E/R doctor schools physicians on treating Covid-19 patients (excellent read)

“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.

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.

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.

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.

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.

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.

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."

Thanks!
I am enjoying the open access on so many of the virus and epidemiology sites so I am taking advantage while I can. Wifey makes me stop and take a walk.

A dear friend, Dr. Nathan Smith is Cardiothoracic Fellow at Albany Medical NY. Tough on them right now. His Grandmother, Doris, is as dear a soul to me as any in the world. Nate has two COVID-19+’s sharing a vent now. We are not worried about him, we are so proud of him. He’ll be fine ya know?

Barry is the best man I know, just got off the phone with him. He quit Ubering three weeks ago and went into total seclusion. He is a total high risk with lung issues and heart problems. His death won’t make the papers. But he says he is in perfect health today. He feels great alone in the woods in the double-wide. However...

The uncle, Chris C., of his son-in-law may have it, and may be in big trouble. Showing the symptoms now. Waiting for test results. No Plaquenil until the test comes back. He had definite direct close contact with a CoV+ at church. Chris has had a bad of habit reinfecting himself by not keeping his CPAP clean...

Dad, 95, is healthy in the VA nursing Home in Seneca SC. His death wouldn’t make the papers either. They are locked down but they still play bingo over the loudspeaker! No +’s so far, but four other deaths this week.

You are so right, your words bring a tear to my eye. God is in control!

but it was an honest error wasn't it

Most likely it was an honest mistake, however, even honest mistakes can have drastic consequences. One of the biggest problems I see was the centralization of making the CDC the sole source for test kits. To limit such a major important cog in the fight against viruses has shown to be the absolute least efficient way of handling crisis situations where time is of the essence.

When I was speaking of the pause button, I was really speaking of actions taken after we had gotten behind the 8 ball so to speak. Because now you enter into the haste makes waste category, and a regroup needs implemented to examine the best way to move forward.

I was not speaking strictly of the CDC. While the CDC may have played a major part in recommending the drastic measures, such as mass closures of events and schools, followed closely with the closure of businesses whose primary function is to serve the public in basics such as food preparation and service thereof in small contained environments, that these probably became necessary measures to retard further spread of the virus. That the issues which had delayed the ability to identify infections that had already spread, the pause button was likely employed to keep from creating additional breakdowns that were likely to occur. The min one being, the country's healthcare institutions becoming overwhelmed. Because once that occurs because of one issue, this virus, then it creates a domino or snowball like affect and now you have several maladies that can no longer be tended to. That becomes a recipe for real disastrous outcomes.

So to prevent that from occurring I do not take issue, as some here do, for the pause that was initiated.

It was the right move to take. While many were convinced that herd immunity would win the day, which is most likely what will ultimately win the day, there would be lots of tragedy along that route as well. So while it may be what finally wins the day, perhaps it is not the best course to tack along at this juncture. Let's get as much of a handle as we can on this virus. Of course the pause cannot be overdone because realities of life make that option a brief one at best.

Since the pause we have gotten those who want to test everything to the point of what amounts to ridiculousness when time is an unavoidable factor, to relent and allow a more immediate form of real world testing to occur. That fact alone has brought about a change that will most save lives that would be lost otherwise. It has also allowed others to work on tests that give faster results. That too will be instrumental in saving lives.

Now we all need to pray that this pause has been a beneficial one that will help us along with the Lord's good grace to overcome this threat to mankind.

I know a long winded answer to what was really a simple question, but hopefully it will eliminate further questions that might have arisen if I had tried to keep is more condensed. I also know that talk is cheap and that these are just my opinions on the subject, so thanks for for having the patience to indulge me. 8>)

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