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Thank God we didn't have this stupid ticker going on news channels during the H1N1 pandemic.
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Correct about what? I have family and friends in NYC as well. Scary times!Originally posted by revenge_of_shocka_khan View PostKung Wu say, man who read woman like book, prefer braille!Comment
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Originally posted by SB Shock View Post
16 cases in Sedgwick. That means 80 additional people with mild to no symptoms also have it here -- are they staying home?Kung Wu say, man who read woman like book, prefer braille!Comment
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As I recall at the time it was just basically "the flu" and H1N1 was just something or other that one heard about on cnn. In real time, I had it.Originally posted by NCAABound View Post
Caught it from a "contagious" patient who was in a hospital room with a family member of mine. Was visiting when the nurse came in and said "you have to leave now."Comment
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I've actually read several earlier accounts of Covid spreading in the subtropical regions. It wasn't known at the time if the disease was being seeded from travelers or community infections. The opinion was that we are hopeful it will diminish in the summer, but so far there is no evidence that it will. I believe it spreads best in the neighborhood of 45F.Originally posted by wsushox1 View Post
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Well dammit, I'm back. Since I'm one of the self-appointed dark overlords of doom and gloom and found a couple fairly gloomy articles, I thought I would share the love (errrr... doom).
This is from a Facebook medical group:
***COPIED***
"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."
Very, very serious bug we are dealing with. Looks like the Plaquenil therapy is not having much affect. I gotta hope it's due to the late administration and if people would treat it like Tamiflu and use it within the first 48 hrs. the results would be different. Otherwise, we've gotta rely on ancient tech and KEEP PEOPLE SEPARATED.
In infectious outbreaks, everything looks fine until it isn't fine.
https://www.facebook.com/itsokaytobe...3119293379367/
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Doctors And Nurses Say More People Are Dying Of COVID-19 In The US Than We Know
“The numbers are grossly underreported. I know for a fact that we’ve had three deaths in one county where only one is listed on the website,” one California ER doctor told BuzzFeed News.
In California, one ER doctor who works at multiple hospitals in a hard-hit county told BuzzFeed News, “those medical records aren't being audited by anyone at the state and local level currently and some people aren’t even testing those people who are dead.”
“We just don't know. The numbers are grossly underreported. I know for a fact that we’ve had three deaths in one county where only one is listed on the website,” the doctor said.And two of the hardest-hit areas in the nation — New York City and Los Angeles County — released guidance earlier this week encouraging doctors not to test patients unless they think the test will significantly change their course of treatment. That means that potentially more people in both places could be admitted to hospitals with severe respiratory symptoms and recover — or die — and not be registered as a coronavirus case.Doctors and nurses working in several hospitals around the country, who spoke with BuzzFeed News on the condition of not being named out of fear of repercussions, said that the official counts of COVID-19 related deaths are not comprehensive for three main reasons: a lack of tests and protective equipment means not everyone who contracted or dies of COVID-19 is diagnosed; overwhelmed hospitals may be running behind on reporting the numbers to state and county authorities; and some hospitals reporting their totals on a daily basis say they’re not being reflected promptly in county and state reports.“We have confirmed at least 5 cases in our hospital, but official state reporting only lists one case in our entire county,” said one department head at a small hospital in Mississippi, referring to patients who had tested positive for COVID-19 but were not reflected in county numbers.
Not a huge fan of Buzzfeed for Trump-related reasons, but some of the testimony shared was compelling.
I know for a fact that few countries are including the tested dead in their numbers. Places like Spain, Germany, and Iran are some I've heard about. Maybe us and China too. Italy supposedly HAS been testing their dead and including the numbers in their totals.
An interesting and disturbing account out of Spain was a situation where a nursing home was left filled with dead residents infected with Covid. Apparently the healthcare workers just said, "Fk it I'm out."
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As of Wednesday afternoon, Kansas reported 127 positive cases and 2,360 negative. Of course I believe there to be multiple orders of magnitude more infections than advertised. That would imply we should be seeing a small flood of patients in local hospitals very soon. Of course we won't know the reality until after the fact since we are flying blind and don't believe in tests in Kansas.Originally posted by SB Shock View Post
I hope my estimates are high but logically they shouldn't be due to what is known about the highly infectious nature of the virus and the fact that we aren't on an island. In fact we are far from an island as we get 6 million visitors a year into the Wichita area. You'd have to expect that one or two would come from major metropolitan cities... :P
If it ends up that we only get a smattering of infections due to some wild stroke of luck, it will really be a GREAT day to be a Wichitan.
Just in case anybody hasn't watched this yet. :P
In case you still won't watch the video, I'll spoon-feed one of the most compelling examples:
In an example of exponential growth and the lily pond; if the lily pond is completely full on day 60, the question is asked, "When will the pond be only 1% full?" The answer is day 54. So the pond (or Kansas) would seem totally devoid of infections for 54 of the first 60 days but then become totally infected over the final 6. Of course we will never see 100% infection rates due to herd immunity and social distancing, but visually, the growth rate is stunning. The pond is at 50% "infected" on day 59, doubling one more time to reach 100% on day 60.
This is why nobody can estimate the number of infections we have in the U.S., or Kansas for that matter, because we aren't testing hardly anybody. Of course the proof is in the pudding, and the pudding will be overloaded hospitals. Eventually we will know how many were infected. At this point all we can do is wait... and OVERREACT.
"I like it when people are thinking I'm overreacting because that means we're doing it just right." - Dr. Fauci
P.S. I said I was gone, but I felt the spirit move me to return. Not sure which spirit. Apologies in advance.
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It's weird that 3 or 4 weeks ago all the math nerds on here were shouting from the mountain that the exponential growth rate of this is real and the potential for crisis is real, and isolation is clearly the best bet in preventing this from becoming a medical crisis. And I would say that 100% of the math nerds still believe that.
Yet then drops in another person -- very late to the party -- who also says that isolation is the best bet for stopping it, but supports it with no math but a bunch of bad factoids, and he assumes because we are pointing them out that we don't understand the math or think that isolation is the key to preventing the crisis.
Kung Wu say, man who read woman like book, prefer braille!Comment
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Bad math? I don't know what you're talking about -- 60% of the time it works every time!!!Originally posted by Kung Wu View PostThe mountains are calling, and I must go.Comment
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The coronavirus test that wasn’t: How federal health officials misled state scientists and derailed the best chance at containment
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