2) It's too late to start battening down the hatches AFTER the storm has hit.
3) the press is torn:
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."
The Obama administration consistently sought to slice hundreds of tens of millions of dollars in funding to the Centers for Disease Control and Prevention (CDC), yearly spending plan requests clearly show — seemingly undercutting previous Vice President Joe Biden’s repeated assaults on the Trump White Residence for its pandemic preparedness. A lot of Democrats, which include Biden, have falsely claimed that Trump slashed the CDC budget, and Biden has advised that he would under no circumstances go after very similar cuts. The Associated Press has famous that those people promises “distort” the specifics, with FactCheck.org pointing out that CDC funding has essentially elevated beneath the existing administration, mostly because Congress insisted on keeping funding amounts for equally CDC and the National Institutes of Wellness (NIH).
However, talking to ABC News’ “This Week” on March 1, Biden claimed: “They’ve cut the funding for the CDC.” On Friday, Biden stepped up his assaults, writing on Twitter: “Donald Trump’s careless, shortsighted steps remaining our country sick-geared up and now People are paying the selling price.”
In its fiscal year 2013 price range, when Biden was vice president, the Obama administration sought a complete funding level of $5.9 billion from the CDC, or a $569 million reduce from the 2012 spending budget of $6.46 billion. In fiscal calendar year 2015, the Obama administration desired a $414 million slash 12 months-above-12 months, and again in the fiscal year 2017 finances, the Obama administration looked to eradicate $251 million in CDC funding.
The proposed cuts consider into account revenue budgeted for The Prevention and Community Health Fund, which was set up less than the Affected individual Protection and Economical Treatment Act of 2010 to bolster the nation’s well being care program. When not which includes that fund, the Obama administration sought CDC cuts in five (Excerpt) Read more at abc14news.com ...
You certainly sound like one.
One might think, inasmuch as you're a member of this forum, you might hold freedom dearer than you hold anything else, but obviously that isn't so.
2) It's too late to start battening down the hatches AFTER the storm has hit.
3) the press is torn:
I used to have a little pamphlet that was cute. “A chance to cut is a chance to cure.” It was full of chuckles. I can’t remember any of them. To be an Orthopod you have to be strong as a bull and half as smart. That one wasn’t even in there. All you need to know to be an Orthopod is how to spell Keflex. When I helped an Ortho resident manage a Spinal Cord ICU we had to work together which was very difficult. She was incredibly beautiful and I was married. For 6 months we had a lot of fun joined at the elbow and worked together very well but we were constantly teasing each other.
I remember an Ortho guy asked me to come watch him do a spine case and out of curiosity I figured, “What the hell?” I was horrified. I was a trained Neurosurgeon who had done spine surgery as taught by Neurosurgeons. Immaculate, pristine field. You could identify every capillary. Bipolar coat made it possible to do cases with 50 cc blood loss. When I watched those guys it was like a blood bath. I asked him how the hell could you possibly see what the f you are doing? He said, “It’s easy, the pedicle is right over there!” I said, yeah, so is the cauda equine, the Vena Cava and the aorta. He said , “That’s why we have blood banks.”
The Western New York regional director for both Sens. Hillary Clinton and Kirsten Gillibrand has lost her job at the Roswell Park Cancer Institute after telling Trump supporters on Facebook that if COVID-19 is just a hoax they should refuse ventilators and just “chew some ibuprofen” if they’ve contracted the virus.
The Buffalo News reports that Laura Krolczyk, Roswell Park’s vice president for external affairs, was fired after an investigation into her remarks, while a co-worker, Lisa LaTrovato, is on leave for her comments (Excerpt) Read more at twitchy.com ...
I am confident our freedom will come back. We are armed to the teeth. It would be a mistake to take that kind of advantage of us, I believe.
The assembly rate for cars is intrinsically linear, as each new car assembled (unlike viruses) does not contain the potential to construct new cars.
The revolver spinning the lies is the NYT and the person playing with it... is your chart maker.
Not to worry though The New York Times always fires blanks.
I’m just a guy who learned to be an asshole from the best. I have been trying to recover from that for decades, my mother would have been quite disappointed.
Now do President Trump.
..And China is Asshoe.
A lot of really serious governing issues are being ignored, like the attempted coup by the CIA, FBI, NSA, etc. and major graft in the Ukraine and (ahem) China!
Late to the party. As my usual salutation is for you and your I’ll:
Good luck and Godspeed
And by good luck I mean
F**k off
How much are you invested in Quinines?
I detect a thread hijack here, which at this point is a relief.
My Dad’s surgeon (nice young lady) was all at the hospital all hours of the day and night. I was too, helping my Dad. At one point she and I were talking and told her that she was at the hospital too much and needed to get a life. She started crying, I felt terrible.
Wish I'd saved the article I saw yesterday morning about a particular bacterial infection rampant in the male homosexual community making co-infection with this Coronavirus much more serious.
So what’s your no bullshit prediction
Number of deaths o great font of knowledge. Roll the dice and show is your remarkable knowledge
No other fearper has the balls to do it. So do you?
We used to joke as a resident you had to lock up your gonads.
I was going to post that but didn’t want to take the time to find the up arrow.
Maybe 2**x works?
There is no crying in surgery.
Hey how are fearpers like surgeons:
Often wrong, never in doubt.
You got to lock yours up? The chief is the department extracted them on our first day
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