Second, as doctors got more experience treating Coronavirus patients, they discovered they didn’t need the ventilators as much as they thought they would.

“Initially we thought we’d see patients get rapidly worse, and we would rather place them on a ventilator in a more controlled fashion than in a crisis when they’re crashing,” said Dr. Marc Rovner, a pulmonologist at Indiana University Health’s Methodist Hospital.

But now, doctors are using mechanical ventilators as a last-ditch tool for making the difference between life and death.

Now “we don’t go right from being OK to being on a ventilator,” Dr. Rovner explained. “We try to wait as long as possible and look for trends that [a patient is] getting better. We put you on a ventilator because we think it’s getting worse: more shortness of breath, breathing faster, getting very anxious about breathing, oxygen saturation below a point we consider safe.”

That’s because, as Kathryn Dreger, a doctor of internal medicine and professor of medicine at Georgetown University, wrote in the New York Times, “These machines can’t fix the terrible damage the virus is causing. [It] buys us time. Ventilators keep oxygen going to the brain, the heart and the kidneys. All while we hope the infection will ease.”

There are some other downsides to ventilator life support that you may not be aware of:

It’s invasive. It calls for inserti9ng a 10-incg long plastic tube into the patient’s windpipe, either through the mouth or through a surgical incision called a tracheostomy in the neck. And because it’s a long process (see below), a feeding tube may be inserted into the stomach.

It’s tricky. “Too much air pressure damages the lung,” says Dr. Dreger, “but too little means the oxygen can’t get in. Doctors try to optimize, to tweak.”

It’s a long, drawn-out process. Coronavirus patients who need ventilator support are usually on it for two or three weeks – sometimes even longer – and in a medically induced coma.

There can be serious complications. According to a study in the Journal of the American Medical Association, as many as 25% of patients’ kidneys fail completely, requiring dialysis. Patients ‘hearts can begin to struggle and fail. Blood pressure can drop, causing shock. Ventilator pressure can collapse lungs or increase risk of pneumonia.

Coming off the ventilator can be hard. It takes a long process of weaning to gradually get patients breathing on their own. Some will struggle enough to need the ventilator again.

Aftereffects can be serious and long lasting. “Research finds that one-quarter of patients who survive a critical illness and an ICU stay experience PTSD,” especially after large amounts of sedation, Johns Hopkins Medicine reports. Weeks of sedation can also cause “profound complications, damaging muscles and nerves, making it hard for those survive to walk, move or even think as well as they did before they became ill,” Dr. Dreger notes.

Patients older than 80 have particularly low survival rates on ventilators, so if you’re that old, it’s important to ask yourself these questions:

  • What do I value about my life?
  • If I’ll die unless I’m put in a medical coma and placed on a ventilator, do I want that life support?
  • What’s the longest you want to be hooked up to a mechanical ventilator?
  • Do I want to stay on it even if my kidneys shut down?
  • Do I want tubes feeding me so I can stay on the ventilator for weeks?
  • Are you up for a prolonged rehabilitation?
  • Or would you rather be made comfortable for the end of life?

Once you know the answers, make sure your family caregivers or a health proxy know too. And make sure the hospital does – in writing.

“A lot of people are going to die on the vent, which is a lousy way to die,” Dr. Dreger told an interviewer. “A lot of family are going to have to say, ‘What did mom or dad, husband or wife, want me to do?’ And have to make it up because they’re not able to be there by their side or not able to ask.”

If you have any questions about coping with the Coronavirus outbreak, or your retirement years in general, please feel free to call or email us. Just as we always have, we’ll be happy to give you honest, objective answers.

Once Virginia starts reopening, should you see your doctor in person?

virginia reopening optToday, most of Virginia starts reopening.

From today until at least the end of the month, restaurants, bars, breweries, wineries, places of worship, indoor shooting ranges, and brick-and-mortar retail stores such as book sellers will be allowed to operate at 50% capacity, subject to certain restrictions. Others, such as schools, beaches, and sleep-away camps, will stay closed.

And, most important from a health standpoint, the ban on so-called “elective” procedures (i.e., those that don’t involve life-or-death threats) is being lifted.

This doesn’t mean that seniors who’ve been putting off routine or chronic care should all rush right down to their doctors’ offices. People over 65 are still the age group most vulnerable to COVID-19, and most of the deaths occur with patients over 80.

So the question is: When should you (or an elder you’re caring for) see the doctor in person? Consult by telemedicine? Or call 911 for an ambulance to the emergency room?

It depends on what the specific problem is:

Honest-to-goodness, life-threatening emergencies – Out of fear of coronavirus infection, many patients with heart attacks, appendicitis, and mild strokes, among other life-threatening conditions, have been risking their lives by showing up at emergency rooms much later than they should have. If you or someone you’re caring for has chest pain, trouble breathing, a drooping face, arm weakness, difficulty speaking, acute injury or trauma, or is in immense pain, call 911 right away. Do not pass go. Do not collect $200.

Urgent non-emergencies – Abnormal changes in your condition – unexplained swelling in an arm or leg, a strange lump, a sudden weight gain shortness of breath, chest pain, or a temperature– may not be cause for alarm, but they could very well be cause for concern. So can changes in a chronic condition, such as hypertension, diabetes, heart or kidney disease. “With an acute illness on top of chronic, it’s really hard to evaluate in an appropriate manner through telehealth,” Dr. Jacqueline Fincher, president of the American College of Physicians, advises. It’s better to call – not email or contact through a patient portal – your doctor, who can triage by phone and then tell you whether or not to come in.

Ongoing treatments – “Some things just don’t work well for telehealth,” says Dr. Colin Delany, chairman of the Cleveland Clinic’s Digestive Disease and Surgery Institute. “Anything needing a physical examination, or a formal assessment before treating, needs to be done in person.” That could include small, growing skin cancers, allergy shots, biologic asthma treatments, and regularly scheduled cancer treatments or dialysis.

Managing chronic conditions – Telehealth lends itself very well to managing diabetes, hypertension, Crohn’s, and colitis – especially if patients have glucometers, blood pressure cuffs, and scales at home. (Check to see if your Medicare plan covers these.) Throughout the pandemic, psychiatrists have been seeing patients virtually.

Routine care you can postpone – Non-urgent dental appointments and routine cancer screenings (unless you have symptoms).

If you’re not sure – A telehealth session that lets your doctor see what you’re talking about (e.g., a swelling or skin rash) helps the doctor triage your condition and determine if it calls for an in-person visit.

If you have questions – Medical practices and hospitals have changed their check-in procedures to help prevent infection, so calling ahead to learn what to expect makes good sense. So does calling if you have any general healthcare questions. And if you have any questions about coping with the Coronavirus outbreak, or your retirement years in general, please feel free to call or email us. Just as we always have, we’ll be happy to give you honest, objective answers.

Be on the lookout for these additional Coronavirus early warning signs

on the lookoutSince the Coronavirus pandemic has been with us for months now, most people already know its basic warning signs: Coughing, fever, trouble breathing or shortness of breath, inability to wake up fully, and new confusion.

But now, partly on the basis of anecdotal evidence, the CDC has added six more that can show up two to 14 days after exposure to the virus.

These are:

  • Chills
  • Repeated shaking with chills
  • Muscle aches and pains
  • Headache
  • Sore throat
  • New loss of taste or smell

Even though some of these symptoms can be severe, some can also be mild. But either way, the CDC says, they’re enough to trigger a need for testing. If you see any of these emergency warning signs, they advise, you should call 911, tell the operator that you think you have, or someone your caring for has, COVID-19. Before medical help arrives, the person with the symptom(s) should put on a cloth face covering.

The Work Health Organization also lists diarrhea as a warning sign.

And doctors in England and Italy report that they’re seeing two more. Coincident with the onset of COVID-19 (though no cause-and-effect relationship has been established yet), doctors in England’s National Health System and clinics in Italy are seeing what the Daily Mail calls “a growing number of reports of infected patients who have developed [skin] rashes.”

“I have seen quite a few patients who don’t normally suffer from eczema or allergies who have a sudden, odd rash,” reports NHS consultant dermatologist Dr. Veronique Bataille. “Then, maybe two or three days later, they have developed typical COVID-19 symptoms.”

In Italy, a study of 88 infected patients at the Lecco Hospital in Lombardy found 20% underwent changes to their skin; almost half of the 18 patients who did (eight) noticed the changes when their symptoms started. Doctors have also reported Corona virus patients with chilblains – red patches on toes and fingers usually caused by cold weather. The American Academy of Dermatology is starting to gather and analyze data from doctors worldwide.

I’m writing about all this not to raise additional fears, but to encourage added vigilance. Since people over 65 years old are especially vulnerable to COVID-19, and have the highest death rates, there’s no such thing as elders and their caregivers being too careful.

If you have any questions about coping with the Coronavirus outbreak, or your retirement years in general, please feel free to call or email us. Just as we always have, we’ll be happy to give you honest, objective answers.

Fight Coronavirus from the Comfort of Your Own Home

fight covid2In hospitals treating Coronavirus patients, N95 protective masks keep infection from spreading from patients to doctors, nurses, and other front-line health workers. While personal protective equipment [PPE] manufacturers have been ramping up production, there still aren’t enough to meet hospitals’ needs everywhere. To say nothing of the needs of long-term care facilities such as assisted living and nursing homes.

But seniors with sewing machines in their homes can reduce the shortages. Normally, each N95 mask is good for just one use. But a homemade cloth mask covering it, a front-line health worker can use it over and over, day after day, for an extended period of time – provided they take the cloth mask home and wash it at the end of the day’s shift.

Sewing homemade masks is also good for seniors, both physically and emotionally. Physically because being self-isolated at home, where there’s less risk of exposure, cloth masks can provide decent protection. And emotionally, because making the masks is not only a new activity, but also one with a feeling of accomplishment, helping out and community connection.

Masks aren’t the only home-sewn things that medical professionals could use during the pandemic. Some hospitals are asking for gowns they can wear over their scrubs or uniforms. Many medical workers want surgical caps. Some nurses have asked for headbands with large buttons sewn on each side at ear height. Another asked-for item is a cotton drawstring bag big enough for nurses and others to take off the uniforms, put them directly in the bag, and throw bag and contents into the washing machine, apart from other laundry.

If you or a family member wants to fight the pandemic from the comfort of your own home(s), here are some pointers:

  • Before the first stitch, make sure you’re sewing from a pattern that’s appropriate and comfortable to use. You can find beginners’ and advanced sewers’ patterns online, as well as tutorials on how to sew them.
  • Make sure the hospital you’re sewing masks for actually wants and needs them.
  • All fabrics aren’t created equal. Knits have openings that are usually too big to do much filtration. Densely woven fabrics, with high thread counts, are best.
  • If you try on any masks or other items fot fit, make sure to wash them before you donate them.
  • Many local fabric stores are offering fabric and elastic for making masks. Some are offering discounts or donations.

If you have any questions about coping with the Coronavirus outbreak, or your retirement years in general, please feel free to call or email us. Just as we always have, we’ll be happy to give you honest, objective answers.

Caregivers for elders with dementia
now face more challenges than ever.

caregivers for elders with dementia optMore than 16 million Americans provided unpaid care worth almost $244 billion last year to family members and friends with Alzheimer’s disease and other dementias.

Almost a quarter of those caregivers – about 4 million of them – belong to the sandwich generation, taking care of their children and someone from their parents’ generation.

Now the Coronavirus pandemic is making their work, which was never easy to begin with, even harder.

In addition to the challenges that ordinarily come with dementia, they now have to help elders ward off a virus that elders are particularly vulnerable to. And that’s hard when the elders in question aren’t aware of or unable to communicate the onset of symptoms.

Here are some things you can do to reduce the vulnerability and the strain:

  • Be extra observant. Keep a sharp eye out for COVID-19 symptoms your family member may not realize they have.
  • Watch out for a sudden change in cognition. Unlike a gradual change, it could mean the onset of fever and the time to call for medical help.
  • Have a plan in case the usual caregiver gets sick and for other possible scenarios. (Senior Insights can help you with that.)
  • Hygiene really matters. So, make sure to keep cleaning down tabletops and other surfaces throughout your home – including your elder’s living quarters. Demonstrate thorough hand washing, and make sure they wash their hands often with soap and water. In addition to reminding them in person, post signs on their bathroom mirror and elsewhere. Put a bottle of alcohol-based (at least 60%) hand sanitizer in their bedroom and bathroom.
  • Try to maintain a normal daily schedule. People with dementia can find changes scary.
  • Take good care of yourself. Almost two thirds (64%) of caregivers of people living with Alzheimer’s disease say ever since becoming caregivers, they’ve had concerns about maintaining their own health. You can get valuable self-care tips by joining an Alzheimer’s Association support group, either online or by conference call. The best thing you can do for the person you’re caring for is to stay healthy and strong.
  • Do everything you can to reduce stress. Be aware that people living with dementia may not fully understand what’s happening; they’re good at sensing and reacting to yours and others’ signs of stress. Now that the pandemic has slammed shut escape hatches like movies, libraries, and normal socializing, find some other ways to take a break – and take it. Take a walk, stroll through a park (maintaining social distancing), meditate, stream movies, chat with friends using Face Time, Duo, Skype, Zoom, or other VOIP platforms.
  • If you have any questions about dementia caregiving, coping with the Coronavirus outbreak, or retirement years in general, please feel free to call or email us. Just as we always have, we’ll be happy to give you honest, objective answers