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."
Bogus disinfo by a dishonest med person who doesn’t want to be exposed as a democrat panic mongering operative. No name or specific location to even vette the lies. Dem scum lies.
Thats why no name or verifiable location.
This is what modern day civil war 2 looks like folks.
Strange to see so many freepers participating in this ongoing demoncrat plan to exploit a flu season.
Classic.
Probably, but what I was trying to suggest is that the person who wrote this was basing his conclusions on the worst of the worst cases. Also, and maybe it went over everybody's head, wondering if perhaps a lot of his cases are from the homosexual population, which has its own particular issues in regard to immunity.
bkmk
Amen. Here and everywhere it’s difficult to separate the facts from all of the wild speculation, misinformation, and disinformation. Some posts are constructive, but far too many of them are pure, unadulterated BS.
I can’t begin to guess since as others have pointed out several parts of his story do not ring true
How do you tattoo a deltoid? Why would you even want to?
Thanks. I needed the chuckle. That said, I clearly remember trying desperately to get some things done before a pediatric neurosurgery case (shunt revision) and the anesthesiologist paged me with, “I can’t get the IV.” I almost feel to the floor. He said he was going to cancel the case if I didn’t come start the IV. I did. And I didn’t even humiliate him. Yes, once i was “that good.” Sadly i am a husk of my former self.
Medically you describe cutaneous phenomenon by the muscle the skin is overlying.
Nice quips. Thanks for the chuckle...
The profession will be okay, but the doctors themselves will see their reputations slide further amongst people who are sick of them using their expertise in one field to pontificate like blowhards in every other.
I have seen some How shall we say....remarkable body art as a gas passer. Both in detail and in anatomical location
What can we realistically do? Every time you leave your house you potentially get infected? There are dozens of youtube channels advising people how to disinfect anything they bring into their homes- mail, groceries. Think about that, not only are people afraid to go out, they are afraid to bring things into their homes from outside.
Every week we will be hearing reports of 20+ people falling ill from church meetings, large offices, etc.
It will be a constant revolving door of closures, deep cleanings, testings, hospitalizations and deaths.
I do believe I have repeatedly said “I am no mathematician”, “I am no...”. All I have ever claimed to be is a retired MD. Who spent 5 years as a Major on Active Duty. Because when the Army tells you what to do you have two options. Do it. Ft Leavenworth.
This isn't a medical forum. It's a political forum supposedly dedicated to maintaining certain conventions first promulgated by the so-called Founding Fathers of the United States.
And dont forget the craven activities of the nefarious Clinton Foundation who commandeered the CDC
and other govt agencies for THEIR purposes. Shielding Americans from a pandemic was not on the C/F agenda
BTW, this write-up has been posted several times already.
The Diamond Princess still remains the petri dish to watch for several reasons. You had several thousand aboard when cases started popping up. They ate together in large dining rooms, they engaged in lots of social mingling, they were in a small defined area, and there was a large population of older people.
The number infected has been steady at 761. Deaths have been steady now at 10 or 1.3% of those infected. The recovery is currently at 601 or 79%. Those still infected stands at 150 or 19.7%
While no one disputes that this isn't the flu, and is really more akin to SARS, in fact it is often referred to as SARS2 Covid-19, and is indeed a faster spreader than SARS and has a higher morbidity rate, due in large part to an aging world population, a lack of knowledge or drugs available to assist in combating the virus.
While it is nothing to dismiss, it is also nothing to go into panic mode over either. It will take its course, and it will claim its victims, but the world will continue on.
I have taken no issues with the actions taken, because if it were to overwhelm medical facilities, care of many other maladies could no longer have been effectively tended to.
Some of the worst case scenarios, derived from doing nothing, was not going to be the outcome, so they were to be ignored from the onset. In fact, they themselves are walking back from the worse case scenarios. They claim it is because something was done, but it was reckless and irresponsible to assume that no action would be taken in the first place.
But what also cannot be allowed to occur is the total devastation of economies as that would surely create an even deadlier situation that would overshadow the virus.
We lost time in dealing with this virus in large part due to the deceptive information being disseminated, the deliberate hiding of truthful information, and the out right destruction of samples by China. Then on top of that the CDC fell flat on their face with the release of faulty test kits at the beginning. It proved they were totally unprepared for an event like this. So this was another reason to hit the pause button and take more drastic measures to assist in the spread retardation of the virus. Lastly, political correctness played a significant role as well, by encouraging people to mingle in large numbers to combat racism. It was in essence a perfect storm of sorts.
But the good news is that we now have something in our arsenal to help get a handle on this virus and assist in reducing the morbidity rate going forward. Some call it the #Trumppills which has indeed shown very positive results. In addition more test kits are available to identify cases. More good news on the horizon are tests kits that will significantly reduce detection time frames from days to minutes. All of these point to an end of the virus controlling us, and the capability of us to begin controlling the virus.
What you mistakenly see as denial is in reality attempts to calm those who believe the worse, and allow fear to control their emotions. The last thing an event like this needs is fear and panic. They have never been known to solve anything, but they have been proven to make things much worse for sure.
And I’m obviously no politician.
With all the abbreviations and acronyms, the post is likely unreadable to anyone who does not work in health care.
We KNOW the NYT is lying. It is virtually all they do. You know this.
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