OtherGround Forums OG doc. AMA on COVID-19

4/5/20 5:10 PM
6/30/07
Posts: 60545
Easters -

A huge narrative since this began is the lack of PPE, and almost everybody seems to be putting this problem solely on the federal government.  My question is, where do the individual hospitals take fault in this?  Every single hospital have inventory specialists who make GOOD money.  Now when the crisis hits and everybody is short on PPE I don't see anybody putting the blame on the hospitals themselves.  It's Trump's fault.  Not saying the Feds have handled this perfectly but what gives?

Hard to plan for an unexpected 1000% increase in PPE burn rate.

4/5/20 5:14 PM
10/23/05
Posts: 3257
NoNeed4aScreenName - 

Have anoyone of the docs seen anyone admitted that has Lupus and has been on plaquenil either?


I haven't but some of my colleagues have.

4/5/20 5:17 PM
1/1/01
Posts: 48010
mataleo1 -
bmr7683 - 

This has been a very informative thread as others have stated so thank you all very much. I came across this video and wanted to hear what some of the Dr's thoughts in here were. It's about a 6 min video from an NYC Doctor stating he believes that the world is treating this disease incorrectly. It's not a conspiracy vid or anything.
 

http://www.worldstarhiphop.com/videos/video.php?v=wshh4OC0el0Bk52HTW4S


I know the guy.

I pretty much agree with everything he said and his points were mentioned on this very thread. He didn't really go into detail about what he would suggest doing differently.

Respiratory failure from COVID is different from what we see with ARDS from other causes (like the flu). Some important differences:
-Patients look pretty well but their O2 saturation is abysmal
-They do much better in the prone position.
-We should not intubate these patients unless they LOOK bad (not based on O2 sats)
-Ventilator parameters are very different. We use low PEEP and high O2 (which is opposite with ARDS)

why is prone better than supine?

i'm not a doctor, just seems counter intuitive. laying on my chest seems like it would put more prssure there and make it hard to breath

4/5/20 5:19 PM
4/26/13
Posts: 4662
Mountain Medic -
Easters -

A huge narrative since this began is the lack of PPE, and almost everybody seems to be putting this problem solely on the federal government.  My question is, where do the individual hospitals take fault in this?  Every single hospital have inventory specialists who make GOOD money.  Now when the crisis hits and everybody is short on PPE I don't see anybody putting the blame on the hospitals themselves.  It's Trump's fault.  Not saying the Feds have handled this perfectly but what gives?

Hard to plan for an unexpected 1000% increase in PPE burn rate.

I can understand for a hot spot like NY or New Orleans but I live in a rural/suburban area and nurses are constantly complaning about lack of PPE but emergency rooms are at 50% of normal capacity right now because we have relatively low covid cases and nobodys going in for other reasons.  I'm like you guys can't handle this?  Crazy.  Hospitals should be held accountable for not preparing!

4/5/20 5:19 PM
2/4/09
Posts: 10828
Easters -
Mountain Medic -
Easters -

A huge narrative since this began is the lack of PPE, and almost everybody seems to be putting this problem solely on the federal government.  My question is, where do the individual hospitals take fault in this?  Every single hospital have inventory specialists who make GOOD money.  Now when the crisis hits and everybody is short on PPE I don't see anybody putting the blame on the hospitals themselves.  It's Trump's fault.  Not saying the Feds have handled this perfectly but what gives?

Hard to plan for an unexpected 1000% increase in PPE burn rate.

I can understand for a hot spot like NY or New Orleans but I live in a rural/suburban area and nurses are constantly complaning about lack of PPE but emergency rooms are at 50% of normal capacity right now because we have relatively low covid cases and nobodys going in for other reasons.  I'm like you guys can't handle this?  Crazy.  Hospitals should be held accountable for not preparing!

As much as a hate to say it, there could also be some staff theft. 

4/5/20 5:21 PM
2/4/09
Posts: 10829
mataleo1 -
NoNeed4aScreenName - 

Have anoyone of the docs seen anyone admitted that has Lupus and has been on plaquenil either?


I haven't but some of my colleagues have.

Thanks. I was just thinking back to the Didier stuff and I ran across one of their observations where they claimed that everyone in the ward for infectious diseases and had Lupus did not contract Covid. I was wondering if people observed similar here. 

4/5/20 5:55 PM
2/4/09
Posts: 10830

Sorry just more questions. I'll have a ton. 

 

are there any clinical tests that can be run in which you measure Angiotensin 1-9 levels?

Edited: 4/5/20 6:59 PM
2/4/09
Posts: 10832

Maybe some thoughts on this study?

 

Circulating angiotensin peptides levels in Acute Respiratory Distress Syndrome correlate with clinical outcomes: A pilot study

 

To date, no study has used the metabolomics approach to determine circulating levels of RAS peptides as predictors of survival outcomes in ARDS. Using this approach, we found that plasma A(1–10) levels were predictive for clinical outcome at study entry. Although a statistically significant difference was also achieved at 72 hours, we avoided possible bias arising from deaths in one of the groups by focusing on the predictive capacity using RAS peptides at study entry. No statistically significant differences were found in plasma levels of A(1–8) and A(1–7) between the two groups at any time point. However, upon analyzing peptide ratios (product/reactant), there were suggested differences in the two groups’ comparative ability to form the active RAS metabolites.

To determine whether higher levels of A(1–10) amongst non-survivors is a consequence of increased biosynthesis or reduced metabolism, we examined levels of both precursor peptides and downstream metabolic peptides. A(1–12) was used as a surrogate marker for angiotensinogen. There was no difference in A(1–12) between the two outcomes group, suggesting that higher levels of A(1–10) in the non-survivor group were not likely due to its increased synthesis. Furthermore, levels of downstream products such as A(1–9), A(1–8) and A(1–7) were lower in the non-survivor group, but not statistically different. Despite the lack of statistical significance, survivors had approximately three times higher median plasma A(1–7) levels suggesting the metabolism to form bioactive peptides may be impeded. Taken together, these findings suggest that non-survivors have reduced metabolism of A(1–10) which could be due to reduction in ACE and/or ACE2 enzymatic activities as a consequence of more severe lung endothelial and epithelial injuries in the non-survivor group.

Cell-associated ACE has significantly higher catalytic activity as compared to circulating ACE [18]. Patients with severe ARDS may sustain more lung injury to the endothelium and epithelium thus reducing the levels of cell-associated enzymes which corresponded with increased SOFA scores and lactate serum levels. Other evidence supporting decreased enzymatic activity in the non-survivor group may be inferred by comparing peptide ratios (product/reactant) between the two groups. Survivors had higher levels of downstream products as suggested by higher peptide ratios of A(1–10)/A(1–12), A(1–8)/A(1–10), A(1–7)/A(1–9) and A(1–7)/A(1–8). The small sample size may account for why median levels of some peptide ratios such as A(1–7)/A(1–9) and A(1–7)/A(1–8) were not significantly different between survival and non-survival groups. Reduction in ACE and ACE2 enzymatic activity may ultimately lead to accumulation of A(1–10) in patients who succumb to ARDS. Therefore, elevated levels of A(1–10) at study initiation may serve as a useful marker to predict non-survival amongst ARDS patient

 

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0213096

4/5/20 7:05 PM
6/30/07
Posts: 60549
Easters -
Mountain Medic -
Easters -

A huge narrative since this began is the lack of PPE, and almost everybody seems to be putting this problem solely on the federal government.  My question is, where do the individual hospitals take fault in this?  Every single hospital have inventory specialists who make GOOD money.  Now when the crisis hits and everybody is short on PPE I don't see anybody putting the blame on the hospitals themselves.  It's Trump's fault.  Not saying the Feds have handled this perfectly but what gives?

Hard to plan for an unexpected 1000% increase in PPE burn rate.

I can understand for a hot spot like NY or New Orleans but I live in a rural/suburban area and nurses are constantly complaning about lack of PPE but emergency rooms are at 50% of normal capacity right now because we have relatively low covid cases and nobodys going in for other reasons.  I'm like you guys can't handle this?  Crazy.  Hospitals should be held accountable for not preparing!

When you go from gowning up once or twice a week to gearing up for every patient it goes fast.

 

We burned through several months of masks in a few weeks when this started.

 

You've also got facilities like Harborview that are currently requiring all EMS (including flight teams) to don fresh ppe that the hospital knows is good before entry. So that right there doubles burn rate right there.

4/5/20 7:39 PM
11/4/11
Posts: 6474
NoNeed4aScreenName -
SC MMA MD -
mataleo1 -
NoNeed4aScreenName - 

Any doctors here notice their turn around times for results? 

 

Based on my minimal observations it would seem a rough estimate of 48 hours for inpatients and 72 hours for health care workers at an outside testing site. 

 

Have any of you guys observed a similar timeframes? If not what would you say yours are?


24h for patients and health workers in Montreal right now.

Our hospital is using an in-house test since last Sunday and we are getting turn-around in a couple hours pretty consistently now

Any chance you know what tests they are running? Are they still using PCR?

They were as of last week. As I am sure you know, things change moment to moment; but I believe they are still using the RNA PCR that runs the same way as the usual respiratory viral pathogen panel. The largest issue with that in the Southeast currently is the viral transport media is is very short supply.

4/5/20 7:40 PM
4/26/13
Posts: 4664
Mountain Medic -
Easters -
Mountain Medic -
Easters -

A huge narrative since this began is the lack of PPE, and almost everybody seems to be putting this problem solely on the federal government.  My question is, where do the individual hospitals take fault in this?  Every single hospital have inventory specialists who make GOOD money.  Now when the crisis hits and everybody is short on PPE I don't see anybody putting the blame on the hospitals themselves.  It's Trump's fault.  Not saying the Feds have handled this perfectly but what gives?

Hard to plan for an unexpected 1000% increase in PPE burn rate.

I can understand for a hot spot like NY or New Orleans but I live in a rural/suburban area and nurses are constantly complaning about lack of PPE but emergency rooms are at 50% of normal capacity right now because we have relatively low covid cases and nobodys going in for other reasons.  I'm like you guys can't handle this?  Crazy.  Hospitals should be held accountable for not preparing!

When you go from gowning up once or twice a week to gearing up for every patient it goes fast.

 

We burned through several months of masks in a few weeks when this started.

 

You've also got facilities like Harborview that are currently requiring all EMS (including flight teams) to don fresh ppe that the hospital knows is good before entry. So that right there doubles burn rate right there.

So how is this the feds fault?

4/5/20 7:51 PM
1/1/01
Posts: 11720
mataleo1 - 
prof - mataleo1

We've all seen mortality rate charts (by age etc). I'm not sure what the overall mortality rate is judged to be at this point but...

I presume the mortality rate is calculated with some number of asymptomatic infections in mind.

I'm wondering if there are calculations for mortality based on "once you show clinical symptoms" of having the virus.

A lot of people I'm sure think of their odds in an abstract way until the actually start to feel sick and "oh shit...I've got this thing, now that I'm actually sick, what are my odds?"

Mortality rate. That's been debated everywhere.

First off, those wishing (sadly) to compare this with the flu should know that we test the flu even less than we test for COVID right now. Since testing for COVID is more widespread, mortality rates are probably more reliable for COVID than they are for the flu.

Anyway, you there are many ways to calculate mortality
Deaths/infected or Deaths/(Deaths + Recovered)

Assume that at least 30% of people will be asymptomatic or almost completely asymptomatic (https://www.newsday.com/news/health/coronavirus/asymptomatic-coronavirus-1.43629598).

So if you believe mortality is 1%
Then it would be 1/(1-0.3) = 1.4% if you have symptoms.



Thanks again!
Edited: 4/5/20 7:58 PM
2/4/09
Posts: 10835
SC MMA MD -
NoNeed4aScreenName -
SC MMA MD -
mataleo1 -
NoNeed4aScreenName - 

Any doctors here notice their turn around times for results? 

 

Based on my minimal observations it would seem a rough estimate of 48 hours for inpatients and 72 hours for health care workers at an outside testing site. 

 

Have any of you guys observed a similar timeframes? If not what would you say yours are?


24h for patients and health workers in Montreal right now.

Our hospital is using an in-house test since last Sunday and we are getting turn-around in a couple hours pretty consistently now

Any chance you know what tests they are running? Are they still using PCR?

They were as of last week. As I am sure you know, things change moment to moment; but I believe they are still using the RNA PCR that runs the same way as the usual respiratory viral pathogen panel. The largest issue with that in the Southeast currently is the viral transport media is is very short supply.

Yeah policy changes daily here. I was just hoping maybe I could run something up the proper chains here and speed up the diagnostics. 

 

We now have 8 confirmed Covids but still waiting on 67 other test results. 

 

I can only imagine policy changes once we run out of room and have to begin changing cohort criteria. 

 

4/5/20 8:00 PM
6/22/03
Posts: 7032
Hi Prof... I'm not a doctor, but here's a source indicating that the true estimate of your chance of dying from covid is 0.66%:
https://www.aafp.org/journals/afp/explore/covid-19-daily-briefs.html

There are two different fatality rates used: the case fatality rate (CFR) and the infection fatality rate (IFR). The CFR looks at fatality rate among those who are confirmed to have the disease. It is easier to be precise with, and presumably has value to doctors who only deal with identified cases. The IFR looks at the fatality rate among all people with the disease (confirmed cases plus all the mild and asymptomatic people who didn't bother getting tested). Right now, anyone reporting the IFR are making educated guesses at best. But for those of us curious to know our chances, the IFR is what you want to know. And the link I gave you above estimates it to be 0.66%. Which is still damn high if 50% of the world's population catches this virus.
4/5/20 9:14 PM
6/30/07
Posts: 60553
Easters -
Mountain Medic -
Easters -
Mountain Medic -
Easters -

A huge narrative since this began is the lack of PPE, and almost everybody seems to be putting this problem solely on the federal government.  My question is, where do the individual hospitals take fault in this?  Every single hospital have inventory specialists who make GOOD money.  Now when the crisis hits and everybody is short on PPE I don't see anybody putting the blame on the hospitals themselves.  It's Trump's fault.  Not saying the Feds have handled this perfectly but what gives?

Hard to plan for an unexpected 1000% increase in PPE burn rate.

I can understand for a hot spot like NY or New Orleans but I live in a rural/suburban area and nurses are constantly complaning about lack of PPE but emergency rooms are at 50% of normal capacity right now because we have relatively low covid cases and nobodys going in for other reasons.  I'm like you guys can't handle this?  Crazy.  Hospitals should be held accountable for not preparing!

When you go from gowning up once or twice a week to gearing up for every patient it goes fast.

 

We burned through several months of masks in a few weeks when this started.

 

You've also got facilities like Harborview that are currently requiring all EMS (including flight teams) to don fresh ppe that the hospital knows is good before entry. So that right there doubles burn rate right there.

So how is this the feds fault?

I don't recall ever saying that it was. I'm just explaining how it actually works in the real world.

4/5/20 9:15 PM
2/4/09
Posts: 10840

Looks like we just got a confirmed result in a 24 hour period. Maybe we were just behind on testing. 

 

Up to 9 confirmed now and plenty of results to come back 

4/5/20 9:55 PM
1/7/09
Posts: 16011

Are there any studies ongoing with hyperbaric oxygen therapy as a treatment?  Use high pressure to drive more oxygen into the blood. It seems like people are having trouble getting oxygen from their lungs into their blood, not necessarily that their breathing muscles just cease to function.  So it makes sense to me that ventilators have such poor outcomes with something around 70% of ventilated patients not surviving.

 

Why not use a treatment that increase concentration of oxygen in the blood vs one that is designed to replace the mechanical function of breathing, when it seems the former and not the latter is the problem? Or am I completely missing something?

4/5/20 10:49 PM
7/25/09
Posts: 1194
turducken -

Are there any studies ongoing with hyperbaric oxygen therapy as a treatment?  Use high pressure to drive more oxygen into the blood. It seems like people are having trouble getting oxygen from their lungs into their blood, not necessarily that their breathing muscles just cease to function.  So it makes sense to me that ventilators have such poor outcomes with something around 70% of ventilated patients not surviving.

 

Why not use a treatment that increase concentration of oxygen in the blood vs one that is designed to replace the mechanical function of breathing, when it seems the former and not the latter is the problem? Or am I completely missing something?

Phil Daru, ATT’s strength coach, talks about how he trains his athletes so they will have greater indurance by always breathing through their nose and doing breath holds, etc. (basically equivalent to high altitude training) and how that increases oxygen in the blood. He mentions he learned it from Patrick McKeown who wrote a book called The Oxygen Adantage. Might be worth a look...

4/5/20 11:24 PM
3/6/06
Posts: 31176
BigJohnSTEWD -
turducken -

Are there any studies ongoing with hyperbaric oxygen therapy as a treatment?  Use high pressure to drive more oxygen into the blood. It seems like people are having trouble getting oxygen from their lungs into their blood, not necessarily that their breathing muscles just cease to function.  So it makes sense to me that ventilators have such poor outcomes with something around 70% of ventilated patients not surviving.

 

Why not use a treatment that increase concentration of oxygen in the blood vs one that is designed to replace the mechanical function of breathing, when it seems the former and not the latter is the problem? Or am I completely missing something?

Phil Daru, ATT’s strength coach, talks about how he trains his athletes so they will have greater indurance by always breathing through their nose and doing breath holds, etc. (basically equivalent to high altitude training) and how that increases oxygen in the blood. He mentions he learned it from Patrick McKeown who wrote a book called The Oxygen Adantage. Might be worth a look...

There is nothing about doing breath holds that simulates altitude training or provides any of the benefits of living at altitude.

4/6/20 2:09 AM
2/4/09
Posts: 10846

One thing I did realize tonight. Even though I dont feel our hospital is overwhelmed, if we didnt cut elective surgeries there is no way we could have handled this as well as it is going. The isolation and logistics of this would have been terrible if we were running at the usual capacity.

Edited: 4/6/20 2:54 AM
11/23/10
Posts: 179
turducken -

Are there any studies ongoing with hyperbaric oxygen therapy as a treatment?  Use high pressure to drive more oxygen into the blood. It seems like people are having trouble getting oxygen from their lungs into their blood, not necessarily that their breathing muscles just cease to function.  So it makes sense to me that ventilators have such poor outcomes with something around 70% of ventilated patients not surviving.

 

Why not use a treatment that increase concentration of oxygen in the blood vs one that is designed to replace the mechanical function of breathing, when it seems the former and not the latter is the problem? Or am I completely missing something?

A ventilator does both: it can increase oxygen pressure in the inhaled air (this is what oxygen by nasal catheter or mask can also do). What makes a ventilator a ventilator is the ability to also adjust the overall air pressure to “blow air into the lungs” and relieve the mechanical work otherwise required from the respiratory muscles (that why you usually start to consider calling the ICU when the patient starts to show signs of fatigueing even if their blood oxygen might still be decent at that point). It can also do other stuff and tweaks to inspiratory/expiratory air pressure, but that’s the basics. 

4/6/20 3:03 AM
6/13/03
Posts: 27423

REBEL Cast Ep79: COVID-19 – Trying Not to Intubate Early & Why ARDSnet may be the Wrong Ventilator Paradigm

4/6/20 3:06 AM
1/7/09
Posts: 16018
Job Security -
turducken -

Are there any studies ongoing with hyperbaric oxygen therapy as a treatment?  Use high pressure to drive more oxygen into the blood. It seems like people are having trouble getting oxygen from their lungs into their blood, not necessarily that their breathing muscles just cease to function.  So it makes sense to me that ventilators have such poor outcomes with something around 70% of ventilated patients not surviving.

 

Why not use a treatment that increase concentration of oxygen in the blood vs one that is designed to replace the mechanical function of breathing, when it seems the former and not the latter is the problem? Or am I completely missing something?

A ventilator does both: it can increase oxygen pressure in the inhaled air (this is what oxygen by nasal catheter or mask can also do). What makes a ventilator a ventilator is the ability to also adjust the overall air pressure to “blow air into the lungs” and relieve the mechanical work otherwise required from the respiratory muscles (that why you usually start to consider calling the ICU when the patient starts to show signs of fatigueing even if their blood oxygen might still be decent at that point). It can also do other stuff and tweaks to inspiratory/expiratory air pressure, but that’s the basics. 

the therapeutic principle of HBOT lies in its ability to drastically increase partial pressure of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT are much higher than those achievable while breathing pure oxygen under normobaric conditions (i.e. at normal atmospheric pressure). This effect is achieved by an increase in the oxygen transport capacity of the blood. At normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is transported by blood plasma. Because the hemoglobin of the red blood cells is almost saturated with oxygen at atmospheric pressure, this route of transport cannot be exploited any further. Oxygen transport by plasma, however, is significantly increased using HBOT because of the higher solubility of oxygen as pressure increases.

 

A ventilator really has the same effect?

4/6/20 3:22 AM
6/13/03
Posts: 27424

After listening to the podcast above. I found it worrysome that methods of treatment may possibly be avoided such as high flow nasula to certain patients, because of PPE concerns, even though they may be more beneficial.

Are there specific protocols in place nation wide that are directing the intubation patients extremely early?

 

4/6/20 7:04 AM
11/23/10
Posts: 180
turducken -
Job Security -
turducken -

Are there any studies ongoing with hyperbaric oxygen therapy as a treatment?  Use high pressure to drive more oxygen into the blood. It seems like people are having trouble getting oxygen from their lungs into their blood, not necessarily that their breathing muscles just cease to function.  So it makes sense to me that ventilators have such poor outcomes with something around 70% of ventilated patients not surviving.

 

Why not use a treatment that increase concentration of oxygen in the blood vs one that is designed to replace the mechanical function of breathing, when it seems the former and not the latter is the problem? Or am I completely missing something?

A ventilator does both: it can increase oxygen pressure in the inhaled air (this is what oxygen by nasal catheter or mask can also do). What makes a ventilator a ventilator is the ability to also adjust the overall air pressure to “blow air into the lungs” and relieve the mechanical work otherwise required from the respiratory muscles (that why you usually start to consider calling the ICU when the patient starts to show signs of fatigueing even if their blood oxygen might still be decent at that point). It can also do other stuff and tweaks to inspiratory/expiratory air pressure, but that’s the basics. 

the therapeutic principle of HBOT lies in its ability to drastically increase partial pressure of oxygen in the tissues of the body. The oxygen partial pressures achievable using HBOT are much higher than those achievable while breathing pure oxygen under normobaric conditions (i.e. at normal atmospheric pressure). This effect is achieved by an increase in the oxygen transport capacity of the blood. At normal atmospheric pressure, oxygen transport is limited by the oxygen binding capacity of hemoglobin in red blood cells and very little oxygen is transported by blood plasma. Because the hemoglobin of the red blood cells is almost saturated with oxygen at atmospheric pressure, this route of transport cannot be exploited any further. Oxygen transport by plasma, however, is significantly increased using HBOT because of the higher solubility of oxygen as pressure increases.

 

A ventilator really has the same effect?

Sorry, I misunderstood you. It’s hard to compare HBOT to a ventilator. It’s an interesting idea.

It’s not traditionally used in pneumonia or respiratory failure. I don’t know why though - I’m guessing it’s because it’s not feasible to put ventilator equipment/staff inside the cramped hyperbaric chamber, and you can’t suddenly decrease the pressure and transfer the patient out of there if you need to.

It’s primarily used in diseases with hypoxia caused by issues outside of the lungs, e.g. compromised local circulation or hemoglobin dysfunction due to severe anaemia or carbon monoxide poisoning.

My only experience with using HBOT was in rare patients with infections with anaerobic bacteria causing gas gangrene, where the added tissue oxygen inhibited the bacteria and toxins. The treatment happened in another location though, so I don’t know much about the practicalities.