Another health care professional who didn't get the memo that telling the truth will panic the proles. On the front lines every day, rather than bullshitting through his teeth from a podium in DC, or sitting in a lounge chair on some FakeNews show.
"I am an ER MD in New Orleans. 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, 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 b***h 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 vent 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 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, but are intermittently running out of IV.
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."
My first expanded lost draft (thanks again MacBook Touch Bar) contained the appropriate hedging, disclaimers, and uncertainty the current understanding of this pandemic deserves. Some of the more concise, unproof-read, hastily rewritten original post (OP) presents itself as more definitive instead of "what I think I know". For this, my apologies. I am not performing clinical trials. I am not involved in cohorting and analyzing data. The academic physicians involved in ER, Infectious Disease and Pulmonary Critical Care are likely (hopefully) way beyond my understanding of Covid 19. Furthermore, I fail to appreciate any additional benefit I could provide to Hospital Administrators who have been preparing and communicating with each other for months; or for some already combating this daily.https://texags.com/forums/84/topics/3102444
Basically, several state medical licensing boards are temporarily loosening their independent practice regulations on NPs, PAs, and to a lesser extent Medical Students. I wrote the OP as much for me to collect and organize my thoughts, as it was to provide a jumping-off platform for providers who may find themselves in an ER-like setting and unknowingly be treating Covid 19 patients or will be treating them soon enough. If any of it helps some of my colleagues hit the ground running then that is something too.
The OP was a summary of thoughts from being immersed in Covid 19 for weeks, reading as much as I can, and following up on my own patients. It is not my intention for this to be taken as dogma. I do not have the answers or the algorithm everyone is searching for. I was merely looking to point the handful of people I thought would read it in a clinical direction best I could. What I think I know evolves every day with the presumption it may very well end up markedly different once this pandemic is better understood. I do not know when this crisis will ultimately be arrested, however, I maintain resolute that each one of us can help make that happen. Stay home. Be safe. Find a way not to have to visit grandma.
Thank you to all the well-wishers and good luck to us all.
If you aren't following the clinical aspects of his notes, I am, and it scares the shit out of me.
70-86% death rate, even with ventilator therapy?
14% of cases coming to the ER require hospitalization?
5% of cases coming to the ER require ICU/intubation?
And Plaquenil (which is hydroxychloroquine) doesn't seem to help?
Cancel Christmas, kids.
This is going to f**k sh*t up in every ER that gets hit with it!
Reality is too Doomy and Gloomy for ya?
Go back to bong hits and shooting up hopeium.
And if that guy's seen a hundred Kung Flu cases, and he's working his whole shift in a PAPR, treat that like him saying he flew 100 missions over Germany in a B-17; that's a certified badass.
Just spitballing, but I think you can forget about going out to play by Easter.
Unless you're a total moron.
At least Easter this year. 2021 is still in play, so far.
Any chance of you defining the medical terms and acronyms for the lay people? I'm interested in knowing what the Dr is saying but I can't translate medspeak.
Quinine with zinc is South Korean treatment was keeping their death rate at .64%, zinc may be important to the process.
-Fred, go to the link and 2nd page is a layman’s translation.
-Aesop, from a Dr. pal’s FB feed. She is near Nurtigen, Germany. It is a non-scientific account of vents in other countries.
I think that the deeper explanation of flu season hospitalizations (420K or whatev last year according to CDC) and the fact that WuHu Kung Flu adds a large percent to existing numbers of seasonal flu hospitalizations is helping me to understand what is going on in terms of capacity vs. demand.
For me: It is a shit show of daily information dumps in which clarity is hard to find.
Running out of versed & fentanyl? I’ve seen an over-zealous paramedic try and incubate an improperly sedated patient once. It was not pretty.
I mistakenly posted this to the wrong post of yours. I think it is even kinda relevant in this post.
Aesop: couldn't it be that the New Orleans doc you quoted, is seeing the results he reports due to the late stage at which the hydroxychloroquine is administered? It seemed to me that that was the case per his narrative. Correct me if I'm mistaken.
"Quinine with zinc is South Korean treatment "
NOT a doc; was Med Affairs director for an ambulance many years ago/taught EMT. So, no decent med qual -- but I (am able to and actively am), read EVERYthing that I can find.
I read somewhere that the SKoreans are medicating WAY early -- that as a 'treatment' it is not effective in late or last stage patients. IF, as hypothesized, the Quin. and zinc are interfering with viral replication; then EARLY process patients will likely benefit; late stage will be too damaged for whatever reduction in viral load occurs.
Cuomo mentioned the other day in his presser that avg time on vents for these patients was 11-21 DAYS. Also that vent was correlated with bad outcome highly. Sooooooo.....all the mewling about getting vents and available vents is then just a big red hopium baloon for the sheeple to watch? Thanks again for your posts, more good info here than anywhere. Straight up no chaser.
I have the same question as Reltney does. Is the issue of hydroxychloroquine seeming not to work on these patients related to the fact it was given to them so late in the game? We have reports out of other countries that hydroxychloroquine does work against ChiComVid-19. Does that mean it has to be given promptly?
And the scarier question, does that mean that by the time a patient is sick enough to be intubated, it's already game over at that point and nothing short of a miracle will save them?
Let me tell you all just HOW THANKFUL! I am that our Dear Leader, Gov Whitmer (MICH), is taking medical care in hand, and telling clinicians how to manage patients!
How can that end, other than well, for us?
This does NOT sound good.
There was a graphic on page 3/5 that showed the prophylaxis dosing schedule for both Chloriquine and Hydroxy Chloriquine supposedly the schedule was from India? The medical papers that investigated Chloriquine compounds all emphasized that the purpose of the Chloriquine was to get ZINC into the cells where it disrupted the ability of the virus to reproduce. Chloriquine doesn't seem to kill the virus itself, nor does it kill the infected cell, it does prevent it from making millions more virii / viruses.
I think the problem using Chloriquine is that they are using it too late. Someone above mentioned that too. Scott Adams Says discussed the in Episode 871 of his podcast. (He also mentioned some doctors are prescribing it for family and friends). The purpose of the Chloriquine and Zinc is to stop the virus reproduction early, before it gets a damaging foothold. Just like penicillin won't do much for your leg injury, if your leg is already swollen, black, and gangrenous. Waiting to start the Chloriquine treatment only after the Chinese Coronavirus infection is confirmed by lab test is probably a bad thing. Start them on the Chloriquine and Zinc immediately, and discontinue if the test is negative. People have died while waiting for the lab test results. Also what happens if the test is a false negative?
I am Hoping they are finding other therapies that are more effective against the late term infections.
A cynical thought. Chloriquine compounds are all Generic Medications. There is not much money to be made if the treatment is effective. Could they be using the medical trial methodology to make the treatment less effective? Delay the treatment by requiring a confirmed lab test, where many of these tests do not provide the results for several days? That gives the Chinese Coronavirus a lot of time to reproduce, further sicken, and even to kill the patient, all while you patiently wait for an overloaded lab to report the test results?
Everything I've anecdotally observed about anti-virals for acute viral infections is that they only make a difference if given early. Like the ones for flu, or shingles, it's official for them, oseltamivir/Tamiflu, first 48 hours, acyclovir/Zovirax or its prodrug, 72 hours.
"70-86% death rate, even with ventilator therapy?"
Unless I misread, isn't that the percentage of people on ventilators who die, not total patients?
Thanks for the update. Front line data is always going to be rough. I can't help but wonder if this hot spot IS a product of Mardi Gras... Friend is an LEO down there, they are being VERY careful how they handle all interactions. They have very limited PPE.
OBE: Overtaken By Events. Doc reports 0% success with that approach.
If it work at all, it's only working early.
Late is too late.
@Rick C: Yes, 70-86% death rate for intubated patients, not all patients. IOW, it's a total waste of time between 2 times out of 3, and 6 times out of 7.
Dunno either, but it's there, and that's how it looks with the blinders off.
It for sure isn't going to be prettier in non-Mardi Gras cities.
Shit Mardi Gras is everywhere this is, unless you starve it off and wipe it out.
For an old man how did you arrive at a 84% death rate, what figures are you using above and below the line?
Try this one: hospitals and Old-Age Nursing Homes are the vectors. South Korea instituted a new protocol for MD/RN (etc) personnel: wash hands before and after patient contact AND before and after touching anything which may carry virus.
It's not a slam on med personnel. It's a reasonable theory.
Thought you'd like to think about that given your knowledge of med facilities.
The current muted Krap-Fest here in Teutonia mostly came from the ski folks in a few nodes in Austria. R-naught, as Dr Campbell tells us, is a combination of the virus' innate capabilites, and the behaviour of its carrier....a hoooman. Isolate, so you don't spread it, and kill all the Grannies and fat smokers, and the medical system. Isolate, so this Krap-Fest dies fast, and the Vultures making profit off it don't make quite as much. It needs a small amount of discipline and self sacrifice, which is why we are bent over the hood getting an unlubed proctological with a splintery chairleg.
I read exactly what the ER doc wrote. 86% death rate for intubated patients is worldwide. 70% death rate for intubated patients is results from Seattle.
If we could isolate everyone for 14 days, and identify all the infected carriers, and isolate them for 30 days, this would be over worldwide on May 1st.
Done. Kaput. Gone.
But we can't do that.
And people are Scheißköpfe.
You mean like we used to do for TB, Plague, Smallpox, Polio, Measles and SpanFlu? Those were real sure 'nuff Problems. Somehow they went away without living on Cellblock E.
Coming up soon....a Scheißkopf Medal, for the hypochondriac paranoids like me that really do isolate and use PPE and disinfect.
Except you don't get a ribbon, or a thank you, just stupid looks, snide comments, and reputation-murder (in German called Ruf-Mord, a litigatable offence, if you can get it proved). In English it's slander, malicious rumour, defamation. Back when honour was real, we killed or died for it.
If the Granny on my corridor gets it and dies, it won't be from me. If any of the 95 other households in my building gets it, it won't be because I was too proud or cowardly to wear goggles and a N100 mask and carry and use 75% ethyl alc. Surprised building management hasn't posted any notices, or even encouraged the "cleaning" ladies to run a rag over the lift buttons for the first time the new lifts were installed 3 months ago. Which brings me to...
LAWYERS. How much of the stupid difficulties we see rear their peculiar heads these days are motivated by a fear of being held LIABLE, or skating past on That's Not My Job. Given that there seems to be built into Corona a Get Out Of Jail OMG Unprecedented Hysteria Oh My The Vapours Card.
Good, I've got my self righteous Scheißkopf Medal, and am at least thankful it wasn't Something Serious. Now I'm thinking of stuff to do now to forestall worse disasters, perhaps even Volunteering my efforts in some effective way to rebuild.
Now, is it going to be directly reconstructive, or temporarily destructive? Change a diaper, or cut a throat? Too early to say...so I make sure I clean my own diaper and avoid burdening someone else, and sharpen my knives. Aesop, I tip my visor to you and your colleagues. Won't blame you if you cut out and set up a tent hospital for Anything But CoV, and fill a ditch out front with Viridiots.
You mean like we used to do for TB, Plague, Smallpox, Polio, Measles and SpanFlu? Those were real sure 'nuff Problems. Somehow they went away without living on Cellblock E.
Somehow they went away back when a horse was considered speedy travel.
We've been fighting it in our house for going on 3 weeks Mon.
Everyone in our house is in great physical shape. None hi risk.
It is a tough bug.
Textbook 'mild flu' symptoms for us. No crashers. Just getting better sooooooooo slowly.
No fevers, breathing difficulties, nose problems, etc.....just major, major aches, fatigue, and trouble thermo regulating.
One or two hours work / day which for us is 90% less than normal capacity.
Get yer big jobs done when you feel well.
Get ready to sleep better than twice than normal.
Eat best you can, take your vitamins with extra C, D3, zinc.
So, your house had/has it. Defeated the Fomites? Not spread it to anyone else? Then your R0 is really 0. At least under 1. Thank you for doing your duty, exemplary and outstanding. Wait a week or two, and you're Vanguard for the Assault on Covid. Replicate yourselves! Hail The Immunes!. Zinc!
IF chloroquine works, its effect is not likely zinc mediated:
"The best chance for inhibiting viral replication, then, lies in increasing cytosolic zinc, not endosomal zinc.
"But chloroquine doesn't increase cytosolic zinc. It traps zinc in lysosomes, where it is irrelevant to viral replication.
"So how does chloroquine kill SARS-CoV and SARS-CoV-2 in vitro? Here's what those in vitro papers found:
"• It increases endosomal pH. Fusion of the virus with the endosome, and later escape of the virus from the endosome, can both be pH-dependent. Increasing endosomal pH appears to prevent fusion of SARS-CoV with the endosome, and to the extent it makes it in, might also prevent its escape into the cytosol. This is supported by the fact that ammonium chloride, another agent that increases endosomal pH, has the same effect.
"• Chloroquine and ammonium chloride also raise the pH in the golgi apparatus, the compartment where sugars are added to proteins in a process known as glycosylation. ACE2, the protein on the cell surface that allows the entry of SARS-CoV and SARS-CoV-2 into the cell, is one of the proteins that are glycosylated in the golgi. Chloroquine and ammonium chloride both interrupt the glycosylation of ACE2. They do not affect the amount of ACE2 on the cell surface, but it is possible that the the virus is less able to dock to ACE2 when the protein hasn't been glycosylated.
"Chloroquine raises the pH of the endosomes, lysosomes, and golgi. This is a clearly toxic effect of the drug on human cells, because it will broadly disrupt the ability of the cell to take in things from its environment, digest things that need to be broken down, and glycosylate things that need to be glycosylated. As a result, chloroquine also interferes with the glycosylation of antibodies, which most likely contributes to its ability to treat autoimmune conditions. However, it might also hurt the immune defense against viruses, which might underly why it acted as an antiviral against chikungunya virus in vitro but enhanced viral replication in vivo [in mice].
"As noted yesterday, despite the routine use of chloroquine against COVID-19 in China and its incorporation into at least two national guidelines for COVID-19, there is as yet no evidence it is effective."
Zinc is best tested in plasma rather than serum. Both suboptimal or insufficient zinc (fairly common) and excessive zinc can impair the immune response, so optimizing zinc status is a reasonable part of your personal health resilience strategy. Zinc supplementation is not a treatment for this infection. We don't understand zinc transport very well; certainly not well enough to manipulate it therapeutically.
That was my thought as well...
The Nawlins Field Report is the top story, highlighted in red, on Citizens Free Press this morning, 29-MAR @8:20AM
Those things went away after crippling/killing millions and millions of people.
What was said in the piece is that when you take all of the patient who’ve been on a ventilator worldwide, 84% died. Seattle counted all of their vented patients total, and 70% died. Its not all patients. Just talking about the ones that got vented.
As others have pointed out, where CQ and HCQ have been used to treat Covid-19 patients with good results, it has been used EARLY. Early as in as soon as the patient tests positive or shows up at the hospital with symptoms. As I understand it, it is the Zinc not the CQ that interferes with the viral replication inside the lung cells. But zinc, because of its positive charge cannot get through the gateway into the cell where it is needed. CQ or HCQ opens up the gateway allowing interstitial zinc entry into the cells where it prevents viral replication.
However, also as I understand it, for the few hospitals that are even trying it, their protocol is to use the CQ or HCQ only when, in spite of all manner of supportive care, the patient is getting decidedly worse and appears to be headed for a date with a ventilator. By that time the virus has had a week to replicate faster than the Federal Reserve replicates money, and at that point no amount of zinc inside the cells is likely to magically undo the damage and bring the patient back from the brink.
These anti-malarial drugs have been around since WWII. The potential side effects are well known, and are mainly of concern for people who are taking them long term, such as cases where they are prescribed off-label for rheumatoid arthritis and certain other auto-immune conditions. In their use for treating Covid-19, the protocol is 500 mg twice a day for ten days. Obviously, Covid-19 patients with significant co-morbidities would need to be monitored very carefully for side-effects.
I am in my late 60's, a lifetime non-smoker, not overweight, normal BP and cholesterol, and I take NO prescription meds as I have no conditions for which I would need any. In short, I am in good health, especially for a guy my age. I have never been prone to respiratory ailments of any kind. If I were to get Covid-19, my expectation is that I would be among the 80 percent who have mild symptoms.
Nevertheless, if I did develop significant symptoms, I would like to have a 10 day supply of CQ in my medical tool kit, along with the Vitamin C, Vitamin D3, selenium, zinc, etc. If I actually had this virus, I think I would much rather fight it at home with Chloroquine, than be at the hospital with all the related supportive care and NO Chloroquine. I make this statement based on the preponderance of the results where it has been used so far. Again, as long as the HCQ or CQ is administered EARLY ON, it appears to have a good success rate for treating Covid-19.
During my annual physical exam last week, I brought this up with my PCP and asked him for a script for CQ. His answer was a flat NO, because "there are no clinical studies yet". Well if I catch Covid-19 next week, and a week after that begin showing all the classic symptoms, I damned well do not agree that I should have to wait for clinical studies before I am able to self-administer a drug that, more often than not, has been shown to help when administered as soon as definite symptoms and/or a positive test occurs. It should by MY choice. As long as I understand and accept the potential risks, I should absolutely have the choice of that course of action, whether at home or in the hospital.
Pete B -- I thought chloroquine was as simple as it reduces immune response, the cytokine storm that ultimately kills COVID-19 patients. Older folks immune systems have a hard time shutting off w/ this virus, knowing when it's 86ed, so CQ helps to stop their body's overwhelming attack on the virus from harming other organs.
"Chloroquine (CQ), a well-known anti-malarial drug, has long been used for the treatment of autoimmune diseases because of its profound immunomodulatory effects"
Accordingly, that's why all anti-antinflammatories are good preventatives for this: NAC, Glutathione, curcumin, ginger, zinc, resveratrol, coQ10, etc. Just google anti-inflammatory supplements.
Aesop, as I understand it, having followed this saga since late January, the hydroxychloroquine, zinc, & Zpak should be prescribed the moment a person gets a sore throat, fever & cough while they are not home. Not when they're gasping for air in the ER. Their personal doc should send prescriptions to their pharmacy ASAP. It's meant to be prescribed well before hospitalization is necessary. I am not medically trained, but have been reading the testimony of physicians on this. I'm beginning to think that we're purposely bollixing this up so we have to wait for expensive big pharma meds or that mythical vaccine.
Do I think this is some kind of miracle cure? No. But we're not giving it the chance to (we hope) shine in the way that it should - not when some poor soul is intubated and near death, but when they're just showing the 1st symptoms.
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