To Vaccinate or Not---The Rat Flu Odyssey Continues

[summit]

At the hospital that you work at, is there a trigger of when to step-up measures or is that reliant on government employee (eg public health officer) stipulated measures?

CDC level setting is a combination of community levels (cases/100K) vs hospital levels (looks at how many admits and what percent of inpatient capacity are COVID patients). CDC levels inform local PH and hospital infection prevention guidance. I set our levels based on my judgement of COVID activity vs our hospital capacity in concert with system policy and PH guidance. That means masks when you are doing patient care or in areas where patients/public are present.

In another place I work, the guidance has been relaxed to "masks recommended, not required."

I'm sticking with masks because flu is still quite busy and COVID rates are increasing in the state.

Is there a mechanism for an off ramp if the guidelines are not following the science? An easy low hanging fruit are the 5 day rule to return back to work (I’m not sure if hospitals are given that same guidance).

CDC not follow the science? *gasp* Well some things you get a free hand with, other things you don't. Example, at the start of the pandemic CDC (and WHO) were flat wrong about the virus not being airborne, so plenty of us put in policies/action to treat it as such. Testing criteria was wild, in flux, and playing catchup, so we bent the rules when supply allowed. There were some wild rules on clearance testing, considerations for previous infection, and more. Judgements and practice were based on the evidence. The CDC was rarely moving as fast as we wanted them to or had unrealistic priorities.

Fast forward from 2020. CDC long ago gave up on setting policy based on highest theoretical safety and instead tried to mix what is practically safe vs other impacts and what people might actually be willing to do.

That is how you got the 5 day rule. That was actually some great foresight by CDC for Omicron. It works like a mask. Most people aren't shedding after day five, but some are, and the masks help with that. So if most people comply, you get better transmission control than if you keep it at 10 and a sizeable proportion of people say "fuck it, I'm not even gonna test."

Hospitals work at a higher standard. If not a a staffing crisis, 10 days off work or 7 days with a negative antigen.

We could potentially end up back in crisis return to work standards with some of these new variants that might cause summer surges.

[summit]

Not sure where to leave this so I'm leaving it here.



90 seconds, right on target. This guys is hilarious.

[old goat]

Appreciate both points. I didn't want to distract from the anxiety by going full thread drift, because evidence suggests my family's greatest risk factor is underdiagnosis, so I assume a personal bias. It really is a question about thinking, though. In your example of the unlikely patient, if that had been your patient, do you want to let that kind of example stand out as a strong warning or minimize it to avoid getting emotionally hung up on past mistakes?

We're talking about the Munchausen patient? He's not an example of anything. At least I sure hope he's not. So does his brother, Joe Montana. At least the guy claimed to be Joe's brother. Wonder why Joe never came to visit him.

[SumJongGuy]

It's not unusual for folks working in healthcare especially at the high integration level to call out psychosomatic or outright faked symptoms. It definitely happens a lot, people crying wolf all the time. However, the worst thing that can happen is for someone in the care setting to ignore or refuse care on the odd chance that the person really isn't faking or imagining things.

That's why we rarely see actual doctors scoffing or dismissing folks but techs and nurses definitely do..

[Trackhead]

My guess is that some long covid will turn out to have identifiable physical pathology and some will be anxiety or other mental disorders, and that it will take years to sort it all out.

Yup. And I continue to read and try to appreciate it more. Interesting study recently about persistent SARS RNA in stool samples out to six months. So it's certainly plausible that could cause a persistent immune response causing fatigue, etc which invariably would lead any sane person to feel anxious, depressed, and have insomnia. I certainly don't doubt there is true pathology to some of it, but I have to accept that the numbers of "long covid" are as high as they are.

[Trackhead]

Not sure where to leave this so I'm leaving it here.



90 seconds, right on target. This guys is hilarious.

He's my hero.

[jono]

We're talking about the Munchausen patient? He's not an example of anything. At least I sure hope he's not. So does his brother, Joe Montana. At least the guy claimed to be Joe's brother. Wonder why Joe never came to visit him.

As not an example of anything he makes a good example of an extreme outlier, right? That was actually the context of my question. Not assuming you'd adjust all your thinking around his specific symptoms, but how does the walking (eventually?) proof that "extremely unlikely things eventually happen if your career is long enough" get incorporated into personal experience?

I have a friend who recites "when you hear hoof beats think horses, not zebras--but don't discount zebras." I don't think he's looked up to see a moose yet, but I hope he does--my brain actually tried to repaint the moose and add a rider for almost 2 seconds when I did it. Kinda cool!

[old goat]

Yup. And I continue to read and try to appreciate it more. Interesting study recently about persistent SARS RNA in stool samples out to six months. So it's certainly plausible that could cause a persistent immune response causing fatigue, etc which invariably would lead any sane person to feel anxious, depressed, and have insomnia. I certainly don't doubt there is true pathology to some of it, but I have to accept that the numbers of "long covid" are as high as they are.

Certainly lots of virus that live in the gut. If it turned out that lots of people become GI carriers of SARS-CoV-2 that would be interesting and problematic.
Might have to start washing our hands again.

As not an example of anything he makes a good example of an extreme outlier, right? That was actually the context of my question. Not assuming you'd adjust all your thinking around his specific symptoms, but how does the walking (eventually?) proof that "extremely unlikely things eventually happen if your career is long enough" get incorporated into personal experience?

I have a friend who recites "when you hear hoof beats think horses, not zebras--but don't discount zebras." I don't think he's looked up to see a moose yet, but I hope he does--my brain actually tried to repaint the moose and add a rider for almost 2 seconds when I did it. Kinda cool!

Yeah--I get what you're getting at. I can't say Mr. Montana changed how I thought about anyone else. He was such an outlier--the only Munchausen I ever ran across and one of the two or three craziest patients I ever had--I can't say I learned anything from him, just a good story.

But the hardest thing in medicine is to keep an open mind.

[summit]

Make sure you observe airborne precautions!

[bodywhomper]

Re: long covid, do you all have personal friends still dealing? I have a few. Some almost 18 months past infection.

I’ve read and seen such a large variety of qualitative range of ailments attributed to long covid and a huge range of % per total infected: recently from 5% (shared by Bob Wachter) to the 58% value from the article that I just posted. A friend was involved in that study published at the end of December that theorizes one pathology related to mitochondrial dysfunction.

[jono]

Yeah--I get what you're getting at. I can't say Mr. Montana changed how I thought about anyone else. He was such an outlier--the only Munchausen I ever ran across and one of the two or three craziest patients I ever had--I can't say I learned anything from him, just a good story.

But the hardest thing in medicine is to keep an open mind.

Thanks, that's helpful. Similarly, the challenge being a patient is often figuring out when to advocate harder for yourself and when to accept the expert opinion.

I'm not sure how it applies any more specifically to COVID, long or short, but using Trackhead's "Rule out what it likely isn’t" step as an example, there are at least a couple of ways to interpret that and knowing which a doc is using can be critical. My last PCP took the most literal/quickest version where "rule out" meant just imagine the unlikely as impossible, no further steps needed. I thought surely he'd eliminate at least the dangerous things first by actually ensuring they were impossible. Because that's how I thought as a patient.

If I'd known we weren't on the same page there I'd have GTFO ASAP and I might still have room in my stomach for a third pancake. That'd be cool. OTOH, I can still bitch and moan about it, which is definitely nice. But there's "critical" for ya. If there is a quick way to screen providers for this I'd love to know about it.

[leroy jenkins]

Are there any vaccine related long term side effects or is it all long covid?

Serious question, how would we know the difference? besides the obvious of someone with long covid symptoms who is unvaxxed.

[leroy jenkins]

What response do you find more appropriate?

Here’s an interesting preprint on the prevalence of long covid: https://papers.ssrn.com/sol3/papers....act_id=4099429

Here’s what Topel has to say about it: “A systematic #LongCovid review of nearly 200 studies and over 120,000 participants, reinforces the high frequency of symptoms > 6 months, not linked to severity of acute illness, and potential for marked disability”

And he included this graphic:
Attachment 415559

I'm not doubting long covid exists, but the 54% thing of at least one symptom seems bizarre when looking at some of those symptoms. Oh you have anxiety depression and trouble sleeping in an increasingly stressful world? Long covid for sure.

I have a couple friends who report feeling clearly different post covid, but they mostly seem to say trouble breathing and not feeling as strong cardio wise.

[oldnew_guy]

CDC has an entire website dedicated to it:

https://www.cdc.gov/coronavirus/2019...cts/index.html

People with post-COVID conditions may develop or continue to have symptoms that are hard to explain and manage. Clinical evaluations and results of routine blood tests, chest x-rays, and electrocardiograms may be normal. The symptoms are similar to those reported by people with ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome) and other poorly understood chronic illnesses that may occur after other infections. People with these unexplained symptoms may be misunderstood by their healthcare providers, which can result in a long time for them to get a diagnosis and receive appropriate care or treatment.

As someone who spent a year plus of my life trying to get my wife to a specialist that understood her disease and was able to quickly and effectively treat it after a cast of physicians were unable to treat and prescribed meditation, mental health, etc I’m a little disturbed by this “psychosomatic” discussion.

[Trackhead]

As someone who spent a year plus of my life trying to get my wife to a specialist that understood her disease and was able to quickly and effectively treat it after a cast of physicians were unable to treat and prescribed meditation, mental health, etc I’m a little disturbed by this “psychosomatic” discussion.

It is disturbing, from the layperson perspective, but I can assure you the psychosomatic complaints certainly are very common and not something to be looked at as a weakness or in a negative light. That's where the defensive posture becomes unproductive, both by the provider and/or the patient. It's not always "in your head", but sometimes it is. Gotta consider both when appropriate.

[riser4]

Not having to wash my hands after using the bathroom was supposed to be part of the reward for making it through the pandemic.

[jono]

CDC has an entire website dedicated to it:

https://www.cdc.gov/coronavirus/2019...cts/index.html



As someone who spent a year plus of my life trying to get my wife to a specialist that understood her disease and was able to quickly and effectively treat it after a cast of physicians were unable to treat and prescribed meditation, mental health, etc I’m a little disturbed by this “psychosomatic” discussion.

I think better communication is key to mitigating these situations--whether that means getting the point across better or just recognizing when to break off the conversation. In that sense, much better to be aware of the challenges and biases of the person you're talking to. No matter how hard we screw on the expert halo, they're still humans. Some of them are even proud of it.

ETA: patients obviously have it as bad or worse--how many people are so invested in denying their own mortality that they'd rather hear "psychosomatic" than learn they have a degenerative disease?

[oldnew_guy]

It is disturbing, from the layperson perspective, but I can assure you the psychosomatic complaints certainly are very common and not something to be looked at as a weakness or in a negative light. That's where the defensive posture becomes unproductive, both by the provider and/or the patient. It's not always "in your head", but sometimes it is. Gotta consider both when appropriate.

I’m admittedly a little touchy on this subject. Maybe I am summarizing in my head incorrectly but what is coming across to me is: “we don’t know, but I think most of this is psychosomatic and indicative of mental health issues not disease”.

“ I also think a large proportion of patients with long covid are suffering psychosomatic complaints and have significant underlying/pre-existing anxiety/depression.

Any person with a predisposition for anxiety/depression who gets covid is going to have a MUCH higher likelihood of assuming they will never return to normal health. It's a recipe for disaster, and we are seeing that now. Tell people they have a disease, and they will believe you. Tell them they may never recover, and they won't.

I've been at this healthcare shit for 25+ years, and while I think there is something to "long covid", I believe we are destroying our populations mental health with how the media and laypeople portray it.”

Ironically, my wife is not and was not a “layperson” in this context when this was occurring. IME it was used as a crutch by people who didn’t have any answers instead of saying “I don’t know how to treat this”. The disease she had has a long history of being labeled an in your head emotional problem by practitioners and the general public.

My understanding is that what, 5% of patients might fall in this category? Which probably seems common when you see it every day.

[Trackhead]

[QUOTE=oldnew_guy;6610514]I’m admittedly a little touchy on this subject. Maybe I am summarizing in my head incorrectly but what is coming across to me is: “we don’t know, but I think most of this is psychosomatic and indicative of mental health issues not disease”.
/QUOTE]

Defensive posture is natural. I agree much we don't know, and write off as psychosomatic. But to ignore that as a possibility is also a disservice to the patient. It remains in the differential diagnosis for many presentations (long covid, chest pain, shortness of breath, dizziness, etc). Also, given Covid was the number #1 story for two years, it's easy to understand how people would be anxious over it. I certainly was.

If something was truly without definitive pathology and the symptoms were psychosomatic, wouldn't you want to know? Would lead to a quicker resolution of symptoms. It's taboo to mention or consider anxiety in our culture. Our society lives with so much stress/anxiety. We work too much, spend too much, and overextend ourselves. We suck at mental health.

[oldnew_guy]

[QUOTE=Trackhead;6610524]

I’m admittedly a little touchy on this subject. Maybe I am summarizing in my head incorrectly but what is coming across to me is: “we don’t know, but I think most of this is psychosomatic and indicative of mental health issues not disease”.
/QUOTE]

Defensive posture is natural. I agree much we don't know, and write off as psychosomatic. But to ignore that as a possibility is also a disservice to the patient. It remains in the differential diagnosis for many presentations (long covid, chest pain, shortness of breath, dizziness, etc). Also, given Covid was the number #1 story for two years, it's easy to understand how people would be anxious over it. I certainly was.

If something was truly without definitive pathology and the symptoms were psychosomatic, wouldn't you want to know? Would lead to a quicker resolution of symptoms. It's taboo to mention or consider anxiety in our culture. Our society lives with so much stress/anxiety. We work too much, spend too much, and overextend ourselves. We suck at mental health.

I just have experienced it being leaned on instead of figuring out or addressing the problem when there was at the end confirmed pathology, with life altering consequences if we didn’t find a doctor who knew what was going on.

The issue for me is that you seem to be saying “I don’t really know” yet seem to be putting it mentally in the “most of this is psychosomatic” category.

Yes, we should do more for mental health.

I also have experienced stress manifesting as physical symptoms, so I’m sympathetic to your angle on this as well.

Anyways, enough about that.

[skiJ]

What response do you find more appropriate?

Here’s an interesting preprint on the prevalence of long covid: https://papers.ssrn.com/sol3/papers....act_id=4099429

Here’s what Topel has to say about it: “A systematic #LongCovid review of nearly 200 studies and over 120,000 participants, reinforces the high frequency of symptoms > 6 months, not linked to severity of acute illness, and potential for marked disability”

And he included this graphic:
Attachment 415559

Thank you for this post -
it has sparked an interesting discussion ;

I have not read the whole paper yet, and I may not ;
I have reviewed the abstract, and I have some concerns -
This study is a literature review, compiling the data from 200 other sources ; it reports patients were followed for six months, but was not itself involved in any of the patient interaction ;

one claim I am struggling with is that 14% of the patients reported experiencing PTSD post-covid -
I can understand how someone who ended-up on a ventilator could/would experience PTSD, but if this is a matter of self-diagnosis . . .
( the other thing I will look for is in reporting these symptoms, were the patients asked if they experienced the symptoms they were reporting/claiming before covid...

in the broadest terms, through life we accumulate "aches and pains" ;
a condition one was experiencing before covid does not become long covid/post covid if those symptoms continue after covid
( those surveys that are prepared by asking patients - yes or no - have they experience symptoms are particularly troubling to me. ))

regarding the idea that psychosomatic complaints are 'common', I can only offer my second-hand experience -
my old country doctor spent the last decade of his primary-care career caring for several patients he felt were seeking prescriptions ;
he always encouraged these patients to make other health changes ( quit smoking, quit drinking ), and to return to report the effects these changes had on their health.
Some patients responded to such ongoing care, some found their prescriptions elsewhere...

I have no doubt people are experiencing long covid / extended symptoms from covid -
two of my friends who are back hard at Work report symptoms including chest tightness (chest discomfort) more than six months after testing positive ;
These men are not looking for anything - except to continue their lives.

I will go back and review -whomper's citation.

Thanks... and
Good luck ! tj


please maintain you resistance with
vaccination and boosters --

[old goat]

The most common mistake in medicine is to make up an explanation--"psychosomatic", "evil humors", "witchcraft"--for that which we do not understand. Physicians have been doing that for thousands of years. No reason to expect that to change.

[SumJongGuy]

It's also possibly a factor that people want it to be over so badly that they're projecting good physical health and poor mental health on to people who claim to still be physically ill. Folks certainly were claiming that it was psychosomatic all along even when being put on a ventilator themselves..

[The SnowShow]

Has anyone under 50 been able to get a second booster? Apparently in CO, we can’t?

[Trackhead]

[QUOTE=oldnew_guy;6610528]

I just have experienced it being leaned on instead of figuring out or addressing the problem when there was at the end confirmed pathology, with life altering consequences if we didn’t find a doctor who knew what was going on.

The issue for me is that you seem to be saying “I don’t really know” yet seem to be putting it mentally in the “most of this is psychosomatic” category.

Yes, we should do more for mental health.

I also have experienced stress manifesting as physical symptoms, so I’m sympathetic to your angle on this as well.

Anyways, enough about that.

Syntax error: Not saying it's all psychosomatic, just that it IS in the differential. That's it. Nothing more. Glad you guys figured out whatever issue it was. No need to share.
I spent a night in the ICU with an abnormal EKG 15 years ago and an elevated troponin. Was all psychosomatic, sort of. Bumped the troponin from running up Snowbird three times, went to ER night shift, felt awful. Did EKG on myself, blah blah blah. LVH from exercise, troponin bumped from running like a madman at elevation. All normal, but set off a six month period of psychosomatic shit. Was horrible. Since then have had a much better understanding of how the mind plays tricks.