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."
My dad was a gas man. While he had some good friends who were surgeons, the complaints he had for them were rich. One sister is a scrub nurse. Saw both sides but certainly sided with the gas man most of the time.
So you are going with “inadvertently”. I continue to have “mixed optimism”.
Can speak for my local hospital. They discharged half the patients to make room and more beds. Now needing to furlough doctors who have little to do. Half-empty and has remained that way.
I bet we'll have a dozen here who claim they are before this thread is over...
No name equals bullshit.
No. I’m going with “hotspots” in certain parts, normal in others and non-existent in others. Shut downs and quarantine where necessary and only where necessary. Put precautions in and start getting this country going again.
Surgeons tend to be assholes because they are too busy to waste time. I was in hospital one day with a Neurosurgeon who was one of the “top ten” in the country. His office paged saying an Internist wanted to talk to him. He called the guy’s office and a secretary answered. She said, “One moment, please.” He hung up. I was flabbergasted. “If he wants to talk to me he should answer the damn phone.” Not kidding..
Also, he's sending people home who might otherwise recover under care, due to space limitations.
Simple truth, but the Fearpers don’t want to hear it.
But it sells end of the world books well which is what he is here to do.
Next week that will probably begin to roll out if the ERs in urban centers are no longing on melt down.
I try to control it but as you can see every once in a while it gets the best of me.
Here, for your edification, is one CDC activity brought to you by (drum roll please) the Clintons and the Clinton Foundation).
SOURCE https://www.politifact.com/factchecks/2016/aug/10/bill-clinton/bill-clinton-hillary-tripled-aids-treatment-withou/
During the Obma admin, on Secy of state Hillary Clinton’s watch, the costs per AIDS patient was driven down by more than half — from $673 when she took control to $338 when she left. The question is, does she deserve the credit? Mead Over, a senior fellow at the Center for Global Development, a Washington policy center, said that while a lot of the work is done by State Department agencies, not all of it is.
The Centers for Disease Control and Prevention and the National Institutes of Health and other govt agencies also play a role.
But at the end of the day, the secretary of state sets the priorities.......in this case, the priority was to expand treatment.
==========================================
Wiki The Clinton Foundation (founded in 1997 as the William J. Clinton Foundation[2] and from 2013 to 2015 briefly renamed the Bill, Hillary & Chelsea Clinton Foundation)[3] is a non-profit organization under section 501(c)(3) of the U.S. tax code. with the stated mission to "strengthen the capacity of people in the United States and throughout the world to meet the challenges of global interdependence."[4] Its offices are located in New York City and Little Rock, Arkansas. Through 2016, the foundation had raised an estimated $2 billion from U.S. corporations, foreign governments and corporations, political donors, and various other groups and individuals.
WIKI---As of January 1, 2010, the Clinton HIV/AIDS Initiative, an initiative of the Clinton Foundation, became a separate nonprofit organization called the Clinton Health Access Initiative (CHAI).
Organizations such as the Clinton Foundation continue to supply anti-malarial drugs to Africa and other affected areas; according to director Inder Singh, n 2011 more than 12 million individuals will be supplied with subsidized anti-malarial drugs.[citation needed]
In May 2007, CHAI and UNITAID announced agreements that help middle-income and low-income countries save money on second-line drugs.
The partnership also reduced the price of a once-daily first-line treatment to less than $1 per day.
CHAI was spun off into a separate health organization in 2010.
Ira Magaziner became CHAI's CEO (Magaziner had been a key figure in the Clinton health care plan of 1993). Chelsea Clinton joined its board in 2011, as did Tachi Yamada, onetime President of the Global Health Program at the Bill & Melinda Gates Foundation.
From the article:
"Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps."
2^x
Maybe not. I pointed out to one that what he had done was actually illegal.
You may be right - but your language suggests a lack of education.
Golly I’m so glad you called me out on that and not the fearbros who started it.
Thanks, Liz. The heavy medical terminology is great to read in the raw. Up close, Coronavirus is a scary threat indeed.
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