One of the most distressing things I am seeing is conspiracy-minded conservatives in the US doubting the mortality numbers from the COVID pandemic. I really get upset as these people try to gas light the nation and convince people that COVID wasn’t that bad. And that people are just inflating the numbers for political gain.
I round at a number of dialysis units. At one unit, I cover the first shift. First shifts are popular. Lots of people want to do their dialysis first thing in the morning and have the rest of their day to themselves. I have 20 odd patients on that shift and every couple of months I’ll get a new patient when a chair opens up. This happens when a patient moves, transfers to another unit, gets transplanted, or unfortunately, passes away. Openings on the first shift are rare and they don’t stay open for long.
I distinctly remember going to round at this unit in late May and almost immediately seeing a new face. So I started my routine, new dialysis patient, spiel, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
And then a few chairs down, I saw another new face, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
And then a bit later, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
And once again, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
I met as many new patients on that one day as I typically get on that shift in a whole year. Each of those new faces represented a patient lost to COVID.
We are not lying about the disease.
We are not exaggerating the dead for political gain.
I lost momentum on the COVID diaries, but today as some people are gas lighting the severity of the COVID-19 pandemic I want to finally publish a couple of posts that I started but never published.
As COVID-19 was raging through Italy one of the storylines that made it back to our shores was the number of docs that were getting sick. The number of doctors who were dying. A scary thought entered my head, in the form of a Twitter poll (it is strange how many of my thoughts are arraigned as tweets)
How many doctors at your hospital will die before you start thinking about heading for the hills?
A. Zero. I’m thinking about bugging out now
B. 4
C. 18
D. Infinity. I ain’t no coward.
I asked the question in a group chat but never on open twitter as it felt too inflammatory. My feeling was that it was less the number and more who got sick. The closer you were to the poor doc on the vent in the ICU the more terrifying it would be. Thankfully Ascension St John didn’t lose any doctors, nurses, or employees. But we did have people get sick. A lot of them.
Early in the epidemic we had an outbreak in the cardiology department. At least 8 of the cardiologists got sick and two of them were hospitalized. I don’t know how the ‘Rona spread through their department, but that gave a sense of how fast the disease could spread without precautions.
The housestaff (residents and interns) were also hit hard. Fully twenty-five percent of the internal medicine residents missed work because of COVID-19.
One in four
Thankfully none of them had to be hospitalized.
Probably another dozen doctors in the department of medicine got sick. A number of them were hospitalized, but no one died. Not because we were good, but because we were lucky.
My father is an oral surgeon and the program director of the oral surgery residency at St John and Beaumont Hospitals. His chief resident got COVID-19 and perished. I was on-call in a hospital full of Covid-19 patients when my dad called to tell me. It was startling and focused the mind. After that I found my self calling old friends just to say “hi.” Kind of getting my personal affairs in order, you know, just in case.
Looking back at the docs that got infected, it is noteworthy that the vast majority of infections were early in the epidemic. They were all in late March and early April. The time when we didn’t know what we were doing. I remember seeing videos on how to take off and safely store your mask between COVID patients.
Those halcion days when we thought we could label patients as COVID and NOT COVID. As soon as that lunacy went away and we just started wearing our mask all the time the infections among the staff melted away. It was a stark before and after experiment, but to my eyes masks worked.
If you have a patient with cerebral edema from acute hyponatremia you need to 3% Saline first and ask questions later.
Matthew Smith Doctor Who GIF
3/ If patients have hyponatremia and have severe symptoms it is 150 ml of 3% then recheck the sodium and give another 150 ml of 3% (I’m using the European guidelines)
This means if the hyponatremia is causing the vomiting, then you have severe symptoms and it is 3% time. But if the vomiting is causing the hyponatremia, that doesn’t automatically indicate severe symptoms and you will need to dig deeper.
4/ The goal of acute mgmt is to raise the Na by 5 or stop the symptoms, which ever is quicker. If you have raised the Na by 5 and they are still seizing, then it is probably not the low Na causing the seizure and you need to 👀 deeper. Algorithm from
Step one check the serum osmolarity (and get a repeat sodium, just to make sure it wasn’t a lab error)
7/ Since we are looking at a low sodium we expect a low osmolarity (don’t worry about the difference between osmolality and osmolarity, anyone who is a stickler about that is being a dick)
If we don’t find a low osmolality something weird is going on:
7b/ Low sodium with a normal osmolarity: Lab error from too much protein (IVIG, multiple myeloma) or too much fat (High lipids or triglys) in the blood. This throws off some lab machines.
(Specifically but not point of care iStats or ABG laboratories)
7c/ Low sodium with a high osmolality: this is usually due to hyperglycemia (but can be seen with mannitol, glycine and other edge cases). The hyponatremia is real, but due to another osmotically active particle (glucose in most cases) the are no consequences to the hyponatremia
8/ So that leaves the true hyponatremia. Low sodium and low osmolarity. The branch point here is:
What is the urine osmolarity?
The urine osmolarity tells us if the kidney is causing the hyponatremia or just unable to correct the hyponatremia (despite the best intentions)
9/ The urine osmolarity is less than 100 (maybe up to 150 or 200 if the patient has CKD). This indicates a lack of ADH and a kidney that is doing its best to correct the hyponatremia. The problem is not the character of the urine but the amount. Right urine, not enough.
9b/ The differential for low sodium, low serum and urine osmolarity is short:
9c/ In low Na, low serum and urine osmolarity the urine is getting rid of excess water but the kidney cannot make enough urine because:
• Kidney failure (low GFR)
• T & T / Beer drinkers (lack of solute)
• Psychogen polydipsia (you are drinking faster than you are peeing)
10 Low sodium, low serum osm, high urine osm. This is ADH dependant hyponatremia. The kidney, stimulated by ADH, is causing the hyponatremia by generating free water. Making more urine here, just makes the Na fall further.
10b/ ADH can be 𝗽𝗵𝘆𝘀𝗶𝗼𝗹𝗼𝗴𝗶𝗰 due to low volume or a perceived low volume state:
Low volume states: GI losses like diarrhea or vomiting; renal losses like diuretics
High volume/low perceived volume: heart failure, liver failure, nephrotic syndrome
