'Different than anything we've seen': ICU doctors question use of ventilators on some COVID-19 patients - Timmins Press | Canada News Media
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'Different than anything we've seen': ICU doctors question use of ventilators on some COVID-19 patients – Timmins Press

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Some are now asking, can we stave off ventilating some patients, and increase the chances of people being discharged from hospital alive?

It started in New York City, in the trenches in the battle against COVID-19. Stressed doctors began worrying that the breathing tubes and pressures being used to open up the tiny air sacs in the lungs of the critically sick could be causing worse harm.

Some are now asking, can we stave off ventilating some patients, and increase the chances of people being discharged from hospital alive?

“In many ways, it’s different than anything we have seen before,” Dr. James Downar, a specialist in critical care and palliative care said Thursday from inside an ICU at The Ottawa Hospital dedicated to critically ill COVID-19 patients. On Thursday, the unit was full.

The pandemic virus seems not only to affect the lungs, making them stiff and inflamed, but other parts of the body as well, including the heart. It’s not clear if it’s a direct effect of the virus on the heart that’s causing heart failure in some cases, or if it’s because the virus is playing with the body’s coagulation system, increasing the risk of blood clots.

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It’s different in another way, too: In a phenomenon reported in the U.S., as well as Italy, and, now, Canada, some patients with severe COVID-19 are arriving in hospital with such low blood oxygen levels they should be gasping for breath, unable to speak in full sentences, disoriented and barely conscious.

Except they’re not in any sort of distress, or very little distress, compared to the burden of illness. They’re talking. They’re lucid. It’s not the classic acute respiratory distress syndrome doctors are used to seeing, and that most guidelines recommend doctors treat as such. One Brooklyn critical care doctor has likened it to high altitude sickness and is urging his colleagues to be cautious about who is being ventilated, and how. The concern is that the pressure may be harming lungs, and that some patients could be more safely treated with less invasive means such as high-flow nasal oxygen.

“To think that we understand this infection, I think is very naive,” Dr. Ashika Jain, an associate professor in trauma critical care and emergency ultrasound at New York University/Bellevue Hospital Center said on a recent  REBEL Cast podcast. “There are so many different theories about how this is behaving. There’s no one cohesive picture. We don’t really understand how to really treat this, because it’s a four-month old virus that we just don’t understand how it’s already running when it didn’t really learn how to walk yet.”

With some Ottawa patients, “we’re giving them all the oxygen we can give them without putting them on a breathing machine, and they’re wide awake and talking,” Downar said. In some situations, people are being flipped onto their stomachs, into the prone position, to improve gas exchanges.

High-flow nasal oxygen, where little plastic tubes are placed in the nostrils, can deliver up to six times the amount of oxygen. “And those high flows actually generate a little bit of positive pressure within the patient’s upper airway, which helps keep the lungs open and improve the oxygen levels in the blood,” said Dr. Claudio Martin, a critical care physician and medical director of critical care at London Health Sciences Centre and Western University.

“The problem with that is, when you’re giving oxygen with such high flows, there is a high possibility the viral particles in the airways are being aerosolized, so you can increase the possibility of spread of the virus in the environment,” Martin said. “Which is why if we do use that it has to be in a negative pressure environment, so that you contain the air in the room. You basically try to contain any virus particles that are aerosolized.” It also means any staff  looking after the patient need to be wearing N95 masks.

It’s not the classic acute respiratory distress syndrome doctors are used to seeing

While the vast majority, some 80 per cent of infections, are mild, the COVID-19 virus can cause pneumonia, which interferes with the ability of oxygen to get in through the lungs, and into the bloodstream. Currently, about six per cent of confirmed cases in Canada have required admission to an ICU.

A ventilator does two things: it provides oxygen as well as pressure to open up the alveoli, the little lung units, to allow the lungs to get oxygen in, and carbon dioxide out. While potentially life saving, it can worsen lung injury.

The strategy, for now, is not to rush to intubate, said Downar, who led the drafting of an Ontario “triage protocol” if hospitals are forced to ration ICU beds and ventilators. “Unless somebody seems to be failing, or their oxygen level is truly at this critical life-changing level, we can maybe hesitate,” Downar said. Even when the decision is made to ventilate, in some cases, “you almost end up having to talk them into it, which is a very unusual situation.”

“But let me be explicitly clear here: These are still the exceptions. The majority are failing … They need to have a tube put down (their throats) and put on a breathing machine to help them breathe.”

It’s not clear what proportion will be discharged alive.


A tube from a ventilator on a sedated patient infected with COVID-19 at the intensive care unit of the Peupliers private hospital in Paris, April 7, 2020.

Thomas Coex/AFP via Getty Images

A study published this week in the Journal of the American Medical Association involved 1,591 people infected with the pandemic virus admitted to ICUs in the Lombardy region of Italy between Feb. 20 and March 18. A high proportion — 88 per cent — required mechanical ventilation. As of March 25, 26 per cent of the ICU patients had died, 16 per cent had been discharged, and 58 per cent were still in the ICU. The median age was 62; 82 per cent were men.

British Prime Minister Boris Johnson remained in an ICU Thursday, where his condition reportedly continues to improve. The 55-year-old is not on a ventilator; according to a spokesman, he’s receiving standard oxygen therapy.

People who have been ventilated have described the experience as awful beyond belief.

The person is sedated, so that they’re calm. “Sometimes you have to relax the breathing muscles so they’re able to open their mouth and accept the tube being inserted,” said Dr. John Granton, head of the division of respirology at Toronto’s University Health Network- Sinai Health System. “If they’re incredibly sick we need to take over their breathing completely, and so we fully sedate them,” meaning a medically induced coma.

“We don’t allow them to wake up from that anaesthetic until their lungs have healed. And then once they’ve healed, or if they’re not that sick, we can allow them to be reasonably aware,” Granton said.

If this ever happened to me, this is what I would not want to look like at the end

With a tube down their throat, however, they can’t speak. They have to communicate by using a board, or moving their lips. “We’ve become expert lip readers in the intensive care unit,” Granton said.

From the experience with H1N1 and SARS, it can sometimes take several weeks, or a month or more for people to recover to the point they can be “liberated” from the machines. For some with a significant underlying condition, like chronic obstructive pulmonary disease, there’s a risk they may never come off.

If nothing else, the pandemic should be encouraging discussions about what people value in life, Granton said, including conversations such as, “If this ever happened to me, this is what I would not want to look like at the end.”

With hospitals in COVID-19 lockdown, families aren’t allowed inside the ICU. Normally, they’re at the bedside. “We’re trying to update them by phone, we’re trying to do Facetime,” Downar said. “To have to see a critically ill family member through a video call and have your questions answered by somebody wearing a face mask … it’s not the way we like to do things. But it’s better than nothing.”

“We’re tired, but this is our job,” Downar said. “People are sending us food. People are honking their horns and putting up signs … It’s really touching.

“We’re going to do our best, and we’re pretty damn good. This is a really strong team. I wouldn’t want to be anywhere else while this is going on than where I am right now.”

(This story has been updated with comments from Dr. Claudio Martin of Western University.)

• Email: skirkey@postmedia.com | Twitter:

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What’s the greatest holiday gift: lips, hair, skin? Give the gift of great skin this holiday season

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Give the gift of great skin this holiday season

Skinstitut Holiday Gift Kits take the stress out of gifting

Toronto, October 31, 2024 – Beauty gifts are at the top of holiday wish lists this year, and Laser Clinics Canada, a leader in advanced beauty treatments and skincare, is taking the pressure out of seasonal shopping. Today, Laser Clincs Canada announces the arrival of its 2024 Holiday Gift Kits, courtesy of Skinstitut, the exclusive skincare line of Laser Clinics Group.

In time for the busy shopping season, the limited-edition Holiday Gifts Kits are available in Laser Clinics locations in the GTA and Ottawa. Clinics are conveniently located in popular shopping centers, including Hillcrest Mall, Square One, CF Sherway Gardens, Scarborough Town Centre, Rideau Centre, Union Station and CF Markville. These limited-edition Kits are available on a first come, first served basis.

“These kits combine our best-selling products, bundled to address the most relevant skin concerns we’re seeing among our clients,” says Christina Ho, Senior Brand & LAM Manager at Laser Clinics Canada. “With several price points available, the kits offer excellent value and suit a variety of gift-giving needs, from those new to cosmeceuticals to those looking to level up their skincare routine. What’s more, these kits are priced with a savings of up to 33 per cent so gift givers can save during the holiday season.

There are two kits to select from, each designed to address key skin concerns and each with a unique theme — Brightening Basics and Hydration Heroes.

Brightening Basics is a mix of everyday essentials for glowing skin for all skin types. The bundle comes in a sleek pink, reusable case and includes three full-sized products: 200ml gentle cleanser, 50ml Moisture Defence (normal skin) and 30ml1% Hyaluronic Complex Serum. The Brightening Basics kit is available at $129, a saving of 33 per cent.

Hydration Heroes is a mix of hydration essentials and active heroes that cater to a wide variety of clients. A perfect stocking stuffer, this bundle includes four deluxe products: Moisture 15 15 ml Defence for normal skin, 10 ml 1% Hyaluronic Complex Serum, 10 ml Retinol Serum and 50 ml Expert Squalane Cleansing Oil. The kit retails at $59.

In addition to the 2024 Holiday Gifts Kits, gift givers can easily add a Laser Clinic Canada gift card to the mix. Offering flexibility, recipients can choose from a wide range of treatments offered by Laser Clinics Canada, or they can expand their collection of exclusive Skinstitut products.

 

Brightening Basics 2024 Holiday Gift Kit by Skinstitut, available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

Hydration Heroes 2024 Holiday Gift Kit by Skinstitut – available exclusively at Laser Clincs Canada clinics and online at skinstitut.ca.

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Here is how to prepare your online accounts for when you die

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LONDON (AP) — Most people have accumulated a pile of data — selfies, emails, videos and more — on their social media and digital accounts over their lifetimes. What happens to it when we die?

It’s wise to draft a will spelling out who inherits your physical assets after you’re gone, but don’t forget to take care of your digital estate too. Friends and family might treasure files and posts you’ve left behind, but they could get lost in digital purgatory after you pass away unless you take some simple steps.

Here’s how you can prepare your digital life for your survivors:

Apple

The iPhone maker lets you nominate a “ legacy contact ” who can access your Apple account’s data after you die. The company says it’s a secure way to give trusted people access to photos, files and messages. To set it up you’ll need an Apple device with a fairly recent operating system — iPhones and iPads need iOS or iPadOS 15.2 and MacBooks needs macOS Monterey 12.1.

For iPhones, go to settings, tap Sign-in & Security and then Legacy Contact. You can name one or more people, and they don’t need an Apple ID or device.

You’ll have to share an access key with your contact. It can be a digital version sent electronically, or you can print a copy or save it as a screenshot or PDF.

Take note that there are some types of files you won’t be able to pass on — including digital rights-protected music, movies and passwords stored in Apple’s password manager. Legacy contacts can only access a deceased user’s account for three years before Apple deletes the account.

Google

Google takes a different approach with its Inactive Account Manager, which allows you to share your data with someone if it notices that you’ve stopped using your account.

When setting it up, you need to decide how long Google should wait — from three to 18 months — before considering your account inactive. Once that time is up, Google can notify up to 10 people.

You can write a message informing them you’ve stopped using the account, and, optionally, include a link to download your data. You can choose what types of data they can access — including emails, photos, calendar entries and YouTube videos.

There’s also an option to automatically delete your account after three months of inactivity, so your contacts will have to download any data before that deadline.

Facebook and Instagram

Some social media platforms can preserve accounts for people who have died so that friends and family can honor their memories.

When users of Facebook or Instagram die, parent company Meta says it can memorialize the account if it gets a “valid request” from a friend or family member. Requests can be submitted through an online form.

The social media company strongly recommends Facebook users add a legacy contact to look after their memorial accounts. Legacy contacts can do things like respond to new friend requests and update pinned posts, but they can’t read private messages or remove or alter previous posts. You can only choose one person, who also has to have a Facebook account.

You can also ask Facebook or Instagram to delete a deceased user’s account if you’re a close family member or an executor. You’ll need to send in documents like a death certificate.

TikTok

The video-sharing platform says that if a user has died, people can submit a request to memorialize the account through the settings menu. Go to the Report a Problem section, then Account and profile, then Manage account, where you can report a deceased user.

Once an account has been memorialized, it will be labeled “Remembering.” No one will be able to log into the account, which prevents anyone from editing the profile or using the account to post new content or send messages.

X

It’s not possible to nominate a legacy contact on Elon Musk’s social media site. But family members or an authorized person can submit a request to deactivate a deceased user’s account.

Passwords

Besides the major online services, you’ll probably have dozens if not hundreds of other digital accounts that your survivors might need to access. You could just write all your login credentials down in a notebook and put it somewhere safe. But making a physical copy presents its own vulnerabilities. What if you lose track of it? What if someone finds it?

Instead, consider a password manager that has an emergency access feature. Password managers are digital vaults that you can use to store all your credentials. Some, like Keeper,Bitwarden and NordPass, allow users to nominate one or more trusted contacts who can access their keys in case of an emergency such as a death.

But there are a few catches: Those contacts also need to use the same password manager and you might have to pay for the service.

___

Is there a tech challenge you need help figuring out? Write to us at onetechtip@ap.org with your questions.

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Pediatric group says doctors should regularly screen kids for reading difficulties

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The Canadian Paediatric Society says doctors should regularly screen children for reading difficulties and dyslexia, calling low literacy a “serious public health concern” that can increase the risk of other problems including anxiety, low self-esteem and behavioural issues, with lifelong consequences.

New guidance issued Wednesday says family doctors, nurses, pediatricians and other medical professionals who care for school-aged kids are in a unique position to help struggling readers access educational and specialty supports, noting that identifying problems early couldhelp kids sooner — when it’s more effective — as well as reveal other possible learning or developmental issues.

The 10 recommendations include regular screening for kids aged four to seven, especially if they belong to groups at higher risk of low literacy, including newcomers to Canada, racialized Canadians and Indigenous Peoples. The society says this can be done in a two-to-three-minute office-based assessment.

Other tips encourage doctors to look for conditions often seen among poor readers such as attention-deficit hyperactivity disorder; to advocate for early literacy training for pediatric and family medicine residents; to liaise with schools on behalf of families seeking help; and to push provincial and territorial education ministries to integrate evidence-based phonics instruction into curriculums, starting in kindergarten.

Dr. Scott McLeod, one of the authors and chair of the society’s mental health and developmental disabilities committee, said a key goal is to catch kids who may be falling through the cracks and to better connect families to resources, including quicker targeted help from schools.

“Collaboration in this area is so key because we need to move away from the silos of: everything educational must exist within the educational portfolio,” McLeod said in an interview from Calgary, where he is a developmental pediatrician at Alberta Children’s Hospital.

“Reading, yes, it’s education, but it’s also health because we know that literacy impacts health. So I think that a statement like this opens the window to say: Yes, parents can come to their health-care provider to get advice, get recommendations, hopefully start a collaboration with school teachers.”

McLeod noted that pediatricians already look for signs of low literacy in young children by way of a commonly used tool known as the Rourke Baby Record, which offers a checklist of key topics, such as nutrition and developmental benchmarks, to cover in a well-child appointment.

But he said questions about reading could be “a standing item” in checkups and he hoped the society’s statement to medical professionals who care for children “enhances their confidence in being a strong advocate for the child” while spurring partnerships with others involved in a child’s life such as teachers and psychologists.

The guidance said pediatricians also play a key role in detecting and monitoring conditions that often coexist with difficulty reading such as attention-deficit hyperactivity disorder, but McLeod noted that getting such specific diagnoses typically involves a referral to a specialist, during which time a child continues to struggle.

He also acknowledged that some schools can be slow to act without a specific diagnosis from a specialist, and even then a child may end up on a wait list for school interventions.

“Evidence-based reading instruction shouldn’t have to wait for some of that access to specialized assessments to occur,” he said.

“My hope is that (by) having an existing statement or document written by the Canadian Paediatric Society … we’re able to skip a few steps or have some of the early interventions present,” he said.

McLeod added that obtaining specific assessments from medical specialists is “definitely beneficial and advantageous” to know where a child is at, “but having that sort of clear, thorough assessment shouldn’t be a barrier to intervention starting.”

McLeod said the society was partly spurred to act by 2022’s “Right to Read Inquiry Report” from the Ontario Human Rights Commission, which made 157 recommendations to address inequities related to reading instruction in that province.

He called the new guidelines “a big reminder” to pediatric providers, family doctors, school teachers and psychologists of the importance of literacy.

“Early identification of reading difficulty can truly change the trajectory of a child’s life.”

This report by The Canadian Press was first published Oct. 23, 2024.

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