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knowledge is power


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Originally Posted by sse
knowledge is power
Indeed. The knowledge that he presented in that video was *very* empowering.


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I really like those hands on videos from front line providers.

They do cut to the chase.

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Originally Posted by sse
From ER doc in New Orleans, little technical.


"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..."


Hey fellas, I've been busy the past few days and haven't been able to check back in. All good here so far.

THIS particular quote (which I have deliberately not completely quoted, which as that growth stunted jerk on the Optics forum might emphasize with "HINT... laughing", tells you that I have this story bookmarked as BOGUS) is not to be taken seriously. Here's why.

There are a LOT of overwhelmed docs in places like New Orleans and NYC. I feel for those folks, they're getting their butts kicked. But their experience is NOT the norm. Their experience is a product of 1) high population density; 2) high rate of homelessness and poverty, with a consequent 3) low level of general health in the community. Couple that with the fact that people with severe diabetes, kidney disease, respiratory disease, and heart disease tend to move into centers near hospitals, so you have a higher-than-normal population of very sick people, on top of the already very high density of population.

So of course we expect the major urban centers to get hit hard.

The problem you get with docs in that sort of front-lines scenario is they often think they are more "in the know" than folks who are standing back and looking at the whole problem. I've been guilty of that myself. And the front-lines doc is usually wrong. He can't see the forest for the trees.

But there's other problems with this story. First and foremost, the doc's numbers don't add up. He says he's discharging 12-15 COVID patients from his ER daily. By extension of ER statistics, that suggests he is admitting 2-5 patients daily. That adds up to 18-20 COVID patients per shift, for this one doctor, and he certainly implies that ALL of his colleagues are seeing similar numbers. His ER, by his numbers, probably has 5 doctors and midlevel providers working every day. So that means this single ER is seeing 80-100 COVID patients per day. There are ten acute care hospitals in New Orleans, so that multiplies out to 800-1000 new COVID cases per day.

But as I said, his numbers don't add up. I was sent this report of 800-1000 new patients per day 2 days ago, which implies it was written 1-2 or more days prior to me getting it. And on Thursday, the day I received it, the TOTAL number of cases in the ENTIRE State of Louisiana was 3405.

In other words, his numbers were either completely fabricated or grossly exaggerated.

Another problem: he cites numbers of patients being admitted, says they don't need to be intubated until Day 10 or later, then goes on to say 80% of patients on ventilators are dying. Again, the numbers don't line up. According to the numbers he provides, his small hospital doesn't have enough ventilators to serve the number of patients he says are being intubated. And they haven't been in hospital long enough yet to know how many are dying.

This tells me these numbers are fabricated. And the story is fabricated. And it's not just me saying so, several other docs I know have read it and agree that it is some truth with a lot of very bad lies thrown in.

It may have been written by a doctor, and if so, he should be ashamed of himself for telling lies. But more likely this was pulled from a variety of stories coming out of Italy, New York, and God knows where else.

So please don't give this bull s h i t story any credence whatsoever.

Last edited by DocRocket; 03/29/20.

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Originally Posted by CharlieFoxtrot
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?

Thanks again.

cf



cf... as far as I am aware, this question is low on the list of priorities for clinicians dealing with COVID patients. Adult Respiratory Distress Syndrome (ARDS) is our biggest worry, and once it sets in we don't have any tools to fight it, other than changing our ventilator settings. lt's a fancy term to denote the end-of-life process for any lung disease or injury... a few people survive it, most don't.

Anticoagulants and thrombolytic meds do not have a significant role in treatment of COVID at this point, to my knowledge.


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Nice to see peer review is alive and well in the scientific community.


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Originally Posted by sse

Preventing infection, extremely informative





I don't have time to watch the whole program, but the 5 minutes I watched seemed really solid.


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Originally Posted by DocRocket
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.


Ya, but they closed our boat launches, and the salmon opener is in just a few days, should I fuel the boat, yes or no, dammit?

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Originally Posted by DocRocket
Originally Posted by sse
From ER doc in New Orleans, little technical.


"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..."


Hey fellas, I've been busy the past few days and haven't been able to check back in. All good here so far.

THIS particular quote (which I have deliberately not completely quoted, which as that growth stunted jerk on the Optics forum might emphasize with "HINT... laughing", tells you that I have this story bookmarked as BOGUS) is not to be taken seriously. Here's why.

There are a LOT of overwhelmed docs in places like New Orleans and NYC. I feel for those folks, they're getting their butts kicked. But their experience is NOT the norm. Their experience is a product of 1) high population density; 2) high rate of homelessness and poverty, with a consequent 3) low level of general health in the community. Couple that with the fact that people with severe diabetes, kidney disease, respiratory disease, and heart disease tend to move into centers near hospitals, so you have a higher-than-normal population of very sick people, on top of the already very high density of population.

So of course we expect the major urban centers to get hit hard.

The problem you get with docs in that sort of front-lines scenario is they often think they are more "in the know" than folks who are standing back and looking at the whole problem. I've been guilty of that myself. And the front-lines doc is usually wrong. He can't see the forest for the trees.

But there's other problems with this story. First and foremost, the doc's numbers don't add up. He says he's discharging 12-15 COVID patients from his ER daily. By extension of ER statistics, that suggests he is admitting 2-5 patients daily. That adds up to 18-20 COVID patients per shift, for this one doctor, and he certainly implies that ALL of his colleagues are seeing similar numbers. His ER, by his numbers, probably has 5 doctors and midlevel providers working every day. So that means this single ER is seeing 80-100 COVID patients per day. There are ten acute care hospitals in New Orleans, so that multiplies out to 800-1000 new COVID cases per day.

But as I said, his numbers don't add up. I was sent this report of 800-1000 new patients per day 2 days ago, which implies it was written 1-2 or more days prior to me getting it. And on Thursday, the day I received it, the TOTAL number of cases in the ENTIRE State of Louisiana was 3405.

In other words, his numbers were either completely fabricated or grossly exaggerated.

Another problem: he cites numbers of patients being admitted, says they don't need to be intubated until Day 10 or later, then goes on to say 80% of patients on ventilators are dying. Again, the numbers don't line up. According to the numbers he provides, his small hospital doesn't have enough ventilators to serve the number of patients he says are being intubated. And they haven't been in hospital long enough yet to know how many are dying.

This tells me these numbers are fabricated. And the story is fabricated. And it's not just me saying so, several other docs I know have read it and agree that it is some truth with a lot of very bad lies thrown in.

It may have been written by a doctor, and if so, he should be ashamed of himself for telling lies. But more likely this was pulled from a variety of stories coming out of Italy, New York, and God knows where else.

So please don't give this bull s h i t story any credence whatsoever.

i'm glad you chimed in on this, the contradictions highlighted def add to the overall confusion, sure do wonder about the pretext for publishing something counter-productive. was pretty sure this was well-circulated in the community already, and if as you state, is nothing novel from the standpoint of both professionals and laymen, whole other can of worms.


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"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. "

Doc, I agree with most of what you say in your excellent post but, differ with some points. We DO need statistically-valid facts before decent projections can be made. I have listened to President Trump's statements over the past 3 years and find him often making statements that "fact checks" find to be misleading (e.g.: https://www.theguardian.com/us-news/2020/mar/28/trump-coronavirus-misleading-claims ). He just seem to say whatever crosses his mind at the moment. Dr. Anthony Fauci appears to offer a more valid assessment and, he seems to have been replaced on the podium by Dr. Deborah Birx with her more palatable assessments.

There are some indicators regarding the trajectory of the Corona Virus pandemic, as shown by the Johns Hopkins Corona Virus Map (see: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 ). By clicking on the US confirmed cases and then enlarging the graph at the bottom right of the screen, you can observe the daily growth of cases and that the rate-of-confirmed-cases is exponentially increasing.

Yes, this virus will eventually die out or subside, but the when is very questionable. I fear that we will have this situation well into the spring and maybe longer, until a vaccine can be developed and mass-produced. As the old saying goes, "Plan for the worst, hope for the best."

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Originally Posted by DocRocket
Originally Posted by sse

Preventing infection, extremely informative





I don't have time to watch the whole program, but the 5 minutes I watched seemed really solid.

i saw another ICU dr on Fox last night who didn't seem nearly as clear cut about the key issues, but he honestly looked a little shell-shocked


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Thanks Doc. Refreshing common sense is always great to read.

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djs, I'm not gonna engage in any discussion of whether President Trump is right or wrong, or what he did or didn't say. Nor am I interested in whether Dr. Fauci or Dr. Birx is higher on the D.C. totem pole. I'm looking at data and medical consensus, not who's making the most noise in Washington. I've had a couple folks send me PM's here trying to bait me into a Trump-said-this-not-that catfight, and I've deleted those PM's without replying. I don't have time for pizzing matches over such nonsense.

The Johns Hopkins map is only one source for data, and while I think it's likely reliable, it's not giving us any information other than the number of positive COVID tests. For now, that's what most websites are reporting, since it's the only thing you can easily report. This is the disease incidence. As I pointed out in my OP, incidence is only a part of the epidemiological story. Prevalence is far more important, and none of the stats websites are updating that number daily. Partly because they don't know it's important, I suspect.

Of course we expect the numbers of COVID-10 positive tests to be growing exponentially. This is inevitable. What we do NOT know is how much of this growth is due to increased availability of testing, although we know this is a major contributor to the slope of the curve. We can flatten the curve really easily just by stopping all testing, you know... which is what China decided to do last week, and hey, presto! their new stats look great! Too bad they're bull s h i t.

More important: instead of looking at the raw numbers, look at the incidence per 100,000 population. If you do that, the growth of the epidemic in the USA looks a lot better than it does in any nation in the world right now with the exception of Germany. I suggest you look at the graphs in this article to see what I'm talking about...
https://pjmedia.com/trending/what-t...PHhaHimUoO3I0jOujeyVh7JE7OzX4hX6mYVb_KYA


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Originally Posted by sse

i saw another ICU dr on Fox last night who didn't seem nearly as clear cut about the key issues, but he honestly looked a little shell-shocked


I'm sure he did.

These guys are getting pounded. Running an ICU under normal conditions is a highly stressful job. Throw in epidemic disease and it's gonna be a s h i t show. I was an ICU resident back in 1992 when we had a meningitis outbreak in my city. I have rarely worked with such intensity in my life. I had a great time as a resident (basically an enlisted man, metaphorically speaking) and learned a heck of a lot in the process. But the intensivists in charge (the officers, to extend the metaphor) looked like he'd been in a war zone by the end of each week of rotation.

Some people handle stress better than others. Some people break down, some persevere. The TeeVee Fearmongers--I mean broadcast journalists--don't want interviews with the folks who are coping well. They want drama, they want quotable quotes, they want blood on the walls or the nearest to that they can get.

Fecking news people. They made this mess. They should be forced to pay for the cleanup.


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Thanks Doc, I didn't mean to question your judgement, but just to voice my opinion. I greatly admire your (and all front line medical personnel) dedication and courage - it must be a very scary situation in ER's and ICU's. Thanks for your service to us all.

I have a friend who is a Professor of Immunology to a large Medical School in the South. I e-mailed him a week ago and voiced my thanks and asked how it was going. His reply was brief: "overwhelmed, its' going to be bad, I'll get back later".

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This is a very long but informative video.

https://www.youtube.com/watch?v=vInjzOXssRw

My wife manages the med surg. and icu in a smallish rural hospital. We are both positive as of this morning.
We've assumed as much since Wednesday and have acted as such.
Overall feel pretty good. First real symptoms was a rare dry cough followed by bad head ache,chills , body aches.low grade fever.
Been handling those with tylenol.
No respiratory issues so far .
Wife also has lost sense of taste.
I feel like i'm over the hump but who knows.
I'm not worried but what happens happens.


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Thanks, DocRocket, for the logical and fact based report.


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Excellent post, thank you.

Are they going to develop serology and a type of testing to assimilate prevelance?

What is the survival rate of ventilation therapy? Is there cross protection of other corona viruses?

Thanks again.


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Originally Posted by DocRocket
...
There are a LOT of overwhelmed docs in places like New Orleans and NYC. I feel for those folks, they're getting their butts kicked. But their experience is NOT the norm. Their experience is a product of 1) high population density; 2) high rate of homelessness and poverty, with a consequent 3) low level of general health in the community. Couple that with the fact that people with severe diabetes, kidney disease, respiratory disease, and heart disease tend to move into centers near hospitals, so you have a higher-than-normal population of very sick people, on top of the already very high density of population.

So of course we expect the major urban centers to get hit hard.

The problem you get with docs in that sort of front-lines scenario is they often think they are more "in the know" than folks who are standing back and looking at the whole problem. I've been guilty of that myself. And the front-lines doc is usually wrong. He can't see the forest for the trees.
...

then goes on to say 80% of patients on ventilators are dying. Again, the numbers don't line up. According to the numbers he provides, his small hospital doesn't have enough ventilators to serve the number of patients he says are being intubated....
]


Thank you for your informative and thoughtful posts. Appreciate it and the work "you people" do in general.

I wanted to share some experiences of people i know and trust implicitly:

So far in two large NY hospitals between 0 and 15% of patients on a vent survive. They are slammed right now, and likely for all of the reasons you laid out (density, poor healthy density, homeless etc etc)

I have several friends who were positive and recovered at home, and a few who didnt get tested, got it while family had it, and recovered/recovering fine. They are all in good health prior, and they said ti was a VERY bad 3 days in a bad flu like week-10 days. One acquaintance with obesity, diabetes, and a I am sure a few other cardio-existing issues is on a vent and reports are not good at all.

It is everywhere here, I am have little doubt that the numbers of infected are full orders of magnitude higher than what we know (via testing).

Hospitals in my immediate area, the outskirts of 3 red hot zones, have shifted all resources to covid and are currently not overwhelmed.

Just fyi.

Last edited by Crockettnj; 03/29/20.

Originally Posted by Archerhunter

Quit giving in inch by inch then looking back to lament the mile behind ya and wonder how to preserve those few feet left in front of ya. They'll never stop until they're stopped. That's a fact.
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