OtherGround Forums OG doc. AMA on COVID-19

Edited: 3/27/20 8:49 PM
2/27/11
Posts: 11223

Lombardy and New York have very similar climate, either in temperature and humidity, any possible link to the high number of infected?

Both are also densely populated which of course does increase the spread but so are other cities that appear to be less hit.

Anyway just wanted to reiterate something other people already said: the naked number of infected doesnt say much unless we know how many tests have been performed and under which conditions.

Initially in Italy they tested this single guy who had covid symptoms AND had contact with a person recently returned from China (which later resulted negative and was excluded to be patient zero), then they tested all his contacts, either symptomatics or not.

When the number increased and had to deal with too many contacts, they started to only test people with symptoms, then in the last weeks they could only test people with multiple symptoms, now they increased the testing potentials and started testing single symptoms  people again.

If you check this site

https://lab24.ilsole24ore.com/coronavirus/en/

And go down to

New daily tests and confirmed cases

You see how the black line which represents the % of infected found by tests is decreasing which i think is a good sign.

Last thing, if you exclude Lombardy, Italy appears like one of the less hit nations.

 

 

 

3/27/20 9:25 PM
6/30/07
Posts: 60333
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."

Interesting, thanks for posting

3/27/20 10:54 PM
12/1/12
Posts: 2395
jcblass -
mataleo1 - 
clattymine - 

Mataleo1- how far away do you think the US is from peak infections and hospital overload? 

Just your best guess .... 

great thread dude. 


I'm starting to change my views on that. I had expected 6-10 weeks, but considering it's full-blown in NY and still in infancy in many states, It might take longer than expected, as other states slowly get cases.

It really depends on how successful we are at locking down NY (and problem counties) and how warmer months might influence transmission.


Couldn't you also conclude that if it's full-blown in NYC, and not in other states, those states are probably on the downside. After two weeks inside and heavily reduced physical contact among the population, surely the virus would show up by now.

I can't imagine people getting sick in large number 4 weeks after quarantine...

The flare up we are seeing now is a byproduct of the week or two before restrictions. If you are dealing with 90 deaths in California, 2 months into this, and 3 weeks into quarantine, the chances of a massive outbreak should be reduced because the number of places you can contract and spread it has also been greatly reduced. No one is in school, airports, gyms, restaurants, etc. So if you are not sick now, and the incubation period is 5-10 days, I don't see a massive and dramatic increase 4 weeks into quarantine.

Maybe you should look online at photos of the wuhan quarantine and NYC quarantine...Or any grocery store phone. Or look at the list of what is considered an essential service. Even the Poui poui thread was showing pictures of completely empty streets and that was in Zhuhai, 1000 km away from Hubei. Your rationale that a quarantine basically pulls the plug on the disease and you just wait through the incubation period is purely theoretical instead of being realistic.

3/27/20 11:01 PM
1/1/01
Posts: 65391
Today was beautiful weather in NYC and there were a lot of people on the street. Not great. I've been going out once in a while for food and I question whether I should even be doing that.
Edited: 3/28/20 1:14 AM
1/1/01
Posts: 21441

Two Italians from Nembro, one of the hardest hit towns, say the real death toll is higher than reports because they find a big spike in non-COVID-19 deaths once the hospitals are overwhelmed. They compare the average death rate (from all causes) this time of year in Nembro with the current death rate. The total deaths due to COVID-19, from untested COVID-19 deaths plus other causes, may be 4 times the known COVID-19 deaths. 

https://www.corriere.it/politica/20_marzo_26/the-real-death-toll-for-covid-19-is-at-least-4-times-the-official-numbers-b5af0edc-6eeb-11ea-925b-a0c3cdbe1130.shtml

Edited: 3/28/20 1:14 AM
1/9/02
Posts: 51309

we've been on shelter in place for a while in CA, plus half of the state has a very temperate climate so ppl can go outside and the virus may dry out quicker. cities are reall crowded here though.

 

think it was the right decision by Newsome so far. If the other states dont get a handle on it it wont matter though. west coast is holding steady for now.

3/28/20 1:16 AM
1/9/02
Posts: 51310
Lofland -

Two Italians from Nembro, one of the hardest hit towns, say the real death toll is higher than reports because they find a big spike in non-COVID-19 deaths once the hospitals are overwhelmed. They compare the average death rate (from all causes) this time of year in Nembro with the current death rate. The total deaths due to COVID-19, from untested COVID-19 deaths plus other causes, may be 4 times the known COVID-19 deaths. 

https://www.corriere.it/politica/20_marzo_26/the-real-death-toll-for-covid-19-is-at-least-4-times-the-official-numbers-b5af0edc-6eeb-11ea-925b-a0c3cdbe1130.shtml

if someone gets a heartattack and cant get a bed because theyre filled with COVID patients is COVID what killed them? this may be what NYC is looking at

3/28/20 1:19 AM
8/2/19
Posts: 1248
gregbrady -

we've been on shelter in place for a while in CA, plus half of the state has a very temperate climate so ppl can go outside and the virus may dry out quicker. cities are reall crowded here though.

 

think it was the right decision by Newsome so far. If the other states dont get a handle on it it wont matter though. west coast is holding steady for now.

You're still 1 or 2 weeks away from shit starting to get real.

3/28/20 1:22 AM
1/9/02
Posts: 51311
jspeed -
gregbrady -

we've been on shelter in place for a while in CA, plus half of the state has a very temperate climate so ppl can go outside and the virus may dry out quicker. cities are reall crowded here though.

 

think it was the right decision by Newsome so far. If the other states dont get a handle on it it wont matter though. west coast is holding steady for now.

You're still 1 or 2 weeks away from shit starting to get real.

maybe

our local growth leveled off and plummetted in the last 2 days. ppl are taking it seriously in my town though

3/28/20 2:11 AM
1/1/01
Posts: 21442

Someone pointed out that we may be understating the fatality rate. The people dying now got the virus 2 to 4 weeks ago. The true death rate would involve counting the number of people who caught it in, say, a particular week, then following them all to see what % died from it over time. Right now, we are comparing the total deaths over the current number of cases. There are a lot more cases now than there were when the dead people caught the virus.  Some of the current cases will die in 2 to 4 weeks but that is not reflected in our figures.

3/28/20 2:13 AM
6/5/02
Posts: 23961

Honestly if those Nembro results start to be seen in other areas then I think we will properly understand the impact of this thing

3/28/20 2:18 AM
6/5/02
Posts: 23962

I have friends who work in ICU in London and they are saying it’s awful - already getting swamped.

If you think about it a normal hospital operates to a particular capacity and in a major city - any significant incident causes a hospital to get temporarily overwhelmed eg a terrorist struck or major incident while they address it

These hospitals are now getting hundreds of not thousands of additional patient flow in to the hospital - every single day. And a significant percentage are staying there for weeks in intensive care.

 

Its very easy to see why they are becoming overwhelmed

3/28/20 4:15 AM
11/23/10
Posts: 147
Lofland -

Two Italians from Nembro, one of the hardest hit towns, say the real death toll is higher than reports because they find a big spike in non-COVID-19 deaths once the hospitals are overwhelmed. They compare the average death rate (from all causes) this time of year in Nembro with the current death rate. The total deaths due to COVID-19, from untested COVID-19 deaths plus other causes, may be 4 times the known COVID-19 deaths. 

https://www.corriere.it/politica/20_marzo_26/the-real-death-toll-for-covid-19-is-at-least-4-times-the-official-numbers-b5af0edc-6eeb-11ea-925b-a0c3cdbe1130.shtml

Those are some concerning numbers...

I certainly didn’t expect that wide of a margin of excess non-COVID-19 deaths with the way they’re routinely testing fatalities in Italy for COVID-19. Maybe in places without post-mortem testing, e.g. Germany. I’ll try to dig up some similar statistics from there and Denmark when they become available.

3/28/20 6:58 AM
10/16/10
Posts: 29950
Didn't NYC have Mardi Gras a few weeks ago?

Thought I saw an NBC piece about the parade a while back. That's obviously what caused the outbreak in NOLA.
Edited: 3/28/20 8:07 AM
6/30/07
Posts: 60335
gregbrady -
Lofland -

Two Italians from Nembro, one of the hardest hit towns, say the real death toll is higher than reports because they find a big spike in non-COVID-19 deaths once the hospitals are overwhelmed. They compare the average death rate (from all causes) this time of year in Nembro with the current death rate. The total deaths due to COVID-19, from untested COVID-19 deaths plus other causes, may be 4 times the known COVID-19 deaths. 

https://www.corriere.it/politica/20_marzo_26/the-real-death-toll-for-covid-19-is-at-least-4-times-the-official-numbers-b5af0edc-6eeb-11ea-925b-a0c3cdbe1130.shtml

if someone gets a heartattack and cant get a bed because theyre filled with COVID patients is COVID what killed them? this may be what NYC is looking at

This is what I've been trying to explain for a while now. This is how hospitals get overrun. Especially smaller rural ones. 

3/28/20 8:49 AM
3/15/06
Posts: 4076
Sounds like Atlanta hospitals are filled and they are now looking at what nearby cities can take their sick.
Edited: 3/28/20 8:51 AM
1/1/01
Posts: 19456

143

Mountain Medic -
gregbrady -
Lofland -

Two Italians from Nembro, one of the hardest hit towns, say the real death toll is higher than reports because they find a big spike in non-COVID-19 deaths once the hospitals are overwhelmed. They compare the average death rate (from all causes) this time of year in Nembro with the current death rate. The total deaths due to COVID-19, from untested COVID-19 deaths plus other causes, may be 4 times the known COVID-19 deaths. 

https://www.corriere.it/politica/20_marzo_26/the-real-death-toll-for-covid-19-is-at-least-4-times-the-official-numbers-b5af0edc-6eeb-11ea-925b-a0c3cdbe1130.shtml

if someone gets a heartattack and cant get a bed because theyre filled with COVID patients is COVID what killed them? this may be what NYC is looking at

This is what I've been trying to explain for a while now. This is how hospitals get overrun. Especially smaller rural ones. 

right.

 

In a way it's possible forjcblass to be correct that it's not as bad as the media says AND for the doctors to be correct that that it's a catastrophe.

 

It really does not take much for a hospital to be overwhelmed. Even at top hospitals.

 

3/28/20 9:09 AM
2/4/09
Posts: 10701
Job Security -
jcblass -
mataleo1 - 
clattymine - 

Mataleo1- how far away do you think the US is from peak infections and hospital overload? 

Just your best guess .... 

great thread dude. 


I'm starting to change my views on that. I had expected 6-10 weeks, but considering it's full-blown in NY and still in infancy in many states, It might take longer than expected, as other states slowly get cases.

It really depends on how successful we are at locking down NY (and problem counties) and how warmer months might influence transmission.


Couldn't you also conclude that if it's full-blown in NYC, and not in other states, those states are probably on the downside. After two weeks inside and heavily reduced physical contact among the population, surely the virus would show up by now.

I can't imagine people getting sick in large number 4 weeks after quarantine...

The flare up we are seeing now is a byproduct of the week or two before restrictions. If you are dealing with 90 deaths in California, 2 months into this, and 3 weeks into quarantine, the chances of a massive outbreak should be reduced because the number of places you can contract and spread it has also been greatly reduced. No one is in school, airports, gyms, restaurants, etc. So if you are not sick now, and the incubation period is 5-10 days, I don't see a massive and dramatic increase 4 weeks into quarantine.

That’s the hope of course. Probably depends on how much the population adheres to the lockdown.

Here in Europe it looks like different countries have very different effects of locking down. Worst case being Lombardy region in Italy, which declared a lockdown on february 22 with just 15 cases and zero deaths. 5 weeks of hell later they are still not plateauing daily deaths (it looked like they were beginning to, but today spiked to the highest number yet, so it could go either way at this point).

It’s too early to evaluate the effect in the other countries here, but at least in my country it seems to be working (locked down at 500 cases and a few deaths on march 12) with only a linear growth in number of hospital-admissions/ICU/deaths so far. Lock-down here was just extended until april 13, probably won’t be longer than that. Economy is getting wrecked of course.

Wouldn't daily death lag behind daily new cases? 

 

Seems like daily new cases might have plateaued 

Edited: 3/28/20 9:27 AM
2/4/09
Posts: 10703

New 80 patient trial results. Not controlled or blind though

 

3/28/20 9:39 AM
8/2/19
Posts: 1250
NoNeed4aScreenName -

New 80 patient trial results. Not controlled or blind though

 

They go from testing all 80 patients to testing 10 on day 7.... wtf.  These types of studies are shady as fuck.  If you have 80 patients to start, you test all 80 days 1-7, post the results.

 

Don't test 80 day 1, test 10 day 7 and then conclude "80% of all patients tested were negative on day 7".  That's deceitful at best.

3/28/20 10:14 AM
2/4/09
Posts: 10704
jspeed -
NoNeed4aScreenName -

New 80 patient trial results. Not controlled or blind though

 

They go from testing all 80 patients to testing 10 on day 7.... wtf.  These types of studies are shady as fuck.  If you have 80 patients to start, you test all 80 days 1-7, post the results.

 

Don't test 80 day 1, test 10 day 7 and then conclude "80% of all patients tested were negative on day 7".  That's deceitful at best.

Perhaps the patients were discharged?

 

In the methods they tested until discharge

3/28/20 10:26 AM
10/23/05
Posts: 3119
NoNeed4aScreenName - 

New 80 patient trial results. Not controlled or blind though

 


I'm getting a weird vibe about this Raoult fella. I read French so was able to read quite a little commentary coming from France. The guy gets a lot of crap from how he excluded prior patients.

Suffice to say that I still believe chloroquine to be promising but until we get a trial (or a robust controlled observational study), I am not convinced.

3/28/20 10:31 AM
10/23/05
Posts: 3120
gregbrady - 
Lofland -

Two Italians from Nembro, one of the hardest hit towns, say the real death toll is higher than reports because they find a big spike in non-COVID-19 deaths once the hospitals are overwhelmed. They compare the average death rate (from all causes) this time of year in Nembro with the current death rate. The total deaths due to COVID-19, from untested COVID-19 deaths plus other causes, may be 4 times the known COVID-19 deaths. 

https://www.corriere.it/politica/20_marzo_26/the-real-death-toll-for-covid-19-is-at-least-4-times-the-official-numbers-b5af0edc-6eeb-11ea-925b-a0c3cdbe1130.shtml

if someone gets a heartattack and cant get a bed because theyre filled with COVID patients is COVID what killed them? this may be what NYC is looking at


This is EXACTLY what is happening.

Plenty of life-saving surgeries are being delayed (cancer resections, aneurysm repairs) bcs they are considered "elective" for the moment. Patients coming in with mild heart attacks are not properly treated and not properly stratified.

3/28/20 10:34 AM
10/23/05
Posts: 3121

Update from NY colleagues.

There is a mass shortage of masks in certain hospitals. I have a friend who is an OB-GYN having to treat COVID patients without a MASK! I wouldn't have believed it...

3/28/20 10:34 AM
2/4/09
Posts: 10705
mataleo1 -
NoNeed4aScreenName - 

New 80 patient trial results. Not controlled or blind though

 


I'm getting a weird vibe about this Raoult fella. I read French so was able to read quite a little commentary coming from France. The guy gets a lot of crap from how he excluded prior patients.

Suffice to say that I still believe chloroquine to be promising but until we get a trial (or a robust controlled observational study), I am not convinced.

He looks like a whack job. I know the first second I saw this guy I was like WTF trumps personal doctor is doing microbiolgy work in france? Lol

 

I shouldn't let personal appearances judge my thoughts though lol. 

 

What have you heard about him in france?