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."
Nicely bypasses chloroquine results coming in from all quarters. Who gains from making this pandemic last as long as possible?
Too late.
Because it's a bullish*t post.
And it's been posted on this forum over and over again. And it has been previously removed by the moderator.
It's an unnamed source on the internet.
It's meant to push the Plaquenil Bad meme. A real doctor would not do that anonymously on the internet. It would be in really bad form.
It is likely being pushed by the same people who pushed the fishtanks cleaner story.
Yes, as should any critical thinker.
This medical antidote is from an unnamed guy on the internet, claiming to be a doctor. Do you understand the problem with that?
My daughter needed some ortho surgery as an infant. First guy was a hack, and wouldn’t listen to the attending nurse that the spica brace was to small. Then we were referred to a brilliant dic out of University of Iowa. He took one look at my kid, one look at me, and said he could fix this with a minimum of surgery and therapy. He also said a lot of orthos are failed carpenters.
Great guy. He jokingly told me if he had seen me as a kid, I wouldn’t have the hip issues I di now.
The girl I’m talking about was one of the most intelligent people I ever met but she wasn’t above using the “dumb blonde” thing to get what she wanted. Made me jealous. I wished I had a dumb blonde card. But she was sick of relentlessly being hit on. I think that was why they teamed her up with me. I was married. But can you imagine spending 12-16 hours everyday working with someone like that for 6 months? I was so relieved when it was over.
Hillary. She benefits.
She’s running.
Joe was never the candidate.
The only other woman who seemed to be staying in the race was tulsi gaberd. And I think she’s out now so the runways been cleared for typhoid Hillary.
She will use this virus to avoid campaign appearances as well as gaining too much public exposure. This time she won’t get caught on live camera having hard seizures.
This may be their ultimate insurance policy against orange man bad.
Thanks for posting this reality based front line report from a real ER doc.. By the way the maxair is not face mask you can buy from Ace or Home Depot.
https://www.maxair-systems.com/images/ProductBrochures/ProductBrochure-1.png
Please excuse, me I am just now reading through the thread if my comment may be premature.
“...not met a flubro who is a medical professional.”
You win my internet award for the day. Thank you for this comment and others. I am a big fan of Jim Noble and wastoute especially. Thanks!
I am stubbornly clinging to hope that zinc and early intervention will be the thing. (sigh.)
OK back to the thread!
We’ve been discussing this for around the last three days. Where’s everybody been?
I tried finding zinc in the local health food store.
No luck.
Some varieties are better absorbed than others. Trying to find one that works well is tough.
Not getting your point? Hospital "melt down" results in looting? How does that work?
Now joblessness...I can see THAT resulting in looting.
Thank you so much for your patience! Why would you come here after work and put up with all this?
I find it very helpful for me to just go to your comments page or your brother’s and read the threads you are commenting on. I am learning a lot.
I am such a fan of you, gas_dr, wastoute, and Jim Noble, mostly wastoute, and many others. Thank you and please know that there are grateful souls who love what you are doing and admire you for it!
I am not necessarily gonna surrender my fearper membership card, yet...:-)
How many are testing negative?
thank you for the kind words. Please surrender your fearper card. whatever this is we will get through it as a nation and individually Fear only makes it worse!
and hang in there. I look forward to the days when we can go back to discussing something else. Honestly I think that feeds a lot of the problem. there are no sports you can’t go to the movies or out to dinner, the democrats nomination is over so people at home get nothing but coronavirus 24/7. i walk outside and see it is spring, the sun is out, the birds are singing and God is still in control. I think we all need a change in perspective! Have a blessed Sunday
The criminals will be looting long before most unemployed.
Very good post. Thanks.
If you will indulge me I think of Dr. Susan Gerber who is Team Lead of Respiratory Viruses Branch at CDC. Under her is John Watson who is Respiratory Viruses Surveillance and Outbreak Support and others who watch for these things. I am never one to stop you whipping up on these folks, but I am at a loss as to how they could have done differently. I understand about the faulty test kits, but it was an honest error wasn't it?
I was a little confused by what you said about them, that they were to "hit the pause button" AND "take more drastic measures." Not disagreeing, because I really did not understand that part of your post. Forgive me if I nitpick, because this was a good post thanks!
What does that have to do with "hospital meltdown" though? That's my question. Or were you just posting random thoughts?
Disclaimer: Opinions posted on Free Republic are those of the individual posters and do not necessarily represent the opinion of Free Republic or its management. All materials posted herein are protected by copyright law and the exemption for fair use of copyrighted works.
