E/R doctor schools physicians on treating Covid-19 patients (excellent read)

citizenfreepress.com ^ | 3/29/20 | ER DOCTOR

[Liz]

“I am an Emergency Room MD in New Orleans, UNC 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 and taste, 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

Worldwide 86% of covid-19 patients that go on a ventilator 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 (hydroxy-chloroquine) 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.

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."

[Travis McGee]

You said you are an engineer, then you must understand timelines.

Guess what? The outbreak didn’t kick off to a global starting gun at the same instant.

Wuhan: December-January.
Italy: January-February.
Spain: February-March
New York: March —>

And so on. Is this a difficult concept?

[gas_dr]

Why just yesterday YOU SAID until there are masks for everyone we should not reopen the country. You are limiting and taking away freedom. And these are YOUR words. You absolutely advocate freedom
Limitations pending the initiation of your misguided order.

[Ymani Cricket]

With all the hydroxychloroquine being stocked up I guess we will be ready for a malaria outbreak in the event of global warming (now climate change) and a mosquito horde ascends from the south... well you never know I guess lol

[wastoute]

If he is using laminar flow the PEEP may be the highest pressure the lungs “see”. We used to get patients like this and in those days they just died.

[Travis McGee]

“Why just yesterday YOU SAID until there are masks for everyone we should not reopen the country.”

Got an actual quote?

[super7man]

ping

[RinaseaofDs]

saw that too

[central_va]

My point is that isolating and caring for those most at risk doesn't require:

• Hysteria
• Lock down
• Spending trillions
• Hype
• Fear mongering
• Generational warfare

[wastoute]

If you recall, I was asked to make a prediction a week ago or so. Reluctantly I agreed. I said, “at some day around March 31 we will have 5,000 total deaths with about 2,000 occurring in the day previously. I may have missed by a day.

[DAC21]

Doc, have a look at Cytosorbents Co. Blood filtration cartridges (Hooks up to existing dialysis equip.) for your CV Sepsis / Cytokine Storm patients. “Compassionate use” protocol. Was / is being used in China and now Italy.

[gas_dr]

Salvage ventilation is accomplished via APRV now. If this guy were legit he would have stated as much. He holds himself out to be giving advice to medical professionals and then writes a lot of nonsensical stuff. You know you can tell when you are dealing with bullshit artists when they can’t weave something together. This is a regurgitation of a lot of things of which the vast majority of clinically incorrect

[HangnJudge]

This was posted several days ago on this board, and the link removed. Although very believably written, clearly in the language of an ER/Intensivist MD, it may be a hoax

[wastoute]

The reason it looks like “log scale is because it is. I should have been whipped for not looking at the axes.

[null and void]

I think he said 5% critical condition, if that means on a ventilator, 70-86% ventilated patients die. For New Orleans that's 3.5% fatalities, rest of the world 4.25%.

Yow.

Comments anyone?

Bring Out Your Dead

Post to me or FReep mail to be on/off the Bring Out Your Dead ping list.

The purpose of the “Bring Out Your Dead” ping list (formerly the “Ebola” ping list) is very early warning of emerging pandemics, as such it has a high false positive rate.

The false positive rate was 100%.

At some point we may well have a high mortality pandemic, and likely as not the “Bring Out Your Dead” threads will miss the beginning entirely.

*sigh* Such is life, and death...

If a quarantine saves just one child's or one old fart’s life, it's worth it.

[wastoute]

I spent years of my. Life managing patients in ICUs. No one is ever going to bulllshit me about what goes on in an ICU. Sure, it was so long ago I would be dangerous today but sick people are sick people. That doesn’t change.

[Skywise]

It seems this has to be said because of all the Fearbros here -

It’s the flu. Very virulent, very contagious and potentially deadly to about 10% who get it.

There’s no cure and, currently, no known treatment. Those are the important facts.

What we CANNOT do is stick our heads in the sand and lock ourselves in our homes for months, potentially years in response to outright hysteria.

We can act as rational and adult human beings, stay home when sick and avoid those who are susceptible and still soldier on.

Fear and hysteria is what they want. Watch their actions, not their words. They want the destruction of individual liberties, they want the destruction of capitalism and free thought.

Did China share its information with us when they had their outbreak? No. They buried it, AND THE PEOPLE, and claim -with their numbers- that they’ve “beaten the flu”. Meanwhile they order the WHO to not admit Taiwan and to get the flu name changed from “Wuhan flu” to COVID-19. Does this sound like a nation that thinks the flu will destroy them?

What’s the first thing Pelosi did to “save us”? Tried to pass a law to make ballot harvesting legal nationwide for THIS election. The same stunt they used to take over California, which is now, effectively, a one party state.
Does this sound like a political leader that thinks the flu will destroy the US?

Don’t lose your head. Be vigilant, wash your hands and don’t go out if you’re sick. Don’t give in to fearbros... that way leads to the dark side.

[Solson]

With all due.... If you think the numbers are fake, part the real ones. Sources would be appreciated.

[wastoute]

If he lives in a rural location he would likely find what you do in your rural location. Be grateful. I live near a city that will soon have the hospital “melt down”. My neighbors are preparing for looters.

[wastoute]

He’s an ER doc, or claims to be. He may not manage vents. Tube ‘em and send ‘em up.

[Solson]

I use a number of different sites and the current deaths in the United States are 2045. That’s from the COVID tracking site which links to reach and every state health report.