He said science is behind, it's for real, stay at home so science can catch up. You gleefully approve.
Any time anyone else here gives credence to staying at home and suggest this is real, you jump their azz and go sideways, call names, claim "fear mongering."
It's pretty obvious your angle.
The DIPCHIT ADD, after a morning of drinking:
You despair, repeatedly, constantly! daily basis? A despair ninny. Sack up, despire ninny.
He said science is behind, it's for real, stay at home so science can catch up. You gleefully approve.
Any time anyone else here gives credence to staying at home and suggest this is real, you jump their azz and go sideways, call names, claim "fear mongering."
Thanks for that Doc. If you have time, I'd know I would get great value of updates on your thoughts as this thing progresses...
Absolutely, and thanks for sharing your insight and expertise Doc.
+100
"Allways speak the truth and you will never have to remember what you said before..." Sam Houston Texans, "We say Grace, We Say Mam, If You Don't Like it, We Don't Give a Damn!"
Okay, I'm gonna be brutally honest here, which I can't be on my "public" posts elsewhere on the innanet. I'm curious to read what the misfits and degenerates here on the 24HCF write in response. By way of preface, I need to tell you that I have been reading (what internet ninjas call "research") as many credible articles as I can every day since early January. I have been frequently interacting with other doctors who are invested in understanding this pandemic; sometimes in person at my hospital, and sometimes on the phone to places as far away as Canada and the England, and by email all over the world. I can honestly say that the Big Picture on COVID-19 is just beginning to come clear, and our collective understanding of the pandemic is emerging slowly and constantly evolving.
I am on the front lines of the battle, so to speak, as an ER doc in a fairly busy urban hospital which also happens to the the County Hospital, so we get all the schitt that nobody else will take. Ground Zero for COVID when it hits. So I am invested very deeply in doing the Right Thing, and am advising people to stay home, shelter in place, wash hands, etc, etc, etc.
As of midnight GMT last night the USA had 69,047 confirmed COVID-19 cases. This is a gross underestimate (more on that later). Total deaths, 1037 (Case Fatality Rate [CFR] = 1.5%). Compared to other countries, we are doing really, really well: Italy's numbers stand at 74,386 and 7503 (CFR 10%) , Iran's at 29,406 and 2234 (CFR 7.8%), China's at 81,285 and 3287 (CFR 4%). So far, the USA is doing well.
And this makes sense. We have a very good healthcare system overall (despite the constant whining from "progressives" that we need to go full-on socialist with our healthcare) and our population of vulnerable people is well cared for, in the main. We have a relatively low smoking rate, compared to other countries. We have more ICU beds per capita than any other nation on earth. And so on. We SHOULD be doing better on those grounds, so let's not start patting ourselves on the back quite yet. We are still in the early stages of the epidemic, nationally speaking, so it may get a whole helluva lot worse.
And therein lies the problem: we don't know what to expect. We don't have good data to use for our analysis. COVID-19 testing is barely starting to catch up to demand, and that's just testing for active cases in sick people. Testing in people who are infected but asymptomatic, infected and only mildly ill, and infected but recovered, is beyond our reach yet, so we don't have any real idea how many people fit into those categories.
And we NEED to know those numbers to adquately predict what's going to happen so we can meet the challenge in the most effective way. More on this in a bit.
Right now, most of America is shutting itself up in homes and closing doors on business. This may be economically catastrophic, or it may be a speed bump in the roadway of life. I have no clue. I'm not a financial guy, I'm a medical guy. But we know it's going to hurt to some degree. The question we need to answer ASAP is how much is this helping, and how much will it hurt? Further to that, should we be doing something else that will produce a better cost/benefit ratio?
We have no choice but to stay the course, for now... the CDC, WHO and the COVID-19 Task Force (C19TF) are calling the shots and the President is going along. But I suspect we are going to see a change in our national strategy sooner rather than later, as the data give us a better picture of what's going on.
For now, let's look at how we got here. I believe the COVID-19 cluster f u c k is a "perfect storm" that was just waiting to happen. All the requisite components had to be in place for this to happen:
1) Public health has been grossly underfunded at the UN and in America for decades, which is squarely the fault of Congress for the past 50 years;
2) A small, but influential, segment of the public is aware of this underfunding, and has been squawking about it. This has not fallen on deaf ears in the mainstream media (MSM);
3) Apocalyptic fiction has been an increasingly popular theme in worldwide fiction (books, TV, movies) for the past 30 years, which has kept more or less insane TEOTWAWKI scenarios constantly before the public eye in that period;
4) The American Public is scientifically illiterate, thanks to our horrid public education system (hence the popularity of #3);
5) China, which has been every virologist's waking nightmare for at least 2 generations, and which has been ground zero for multiple pandemics and near-pandemics in the past, is reaching a tipping point for poisoning itself out of existence and was ripe for breeding the wild COVID-19 virus (but they've been producing pandemics for centuries, this isn't really anything new... not that the American Public would know that, as they are Historically Illiterate in addition to being Scientifically Illiterate);
6) The bulk of journalists in America have become so deranged by anti-Trump rhetoric that they have completely lost the ability to report any news story in a manner that could be even remotely described as rational discourse; so, finally,
7) The MSM has capitalized on #1-6 to create a firestorm of alarmism, emotion, and knee-jerk overreactions.
Despite the above, the medical community continues to search for REAL answers to our problem. The science is far from settled, shall we say. I have read a number of good articles from all over the world in the past five days that tell us that shutting down whole economies is probably not doing what we hope it will, so it isn't necessary. What they are saying is this:
1) Let's find out what the actual prevalence of this disease is (total number of people who are and have been infected), rather than focusing on incidence (number of new cases); estimates from many sources say prevalence is at least 10X the number of reported cases, as many infected persons are asymptomatic or mildly symptomatic, and thus are not tested;
2) This can only be done when we expand our testing to a larger segment of the population, and we don't have the capacity for that yet, so we need to maintain social isolation measures until we can catch that up;
3) Using prevalence data, we can calculate an actual relative risk (RR) and case fatality rate (CFR) for this pandemic, which will certainly be much lower than the CFR's being touted currently;
4) Once we have a handle on RR and CFR, we can concentrate our isolation/quarantine efforts on segments of the population who are at high risk, and lift restrictions at populations at low risk;
5) Use the new anti-viral treatment protocols (hydroxychloroquine, hydroxychloroquine + azithromycin, hydroxychloroquine + zinc sulfate) to treat high-risk and seriously ill patients to keep them out of the hospitals and ICU's. (The new anti-viral protocols are the most important development in the pandemic response to date. We can thank doctors in Israel and France for this development, by the way.)
President Trump told us a couple of days ago he expects we will be able to lift the restrictions "by Easter". I doubt he would have made that statement if he didn't have knowledge from the C19TF to inform his decision. And that knowledge isn't restricted to the C19TF... as I said in the beginning of this piece, there are a LOT of doctors and medical researchers out there who are reaching this same conclusion.
Again: the science isn't settled by any means. But we know more every day than we did the day before, and the epidemiologists and infectious disease specialists who are working on the medical solution to this mess are going to come up with a good response. So far it appears that the CDC, the C19TF, and President Trump are listening to that consensus. And that is a good thing.
Please be clear: we are NOT at the point of being able to lift social isolation/quarantine yet. People who disregard the measures in place are unquestionably hastening the spread of the epidemic, and putting our nation's hospitals at risk of being overwhelmed. So keep doing the positive things, my friends, and wait for the smart guys to figure this out. I am confident they will.
Don't sweat it Doc, as very few here are capable of conversing/dealing with normal people anyway.
"I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.
Clinical course is predictable. 2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.
Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.
81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.
Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.
China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.
Diagnostic CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.
Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95% CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated. Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.
Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.
A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.
Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.
Disposition I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.
We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.
Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.
Treatment Supportive
worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.
Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.
We are also using Azithromycin, but are intermittently running out of IV.
Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.
Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.
Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.
Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.
The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.
Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.
We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.
One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.
I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."
Okay, I'm gonna be brutally honest here, which I can't be on my "public" posts elsewhere on the innanet. I'm curious to read what the misfits and degenerates here on the 24HCF write in response. By way of preface, I need to tell you that I have been reading (what internet ninjas call "research") as many credible articles as I can every day since early January. I have been frequently interacting with other doctors who are invested in understanding this pandemic; sometimes in person at my hospital, and sometimes on the phone to places as far away as Canada and the England, and by email all over the world. I can honestly say that the Big Picture on COVID-19 is just beginning to come clear, and our collective understanding of the pandemic is emerging slowly and constantly evolving.
I am on the front lines of the battle, so to speak, as an ER doc in a fairly busy urban hospital which also happens to the the County Hospital, so we get all the schitt that nobody else will take. Ground Zero for COVID when it hits. So I am invested very deeply in doing the Right Thing, and am advising people to stay home, shelter in place, wash hands, etc, etc, etc.
As of midnight GMT last night the USA had 69,047 confirmed COVID-19 cases. This is a gross underestimate (more on that later). Total deaths, 1037 (Case Fatality Rate [CFR] = 1.5%). Compared to other countries, we are doing really, really well: Italy's numbers stand at 74,386 and 7503 (CFR 10%) , Iran's at 29,406 and 2234 (CFR 7.8%), China's at 81,285 and 3287 (CFR 4%). So far, the USA is doing well.
And this makes sense. We have a very good healthcare system overall (despite the constant whining from "progressives" that we need to go full-on socialist with our healthcare) and our population of vulnerable people is well cared for, in the main. We have a relatively low smoking rate, compared to other countries. We have more ICU beds per capita than any other nation on earth. And so on. We SHOULD be doing better on those grounds, so let's not start patting ourselves on the back quite yet. We are still in the early stages of the epidemic, nationally speaking, so it may get a whole helluva lot worse.
And therein lies the problem: we don't know what to expect. We don't have good data to use for our analysis. COVID-19 testing is barely starting to catch up to demand, and that's just testing for active cases in sick people. Testing in people who are infected but asymptomatic, infected and only mildly ill, and infected but recovered, is beyond our reach yet, so we don't have any real idea how many people fit into those categories.
And we NEED to know those numbers to adquately predict what's going to happen so we can meet the challenge in the most effective way. More on this in a bit.
Right now, most of America is shutting itself up in homes and closing doors on business. This may be economically catastrophic, or it may be a speed bump in the roadway of life. I have no clue. I'm not a financial guy, I'm a medical guy. But we know it's going to hurt to some degree. The question we need to answer ASAP is how much is this helping, and how much will it hurt? Further to that, should we be doing something else that will produce a better cost/benefit ratio?
We have no choice but to stay the course, for now... the CDC, WHO and the COVID-19 Task Force (C19TF) are calling the shots and the President is going along. But I suspect we are going to see a change in our national strategy sooner rather than later, as the data give us a better picture of what's going on.
For now, let's look at how we got here. I believe the COVID-19 cluster f u c k is a "perfect storm" that was just waiting to happen. All the requisite components had to be in place for this to happen:
1) Public health has been grossly underfunded at the UN and in America for decades, which is squarely the fault of Congress for the past 50 years;
2) A small, but influential, segment of the public is aware of this underfunding, and has been squawking about it. This has not fallen on deaf ears in the mainstream media (MSM);
3) Apocalyptic fiction has been an increasingly popular theme in worldwide fiction (books, TV, movies) for the past 30 years, which has kept more or less insane TEOTWAWKI scenarios constantly before the public eye in that period;
4) The American Public is scientifically illiterate, thanks to our horrid public education system (hence the popularity of #3);
5) China, which has been every virologist's waking nightmare for at least 2 generations, and which has been ground zero for multiple pandemics and near-pandemics in the past, is reaching a tipping point for poisoning itself out of existence and was ripe for breeding the wild COVID-19 virus (but they've been producing pandemics for centuries, this isn't really anything new... not that the American Public would know that, as they are Historically Illiterate in addition to being Scientifically Illiterate);
6) The bulk of journalists in America have become so deranged by anti-Trump rhetoric that they have completely lost the ability to report any news story in a manner that could be even remotely described as rational discourse; so, finally,
7) The MSM has capitalized on #1-6 to create a firestorm of alarmism, emotion, and knee-jerk overreactions.
Despite the above, the medical community continues to search for REAL answers to our problem. The science is far from settled, shall we say. I have read a number of good articles from all over the world in the past five days that tell us that shutting down whole economies is probably not doing what we hope it will, so it isn't necessary. What they are saying is this:
1) Let's find out what the actual prevalence of this disease is (total number of people who are and have been infected), rather than focusing on incidence (number of new cases); estimates from many sources say prevalence is at least 10X the number of reported cases, as many infected persons are asymptomatic or mildly symptomatic, and thus are not tested;
2) This can only be done when we expand our testing to a larger segment of the population, and we don't have the capacity for that yet, so we need to maintain social isolation measures until we can catch that up;
3) Using prevalence data, we can calculate an actual relative risk (RR) and case fatality rate (CFR) for this pandemic, which will certainly be much lower than the CFR's being touted currently;
4) Once we have a handle on RR and CFR, we can concentrate our isolation/quarantine efforts on segments of the population who are at high risk, and lift restrictions at populations at low risk;
5) Use the new anti-viral treatment protocols (hydroxychloroquine, hydroxychloroquine + azithromycin, hydroxychloroquine + zinc sulfate) to treat high-risk and seriously ill patients to keep them out of the hospitals and ICU's. (The new anti-viral protocols are the most important development in the pandemic response to date. We can thank doctors in Israel and France for this development, by the way.)
President Trump told us a couple of days ago he expects we will be able to lift the restrictions "by Easter". I doubt he would have made that statement if he didn't have knowledge from the C19TF to inform his decision. And that knowledge isn't restricted to the C19TF... as I said in the beginning of this piece, there are a LOT of doctors and medical researchers out there who are reaching this same conclusion.
Again: the science isn't settled by any means. But we know more every day than we did the day before, and the epidemiologists and infectious disease specialists who are working on the medical solution to this mess are going to come up with a good response. So far it appears that the CDC, the C19TF, and President Trump are listening to that consensus. And that is a good thing.
Please be clear: we are NOT at the point of being able to lift social isolation/quarantine yet. People who disregard the measures in place are unquestionably hastening the spread of the epidemic, and putting our nation's hospitals at risk of being overwhelmed. So keep doing the positive things, my friends, and wait for the smart guys to figure this out. I am confident they will.
Don't sweat it Doc, as very few here are capable of conversing/dealing with normal people anyway.
Least of all me.
Stuart, I hope you and your Aussie brethren are okay and are weathering the pandemic well. Best wishes.
Doc, I appreciate your giving clarity to this thing. I know you're beyond busy. I have a question and am hoping if you see this post you can shed a little light on it.
I'm reading where tPA has shown some promise in those with advanced COVID-19 by breaking up pulmonary clots and also small clots in the aveoli. Apparently COVID pts are hypercoagulable and are clotting off their IVs, as well as having kidney and heart failure. A 2001 study showed promise in this area and I believe there is a compassionate use study underway. As an ER doc, I assume you've had experience with lytics for MI and stroke. I know it's damned expensive, but nearly every ER should have it on hand. Any thoughts regarding tPA as advanced COVID therapy?
Very true DF. I expect that we are first in the number of cases now because of the ramped up testing and that the positive-but-not-sick denominator, to the critically-ill-to-death numerator, will grow very large.
One thing — Trump seems to have true fondness for China’s Xi, not I hope, to his blindness to their ultimate goal. They will only be “our friends” as it suits their purpose to economic world domination.
“We struggle not against flesh and blood but against powers and principalities.”
I couldn't help thinking of the Genesis.story about the plagues in Egypt, pestilance in Revelation.
Hope we come out of this better, wiser and ever grateful....
We really pulled together after 9-11, but it seemed to wear off after a few weeks.
Very true DF. I expect that we are first in the number of cases now because of the ramped up testing and that the positive-but-not-sick denominator, to the critically-ill-to-death numerator, will grow very large.
One thing — Trump seems to have true fondness for China’s Xi, not I hope, to his blindness to their ultimate goal. They will only be “our friends” as it suits their purpose to economic world domination.
“We struggle not against flesh and blood but against powers and principalities.”
I couldn't help thinking of the Genesis.story about the plagues in Egypt, pestilance in Revelation.
Hope we come out of this better, wiser and ever grateful....
We really pulled together after 9-11, but it seemed to wear off after a few weeks.
Time will tell...
DF
It still hasn't worn off here. Nobody voted Democrat for President here since 1964. It wore off in New York where the memories should have still been fresh.
"I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.
Clinical course is predictable. 2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.
Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.
81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.
Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.
China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.
Diagnostic CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.
Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95% CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated. Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.
Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.
A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.
Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.
Disposition I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.
We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.
Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.
Treatment Supportive
worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.
Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.
We are also using Azithromycin, but are intermittently running out of IV.
Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.
Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.
Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.
Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.
The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.
Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.
We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.
One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.
I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."
Thanks for posting that. I printed it up. It's a window into the daily decision making of a stressed ER doc in the greater NO area.
I'm glad we have guys (and gals) like that who go to work every day, facing a real monster of a disease. And his account of how fast patients crash once they reach a critical phase he described as their cytokine storm. Pretty amazing.
Reportedly he's not seeing much help with Plaquenil as reported by others, running out of IV Azrithromycin. And, the usual sepsis treatments with steroids, fluids, seem to make it worse.
I appreciate his PPE precautions, changed his gear in the garage, head for the shower. And, his family moved to a safer location in Hattisburg.
![[Linked Image from i.postimg.cc]](https://i.postimg.cc/qMjL6f8C/27-FD3-F35-D9-CF-4-FC0-AE24-D01508-F7-AF1-C.gif)
![[Linked Image from i.imgur.com]](https://i.imgur.com/m0zk1a7.jpg)
