Total Isolation on Bombertalk?

[grassy1]

Whilst we all have our worries with all that’s going on,must we seriously practice Social Isolation here,guys?

Or are things that bad,we can’t occasionally make a post?!

I know this Virus is Deadly Serious business,but if we can’t have the occasional chat here,things must be desperately Bad!

[Crazyman]

What’s to post? The whole f****** economy has put on hold.

[grassy1]

Yeah,I know.

Post in the not so serious thread for awhile.

Toss around a few things on how you think Governments around the world are handling this Insidious Pandemic.

Is Crikey a better reference to it,than the Mainstream Media.

Or Mediawatch!

Virus Hotspots,low spots!

How,why?

Cures,impediments to cures!

The Belarus Football League!

Only joking on that one.

[grassy1]

Oh yeah,here’s one for you Crazy.

People’s Infatuation with the Beach right now in great numbers,when there shouldn’t be!!!!!!

Particularly in Bondi and Manly.

[Crazyman]

Sorry, I agree we need to be careful, but this is a massive over-reaction globally.

It is what is, but it’s f****** stupid...

[grassy1]

Wish I could say it was an over -reaction mate,but I couldn’t believe my ears when I heard on 6PR about a young fella,who was a physically fit chap,with no underlying conditions,gone within 48 Hours!

It could be that his Immune system was doing it’s job,but the rapid action of that,did him in.

Bizarre if true.

[s'dreams]

Interesting that some pundits are saying that this is an over reaction and that we should cut he hysteria and get back to work.

Just three facts.

1. There is no native immunity for this virus - everyone who is exposed gets infected.
2. While most people have mild or even no symptoms, 1 in 7 (14.3%) people get serious symptoms requiring medical intervention.
3. Of that 1 in 7 with serious symptoms, 42% will develop pneumonia in both lungs and require significant medical intervention to obtain enough oxygen to stay alive.

That's correct, based on experience to date, 6% of the population will require hospitalization and respirators (though respirator requirements may be reduced with costly antiviral therapies which still require early medical intervention).
(This figure excludes the USA figures which because of under-testing actually inflate the rate of serious symptoms and pneumonia).

In Australia - that equates to 1,500,000 hospitalizations that will be required to avoid most of the seriously symptomatic dying (though as we have seen, many do die despite respirator and drug therapy).

Small percentages can mean very big numbers sometimes.

[BenDoolan]

There is so much information out there about Covid-19. A lot of it is brilliant, a lot of it is crap. I would like to share the ones I think are brilliant, but I won’t.

There is one thing I did see that was plain and simple. I’d like to share that...

The virus doesn’t move. People move the virus. Without people moving, the virus stop moving, and the virus will die. So stop moving / keep your distance

Pretty simple really.

Just listen and act on the medical advice and authorities.

[s'dreams]

There is so much information out there about Covid-19. A lot of it is brilliant, a lot of it is crap. I would like to share the ones I think are brilliant, but I won’t.

There is one thing I did see that was plain and simple. I’d like to share that...

The virus doesn’t move. People move the virus. Without people moving, the virus stop moving, and the virus will die. So stop moving / keep your distance

Pretty simple really.

Just listen and act on the medical advice and authorities.

It is just unfortunate that each year, an unknown number of "stoopid" are born and/or are nurtured that way... Unfortunately these people also impact on the lives of others...

Into that category I would place the group of 7 uni-aged friends I saw today in Kmart discussing the pros and cons of buying either one or two games of Twister to play during the extended "holiday".

[grassy1]

Well there’s one bunch that I can truly say to,”Get Knotted!”

[F111]

https://coronavirus.jhu.edu/map.html

[F111]

https://texags.com/forums/84/topics/3102444/2
Clinical Pearls Covid 19 for ER practitioners - Page 2 | TexAgs
Page 2 of the Clinical Pearls Covid 19 for ER practitioners discussion on the TexAgs Coronavirus/COVID-19 News & Information forum.
texags.com
Notes added in parenthesis for the layperson.

I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.

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 (general muscular pain; back pain indicated as common), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB (shortness of breath), and bilateral viral pneumonia (double pneumonia) from direct viral damage to lung parenchyma (the portion of the lung involved in gas transfer - the alveoli, alveolar ducts and respiratory bronchioles.)

Day 10- Cytokine storm (overproduction of immune cells and their activating compounds (cytokines), signaling an inflammatory response flaring out of control) leading to acute ARDS (Acute respiratory distress syndrome) 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 (poor oxygen saturation; below 90%) even 75% without dyspnea (labored breathing). I have seen Covid patients present with encephalopathy (brain injury, headache), renal (kidney) failure from dehydration, DKA (Diabetic ketoacidosis: occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic). 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 (Congestive heart failure) 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 (ST-Elevation Myocardial Infarction; serious heart attack) at all of our facilities are getting TPA (Tissue plasminogen activator used to dissolve blood clots) in the ED (Emergency Department) and rescue PCI (Percutaneous Coronary Intervention; aka angioplasty with stint) at 60 minutes only if TPA fails.

Diagnostic
CXR (Chest X-Ray)- bilateral interstitial pneumonia (anecdotally starts most often in the RLL (lower lobe of the right lung) 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 (white blood cell count) low, Lymphocytes low, platelets lower than their normal, Procalcitonin (substance produced in response to bacterial infections but also in response to tissue injury) normal in 95%.
CRP (C-Reactive Protein Test: A plasma protein that rises in the blood with the inflammation from certain conditions) and Ferritin (blood protein that indicates iron level) elevated most often. CPK (creatine phosphokinase: elevated levels indicate muscle trauma, including heart), D-Dimer (a small protein fragment present in the blood after a blood clot is degraded by fibrinolysis), LDH (Lactate dehydrogenase: plays an important role in cellular respiration, the process by which glucose (sugar) from food is converted into usable energy for our cells.), Alk (Anaplastic lymphoma kinase: plays a pivotal role in cellular communication and in the normal development and function of the nervous system), Phos (Phosphorus level: key to kidney function)/AST (Aspartate aminotransferase: released into blood when the liver or heart is damaged)/ALT (alanine transaminase: high levels can indicate a liver problem) commonly elevated.
Notice D-Dimer- I would be very careful about CT PE (CT pulmonary angiography used to detect pulmonary embolisms) these patients for their hypoxia. The patients receiving IV contrast are going into renal (kidney) 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 (type of white blood cell) count to absolute lymphocyte (type of white blood cell) 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: stimulates the inflammatory and auto-immune processes in many diseases) 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 (low blood platelet count) and LFTs (liver function test) 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 (angiotensin-converting enzyme) 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 (refers to an interval seen in an electrocardiogram (EKG) test of heart function) 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 (Bilevel Positive Airway Pressure, and is very similar in function and design to a CPAP machine )- 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 (Metered-dose inhaler). 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 (upper respiratory infection)/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 (saturated O2 level in the blood) 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.

[grassy1]

Thanks for the Imfo,F111.

Pretty heavy stuff reading how nasty this Virus can really get!

We know how deadly this can be.

Those Virologists had better hurry up.Or should I say,the pollies should hurry up assisting the virologists,cutting any unnecessary Red Tape and Not listening to any Pharmaceutical Lobby Groups screaming Blue Murder,fearing missing out in making Squillions with their cut of a Major Miracle!

[s'dreams]

Thanks for the Imfo,F111.

Pretty heavy stuff reading how nasty this Virus can really get!

We know how deadly this can be.

Those Virologists had better hurry up.Or should I say,the pollies should hurry up assisting the virologists,cutting any unnecessary Red Tape and Not listening to any Pharmaceutical Lobby Groups screaming Blue Murder,fearing missing out in making Squillions with their cut of a Major Miracle!

It is important to remember that virologists may never find a vaccine. In the mid 1980's, it was hopeful that they would find a vaccine for HIV/AIDS, and some researchers and volunteers sadly went through vaccine trials and some deliberately infected themselves. There is still no vaccine yet but with the current regime of anitvirals, the life expectancy of HIV infected is nearly identical to non-infected.

[grassy1]

That isn’t very encouraging,s’dreams!

[grassy1]

Gone quiet again here folks.

You holding your breath a bit over Cedar Meats and McDonalds?

Can hardly blame you.

Things going ok at the moment in the West(touch wood),but with this Bastard of a Virus the way it is,you never can tell!