OtherGround Forums OG doc. AMA on COVID-19

3/27/20 4:20 AM
12/9/13
Posts: 27491
turducken -

When people are on a ventilator, how do they eat?  Are patients in critical condition being fed with a peg tube?

IV

3/27/20 5:23 AM
2/10/20
Posts: 704
thebehemoth73 -
Piyo -

Somebody, please make a case to me that these shelter-in-place orders aren’t ridiculous and excessive.

Here’s what experts have told us:

1) The issue is exponential growth. 
2) Everyone will get it eventually 
3) The R-0 when taking no measures at all is about 2.5.

So, this means an R-0 of 1.0 is not an issue. It won’t overwhelm the system, and the final result will be the same anyway.

Hence, assuming *no* other measures (like extra hand washing, isolation in face of symptoms, masks, etc) if the average person cuts their personal interactions by 60%, we’re in the clear. Anything beyond that is useless economic damage. SIP orders are *clearly* causing a much, much greater reduction than that. Therefore, these orders are ridiculous and extremely harmful. 

How am I wrong?

You are not looking at exponential growth of the virus. If we lift shelter in place the numbers will absolutely get out of hand and overwhelm the hospitals like they already have. Some patients take LONGER to recover then others, some die. Taking shelter in place out right now would be an absolute disaster. I cannot believe ppl think the magic number for all this to go back to normal is 2 weeks or mid April or even at the end of April. This COULD last well into August or September or even the holidays. 

Thier God Emperor said Easter, so the sheep must comply and think the same...

3/27/20 7:05 AM
10/16/10
Posts: 29947
thebehemoth73 - 
Piyo -

Somebody, please make a case to me that these shelter-in-place orders aren’t ridiculous and excessive.

Here’s what experts have told us:

1) The issue is exponential growth. 
2) Everyone will get it eventually 
3) The R-0 when taking no measures at all is about 2.5.

So, this means an R-0 of 1.0 is not an issue. It won’t overwhelm the system, and the final result will be the same anyway.

Hence, assuming *no* other measures (like extra hand washing, isolation in face of symptoms, masks, etc) if the average person cuts their personal interactions by 60%, we’re in the clear. Anything beyond that is useless economic damage. SIP orders are *clearly* causing a much, much greater reduction than that. Therefore, these orders are ridiculous and extremely harmful. 

How am I wrong?

You are not looking at exponential growth of the virus. If we lift shelter in place the numbers will absolutely get out of hand and overwhelm the hospitals like they already have. Some patients take LONGER to recover then others, some die. Taking shelter in place out right now would be an absolute disaster. I cannot believe ppl think the magic number for all this to go back to normal is 2 weeks or mid April or even at the end of April. This COULD last well into August or September or even the holidays. 


Just in the last two days, three people I know have been laid off.

I understand that we're dealing with a lot of unknowns and current safety measures are based on the best information available but there is real and potentially long term damage being done to the global economy just as the largest cohort is nearing retirement age.

The boomer generation does not have time to recover from a deep and prolonged recession or depression, and their financial health is paramount to maintaining social safety nets and our general standard of living. We need to tread very lightly here and only take action that is absolutely necessary.
3/27/20 7:16 AM
2/23/12
Posts: 14899

My brother and his wife (a nurse working on a covid ward) are both working through this and have different schedules that makes it difficult for them to look after their dog during the day. Would it be a bad idea for me to take the dog during the day and pass him between houses? I haven’t offered to do it yet 

3/27/20 7:24 AM
10/23/05
Posts: 3109
used2wrestle - 

Hey doc,

I'm still having chest pains, pain in my left shoulder and arm. Been about a month now and getting worse. Not worried that it's CV but was wondering how I should get looked. Is a telemedcine appointment with a doctor a good start or should I book an appointment at a clinic? Basically, I'm thinking with my symptoms they might just tell me to go to the ER and I don't want to expose myself unnecessarily to a doctor's office.

Thanks in advance


Hey man.

I again think this is potentially serious. It might be many things but that includes angina or pulmonary emboli.

You need a proper physical examination, some lab tests and an EKG (at the very least). You need to go to the ER. The risks of you not going exceed those of going.

3/27/20 7:26 AM
10/23/05
Posts: 3110
turducken - 

When people are on a ventilator, how do they eat?  Are patients in critical condition being fed with a peg tube?


They put in a tube that goes from your mouth/nose to your stomach through which they put in some type of feeding (like Ensure).

If that doesn't work (rare) they'll feed you through an IV

3/27/20 7:29 AM
10/23/05
Posts: 3111
Jored1990 - 

My brother and his wife (a nurse working on a covid ward) are both working through this and have different schedules that makes it difficult for them to look after their dog during the day. Would it be a bad idea for me to take the dog during the day and pass him between houses? I haven’t offered to do it yet 


I don't think dogs are vectors but they certainly can carry a shitload of droplets. I'm sure your brother's wife respects protocol but I wouldn't take the risk here.

3/27/20 8:27 AM
2/23/12
Posts: 14900
mataleo1 -
Jored1990 - 

My brother and his wife (a nurse working on a covid ward) are both working through this and have different schedules that makes it difficult for them to look after their dog during the day. Would it be a bad idea for me to take the dog during the day and pass him between houses? I haven’t offered to do it yet 


I don't think dogs are vectors but they certainly can carry a shitload of droplets. I'm sure your brother's wife respects protocol but I wouldn't take the risk here.

It’s what I thought. Thanks 

3/27/20 9:28 AM
10/23/05
Posts: 3113
Eskimo - 
If it ain't Dutch, it ain't much -
SC MMA MD -
NoNeed4aScreenName -

Dude is not verified so take it for what it's worth.

 

Likely pretty accurate for areas not swamped with COVID patients. Hospitals have stopped non-emergent procedures due to lack of PPE and lots of patients are rescheduling non-urgent outpatient visits to avoid going to medical centers and possibly being exposed. It is eerie how quiet the hospitals and clinics in my area are now

My friend in vegas works at a hospital and was telling me how they normally have 70 or so patients in there and now they got 10 if that. They are setting up for the rush of patients but are going to get very low very fast on protective equipment and said he wont work once they run out. I wonder once that starts happening and the odds of a Dr/Nurse/EMT increases drasticallyl of getting sick themselves, how many stop coming into work? Any ideas, just asking as IDK the mentality of people in those fields since I don't work in them.

Statistics on this are usually around 30% when workers are anonymously polled. I imagine it will be much higher.


Where I work, essential health care workers have been issued strict guidelines:

-No vacation days until further notice
-As doctors, we need to put 2 backups for every clinical on-call resource (so if we are 2 on-call, there needs to be 4 back ups)
-No one can retire until further notice
-People can call in sick but this needs to be either backed with a medical note or from quarantine (and then testing is needed)

They just forced a pregnant pharmacist to stay at work.

3/27/20 9:37 AM
7/15/02
Posts: 11785
thebehemoth73 -
Piyo -

Somebody, please make a case to me that these shelter-in-place orders aren’t ridiculous and excessive.

Here’s what experts have told us:

1) The issue is exponential growth. 
2) Everyone will get it eventually 
3) The R-0 when taking no measures at all is about 2.5.

So, this means an R-0 of 1.0 is not an issue. It won’t overwhelm the system, and the final result will be the same anyway.

Hence, assuming *no* other measures (like extra hand washing, isolation in face of symptoms, masks, etc) if the average person cuts their personal interactions by 60%, we’re in the clear. Anything beyond that is useless economic damage. SIP orders are *clearly* causing a much, much greater reduction than that. Therefore, these orders are ridiculous and extremely harmful. 

How am I wrong?

You are not looking at exponential growth of the virus. If we lift shelter in place the numbers will absolutely get out of hand and overwhelm the hospitals like they already have. Some patients take LONGER to recover then others, some die. Taking shelter in place out right now would be an absolute disaster. I cannot believe ppl think the magic number for all this to go back to normal is 2 weeks or mid April or even at the end of April. This COULD last well into August or September or even the holidays. 

I don’t know what this means. I’m not “looking at exponential growth”? My whole post involves exponential growth.

3/27/20 9:51 AM
11/10/18
Posts: 6742
thebehemoth73 -
Piyo -

Somebody, please make a case to me that these shelter-in-place orders aren’t ridiculous and excessive.

Here’s what experts have told us:

1) The issue is exponential growth. 
2) Everyone will get it eventually 
3) The R-0 when taking no measures at all is about 2.5.

So, this means an R-0 of 1.0 is not an issue. It won’t overwhelm the system, and the final result will be the same anyway.

Hence, assuming *no* other measures (like extra hand washing, isolation in face of symptoms, masks, etc) if the average person cuts their personal interactions by 60%, we’re in the clear. Anything beyond that is useless economic damage. SIP orders are *clearly* causing a much, much greater reduction than that. Therefore, these orders are ridiculous and extremely harmful. 

How am I wrong?

You are not looking at exponential growth of the virus. If we lift shelter in place the numbers will absolutely get out of hand and overwhelm the hospitals like they already have. Some patients take LONGER to recover then others, some die. Taking shelter in place out right now would be an absolute disaster. I cannot believe ppl think the magic number for all this to go back to normal is 2 weeks or mid April or even at the end of April. This COULD last well into August or September or even the holidays. 

Lol I can’t believe people think there will even be a country if we don’t start working in May or June. This has been a real wake up call for me about how economically stupid the average person really is.

3/27/20 9:57 AM
8/11/12
Posts: 10740
mataleo1 -
Eskimo - 
If it ain't Dutch, it ain't much -
SC MMA MD -
NoNeed4aScreenName -

Dude is not verified so take it for what it's worth.

 

Likely pretty accurate for areas not swamped with COVID patients. Hospitals have stopped non-emergent procedures due to lack of PPE and lots of patients are rescheduling non-urgent outpatient visits to avoid going to medical centers and possibly being exposed. It is eerie how quiet the hospitals and clinics in my area are now

My friend in vegas works at a hospital and was telling me how they normally have 70 or so patients in there and now they got 10 if that. They are setting up for the rush of patients but are going to get very low very fast on protective equipment and said he wont work once they run out. I wonder once that starts happening and the odds of a Dr/Nurse/EMT increases drasticallyl of getting sick themselves, how many stop coming into work? Any ideas, just asking as IDK the mentality of people in those fields since I don't work in them.

Statistics on this are usually around 30% when workers are anonymously polled. I imagine it will be much higher.


Where I work, essential health care workers have been issued strict guidelines:

-No vacation days until further notice
-As doctors, we need to put 2 backups for every clinical on-call resource (so if we are 2 on-call, there needs to be 4 back ups)
-No one can retire until further notice
-People can call in sick but this needs to be either backed with a medical note or from quarantine (and then testing is needed)

They just forced a pregnant pharmacist to stay at work.

Wow man holy shit. What is your opinion on the entire situation now? Do you think the quarantine lasts more than two weeks from now? More than a month? 

3/27/20 10:07 AM
11/10/18
Posts: 6743
mataleo1 -
Eskimo - 
If it ain't Dutch, it ain't much -
SC MMA MD -
NoNeed4aScreenName -

Dude is not verified so take it for what it's worth.

 

Likely pretty accurate for areas not swamped with COVID patients. Hospitals have stopped non-emergent procedures due to lack of PPE and lots of patients are rescheduling non-urgent outpatient visits to avoid going to medical centers and possibly being exposed. It is eerie how quiet the hospitals and clinics in my area are now

My friend in vegas works at a hospital and was telling me how they normally have 70 or so patients in there and now they got 10 if that. They are setting up for the rush of patients but are going to get very low very fast on protective equipment and said he wont work once they run out. I wonder once that starts happening and the odds of a Dr/Nurse/EMT increases drasticallyl of getting sick themselves, how many stop coming into work? Any ideas, just asking as IDK the mentality of people in those fields since I don't work in them.

Statistics on this are usually around 30% when workers are anonymously polled. I imagine it will be much higher.


Where I work, essential health care workers have been issued strict guidelines:

-No vacation days until further notice
-As doctors, we need to put 2 backups for every clinical on-call resource (so if we are 2 on-call, there needs to be 4 back ups)
-No one can retire until further notice
-People can call in sick but this needs to be either backed with a medical note or from quarantine (and then testing is needed)

They just forced a pregnant pharmacist to stay at work.

In another 4-6 when the entire economy has crashed and burned and civil unrest starts, people won’t care about their jobs or those patients. It’s obvious that most on here can’t see the forest for the trees. Nobody wants granny to die or the hospital overwhelmed. But they just shutdown the largest Toyota plant in the country through the end of April. The government will own every big business in the country and every small business will close. We’re gonna have 30% or higher unemployment after this. You guys advocating for shutting everything down to save a million old people now have no idea what’s coming. It’s sad and I feel sorry for all of us. You guys really think civil unrest is some impossibility. Society is super fragile and we’re about to experience that firsthand. 

3/27/20 10:10 AM
2/4/09
Posts: 10694
Caladan -
NoNeed4aScreenName -
mataleo1 -
The Stewed Owl - 

mataleo1, I'd be interested in hearing your opinion on the new "Oxford model" if you have time to read it. Seems like either very good news or very very bad news if wrong. 

The latest study is surprisingly encouraging


Yes I had read that. I actually have friends (in Oxford!) who do AI-based epidemiological models. Their conclusions: according to their model, this could turn out to weather the storm quicker than those proposing very stringent isolation. HOWEVER, considering the unknowns there are small chances that this will produce VERY bad results.

Something like (that's how they voiced it):
Oxford: 96% good outcome, 2% bad outcome, 2% catastrophic
Confinement: 95% good outcome, 4% bad outcome, 1% catastrophic

Their conclusions: bad idea. The risks of a catastrophic outcome do not compensate for a significant potential for a quicker recovery

So he mentioned an imperial study. Looks like that imperial study has also been revised?

 

No it wasn't. Thread here:

 

Sounds like people might want to see his work now

 

Edited: 3/27/20 10:46 AM
2/4/09
Posts: 10695
Caladan -
NoNeed4aScreenName -
mataleo1 -
The Stewed Owl - 

mataleo1, I'd be interested in hearing your opinion on the new "Oxford model" if you have time to read it. Seems like either very good news or very very bad news if wrong. 

The latest study is surprisingly encouraging


Yes I had read that. I actually have friends (in Oxford!) who do AI-based epidemiological models. Their conclusions: according to their model, this could turn out to weather the storm quicker than those proposing very stringent isolation. HOWEVER, considering the unknowns there are small chances that this will produce VERY bad results.

Something like (that's how they voiced it):
Oxford: 96% good outcome, 2% bad outcome, 2% catastrophic
Confinement: 95% good outcome, 4% bad outcome, 1% catastrophic

Their conclusions: bad idea. The risks of a catastrophic outcome do not compensate for a significant potential for a quicker recovery
 

So he mentioned an imperial study. Looks like that imperial study has also been revised?

 

No it wasn't. Thread here:

 

One more thing. Politics has made me become aware of very carefully worded statements. 

 

Is he saying that his mortality of symptomatic patients remains the same? 

 

Because that does drastically changed if a very high percentage of people have already got the virus and remained asymptomatic. 

 

Is what I am saying makes sense?

 

I have yet to see his new report. Heres a link to the PDF of the first before he got corona virus

 

https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf

 

Heres my prediction. Not one of these predicted simulation models will be right. 

 

Not one of these predictions will have taken the right factors under consideration to make their simulations correct.

 

Edited to add link to new report

 

https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-Global-Impact-26-03-2020.pdf

3/27/20 10:31 AM
3/9/13
Posts: 4437
NoNeed4aScreenName -
Caladan -
NoNeed4aScreenName -
mataleo1 -
The Stewed Owl - 

mataleo1, I'd be interested in hearing your opinion on the new "Oxford model" if you have time to read it. Seems like either very good news or very very bad news if wrong. 

The latest study is surprisingly encouraging


Yes I had read that. I actually have friends (in Oxford!) who do AI-based epidemiological models. Their conclusions: according to their model, this could turn out to weather the storm quicker than those proposing very stringent isolation. HOWEVER, considering the unknowns there are small chances that this will produce VERY bad results.

Something like (that's how they voiced it):
Oxford: 96% good outcome, 2% bad outcome, 2% catastrophic
Confinement: 95% good outcome, 4% bad outcome, 1% catastrophic

Their conclusions: bad idea. The risks of a catastrophic outcome do not compensate for a significant potential for a quicker recovery
 

So he mentioned an imperial study. Looks like that imperial study has also been revised?

 

No it wasn't. Thread here:

 

One more thing. Politics has made me become aware of very carefully worded statements. 

 

Is he saying that his mortality of symptomatic patients remains the same? 

 

Because that does drastically changed if a very high percentage of people have already got the virus and remained asymptomatic. 

 

Is what I am saying makes sense?

 

I have yet to see his new report. Heres a link to the PDF of the first before he got corona virus

 

https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf

 

Heres my prediction. Not one of these predicted simulation models will be right. 

 

Not one of these predictions will have taken the right factors under consideration to make their simulations correct.

Of course not.

3/27/20 10:36 AM
2/4/09
Posts: 10696
If it ain't Dutch, it ain't much -
SC MMA MD -
NoNeed4aScreenName -

Dude is not verified so take it for what it's worth.

 

Likely pretty accurate for areas not swamped with COVID patients. Hospitals have stopped non-emergent procedures due to lack of PPE and lots of patients are rescheduling non-urgent outpatient visits to avoid going to medical centers and possibly being exposed. It is eerie how quiet the hospitals and clinics in my area are now

My friend in vegas works at a hospital and was telling me how they normally have 70 or so patients in there and now they got 10 if that. They are setting up for the rush of patients but are going to get very low very fast on protective equipment and said he wont work once they run out. I wonder once that starts happening and the odds of a Dr/Nurse/EMT increases drasticallyl of getting sick themselves, how many stop coming into work? Any ideas, just asking as IDK the mentality of people in those fields since I don't work in them.

Yeah we have  been waiting on a rush as well. It's already been called a state of emergency in the city but theres not much action going on yet. 

 

I'm surprised at the delay it took for some of the test results internally though. Hopefully it picks up pace

Edited: 3/27/20 10:42 AM
2/4/09
Posts: 10697
OxymoronicalAmbiguity -
NoNeed4aScreenName -
The Stewed Owl -
SC MMA MD - 
NoNeed4aScreenName -

Dude is not verified so take it for what it's worth.

 

Likely pretty accurate for areas not swamped with COVID patients. Hospitals have stopped non-emergent procedures due to lack of PPE and lots of patients are rescheduling non-urgent outpatient visits to avoid going to medical centers and possibly being exposed. It is eerie how quiet the hospitals and clinics in my area are now

 

Fewer people on the road and in the workplace may = fewer accidents, too. Also less non-COVID-19 communicable diseases being passed.

 

 

By cancelling elective surgeries we cut anywhere from 50-75 new admissions for the week already. 

 

I'm going to assume we also cancelled the day surgeries as well. 

 

The no visitor policy only further makes the hospital feel especially empty

I read that the hospitals in the Santa Barbara area (Sansum) are looking at lay offs because they have lost so much money due to the cancellation of elective procedures and people who are afraid to go to the hospital. Do you think this is likely a bluff to get more funding? It seems like lay off's right before this gets worse would be horrible. 

I dont think it's a bluff. I think everyone expects a very bad outcome due to the virus. Our hospital has the same measures in place. 

 

I think we might have been able to redirect resources from areas that, I think, based on median age and existing conditions we can predict the best prepared areas and redirect their resources to the most at risk demographics. 

 

That's just my opinion though.

3/27/20 11:14 AM
2/4/09
Posts: 10698
NoNeed4aScreenName -
OxymoronicalAmbiguity -
NoNeed4aScreenName -
The Stewed Owl -
SC MMA MD - 
NoNeed4aScreenName -

Dude is not verified so take it for what it's worth.

 

Likely pretty accurate for areas not swamped with COVID patients. Hospitals have stopped non-emergent procedures due to lack of PPE and lots of patients are rescheduling non-urgent outpatient visits to avoid going to medical centers and possibly being exposed. It is eerie how quiet the hospitals and clinics in my area are now

 

Fewer people on the road and in the workplace may = fewer accidents, too. Also less non-COVID-19 communicable diseases being passed.

 

 

By cancelling elective surgeries we cut anywhere from 50-75 new admissions for the week already. 

 

I'm going to assume we also cancelled the day surgeries as well. 

 

The no visitor policy only further makes the hospital feel especially empty

I read that the hospitals in the Santa Barbara area (Sansum) are looking at lay offs because they have lost so much money due to the cancellation of elective procedures and people who are afraid to go to the hospital. Do you think this is likely a bluff to get more funding? It seems like lay off's right before this gets worse would be horrible. 

I dont think it's a bluff. I think everyone expects a very bad outcome due to the virus. Our hospital has the same measures in place. 

 

I think we might have been able to redirect resources from areas that, I think, based on median age and existing conditions we can predict the best prepared areas and redirect their resources to the most at risk demographics. 

 

That's just my opinion though.

To visually show growth in other us states vs New York

 

3/27/20 11:34 AM
2/4/09
Posts: 10699

On the flip side. Heres an article from the san Fran Chronicle which makes claim of the possible aggressive sheltering being the case. 

 

https://www.google.com/amp/s/www.sfchronicle.com/health/amp/NY-has-10-times-the-coronavirus-cases-CA-has-Why-15154692.php

 

 

Personally, I think theres more then just the sheltering at play. 

 

Is this correct that outside New York the most densely packed city is maywood california?

3/27/20 11:41 AM
8/26/10
Posts: 1140

I suspect a lot of it is also how many people are tested.

 

In Sweden, they are reporting relatively few cases for the number of deaths.  They are not encouraging social distancing yet their curve looks very different from all other countries.  Seems odd.

3/27/20 11:43 AM
1/1/01
Posts: 18638
New Orleans (my hometown) is getting it bad now.

This was posted by a colleague of mine who said it was from an ER doc down there. To Mataleo and others, does this seem legit?

"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."
3/27/20 11:50 AM
1/13/04
Posts: 14718
NoNeed4aScreenName - 

On the flip side. Heres an article from the san Fran Chronicle which makes claim of the possible aggressive sheltering being the case. 

 

https://www.google.com/amp/s/www.sfchronicle.com/health/amp/NY-has-10-times-the-coronavirus-cases-CA-has-Why-15154692.php

 

 

Personally, I think theres more then just the sheltering at play. 

 

Is this correct that outside New York the most densely packed city is maywood california?


I personally think its the sheltering and the weather. People in warmer weather area's typically are not as close to other's thus slowing the spread..
3/27/20 11:55 AM
10/23/05
Posts: 3114
None So Blind - New Orleans (my hometown) is getting it bad now.

This was posted by a colleague of mine who said it was from an ER doc down there. To Mataleo and others, does this seem legit?

"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."

Good post. Pretty much sums up what was said on this thread.

Keep safe people

3/27/20 11:59 AM
4/11/14
Posts: 9685
mataleo1 -
turducken - 

When people are on a ventilator, how do they eat?  Are patients in critical condition being fed with a peg tube?


They put in a tube that goes from your mouth/nose to your stomach through which they put in some type of feeding (like Ensure).

If that doesn't work (rare) they'll feed you through an IV

Btw, the “food” they give you is the lowest quality trash imaginable. Corn syrup and soybean oil slurry made by Nestle....amazing anybody recovers.