Posted on 03/29/2020 4:18:02 AM PDT by 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."
No it isn't.
No mention of zinc, vitamin C, or vitamin D, either.
I agree tube em and send em up. But that is where he fails the sniff test. No ER doc would give advanced MVS advice like this. He is also flat wrong on his sedation statements. There are a whole lotta holes in this post. Some obvious. Some subtle
And it is the same post that has come from
Upstate NY. NOLA etc almost verbatim.
One thing I have noticed inn “the numbers” is they seemingly arbitrarily change the “cut off” all over the place. 7 PM, 5 AM, midnight, 10 PM. Intentionally or not it appears the data inflow was being throttled. That led to an impression that clearly was not true.
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
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Hopefully something like that plays out. Part of a solution should involve the elderly not having to leave their homes. At all. A program announced very LOUD that they can have anything they need (food, prescriptions) delivered would seem like an obvious place to start.
Ok fair enough, but do me a favor. Visit you local rescue squad and ask them if their calls for aid/transport have increased or the volume changed as a result of COVID. Ask the about pulmonary distress ceases. Then get back to us.
That’s because each state reported at different times. That’s been transparent. NY is reporting a few times per day. Other states once per day and at varying times.
I have noticed this too
Any comparisons to Chinese numbers are meaningless.
According to a Mossad and British analysis (made public), the Chinese numbers understate by a factor of 40 and show not only selective data gathering but transparently obvious manipulation after the fact.
Wow.
They will still be in denial.
Good catch. Like I say, my experience was 30 years ago. I was a damn wizard in the ICU. You had to prove that in my day to get a “seat in the OR” in your next year. Some programs surgical interns didn’t know where the damn OR was. Thankfully, not mine. I did a couple gall bladders the “old way” as an intern. That was a reward damn few got.
Today I don’t recognize the names of drugs, the old MA IIs are long gone. When I was a Neurosurgery Resident I set the vent wherever I wanted it and told the Nurse to document the order. When I was a Family Practice resident a number of folks didn’t realize I had done a prior Residency. I vividly recall changing the vent settings on a patient and you’d have thought I had set the damn building on fire. People came running form all corners of the ICU yelling, “What are you doing?”. I realized they were probably right. I never touched a vent again.
I would like all the fearpers to roll the dice and play monopoly. I want them to publish a single number that is their estimate or the number of deaths we will have as a result of this pandemic. No wiggling around it. No qualifiers. I have a number in my mind. Let’s see if they are brave enough to come out and say what they think. Travis is the worlds smarter guy. So I think he should know. And for his gratification I stated he wrote something on a different threat. It was in fact DannyTn so much apologies to Travis. Nonetheless between these two there is a distinction without difference
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AND DON'T, I REPEAT DON'T resort to childish names of those you disagree with as part of your argument.
It serves absolutely no purpose except to antagonize and get those basically on the same side fighting against each other.
A day without this cartoon would be like a day without Travis....
Apples and oranges.........
I just knew you had surgical training somewhere. It’s why we argue and disagree but still can maintain relationships. Surgeons and anesthesiologists. The odd couple of medicine.
And I have no idea where the NYT gets their data from but it’s different than what the states are reporting.
Oh, you again .... of course...
I have seen surgeons scream at the gas guy. I always thought it was a little unbecoming. Yes we are from different tribes. But I also did a Family. Practice Residency and had a private practice which was very satisfying because my patients were “friends” so as much as I hated Primary Care it was fun.
There are vast regions that may never experience the exponential phase. Right now they are wondering what all the fuss is.
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