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Be sure to read this post! Beware of scammers. https://www.indianagunowners.com/threads/classifieds-new-online-payment-guidelines-rules-paypal-venmo-zelle-etc.511734/
Coronavirus II
- Thread starter churchmouse
- Start date
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Some people just need to be shot...
Pennsylvania grocery store loses estimated $35K in food after woman's 'twisted' coronavirus prank, co-owner says
There's a happy ending to the story though, according to the comments in the article:
Have fun with those felony terrorism charges!
Pennsylvania grocery store loses estimated $35K in food after woman's 'twisted' coronavirus prank, co-owner says
There's a happy ending to the story though, according to the comments in the article:
Have fun with those felony terrorism charges!
Hatin Since 87
Bacon Hater
This really makes me lose hope for humanity. Maybe the world dying and repopulating is for the best. I have a 3 month old baby, I hope he gets to grow up in a “normal” (whatever that is anymore) world, and this virus doesn’t take me my wife or our parents from him. But geez, these people really make me question if the human race will survive much longer.
It (he) has a name which has been withheld for OPSEC. The details he reports are accurate and substantiated from an experienced medical professional. He is a reliable, trusted source with years of experience and a trusted friend. I have no doubts as to the validity of his claims.
Is this not the type of "on the ground" reporting and intel that we have been looking for?
While I agree that numbers modeling is important, and links to important intelligence provide a broader picture, are we not concerned with verifiable resources on the ground providing real-time information? I can look at numbers all day, and read reports and weblinks from all around the globe, but neither of those do anything to help me know what's going on in my own back yard.
It seems that INGO members are relegated to one camp or the other in regards to COVID-19:
1. The end is near/TEOTWAWKI/Martial Law/Doom and gloom; or
2. "It's just the flu and it's going to ruin the economy.
Are we not allowed to be somewhere in the middle and trying to establish our own judgement based on all intel received? Are we not allowed to be somewhere in the middle? Personally, I see relevant information from all sides.
And for those that know me, they know what I do and know that I don't post that information lightly.
Yes, and thank you.
The "insider" updates on INGO have had me at least 2 days ahead of most everybody else as this has unfolded, and I appreciate that. You guys with actual front line knowledge shouldn't get lumped into BS from Facebook or 'other sources".
Now, if I did want to post some crazy $h!t, another trusted source sent me a text picture of an email that he received from a friend at a central Indiana hospital. The email (verified) said:
Subject: If we have a COVID death - IMPORTANT
Patient needs a bag tightly sealed around their head and double bagged prior to going to the morgue.
The conspiracy theorist in me says "ooohhh, zombies" but the realist in me figures it's just a precaution to keep a decomposing body from expirating infected gases. (I am not a medical professional.)
Subject: If we have a COVID death - IMPORTANT
Patient needs a bag tightly sealed around their head and double bagged prior to going to the morgue.
The conspiracy theorist in me says "ooohhh, zombies" but the realist in me figures it's just a precaution to keep a decomposing body from expirating infected gases. (I am not a medical professional.)
Great video on how important celebrities are during covid-19.
https://twitter.com/i/status/1242237138239881216
Here is a paper on sars-cov-2 released yesterday. For most here it is not something you will want to read.
It is more about how the virus works in your body. If that is something you would like to understand this
is an important study,and more in depth than most. It moves our understanding of the virus forward.
https://science.sciencemag.org/content/367/6485/1444
Another paper released in the last day on transmission of sars-cov-2.
https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2
[FONT=&]Disease spread through both direct (droplet and person-to-person) as well as indirect contact (contaminated objects and airborne transmission) are indicated, supporting the use of airborne isolation precautions.
EPA has updated a list of Disinfectants with guidance for use of each one. These are tested and confirmed to destroy viable virus. Something the EPA had been previously not able to do(no such testing was being done even last week as the EPA stated they lacked a sample of the virus). So this is progress on that to be sure.
[/FONT]https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
This next one is for those doing their own modeling. How would you like to try the Swiss governments model,but you have full control of all variable?
Well now you can. It is a complex tool with a steep learning curve,but I am trying to get up to speed to learn from it. FAIR warning when you run your model it will use EVERY resource your PC has. Even with a very nice up to date PC my last model run took awhile.
https://swissmodel.expasy.org/
https://twitter.com/i/status/1242237138239881216
Here is a paper on sars-cov-2 released yesterday. For most here it is not something you will want to read.
It is more about how the virus works in your body. If that is something you would like to understand this
is an important study,and more in depth than most. It moves our understanding of the virus forward.
https://science.sciencemag.org/content/367/6485/1444
Another paper released in the last day on transmission of sars-cov-2.
https://www.medrxiv.org/content/10.1101/2020.03.23.20039446v2
[FONT=&]Disease spread through both direct (droplet and person-to-person) as well as indirect contact (contaminated objects and airborne transmission) are indicated, supporting the use of airborne isolation precautions.
EPA has updated a list of Disinfectants with guidance for use of each one. These are tested and confirmed to destroy viable virus. Something the EPA had been previously not able to do(no such testing was being done even last week as the EPA stated they lacked a sample of the virus). So this is progress on that to be sure.
[/FONT]https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-sars-cov-2
This next one is for those doing their own modeling. How would you like to try the Swiss governments model,but you have full control of all variable?
Well now you can. It is a complex tool with a steep learning curve,but I am trying to get up to speed to learn from it. FAIR warning when you run your model it will use EVERY resource your PC has. Even with a very nice up to date PC my last model run took awhile.
https://swissmodel.expasy.org/
Last edited:
Very important update with new CDC data.
Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians - 03-23-20
Recent data from the CDC suggests younger patients (20-44 years of age) are not as immune to significant disease as previously reported and have up to a 20% hospitalization rate; however, children aged < 18 years are generally spared from significant morbidity or mortality.
In preparation for the arrival of patients suffering from COVID-19, emergency departments (EDs), hospitals, and healthcare systems should make immediate and necessary structural and process changes to prepare for high volumes of patients, primarily in respiratory distress, who will require mechanical support. Lots of guidance listed in the paper.
https://www.ebmedicine.net/topics/infectious-disease/COVID-19
I am going to include this next link simply because I would like to see more testing. This link is not for anyone but those who work in an environment with access to a lab capable of testing for covid-19. It is a materials link to help them to become certified to test. There are likely more updated forms of testing,but this may help a lab get certified so I am posting it.
https://www.seracare.com/AccuPlex-SARSCoV2-Reference-Material-Kit-0505-0126/
French took a look at viable virus on surfaces and in the air. They used 3 studies to do so including the NIH/CDC study.
They came to almost the same conclusions as our most recent CDC with slightly longer times. For example 4 hours in the air and 2 days 8 hours on aluminium.
Again like the US study it was not when all viable virus was gone,but when it was reduced by 50%.
https://www.lemonde.fr/les-decodeur...ectieux-sur-des-surfaces_6034549_4355770.html
Novel 2019 Coronavirus SARS-CoV-2 (COVID-19): An Updated Overview for Emergency Clinicians - 03-23-20
Recent data from the CDC suggests younger patients (20-44 years of age) are not as immune to significant disease as previously reported and have up to a 20% hospitalization rate; however, children aged < 18 years are generally spared from significant morbidity or mortality.
In preparation for the arrival of patients suffering from COVID-19, emergency departments (EDs), hospitals, and healthcare systems should make immediate and necessary structural and process changes to prepare for high volumes of patients, primarily in respiratory distress, who will require mechanical support. Lots of guidance listed in the paper.
https://www.ebmedicine.net/topics/infectious-disease/COVID-19
I am going to include this next link simply because I would like to see more testing. This link is not for anyone but those who work in an environment with access to a lab capable of testing for covid-19. It is a materials link to help them to become certified to test. There are likely more updated forms of testing,but this may help a lab get certified so I am posting it.
https://www.seracare.com/AccuPlex-SARSCoV2-Reference-Material-Kit-0505-0126/
French took a look at viable virus on surfaces and in the air. They used 3 studies to do so including the NIH/CDC study.
They came to almost the same conclusions as our most recent CDC with slightly longer times. For example 4 hours in the air and 2 days 8 hours on aluminium.
Again like the US study it was not when all viable virus was gone,but when it was reduced by 50%.
https://www.lemonde.fr/les-decodeur...ectieux-sur-des-surfaces_6034549_4355770.html
Last edited:
I'm changing shifts and will be working Sunday-Thursday starting Sunday. If you come in the Indianapolis VA Med Center be nice to the screener asking questions, it might be me.
You must spread some Reputation around before giving it to jsx1043 again.
Yes. Yes we are allowed.
I think if you’re willing to take in information and not care about sides or ideology, just take everything in and accept the facts into evidence, you’ll probably be somewhere in between. It’s not just the ***damn flu. It’s not all doom and gloom. There are some facts that support a bit of each. If you’re eager to accept all the facts that support one way, and reluctant to accept any facts the other way, you’re gonna be stuck with an unrealistic outlook.
I think sadly this may be the political way forward(they may not be honest with you if they actually follow this plan).I do not think it is wise,but it does seem to be the direction we are headed.
In this new model they show how to spread out infections and keep hospitals just slightly under capacity...until 2022.
They are saying worst case every month we stop social distancing and work for 1 week until the end of 2022.Worst case anymore than that and hospitals lose all relevance as they are overwhelmed.
Best case. We end social distancing for one month at a time until January of 2021 working one month and everyone staying home the next,and hospitals would still be functional.
I only mention this study because I would like you to understand the choices being presented to those in government.
Is this politically viable? Depends on how they sell it to politicians honestly. They may think it is.
Will the public follow it? I seriously doubt it.
It does seem the way we are headed though.
This is not a preprint,this is a peer reviewed model and study.
Lots of charts,graphs,and information about how they came to these conclusions in the study.
https://www.medrxiv.org/content/10.1101/2020.03.22.20041079v1.full.pdf+html
Department of Immunology and Infectious Diseases, Harvard
A single period of social distancing will not be sufficient to prevent critical care capacities frombeing overwhelmed by the COVID-19 epidemic, because under any scenario considered itleaves enough of the population susceptible that a rebound in transmission after the end of theperiod will lead to an epidemic that exceeds this capacity. This resurgence could be especiallyintense if it coincides with a wintertime rise in R0. Intermittent social distancing can maintain theprevalence of critical COVID-19 illness within current capacities, but this strategy could prolongthe overall duration of the epidemic into 2022
In this new model they show how to spread out infections and keep hospitals just slightly under capacity...until 2022.
They are saying worst case every month we stop social distancing and work for 1 week until the end of 2022.Worst case anymore than that and hospitals lose all relevance as they are overwhelmed.
Best case. We end social distancing for one month at a time until January of 2021 working one month and everyone staying home the next,and hospitals would still be functional.
I only mention this study because I would like you to understand the choices being presented to those in government.
Is this politically viable? Depends on how they sell it to politicians honestly. They may think it is.
Will the public follow it? I seriously doubt it.
It does seem the way we are headed though.
This is not a preprint,this is a peer reviewed model and study.
Lots of charts,graphs,and information about how they came to these conclusions in the study.
https://www.medrxiv.org/content/10.1101/2020.03.22.20041079v1.full.pdf+html
Department of Immunology and Infectious Diseases, Harvard
A single period of social distancing will not be sufficient to prevent critical care capacities frombeing overwhelmed by the COVID-19 epidemic, because under any scenario considered itleaves enough of the population susceptible that a rebound in transmission after the end of theperiod will lead to an epidemic that exceeds this capacity. This resurgence could be especiallyintense if it coincides with a wintertime rise in R0. Intermittent social distancing can maintain theprevalence of critical COVID-19 illness within current capacities, but this strategy could prolongthe overall duration of the epidemic into 2022
Last edited:
[FONT=&]“When this is all over, the NHS England board should resign in their entirety.” So wrote one National Health Service (NHS) health worker last weekend. The scale of anger and frustration is unprecedented, and coronavirus disease 2019 (COVID-19) is the cause. The UK Government's Contain–Delay–Mitigate–Research strategy failed. It failed, in part, because ministers didn't follow WHO's advice to “test, test, test” every suspected case. They didn't isolate and quarantine. They didn't contact trace. These basic principles of public health and infectious disease control were ignored, for reasons that remain opaque.
The UK now has a new plan—Suppress–Shield–Treat–Palliate. But this plan, agreed far too late in the course of the outbreak, has left the NHS wholly unprepared for the surge of severely and critically ill patients that will soon come. I asked NHS workers to contact me with their experiences.
Their messages have been as distressing as they have been horrifying. “It's terrifying for staff at the moment. Still no access to personal protective equipment [PPE] or testing.” “Rigid command structures make decision making impossible.” “There's been no guidelines, it's chaos.” “I don't feel safe. I don't feel protected.” “We are literally making it up as we go along.” “It feels as if we are actively harming patients.” “We need protection and prevention.” “Total carnage.” “NHS Trusts continue to fail miserably.” “Humanitarian crisis.” “Forget lockdown—we are going into meltdown.” “When I was country director in many conflict zones, we had better preparedness.” “The hospitals in London are overwhelmed.” “The public and media are not aware that today we no longer live in a city with a properly functioning western health-care system.” “How will we protect our patients and staff…I am speechless. It is utterly unconscionable. How can we do this? It is criminal…NHS England was not prepared…We feel completely helpless.”[/FONT]
[FONT=&]
[/FONT]
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30727-3/fulltext
Sadly I think I may know another country in the same situation.
Unrelated. Choir of 60 meets for practice,and practices social distancing. No hugging,no hand shakes,no touching each other.Hand sanitizer provided even.No one who was symptomatic came to the practice. March 10th.
Of those who attended 45 have now developed symptoms.27 have tested positive by 3/26. Washington state Skagit Valley Chorale, based in the rural valley north of Seattle
https://www.nytimes.com/live/2020/c...0-people-show-up-for-practice-now-45-are-sick
The UK now has a new plan—Suppress–Shield–Treat–Palliate. But this plan, agreed far too late in the course of the outbreak, has left the NHS wholly unprepared for the surge of severely and critically ill patients that will soon come. I asked NHS workers to contact me with their experiences.
Their messages have been as distressing as they have been horrifying. “It's terrifying for staff at the moment. Still no access to personal protective equipment [PPE] or testing.” “Rigid command structures make decision making impossible.” “There's been no guidelines, it's chaos.” “I don't feel safe. I don't feel protected.” “We are literally making it up as we go along.” “It feels as if we are actively harming patients.” “We need protection and prevention.” “Total carnage.” “NHS Trusts continue to fail miserably.” “Humanitarian crisis.” “Forget lockdown—we are going into meltdown.” “When I was country director in many conflict zones, we had better preparedness.” “The hospitals in London are overwhelmed.” “The public and media are not aware that today we no longer live in a city with a properly functioning western health-care system.” “How will we protect our patients and staff…I am speechless. It is utterly unconscionable. How can we do this? It is criminal…NHS England was not prepared…We feel completely helpless.”[/FONT]
[FONT=&]
[/FONT]
https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30727-3/fulltext
Sadly I think I may know another country in the same situation.
Unrelated. Choir of 60 meets for practice,and practices social distancing. No hugging,no hand shakes,no touching each other.Hand sanitizer provided even.No one who was symptomatic came to the practice. March 10th.
Of those who attended 45 have now developed symptoms.27 have tested positive by 3/26. Washington state Skagit Valley Chorale, based in the rural valley north of Seattle
https://www.nytimes.com/live/2020/c...0-people-show-up-for-practice-now-45-are-sick
Last edited:
A RN friend shared this with me of a colleague:
"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 ***** 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
Supportive
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."
"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 ***** 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
Supportive
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."
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