Introduction: Novel Corona Virus Disease 19 has created unforeseen burden on health care. New York city is one of the epicenters of pandemic and here we explore physical, mental and social impact of COVID 19 on Resident Physicians (RP) working within the center of this epicenter. Methods: This is a single-center cross-sectional web-based survey involving RP of a community hospital in Brooklyn, New York. Questionnaire was formulated in online platform. We used a convenient sampling method. Univariate analysis was conducted and presented the distribution of qualitative responses as frequency and percentages. Result: COVID19 related symptoms were reported by 39.8% RP. COVID19 IgG and IgM antibodies, both negative were reported by 34.9%, while only 6% RPs were IgG antibody positive. Symptomatic RP tested for COVID19-PCR was positive in 42.42%. Self-isolation from family during the pandemic was reported by only 14.5%. Financial constraints, lack of accommodation, and emotional reasons were main reasons of not being able to self isolate. Being bothered by 'Anxiety' and 'Nervousness' were reported by 8.5% on 'Almost every day' while 46.3% reported on 'several days in the two weeks duration'. 'Uncontrollable worrying', 'Feeling down', 'Depressed,' or 'Hopeless' was reported as 'Not at all' by 78.8% and 3.7% reported it to 'occur nearly every day for the last two weeks'. Conclusion: Aftermath of fight against pandemic has left RP with significant physical, mental, and social impact. Appropriate stress management and safety interventions are urgently needed. Further studies are needed to explore the detailed impact of COIV19 on RP.

RationaleKetamine has been used as a sedative analgesic in trauma setting, but data regarding its efficacy and safety is lacking in severe ARDS. This retrospective study aims to determine if Ketamine is safer as a sedative agent in mechanically ventilated patients. During the COVID pandemic, as there was a shortage of sedative agents, Ketamine was used. ObjectivesThe primary objective was to compare the safety of ketamine to other sedatives. The secondary objective was to compare the effect of ketamine to other sedatives regarding the need for vasopressor, incidence of delirium, infectious complications, acute kidney injury, hospital length of stay, and length of ventilator days. MethodsA retrospective, observational cohort study was conducted. Measurements and Main ResultsOne hundred and twenty-four patients (63 men and 61 women) were included. Thirty-four patients received ketamine, while 90 patients received other traditionally used sedatives such as propofol and midazolam. The patients' median age was 64 years in the ketamine group and 68 years in the non-ketamine group. Seventeen patients in the ketamine group (50%) and 65 patients (72%) in the non-ketamine group had mortality (p < 0.02). The hospital length of stay was 22.85 days (± 16.36) in the ketamine group and 15.62 days (± 14.63) in the non-ketamine group (p < 0.02). There was no statistically significant difference among the outcomes of the need for vasopressor, the incidence of delirium, infectious complications, and acute kidney injury. ConclusionsKetamine as a sedative-analgesic agent in COVID-19 patients with severe acute respiratory distress syndrome demonstrated safety with reduced mortality. The ketamine group had a higher hospital length of stay, but a similar complication profile compared to the non-ketamine group. Further prospective randomized controlled trials are warranted to confirm these findings.

Bradycardia, renal failure, atrioventricular (AV) nodal blockade, shock, and hyperkalemia (BRASH) syndrome commonly occurs in the elderly population with compromised renal function and a history of taking AV nodal blocking agents on a regular basis. Hypovolemia and worsening of renal function are considered to be the major risk factors. BRASH syndrome should be differentiated from pure intoxication with AV nodal blocking agents, as the therapeutic goals of these conditions are different from each other. It encompasses a vicious cycle of bradycardia and decreased cardiac output leading to organ dysfunction including renal failure with hyperkalemia, further augmenting bradycardia. It is usually associated with high morbidity and mortality. Typically, the treatment involves increasing renal blood flow by augmenting cardiac output using catecholamine infusion. Very rarely, interventions such as intralipid emulsion and continuous renal replacement therapy (CRRT) may be required on a case-to-case basis. Promptly recognizing the symptoms of BRASH syndrome can help to avoid diagnostic delays and reduce mortality rates.

Although atrial fibrillation (AF) has been correlated with hyponatremia, it has not been described in association with the correction of chronic hypernatremia in previous studies.Here, we describe three elderly patients who had hypernatremia on presentation, most likely secondary to dehydration. Their electrocardiogram (EKG) on presentation was normal, and they had no known history of AF but developed transient AF during the course of hypernatremia correction. Similar occurrences have not been reported previously though there have been studies showing the relation between hyponatremia and AF. It is known that atrial stretch can increase the propensity of rapid firing from the pulmonary veins as a result of stretch-sensitive ion channels. Therefore, the occurrence of AF in these patients could be explained by the phenomenon of increase in right atrial diameter, i.e atrial stretch, in response to the increase in preload during the course of treatment. However, there are many other clinical scenarios where boluses of fluid are given during treatment but no occurrences of AF have been reported so far. So, we put forward the possibility of the occurrence of AF being independently associated with the drop in sodium level. Further studies like speckle tracking echo might shed more light on these findings.

Barium studies are commonly used to rule out gastrointestinal (GI) pathologies and sometimes they are associated with complications such as barium aspiration with heterogeneity in clinical features ranging from mild to severe symptoms. We present a case of large volume barium aspiration in a 73-year-old male with past medical history of dysphagia diagnosed with diffuse esophageal spasm. Barium is an inert material commonly used for GI tract study. Although complications associated with barium studies are rare, aspiration of barium can have dramatic findings resulting in mild to severe symptoms. Clinically patient had very minimal symptoms but radiographic studies appeared dramatic. Therefore, a clinical and radiographic paradox must be kept in mind when evaluating patients and reviewing large volume barium aspiration imaging. Our case remained asymptomatic and had no respiratory complaints, nor did he develop any respiratory distress post barium aspiration.