And, another covidiot moron chines in.
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."
Wow you are in rare form today. Again. When you decide to show up to a hospital and treat patients. Once you have Afros at bedside and treated ARDS you can have some credibility. Yesterday in America 3x the amount of people died of cancer than this.
Keep call names. You and your ilk have thus far been proven wrong on virtually everything
You are voluntarily throwing away your liberties. Don’t force me to do the same particularly on untrue and fake internet posts
Please you and your bully fear bro’s stop the personal attacks and threats. I have been threatened with everything from legal procedures to fbeing doxed to one of your brethren wishing I get the disease and die.
From a list of so called freepers whose names are known based on their panicking posts.
As I said to one of your brethren yesterday and I mean this will all of my heart
Good luck and Godspeed
And by good luck I mean
F**k off
The author's experiences are as valuable as those that other medics are experiencing.
And, another covidiot moron chines in.
What an inspirational read!
Cannot understand all the medspeak, but I understand enough to know I don’t want it.
Sure thing, doc.
It’s just a hoax.
Your right it’s not apples to apples and this ends the comparison
I’ve read that hydroxychloroquine administered EARLY is effective. After cytokine storm not so.
In the link’s comments there are interesting comments, especially about the source doctor and https://noqreport.com/2020/03/26/covid-act-now-bad-data-and-a-lot-of-lost-jobs/
My sister had a bad case of pneumonia and was vented for a couple of weeks. She barely made it. She was in an induced coma for a bit. I watched the doctors and therapists and what they did with the vent settings. It seemed a mix of science and art. Lost of blood work and adjusting. O2 settings and pressure and pace. Amazing machine and people that run them. Saved my sister.
Lots of blood work...
Re: 47 - Thank you for posting this.
Except the author offers points that show him not to be a physician. Except this exact same bullshit post has been circulating for coming up on a week
Except there is no evidence from the ER this is true.
We still call things that are not true out. Remember as is evident with this whole fiasco....
Rumor and innuendo are halfway around the world before truth laces up its running shoes
An example of an exponential function is the growth of bacteria.
Some bacteria double every hour. If you start with 1 bacterium and it doubles every hour, you will have 2x bacteria after x hours.
Not projections, models, or forecasts. Just data.
Naturally, nobody believes the numbers from China or Iran, but the statistician is only recording the numbers, readers can decide what to make of them.
Oh BS - you’re personally attacking everyone on this post who doesn’t agree with you.
Your numbers on your posts are utter falsehoods - you still haven’t responded as to why one scary chart shows 1800 deaths in the US as of yesterday but another scary chart shows 1250 deaths as of yesterday.
But you’re just spewing numbers bro?
You’re not a doctor. It’s obvious you don’t understand statistics or even simple math but please, post another meme to show us all how clever you are because you can squawk the Democrat line like a good parrot.
You are an unbearable narcissist and liar. When have I said it’s a hoax. You are putting words in everyone’s mouth and calling it the truth and do not respond to a single clinical fact I presented. And one other thing you braying jackass. If ONE emergency room had this CNN and MSNBC would have Wolf and Rachel larked outside in a radiation suit broadcasting this for the world to see so desperate are they for this wet dream scenario of the bed wetting communists. You would probably be holding their cue cards to read
If you can read, the 1250 was from March 27.
Huh... more socialist charts - if only we lived in a socialist dictatorship with universal health care bro...
Oh, I see. Numbers you don’t like mean they are “socialist charts.”
He has pretty charts. Someone else forecasted of the fear bro’s. Over 1000 deaths yesterday. 10000 a day by the end of this week. Looks like a swing and a miss
Good point ...but "rumor and innuendo" may not apply to all virus narratives.
Even if only one grain of truth emerges from this narrative, that takes us one step head of the virus.
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