Allowing Kidney Injury in the Setting of Ventilator Need

Patients who have coronavirus are at risk for fluid overload. Please be cautious using too much during the Covid-19 crisis.

Please note: these suggestions are just that, suggestions, which are  based on the current situation.  It is important to tailor your situation accordingly and collaborate via a team-based approach.

I had a great discussion with my critical care colleagues the other day.  We were discussing the paradigm shifting approach to treating Covid-19 which is very different from the current sepsis guidelines. The goal is to avoid the need to intubate a patient.

When a person is infected with the novel coronavirus, the patient appears to be at high risk for fluid overload and the need for intubation -- which by definition requires a ventilator. As we all know, there is a ventilator shortage. We need to do everything possible to avoid using ventilators while saving lives. Can kidney doctors (nephrologists) work with their critical care colleagues and emergency room physicians to facilitate? Yes, we can!

Caring for these patients, we physicians are normally asked to provide the patient with intravenous fluid -- lots of it. In fact, hospitals can get "into trouble" if they don't give patients who present with severe infection several liters of fluid. Note: there are 33 ounces in 1 liter.

It is turning out that if we avoid this approach (use less fluid) we can avoid ventilator use and keep more people alive, especially when there is a ventilator need. There is a shortage of ventilators.

Consider that as of April 1st, it is projected that Nebraska is going to have a ventilator deficit of 169.

Learn more: Covid-19 projections. Click to find the projected ventilator need in your state.

Invasive ventilators needed in the state of Nebraska: 169 ventilators (projected).

A fascinating abstract in emergency medicine news has suggested that we keep patients relatively volume down (dehydrated) despite a faster heart rate and worsening kidney function (acute kidney injury).

Learn more about the recommendation to allow kidney injury, keeping patients dry to avoid the need to use ventilators and keep patients alive.

The recommendations are constantly changing. The above link provides updated information.

So, how to maintain blood pressure in the patients we serve if we aren't going to give them lots of intravenous fluid?

Again, try to avoid fluid overloading these patients.

Consider the early use of low dose pressors to support the blood pressure.  If the patient appears to be severely dehydrated, consider a small bolus of intravenous fluid. 500 ml of normal saline has been suggested. In contrast, it is usually suggested to give patients with suspected shock caused by a severe sepsis viral infection up to 2000 milliliters of fluid over thirty to sixty minutes, with additional fluid challenges given as required.

500 ml of normal saline as an initial bolus is suggested if the patient appears to be dehydrated and in kidney failure.

Also, avoid maintenance intravenous fluids, especially if the patient's oxygen status is low. Moreover, if the patient is low on oxygen and has normal blood pressure, it has been suggested that a dose of furosemide (also called Lasix) be given. Some have suggested that this will delay the need to use a ventilator for days. This may be a way to mitigate the above ventilators required curve.

So in the short term, while we weather the Covid-19 storm, we need to allow some kidney failure. We need to be patient and treat accordingly as we wait for the coronavirus vaccine.

I know this is paradigm shifting, but I do think this approach will save lives.

I am not a dog on a chain, I use my own brain -- Morrissey on YouTube

That said,  I would suggest following the surviving sepsis campaign as much as possible.



Read more:  Dr. Aaronson Back on the Chain Gang. Stay Healthy and Exercise at Home as We Wait for the Covid-19 Vaccine.

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis 

Dr. Aaronson Back on the Chain Gang. Stay Healthy and Exercise at Home as We Wait for the Covid-19 Vaccine.

Dr. Aaronson is back on the chain gang, social distancing, riding his indoor bicycle using a power meter. The platform is Rouvy. The route is Ironman. Another great platform to consider is Kinomap.

As people are asked to stay home, social distance, and stay safe, they find themselves bored out of their minds. After the third puzzle or second binge-watch of their favorite Netflix series, some turn to eating out of boredom.

The sanest days are mad! Why don't you find out for yourself? -- Morrissey on YouTube

One option I have not heard on the news is exercising at home to stay healthy and mitigate the risk with respect to Covid-19.

What difference does it make? -- Morrissey on YouTube

If you can afford an indoor power meter to track your progress on an exercise bike, I would suggest it.

"Circumstance beyond our control... " Back on the Chain Gang -- Morrissey on YouTube

God forbid you develop Covid-19, the novel coronavirus. You want as much lung reserve as possible. You want to be as fit as possible. You want to be as healthy as possible. A sedentary life style and eating junk food will in my opinion increase your risk if you contract the disease.

Given the appropriate social distancing recommendations we have been placed under, you can't go to the gym. Most people have to stay at home. And you should follow these recommendations. So, how do you prepare your body for the stress if you get coronavirus? You should eat right and exercise.

I'm not suggesting that exercise "cures" the disease. What I'm suggesting is that if you get Covid-19, your chances of staying alive might be improved if you are healthier than a couch potato (defined as a human who does not exercise and rather spends most of the day sedentary viewing content on a device).

I'm basing my opinions on how coronavirus kills and the epidemiologic data of the infectious disease. Please keep reading to learn more.

Has my Dad gone crazy from social distancing? 

 Has My Dad, Dr. Aaronson, Gone Crazy? -- Eminem on YouTube (Clean)

and Oh, so many illustrations -- Morrissey on YouTube

Morrissey practices social distancing in America. Please try to stay 6 feet (1.83 meters) away from others at all times!

In addition to what is currently suggested, a vaccine will protect us. The problem is this takes time. How do we get the vaccine sooner? Some have opined we test in young, "healthy" volunteers.

One of the biggest hurdles will be showing that a vaccine works. Typically, this is done through large phase III studies, in which thousands to tens of thousands of people receive either a vaccine or a placebo, and researchers track who becomes infected in the course of their daily lives. 

A quicker option would be to conduct a ‘human challenge’ study, argue scientists in a provocative preprint published this week. This would involve exposing perhaps 100 healthy young people to the virus and seeing whether those who get the vaccine escape infection. Read more: Should scientists infect healthy people with the coronavirus to test vaccines?

I'm not necessarily suggesting this option. But what does seem clear is that most scientists would agree that a healthier population mitigates our risk in general. Why? Because younger, healthier people require less hospitalization and fewer ventilators. In addition, healthier patients have less of a need for hospitalization caused by illnesses such as heart disease. This makes hospital beds available to the ones in dire need.

You may not be "young," but if you are healthier, you will most likely have more "heart" reserve and have a better chance to survive while we wait for the Covid-19 vaccine. What I find refreshing from the quoted article above is that researchers are doing everything they can to find a vaccine as soon as possible.

For those states less stricken with coronavirus, don't be fooled with a false sense of security. Be smart. Continue to keep the risk low and stay home as much as possible. Practice social distancing if you do need to go out. And avoid panic.

Panic on the streets of London. Panic on the streets of Birmingham. I wonder to myself, Could life ever be sane again? -- Morrissey on YouTube

Learn more: Here is the link I am using to determine what is happening with the coronavirus in my state:

COVID-19 Projections (link)

Expected deaths per day at the peak of the Covid-19 crisis in Nebraska. This site provides great information.

What you get: assuming full social distancing through May 2020

• Number of days until peak resource use: Data grab as of April 1:
• For example, in Nebraska, the peak is expected to be April 23. But that changes based on the data.  Click the projections link above to get up-to-the-minute data.
• Resources needed for COVID-19 patients on peak date
• Nebraska needs 169 ventilators.
• And more for your state and the United States at large.

So in addition to PPE, masks, and social distancing, consider eating right and exercising at home. Indoor cycling or using a treadmill, etc. are options to consider.

"Now we're back in the fight" -- Back on the Chain Gang  Morrissey on YouTube.

I have many resources on my web page that will help you cost effectively set up an exercise bike at home that can be used with the above services.

Learn more ways to mitigate the risk of the Covid-19 pandemic: Allowing Kidney Injury in the Setting of Ventilator Need

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis



@BCBSAssociation @MedicareGov #morrissey

Dr. Aaronson Offers Telehealth and Curbside Options For Patients During Covid-19 Crisis

During the coronavirus crisis most insurance companies are offering Telemedicine services to accommodate the desperate need for patients to see their doctor while avoiding the risk of transmitting Covid-19.

Are you curious if you qualify to be seen using this modality? Please ask our front desk to see if you can be seen using this approach.

How does it work?

It is so easy! There are three ways to connect:
1. Use the web -- click here for the link to start a telehealth encounter.

Start a telehealth call with Dr. Aaronson

Click here to go to our web page to start a telehealth call with Dr. Aaronson.

2. We can text you on your phone. The process is easy. No app installation is required.
3. We can email you to either your computer, tablet, or phone. No app installation is required.

For all the options you click on the link (any of the three above), and you are sent to the Welcome screen. Enter your name and you will be sent to the virtual waiting room.

Welcome to Dr. Aaronson's Telehealth waiting room.
Enter your name, check in, and you are all set.

Make sure your device has a camera, so we can see you.

There are many benefits of Telehealth:
- HIPAA compliant, so you have your privacy.
- The approach is fully encrypted. No one will be watching.
- After the doctor visit, you can securely chat through text with nursing.
- It doesn't matter if you have Android, Windows, or Apple products. This system works with everything. All you need is a web browser and a camera of course to be able to video chat.
- No travel time required to get to your telehealth appointment. Your nurse will be with you shortly followed by your doctor.

Please note: we are also offering curbside options. Many are covered using this modality if you don't want to come into the office.

Why is it so important to see your doctor and not postpone your visit?

I think postponing your appointment has risk and may be dangerous. If you are not experiencing Covid-19 symptoms, or are in quarantine, or are concerned about transmission, you might want to consider telehealth if it is an option. If your insurance company is not offering this service, you might want to call them and ask them why not.

Feeling Socially Isolated From Social Distancing, Consider Relax Listening and Perhaps Something More.

Marconi Union's 10-hour anti-anxiety song  Weightless is available on YouTube. 

Are you feeling socially isolated from socially distancing yourself? Are you in self-isolation for 2 weeks waiting to rid yourself of that pesky coronavirus? Consider listening to Marconi Union's anti-anxiety song Weightless to help get you through. I'm using it at night instead of white noise to help me get a good night's sleep. Some people I know are listening to this song during the day to help alleviate anxiety.

Want something upbeat? Add Your Arsenal to your arsenal. Listen to Glamorous Glue -- Morrissey on YouTube.

Morrissey: Your Arsenal

Third week with "the Jar"

You find

Everything dies -- Morrissey

Want access to the best list of relaxing songs available today? Check out myNoise on YouTube.  Created by Dr. Ir. Stéphane Pigeon, it's the greatest collection of sound to focus, relax, and sleep out there.

Please note: there are other ways to help prevent anxiety and depression during these trying times while staying away from others. Be creative. An example: the Aaronson family opted to foster a puppy at risk and saved a life, read more.

The pleasure brought to the Aaronson Family: Morrissey's New Album I Am Not A Dog on a Chain. Dr. Aaronson and Family Save a Life.

Read more about social distancing during this coronavirus Covid-19 crisis: Dr. Aaronson Suggests Social Distancing to Prevent Coronavirus Spread.

Dr. Aaronson Suggests Social Distancing to Prevent Coronavirus Spread

The predicted exponential growth of the coronavirus in Minnesota. Source: Jonathan Sellman, MD, MPH

Attention Nebraskans: learn the power of exponential growth and how fast coronavirus can spread from the above graft I sourced from Dr. Sellman, an infectious disease specialist (learn more from Dr. Sellman here.)


Minnesota currently has 54 documented coronavirus or COVID19 cases. The state of Minnesota is on track to have an outbreak, similar to outbreaks seen throughout the world which have consistently shown an exponential rise in the number of cases of coronavirus, which double every 3 days.

For perspective, unless we change the above curve, by April 11th, 2020, and as shown above, Minnesota will have approximately 18,000 cases. By April 26th, the state is projected to have 373,000 cases.

How about Nebraska? What are the numbers here? CURRENT COVID-19 STATISTICS AS OF MARCH 13, 2020
State of Nebraska cases: 12
UPDATE: March 17, 2020: 23

But don't be fooled!

Look again at the above graft. Note how infectious the coronavirus disease is. Note how quickly it goes from 54 to 373,000 (exponential rate of growth). Think about what is happening in other parts of the United States. Ponder about what is happening in Italy. And then consider that until a cure and or vaccine is available for this pandemic we have one option that does indeed work:

Social distancing means you keep away from others. This strategy is critical to avoid spreading this highly infectious disease. We need to take this approach seriously. Also remember to wash your hands, cough into your elbow, don't touch your face, stay at least 3 feet (0.91 meters), and preferably 6 feet (1.83 meters), apart from others when you must interact, and if you feel sick stay at home.

That said, if you have concerns about going to your doctor's appointment, and you have been exposed to coronavirus (or don't know) and are currently experiencing any of the following:
·  Fever of 100 degrees or higher
·  Sore throat
·  Cough
·  Difficulty breathing

I encourage you to please call your doctor, your specialist, for next steps.  There are hotlines, drive-thrus, specific locations to go to for testing if you qualify for assessment, and lab testing location options to consider.

Let's do our best to try preventing the spread of this highly contagious infectious disease.

#Stay_safe.

Thank you Dr. Aaronson for the Work You Have Done

Thank you Dr. Aaronson for the work you have done.

"Dear Dr. Aaronson, I want to write and thank you for the work you have done with our Family Medicine residents. I have received very positive feedback on evaluations from our residents, indicating that they enjoy learning from you and working with you. Thank you so very much for participating in the education of our residents. We appreciate you!"

Staircase at the University -- Morrissey on YouTube

Dr. Michael Aaronson, Nephrologist at Lincoln Nephrology and Hypertension responds:

"The pleasure, the privilege is mine."

There is a light that never goes out -- Morrissey The Smiths on YouTube

The front cover. Thank you Dr. Aaronson.

Fitbit Allergic? Not Reading Right? Wear Around Ankle Securely Using Proven Method Demonstrated by Dr. Michael Aaronson.

Are you allergic to the Google Fitbit band? Do you find when you wear the device on your wrist your steps don't record accurately (for example when shopping and pushing a cart, are you getting credit for your steps)? Also, do you want to get "credit" for steps when you are riding your exercise bike (using setups such as Kinomap)?

Dr. Michael Aaronson shows you how to secure the Google Fitbit around your ankle, over your sock, using this proven method.

Importantly, you won't lose the device. It's secure. For this demonstration, I'm using the Google Fitbit Inspire, but all the devices should work in theory. Note, you will likely lose the heart rate functionality. You might consider using a Wahoo TIKR heart rate monitor as an alternative.

Let's go:

Necessary equipment: an additional large, bottom wristband is included in the box. Both the top and bottom wristbands are meant to be swapped when using the Google Fitbit on the wrist. For this setup, you want to attach both in order for the ankle attachment to be secure. See above how the 2 holes can be threaded using a Velcro strap that you will need to purchase to complete the connection.

Helpful hint: if you have a large ankle you may need two Velcro straps, connecting them together for extra length.

The next step is to thread the Velcro band through the wrist bands.

Which leg do I attach my Google Fitbit? The right. However, either leg will work.

"Have you seen him go, though?" Boy racer -- Morrissey on YouTube

Next step: crisscross the strap to attach the Google Fitbit securely to your ankle. See how it makes an "X"? You can tighten as much as you want. Don't cut off your circulation when you make the final connection. After losing a few Google Fitbits from faulty connections, I wanted a system that would not fail me. This step is the secret which keeps the device on your body. 

Helpful suggestion for Google: maybe include an ankle strap similar to the one above in the box? It may improve your market share versus your competitor the Apple Watch! ;-)

Finally, Velcro the strap together. The Google Fitbit fits perfectly. For clarity, the Inspire is on the right and the Velcroed strap is on the left. Congratulations! You are done!

I attach the strap every morning, disconnect in the evening, and charge the Fitbit at night. Once you get the hang of it, this connection takes no time at all to set up.

Other thoughts: some people want to use the Google Fitbit to record their sleep. This setup does successfully record sleep at night, if you wish to have that information.  I have had no bluetooth connection problems. It really works great and should be considered an option for those who have a Fitbit allergy or for those who have Fitbits that do not accurately record their steps when worn on the wrist.

Dr. Aaronson thanks the Huskers for supporting Patients at Bryan Health

Dr. Michael Aaronson thanks the team for supporting patients at Bryan Health

"There's a place in the sun for anyone who has the will to chase one, and I think I have found mine." -- Morrissey on YouTube

They Might Be Giants.

@Bryan_Health
@huskers
@Morrissey

Dr. Aaronson Helps you Convert Watts to Calories to Make Sense of Your Stationary Bike Workout

Dr. Aaronson rides his stationary bike for an average of 1 hour at an average Wattage of 104 resulting in 374 calories burned.

Power has become the holy grail of assessing your bike workout. That's the metric that propels you forward when you use games like Rouvy and Zwift.  But what does that mean in terms of energy expenditure with respect to calories?

If you are exercising to lose weight and become healthier, calories burned during your routine may be of importance to you. I enjoy using online apps such as Rouvy, Zwift, and Trainer Road not only to help me achieve my exercise goals but also to prevent boredom. An example: TrainerRoad can provide an average power and give you the total time of your bicycle ride which can be plugged into the above online calculator to help you easily calculate calories expended.

Here is the link to the Watts to Calories Converter Calculator. I find this link so helpful, I bookmarked it myself for my own personal use!

Here is the calculation if you prefer to do your own math:
energy (kcal) = avg power (Watts) X duration (hours) X 3.6

So let's do some math to see if exercise in addition to dietary restriction helps with weight loss.

• There are 3500 calories in a pound.
• If you exercise at 100 watts for an hour 5 times a week, you will burn approximately one pound every 2 weeks: 374 calories times 10 sessions equals 3740 calories.
• To lose weight, you must control your food consumption. There are multiple strategies to do this.
• One strategy is to use a system like MyFitnessPal to help you track your progress (see my link Wearables, Apps, and Weight Loss. How Much Weight has Dr. Michael Aaronson Lost? to learn more). This approach should help you start losing weight over time, as your doctor may have prescribed.
• If you increase the intensity of your workout, you will burn your calories quicker. For example: if you average 150 watts an hour you will burn 540 calories an hour.

All of this said, please remember to pace yourself when exercising. If you get injured, you will not be able to exercise at all.  Safety first!

Keeping it Simple

Dr. Aaronson suggests you keep it simple.

"Sometimes the questions are complicated and the answers are simple." — Dr. Seuss