#1 Would be taking it seriouslyQuote:
Originally Posted by D-West & PO-Z
Printable View
#1 Would be taking it seriouslyQuote:
Originally Posted by D-West & PO-Z
WAIT! Are suggesting people skip Spring Break and Mardis Gras in the face of a GLOBAL PANDEMIC? We can’t steal their fun!Quote:
Originally Posted by Mrs. Garrett
I hope they learn, but I’m not confident.
A fiasco in the making? As the coronavirus pandemic takes hold, we are making decisions without reliable data:
https://www.statnews.com/2020/03/17/...reliable-data/
A credentialed author, for those who make their decisions based on ad hominem reasons rather than reason itself:
John P.A. Ioannidis is professor of medicine and professor of epidemiology and population health, as well as professor by courtesy of biomedical data science at Stanford University School of Medicine, professor by courtesy of statistics at Stanford University School of Humanities and Sciences, and co-director of the Meta-Research Innovation Center at Stanford (METRICS) at Stanford University.
Regarding the mortality rate (please read the entire article before commenting on this one quote):
The one situation where an entire, closed population was tested was the Diamond Princess cruise ship and its quarantine passengers. The case fatality rate there was 1.0%, but this was a largely elderly population, in which the death rate from Covid-19 is much higher.
Projecting the Diamond Princess mortality rate onto the age structure of the U.S. population, the death rate among people infected with Covid-19 would be 0.125%. But since this estimate is based on extremely thin data — there were just seven deaths among the 700 infected passengers and crew — the real death rate could stretch from five times lower (0.025%) to five times higher (0.625%). It is also possible that some of the passengers who were infected might die later, and that tourists may have different frequencies of chronic diseases — a risk factor for worse outcomes with SARS-CoV-2 infection — than the general population. Adding these extra sources of uncertainty, reasonable estimates for the case fatality ratio in the general U.S. population vary from 0.05% to 1%.
The author does a great job speaking to the consequences of being wrong:
One of the bottom lines is that we don’t know how long social distancing measures and lockdowns can be maintained without major consequences to the economy, society, and mental health. Unpredictable evolutions may ensue, including financial crisis, unrest, civil strife, war, and a meltdown of the social fabric. At a minimum, we need unbiased prevalence and incidence data for the evolving infectious load to guide decision-making.
Principal
Thanks, that was interesting.
Biggest problem seems to me to be that we can't test everyone to get the best handle on how pervasive it really is.
Or I guess, even test a random sample to statistically project that answer.
Meanwhile, he wrote that on March 17th when he noted 68 deaths nationally.
11 days later we have 1600 deaths nationally, at 2% of tested cases.
I wonder if there is enough data to know the mortality rate with proper treatment vs no treatment? If the ICU beds are not available for the percent that need them, I would have to imagine the mortality rate would jump significantly as compared to if we have sufficient ICU beds and ventilators to treat those that need it.
Also can't exactly stop having heart attach when the ICU is full.
That certainly is an interesting perspective. And I wish it were true and actually going to play out that way. The problem is that that study takes a very small isolated population it does not take into account the high level of infection in contagious quality of this organism. The reason this kills people is it overwhelms healthcare systems. The small amount of people on an isolated cruise ship in general will not overload a healthcare system. Also, why don’t you just do a Google search on for dead coronavirus Holland cruise ship and you’ll find a much more somber story.Quote:
Originally Posted by principal
I think this might provide some real world perspective of what is going on. This is a copy and pasted email I received from the ER doc in New Orleans
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."
kmcrawfo, thanks for sharing that doctor's experiences in the ER.Quote:
Originally Posted by kmcrawfo
I found the above sentence the most disturbing, given the increasing need for ventilators in our country right now,
That was the most disturbing part of the information for me as well. Well ventilators may extend life against this virus, they don’t seem particularly effective at saving lives unfortunatelyQuote:
Originally Posted by paulxu
In Ohio, 17% of confirmed cases are healthcare workers. That’s a lot... We currently test many people that are presumed positive, which doesn’t really change anything if they are very ill. We should be routinely testing healthcare workers at least once/week.
The email from the ER doc in New Orleans is fairly frightening... There is increased evidence of this spreading in hospitals through healthcare workers as well. It makes sense to convert convention centers etc to temporary hospitals, and have teams of medical personnel to run it. Logistics remain difficult.
Ohio 3/28 update:
1406 cases
344 hospitalizations
123 in ICU
25 deaths
52 median age
After taking more than a month to get to 1000, it took two days for the next thousand dead. Scary stuff.
NY had 270 deaths in the last 24 hours. 8 days ago as an entire country we had less than that.
Don't tell Clay Travis.Quote:
Originally Posted by D-West & PO-Z
Man he just continues to double and triple down on this not being a big deal right? And he honestly thinks he is presenting just facts that say so.Quote:
Originally Posted by SemajParlor
I have a 45 min commute to work in morning and I split listening to Mike and Mike and Clay Travis. I typically disagree with a lot of things Clay says but find his show entertaining but at other times like with this he is absolutely unbearable.
I have been working from home but so havent heard what hes talking about on the show but have seen him on twitter. Its crazy.
I think part of that can be attributed to more people being tested now compared to a the previous 3-4 weeks. Still a big jump regardless.Quote:
Originally Posted by smileyy
Sent from my iPad using Tapatalk
Feel the same way here. Can probably go on and on about a lot things but will leave it that I think frankly he's been embarrassing and irresponsibly using his platform.Quote:
Originally Posted by D-West & PO-Z
This isn’t positive tests, this is deaths. There isn’t exactly a catch-up rate in deaths unless we were under reporting them before.Quote:
Originally Posted by bjf123
My bad.Quote:
Originally Posted by STL_XUfan
Sent from my iPhone using Tapatalk
Wouldn’t a positive test be needed to count in the death rate? If so, then certainly people have died of it without being tested, so yes, the death rate would have been underreported.Quote:
Originally Posted by STL_XUfan
Talking to my best friend who's a resident at a Cleveland area hospital yesterday, and they ran a sputum sample of a COVID patient and it ended up growing the mold Aspergillosis in it. I wonder how many secondary infections played a role in the mortality as well, and I wonder if areas in the US like the Ohio River Valley that has a decent chance of getting histoplasmosis/blastomycoses plays a role in outcomes, opposed to what fungal things grow in China.
I heard a Dr on CBS this morning say one solution to quarantine is a blood test people could take to see if they are immune to the virus. Those people could go back to work wi thout posing a danger to others. I'm not a Dr so I don't fully understand that, but it sounds like a good idea to me. Also are any patients being given the hydrochloriquine yet ?
Testing through blood is gaining steam but still not close to being utilized on a widespread rapid basis. It does exist though and there is some discussion on this several posts ago from Dr Crawford.Quote:
Originally Posted by JTG
There are many patients whom have received hydroxychloroquine with varied results. There are also studies on Actemra (One here in Cleveland that I have been familiar) that is targeting IL6 (check the email from Dr Crawford’s ER doc friend) to reduce the cytokine storm that has been associated with this illness.
Could you translate that last paragraph. I'm good with acct. and numbers but I was lucky to get Cs in science.Quote:
Originally Posted by Lloyd Braun
I heard an interesting thing this morning about the fatalities in Italy. The average age of those succumbing to COVID-19 there is 80. This was as of a week ago, so the average might have changed. Still, it’s an interesting fact that is not really being reported. Regardless, wash your hands and stay home!
Sent from my iPhone using Tapatalk
Sorry.... basically hydroxychloroquine has some effect but has varied data. It is far from a reliable treatment especially in the very ill. During this course of illness there seems to be an inflammatory reaction in those that are severely ill. This reaction can be measured through interleukin-6 levels in the blood. The drug Actemra inhibits this response and there have been some positive results though the population in the current study is too low.Quote:
Originally Posted by JTG
Basically, I wouldn’t rely on hydroxychloroquine to be the savior, and there is advancing treatments in the pipeline that will hopefully decrease mortality.
Ohio 3/29 update:
1653 cases
403 hospitalizations
139 ICU
29 deaths
52 median age
Apparently more than 40k died in Wuhan alone. Crazy numbers.
.....so.....enough to fill up Cintas FOUR TIMES. Insane! How do they even deal with the bodies?Quote:
Originally Posted by GoMuskies
Some more perspective from an ER doc
Where did you get that? This source shows less than that in the world:Quote:
Originally Posted by GoMuskies
https://www.worldometers.info/coronavirus/
Looks like stories are being run with Wuhan locals (just random people, not doctors) saying it must've been 40,000. Not sure that's a reliable number...Quote:
Originally Posted by Muskie in dayton
https://www.washingtonexaminer.com/n...-than-reported
Thanks. I’m certainly not surprised. It sounds like a lot of lines of evidence that point to a sad truth. It sure would have been nice if the Chinese were honest about this to help the rest of the world appreciate the situation.Quote:
Originally Posted by XU '11
The Johns Hopkins tracker I've been using is showing a pretty substantial drop in new cases from 3/27 to 3/28. Could just be a blip, but hopefully it's a good sign that we might see some decline (or at least leveling off) in the number of new cases/day.
https://www.arcgis.com/apps/opsdashb...23467b48e9ecf6
Is anyone else getting really tired of being part of a historical event?
Personally, I preferred watching the moon landing.Quote:
Originally Posted by xubrew
Yeah, it's the only think people talk about, I've had to explain so much to my Dad (he's the perfect practice for dealing with non-compliant patients to be honest), and all you see on social media, etc. unfortunately don't think there's going to anything that changes this for a while though :/Quote:
Originally Posted by xubrew
I saw that as well. Based on what we are seeing now this seems more reliable that the initial numbers we saw from China. The big question would be what the true number of infected people was. It seems its obviously quite a bit more than the ~80K that they initially reported.Quote:
Originally Posted by GoMuskies