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.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks again for the post!
Don’t you mean CASES??
Don't be purposfully obtuse just for the sake of stirring chit. You understand my point - that science has not caught up to the virus yet.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks again for the post!
Don’t you mean CASES??
Don't be purposfully obtuse just for the sake of stirring chit. You understand my point - that science has not caught up to the virus yet.
I’ll give you a directive also. Don’t promote panic.
Testing, testing, testing, we need to know who has it, who doesn't, and who has developed antibodies to C19. Right now we are flying blind, the more we know, the better decisions we can make going forward.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks again for the post!
Don’t you mean CASES??
Don't be purposfully obtuse just for the sake of stirring chit. You understand my point - that science has not caught up to the virus yet.
He's not being purposely obtuse, he's just genuinely stupid. That's easy to see from reading his posts. IQ roughly equivalent to that of a carrot.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks again for the post!
Don’t you mean CASES??
Don't be purposfully obtuse just for the sake of stirring chit. You understand my point - that science has not caught up to the virus yet.
He's not being purposely obtuse, he's just genuinely stupid. That's easy to see from reading his posts. IQ roughly equivalent to that of a carrot.
Thanks Doc for the well thought out post. In many conversations with my mother (Ph.d., Nurse Practioner) she has made many of the exact same level headed observations.
The truth is, the trend line of infections is still just about vertical. Until that slows down and science can catch up a bit, I feel we (or at least I) have an obligation to my fellow citizen and my country to ttake this seriously and act accordingly. I reached that decision not because of any fear mongering by the MSM like many here would suggest, but because I am capable of educating myself, open to talking to people in the medical field, and making my own decisions.
Thanks again for the post!
Don’t you mean CASES??
Don't be purposfully obtuse just for the sake of stirring chit. You understand my point - that science has not caught up to the virus yet.
He's not being purposely obtuse, he's just genuinely stupid. That's easy to see from reading his posts. IQ roughly equivalent to that of a carrot.
I can't understand why we're spending $2.5 trillion in stimulus and another $3 trillion in QE if we're going to reopen by Easter. That's ~2 weeks away and those funds are in addition to existing programs like unemployment insurance.
Until we know more, I'll just stay mostly hunkered down at home behind my cases of toilet paper with my AK 14 and hundred-round clips nearby waiting for Dopey Joe to save us.
Disagree on one point Doc, piss on funding the UN for anything. Also when do you believe the CDC can report the preliminary burden estimates for Covid-19 like they guesstimate for the commom flu ?
Flu estimates October 2019 thru March 2020 38 to 54 million flu illnesses 17 to 35 million flu medical visits 390,000 to 710,000 flu hospitalizations 23,000 to 59,000 flu deaths
In other words , when can we expect some perspective ?
First of all, I wish you well and healthy. My former (I’m retired) administrator did mention to me Iowa’s allowing retired and “expired” (within five years) health care providers could be pressed into service. I highly doubt it here in Iowa where we have some hundred + cases and “only” one death to date as of last Tuesday. My hospital is only doing emergent surgery now and postponing all elective cases. But, who knows; where are we on the curve of critically ill people?
My wife and I are of the “vulnerable class” and remain mostly home-bound. Not worried or frenzied at all, but going by guidelines as particular to our state to be responsible. Re-evaluation of all this will be given plenty of time later.
As to China, there’s a good article on American Thinker today as to the different communist factions who have used the virus to maneuver for position before ever even acknowledging the virus itself. China is never, ever to be trusted as is true of all Marxist-communists. Cue in the despicable progressives and DNC leadership, who again, showed their true colors in cobbling up the “rescue” bill. https://www.americanthinker.com/articles/2020/03/wake_up_america_emchinaem_is_the_pandemic.html
As to the economy, there is an interface somewhere between the efficiently sequestering everybody To minimize spread vs. the jump-starting of the economy again before serious failure occurs. Nobody, at this time knows where that point is. It’s clear Trump wants to get people back to work sooner rather than later.
The media? Mostly, without exception, a bunch of ignorant, deluded, deceptive incorrigibles. Which, along with their mother-arm, the DNC leadership and their progressives in this country remain far more insidious and dangerous than this virus will ever be.
expand our testing to a larger segment of the population
What would that entail? Testing everyone, or everyone who asks, or...? I have none of the symptoms listed on the CDC site nor does anyone in my household, and it is just us here. We go out and climb or hike or the like, mind good preventive practices when we do, etc. so we think we pretty good on the risk front.
Would it make any sense to test one or all of us?
And also: help me understand how that would help us be more predictive. If say 50% of infected become symptomatic, and we test 50% of people who report with symptoms, and 50% of those come back positive....isn’t that enough data to model how many ICU beds and such we will need? Or do the missing data have a large impact because the model is exponential?
As an old test (high tech) guy, you need data to make decisions. To get that we need testing. Test, Test, and Test again. We're not going to get a handle on this until we know who, where, and how many are infected or exposed (antibodies).
Thanks for taking the time for the research and for posting such a level headed post. You'll never get ahead with this type of info instead of fear hype. Again, thanks.
Good, solid info from the perspective of a front line, boots on the ground provider. Well done, Doc. We have some of the smartest minds in medicine really putting their shoulder into it and America's healthcare system is second to none. That puts me at ease.
There's a good chance that this thing comes around again in the fall. Southern hemisphere countries are just starting their winter and have + cases. Good evidence based science will hopefully have a handle on it by then.
Thank you, Doc! Best synopsis of where we are with this virus that I have read.
Wife and I are high risk, and have self isolated ourselves for more than 4 weeks now, pretty totally. Grandkids leave any fresh produce we need on the porch and I disinfect containers before opening, etc. I hunt, fish, do yard work and walks with wife in our mountains, or did till today when our governor shut down anything but walking with the herd on paved town trails.
I have wondered for weeks why we don't isolate at-risk folks like me and let everybody else carry on.
Tx doc. My wife is a rural family practice doc.... she started doing telemedicine for the first time yesterday.... there is concern that the office staff will just quit in mass after a few more days of them trying to explain to sick elderly people how to use Facebook (or whatever it is they are trying). Not having enough personal protective gear is criminal. Jayne took the clear flip down face shield I use when casing bullets into work so the staff have that between them and the patients they prescreen out in the parking lot....
Everyone is stressed but the people who are "not emotionally well" in everyday life are loosing it. Beware of little old ladies packing claw hammers in their purse who go postal when they don't get to see the doc they want too.
I know the Good Doctor has better things to do, I'd like to read his posts more often.
+1, He hit the nail on the head. Until we get widespread testing in place and get a handle on the numbers of people actually infected, we're driving blind.
Good read Doc, informative, reasoned and filled with common sense. All 3 of those traits are mostly absent in DC and the MSM. Simply put - we don't know what we don't know until we do know more about what we do know.
Hope to read more of your thoughts/experiences in the coming days and weeks. Don't be a stranger . . . although I do understand you are a tad bit busy in the ER.
Take care of your patients AND yourself and family . . .
Thank you, Doc Rocket, for taking the time and consideration to provide us with very valuable information. Best of health to you, your medical staff, and your wife.
Much appreciated Doc, and much anticipated. Getting info from the "source" that is.
Loved you numbered lists of items. Easy, even for the non-scientifically trained to absorb I hope.
First list comments:
1, 50 years of underfunding by Congress, the we taxpayers elect (in theory?) Until the American public accepts having to fund "public health" by paying taxes, that situation might not change. Perhaps this crisis will spark a change?
4. See 1. above. Funding, and in the case of education, perhaps a change in culture as to what is important, really important in education. A return perhaps to the three R's along with some more emphasis on STEM?
7. Absolutely right, it sells ad time on the nightly news. I wonder what the ratings have been recently for the alphabet networks, up a bit I'd hazard a guess. However, this crisis is also being capitalized on by the non-mainstream media in attempts to get folks to go along with their viewpoints..........both side of the issue that is.
Second list comments:
Doc, gee that whole list sounds a lot like.....science, that which so many do not understand due to # 4 in your first list, as you so rightly stated.
#5 on you second list is very interesting. I wonder if these same therapies that show promise might work on the "common cold". Seems in my readings here lately, some of the controversy on use of the chloroquines is the possible damage from side effects. Apparently, at least according to one knowledgeable source here, most of those harmful effects are from long term use, not really an issue for getting over a cold faster. Maybe those therapies might work on other viruses too, even though not very similar to the Coronas?
Excellent post Doc, and quite timely too, before this place goes full "retard".
As others have said, stay safe and keep us informed when you have a chance.
Thanks for the post . Just a few days ago I was thinking of you and the schooling that you gave here about getting or not getting the annual flu shots.
Many of us at that time did not think it was that important . You gave us your knowledge of the early 1900`s flu.. We did not understand may of the killed were young & healthy.
I appreciate your knowledge and hearing from you. Thanks
"This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively."
"This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively."
Published 28FEB. Much has changed since then.
And, given the lag time between research, writing, submitting, review, and final publication it's likely rather dated now.
First of all, I wish you well and healthy. My former (I’m retired) administrator did mention to me Iowa’s allowing retired and “expired” (within five years) health care providers could be pressed into service. I highly doubt it here in Iowa where we have some hundred + cases and “only” one death to date as of last Tuesday. My hospital is only doing emergent surgery now and postponing all elective cases. But, who knows; where are we on the curve of critically ill people?
My wife and I are of the “vulnerable class” and remain mostly home-bound. Not worried or frenzied at all, but going by guidelines as particular to our state to be responsible. Re-evaluation of all this will be given plenty of time later.
As to China, there’s a good article on American Thinker today as to the different communist factions who have used the virus to maneuver for position before ever even acknowledging the virus itself. China is never, ever to be trusted as is true of all Marxist-communists. Cue in the despicable progressives and DNC leadership, who again, showed their true colors in cobbling up the “rescue” bill. https://www.americanthinker.com/articles/2020/03/wake_up_america_emchinaem_is_the_pandemic.html
As to the economy, there is an interface somewhere between the efficiently sequestering everybody To minimize spread vs. the jump-starting of the economy again before serious failure occurs. Nobody, at this time knows where that point is. It’s clear Trump wants to get people back to work sooner rather than later.
The media? Mostly, without exception, a bunch of ignorant, deluded, deceptive incorrigibles. Which, along with their mother-arm, the DNC leadership and their progressives in this country remain far more insidious and dangerous than this virus will ever be.
Good points.
My prayer is that what is hidden will be revealed. There is an undertow of darkness trying to squeeze us into submission. Pure evil.
Great insight, DocRocket. Appreciate your taking the time to produce an excellent piece.
I enjoyed your Africa writing more... But this piece was timely, well done and well received.
Stay safe, use your PPE's, don't get careless. Ya can't get in a hurry, gotta follow the protocols, even when you're tired and pressed.
Mass testing is the answer, so we'd know the "denominator" before we start calculating percentages. As is, the RR, CFR and the Ro numbers are skewed because we don't have a good handle on the affected population. I liked the points you make about prevalence vs. incidence. So, until we get a better handle on the depth of the problem, we're just guessing.
I enjoyed the President scolding reporters following some very negative and loaded questions. MSM loves sensationalism as it promotes them, their power and importance. To heck with truth and balanced news. Agendas rule, unfortunately.
We ARE at war, not only with this virus but with forces than seek to conquer, dominate and control.
It is indeed a strange time, the likes of which we've never seen.
............ 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. ............
Thanks for posting Doc. Nice to hear from someone knowledgeable in the middle of it who considers a lot of good points.
Regarding the numbers you listed in the quote above, do you have a link that individuals can go to check these? Not fact checking...I'd like to watch the numbers day to day.
I just read a long post elsewhere that says they can test for corona, but cant differentiate c19 from others. Also the antibodies are oresent in a lot of us
Given the relative newness of C-19, I really can't imagine how anyone would really think much about it to be settled science.
But my son is a PA & his fiance is an MD at U-W hospital in Milwaukee, & their comments to us more or less follow what DR has said here.
Going to be a longer haul that most want to hear about to get enough of a treatment drug(s) to the masses & for sure a very long time frame for a possible vaccine & it will likely run its course, either way it turns out, by that time.
And the economic toll of the country will be staggering.................even if were to only be the $2 trillion bail out plan.
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.
DocRocket, Thanks so much for this thoughtful, informative write up.
A couple questions?
What, in your opinion, are the chances that it will be safe for high risk individuals, or their close family members, to go out in public by Easter?
We are all anxious to hear of a successful treatment regimen. Are we actually seeing positive results yet from such treatments beyond the initial reports we heard a week or so ago?
And thanks so much for the last two paragraphs. Especially the last. That is so important for the public to understand.
Thank you for your service on the front lines of this battle. I am sure the worst is yet to come for your location. Good luck, and stay safe.
"This suggests that the overall clinical consequences of Covid-19 may ultimately be more akin to those of a severe seasonal influenza (which has a case fatality rate of approximately 0.1%) or a pandemic influenza (similar to those in 1957 and 1968) rather than a disease similar to SARS or MERS, which have had case fatality rates of 9 to 10% and 36%, respectively."
Published 28FEB. Much has changed since then.
Actually everything he said is holding true. The death rate is much lower than what is being reported since not everyone is being tested.
At least, as settled as it can be, in an area where estimation is the prescribed course.
It's just being ignored.
The number of people contracting the flu is estimated every year, as it has been for 100 years.
And that's because the impact of each year's flu, as a social health issue, isn't important enough to warrant an all-out study.
Number of people contracting Colds? .gov doesn't even bother to estimate, because colds are even lower on the danger scale, than the flu.
Mortality statistics for colds and flu are well known, and accepted as part of life.
The Coronavirus genus has been around for 60 years, and its lethality, characteristics and propensities are well known.
And it's known to be a relatively mild strain of the cold virus.
This year, is like any other year, cold-virus wise.
But somehow, this election year, with President Trump in office, science, in the sense of the known history of the cold and flu season, is being ignored.
The course of this year's corona virus is the same, or less significant, than past years of corona virus.
These circumstances are well known, and being intentionally ignored, to generate hysteria.
Doc, I'll never forget the thread you made about getting the flu shot. Since then, I have gotten the shot every year after reading your ideas about the major threat a virus pandemic was to all of us and building a defensive library. As soon as this virus began making news I immediately thought of that thread and hoped you would speak on Covid-19.
If I could find that old thread I would bump it as it is especially worthy of a read now.
Thank you for the fantastic post Dr. It’s so important to get the right message out and to hear it from people we know and trust. This is especially vital when so many distrust the media and our scientific and political institutions.
Thank you for being on the front lines. I missed you (and the rest of the crew) in TX this year, but you have been in my thoughts. Please be safe and don’t hesitate to reach out, if there’s anything I can do.
Thank you for the fantastic post Dr. It’s so important to get the right message out and to hear it from people we know and trust. This is especially vital when so many distrust the media and our scientific and political institutions.
Thank you for being on the front lines. I missed you (and the rest of the crew) in TX this year, but you have been in my thoughts. Please be safe and don’t hesitate to reach out, if there’s anything I can do.
Thank you very much for posting this! I forwarded it to everybody I know. I'm not worried about myself (retired) or my kids and their spouses (working at home) but I am a little concerned about my 5 grand kids going back to school.
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.”
Thanks for taking the time to type it up, Doc. In this day and time we rarely know who to trust. Having shared a camp with you, I have no doubt in mind. Stay safe. CT
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."
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."
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.
"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.
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.
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?
"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.
"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."
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
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.
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".
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.
... 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.
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.
I haven’t seen any updates lately that I trust, but previous numbers showed fewer than 20% of COVID test-positive patients requiring hospital care, and about 2-4% requiring mechanical ventilation. Most of those on the vents survive. The 80% death rate on ventilators being reported by some hospitals is NOT representative as I understand.
Serological testing for antibodies to COVID-19 is being worked on. It should be coming on stream within a couple of months if not sooner. That will give us a better grasp of the prevalence and rate of asymotomatic vs minimally symptomatic infections.
Yes, immunity to other corona viruses confers some protective effect, but this hasn’t been measured yet. If that didn’t exist, the death rate would be much, much higher.
Doc what are the chances of getting Covid a second time if someone has already had it? If this has been asked and answered I apologize. I don’t personally know anyone who has had it but it has been a topic of conversation more than once.
Is there a way to find strains in the covid 19 family, or another corona virus to devolop a MLV if you will, to get immunity sooner without the lag time required with killed vaccine?
Hey Doc! Thank you for doing what you do. I am going to send prayers for you. Question: Do you have access to Facebook Group BAFERD? Do they have better medical insights on the nature of viral loads and high population communities?
May you find the "hands" of the Lord, helping you during this dangerous time.
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.
Thank you. After further reading it seems mostly geared towards salvage therapy. The one human trial (N=20) showed a 30% reduction in mortality, but it was given to pts. who were in severe distress with ARDs and not expected to live. Folks at MIT and UofCO are looking at it.
I haven’t seen any updates lately that I trust, but previous numbers showed fewer than 20% of COVID test-positive patients requiring hospital care, and about 2-4% requiring mechanical ventilation. Most of those on the vents survive. The 80% death rate on ventilators being reported by some hospitals is NOT representative as I understand.
Hope you don't mind Doc. Here's some info I printed a few weeks back, for you to see a study showing death rates on vents.
Re-posting here, to try to help save some lives:
Of the people who go onto a ventilator, under any medical condition, only 50% survive to come off it. Only 30% of the total that are put on survive a year. There was a study in the medical industry that created those statistics.
We reviewed a 5-year experience with mechanical ventilation in 383 men with acute respiratory failure and studied the impact of patient age, cause of acute respiratory failure, and duration of mechanical ventilation on survival. Survival rates were 66.6 percent to weaning, 61.1 percent to ICU discharge, 49.6 percent to hospital discharge, and 30.1 percent to 1 year after hospital discharge.
With the Covid-19, and it being a virus that “directly” attacks the lungs, that 50% that come off it above, could fall quite a bit. It could be extremely low, and they aren’t reporting those numbers. Wonder why.
Bottom line, if your lung capacity is low from the start, before you even get the virus, you’re in a bad situation right off the bat, because the virus will diminish your lung capacity by about 5 MET, so you’ll need an extra tank of gas (additional lung capacity above 5 MET) to be able to breath and supply oxygen to your body.
A normal person with zero health issues: No smoking, no COPD, diabetes, no severe over weight, etc. consumes the following MET:
1 - MET – sitting 2/3 - MET walking around, working 8 – MET working out on a stair stepper, fast walk sustained 30 minutes, or casual jog 10-12 min./mile for 2.5 – 3 miles.
So you see, if you start with 8 MET and the virus robs you of 5 MET, you’ll have 3 MET reserve capacity left to just lay in bed, and breath or get up and walk to eat, etc.
That is why it is critical for people to start doing a cardio work-out, however they can RIGHT NOW, to build up their lung capacity, so they’ll have a chance to fight it. It takes about 2 months normally, some faster. Just depends where you’re starting from capacity wise.
You can see, if you start off with a diminished capacity, you’re cooked right off the bat. A ventilator can not make up that capacity.
Even if the elderly have leg joint issues, et al., they can give their lungs a workout just doing deep breathing, slow so they don’t hyperventilate, for an extended period, to build up.
The reason it isn’t killing kids, is the fact they have good lungs: run around all day. As people get older, they stop staying in shape (low lung capacity), thus the death rate climbs as the age goes up.
It’s a bad deal all around with the way it attacks the lungs.
** I wrote the above back on March 19, 2020 to help you guys in another thread.
Re-posting here to help who I can, to encourage you to get your lung capacity up, if you are not in shape.
"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..."
So please don't give this bull s h i t story any credence whatsoever.
Thanks for the info. Do you know of any website that has debunked that story? The reason I ask is my wife sent me the story from her work. She is the JAG for a ANG wing and asked me what I thought as it had been circulated by the med staff to read. As a clinical hospital pharmacist I saw enough things that matched info on up-to-date but also had numbers I could not find or verify anywhere, like ventilator mortality rates. I'll pass on what you said. Best I can tell this is where the original story came from on 3/25: https://texags.com/forums/84/topics/3102444/1 This is the disclaimer he has now added:
Quote
My first expanded lost draft (thanks again MacBook Touch Bar) contained the appropriate hedging, disclaimers, and uncertainty the current understanding of this pandemic deserves. Some of the more concise, unproofread, hastily rewritten original post (OP) presents itself as more definitive instead of "what I think I know". For this, my apologies. I am not performing clinical trials. I am not involved in cohorting and analyzing data. The academic physicians involved in ER, Infectious Disease and Pulmonary Critical Care are likely (hopefully) way beyond my understanding of Covid 19. Furthermore, I fail to appreciate any additional benefit I could provide to Hospital Administrators who have been preparing and communicating with each other for months; or for some already combating this daily.
I'm currently fighting with the powers that be at my hospital just to have a safe place to work. Our ICU is designed to be negative pressure, but does not have an anteroom or any passthrough to get meds/labs/etc. in and out other than be exposed to the ICU air. They built a false wall 10 feet inside the door and put a large door in it, and called that an ante room. Of course both doors can be opened at the same time and the design allows that room air to mix with the ICU air the instant it's open, etc. I've pointed out the only safe way to use it is to be in full PPE before entering, but they put the PPE inside the room. Sometime it feels that getting it as a health care worker is inevitable.
On the plus side, we have a ton of Plaquenil and Zithromax to throw at everyone in hope it helps somebody, while we barely have enough propofol, levophed, versed, etc.
I haven’t seen any updates lately that I trust, but previous numbers showed fewer than 20% of COVID test-positive patients requiring hospital care, and about 2-4% requiring mechanical ventilation. Most of those on the vents survive. The 80% death rate on ventilators being reported by some hospitals is NOT representative as I understand.
Hope you don't mind Doc. Here's some info I printed a few weeks back, for you to see a study showing death rates on vents.
Re-posting here, to try to help save some lives:
Of the people who go onto a ventilator, under any medical condition, only 50% survive to come off it. Only 30% of the total that are put on survive a year. There was a study in the medical industry that created those statistics.
We reviewed a 5-year experience with mechanical ventilation in 383 men with acute respiratory failure and studied the impact of patient age, cause of acute respiratory failure, and duration of mechanical ventilation on survival. Survival rates were 66.6 percent to weaning, 61.1 percent to ICU discharge, 49.6 percent to hospital discharge, and 30.1 percent to 1 year after hospital discharge.
With the Covid-19, and it being a virus that “directly” attacks the lungs, that 50% that come off it above, could fall quite a bit. It could be extremely low, and they aren’t reporting those numbers. Wonder why.
Bottom line, if your lung capacity is low from the start, before you even get the virus, you’re in a bad situation right off the bat, because the virus will diminish your lung capacity by about 5 MET, so you’ll need an extra tank of gas (additional lung capacity above 5 MET) to be able to breath and supply oxygen to your body.
A normal person with zero health issues: No smoking, no COPD, diabetes, no severe over weight, etc. consumes the following MET:
1 - MET – sitting 2/3 - MET walking around, working 8 – MET working out on a stair stepper, fast walk sustained 30 minutes, or casual jog 10-12 min./mile for 2.5 – 3 miles.
So you see, if you start with 8 MET and the virus robs you of 5 MET, you’ll have 3 MET reserve capacity left to just lay in bed, and breath or get up and walk to eat, etc.
That is why it is critical for people to start doing a cardio work-out, however they can RIGHT NOW, to build up their lung capacity, so they’ll have a chance to fight it. It takes about 2 months normally, some faster. Just depends where you’re starting from capacity wise.
You can see, if you start off with a diminished capacity, you’re cooked right off the bat. A ventilator can not make up that capacity.
Even if the elderly have leg joint issues, et al., they can give their lungs a workout just doing deep breathing, slow so they don’t hyperventilate, for an extended period, to build up.
The reason it isn’t killing kids, is the fact they have good lungs: run around all day. As people get older, they stop staying in shape (low lung capacity), thus the death rate climbs as the age goes up.
It’s a bad deal all around with the way it attacks the lungs.
** I wrote the above back on March 19, 2020 to help you guys in another thread.
Re-posting here to help who I can, to encourage you to get your lung capacity up, if you are not in shape.
New Zealand is in TOTAL lock down to try to eliminate the virus. The USA looks like it is in big trouble. Any comments DocRocket (and this is not a nasty question, it's just a question as to what the US situation looks from your point of view). Thanks.
I believe there may have been cases in the US a few months earlier than the virus was reported in China. The week before Thanksgiving I was deer hunting in KY, my guide had a really bad cough and upper respiratory infection that was kicking his azz. Before departing for my trip my wife had a moderately severe cough too, she did her best to socially distance herself from me so I wouldn't come down with a cough. About a week after returning from KY you guessed it I came down with a nasty cough that took longer to get rid of that usual. These examples lead me to believe that the virus was present in a weaker form prior to being recognized for being what it was.
I believe there may have been cases in the US a few months earlier than the virus was reported in China. The week before Thanksgiving I was deer hunting in KY, my guide had a really bad cough and upper respiratory infection that was kicking his azz. Before departing for my trip my wife had a moderately severe cough too, she did her best to socially distance herself from me so I wouldn't come down with a cough. About a week after returning from KY you guessed it I came down with a nasty cough that took longer to get rid of that usual. These examples lead me to believe that the virus was present in a weaker form prior to being recognized for being what it was.
It seems everywhere I look I see people wanting to be one of the first to have this virus. I guess we should all be thankful all those people who had corona Nov through Jan here in the US stayed out of the hospitals and didn't need any care other than fluids and rest. Who knows, maybe it was here for months and only affected younger, healthy people until it kicked things up a notch in Feb.
I believe there may have been cases in the US a few months earlier than the virus was reported in China. The week before Thanksgiving I was deer hunting in KY, my guide had a really bad cough and upper respiratory infection that was kicking his azz. Before departing for my trip my wife had a moderately severe cough too, she did her best to socially distance herself from me so I wouldn't come down with a cough. About a week after returning from KY you guessed it I came down with a nasty cough that took longer to get rid of that usual. These examples lead me to believe that the virus was present in a weaker form prior to being recognized for being what it was.
It seems everywhere I look I see people wanting to be one of the first to have this virus. I guess we should all be thankful all those people who had corona Nov through Jan here in the US stayed out of the hospitals and didn't need any care other than fluids and rest. Who knows, maybe it was here for months and only affected younger, healthy people until it kicked things up a notch in Feb.
I believe there may have been cases in the US a few months earlier than the virus was reported in China. The week before Thanksgiving I was deer hunting in KY, my guide had a really bad cough and upper respiratory infection that was kicking his azz. Before departing for my trip my wife had a moderately severe cough too, she did her best to socially distance herself from me so I wouldn't come down with a cough. About a week after returning from KY you guessed it I came down with a nasty cough that took longer to get rid of that usual. These examples lead me to believe that the virus was present in a weaker form prior to being recognized for being what it was.
It seems everywhere I look I see people wanting to be one of the first to have this virus. I guess we should all be thankful all those people who had corona Nov through Jan here in the US stayed out of the hospitals and didn't need any care other than fluids and rest. Who knows, maybe it was here for months and only affected younger, healthy people until it kicked things up a notch in Feb.
