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."
Our data suggest the possibility of extended duration of viral shedding
in faeces, for nearly 5 weeks after the patients' respiratory samples
tested negative for SARS-CoV-2 RNA. Although knowledge about the
viability of SARS-CoV-2 is limited,the virus could remain viable in the environment for days, which could
lead to faecal–oral transmission, as seen with severe acute respiratory
virus CoV and Middle East respiratory syndrome CoV
Mutation accumulation in SARS-CoV-2 strains as of 26Mar20 from nextstrain.org/ncov
The picture above shows the length of the genome (0 to 29,000 bases)
and the bars above show how many mutations have been detected at a given
nucleotide. The long, color coded bars underneath represent the protein
produced by that section of the virus.
Now, the analysis, by someone who knows their onions.
Overall, we’re seeing what you would hope to see in a virus, a lot of
broad, non-specific mutation locations. This means there is no
particular pressure on the virus to change an aspect of its proteins
rapidly.
Overall, we’re looking at wonderful news for
people developing treatments and vaccines. While this virus is mutating,
it’s not showing anything dangerous or anything that can prevent
treatments from working in the near future. The virus will continue to
spread, but we’ll continue to monitor it; as the virus accumulates more
isolated differences, we’ll even be able to tell where a case was from
based on its unique sequence.
There is concern about the ability of this disease to reinfect
someone after they recover from an initial bout of COVID-19. I am no
virologist and can’t say it won’t happen in the future, but for now it
looks like that isn’t possible. While there have been some reports of
reinfection in people, it could be that they had false negative test
results or just hadn’t quite recovered as much as they thought they had,
leading people to be readmitted to the hospital. A trial performed in
monkeys showed no signs of a second infection after the monkey was
initially exposed, which is great news for us.
A summer marked by hazardous air quality and bushfire smoke may have
cost 31 Canberrans their lives, according to a new study published in
the Medical Journal of Australia.
The study did not analyse pre-existing conditions but measured what
public health experts describe as “excess deaths”, or the factor by
which observed mortality rates exceed expected mortality rates when
major risks like heatwaves, bushfires, pandemics, famine or war are
present.
The study estimated that in the ACT, 229 people were admitted to
hospital – 82 for cardiovascular problems, and 147 for respiratory
problems – while 89 people attended the emergency department because of
asthma-related issues.
There were a total of 417 estimated excess deaths because of the
bushfire smoke and 4,456 hospitalisations and emergency department
visits across NSW, Queensland, Victoria and the ACT.
Between October 2019 and February 2020, the concentration of PM2.5 –
fine particles that irritate the respiratory system – exceeding the 95th
percentage of historical daily averages was recorded by at least one
air-quality monitoring station on 94 per cent of days.
More than a third of Canberra’s summer was spent with air quality
levels above hazardous as bushfire smoke blanketed the ACT. Canberra
regularly had the world’s worst air quality levels on days throughout the 2020 bushfires.
The air quality in Canberra reached 22 times the hazardous threshold
on New Year’s Day, dragged across from the South Coast by unrelenting
easterlies.
And now to the fast moving situation regarding COVID-19.
One person who was diagnosed with the COVID-19 virus has made a full recovery and is now out of self-isolation.
An ACT Health spokesperson confirmed the good news early this afternoon. The person was first diagnosed on 12 March.
“This person has now shed the virus and is no longer required to self-isolate,” the ACT Health spokesperson said.
However, the number of confirmed cases of COVID-19 in the ACT in the
past 24 hours continues to rise, with a further nine people testing
positive.
This brings the ACT’s total to 53 people with the virus.
The new cases include six males and three females, aged between 21 and 83.
“ACT Health is undertaking thorough contact tracing but can confirm
that eight of the cases are linked to overseas travel, including cruise
ships, and one is a close contact of a confirmed case,” ACT Health said
in a statement.
ACT Health said there is still currently no evidence of community transmission in the ACT.
There have been 3219 negative COVID-19 tests in the ACT to date.
There are currently three
COVID-19 patients in the Canberra hospital. All are in a stable
condition. The rest are isolating at home with ACT Health support.
Aside from not adhering to an intent-to-treat design, here’s where the study is truly revealed to be crap.....
But like Chicken Soup, it can't hurt, right? Welll..not usually... but sometimes it does hurt.
Hydroxychloroquine (trade name Plaquenil) is a derivative of
chloroquine (trade name Aralen), a common antimalarial drug. Indeed,
some of you reading this might well have taken chloroquine as
prophylaxis to prevent malaria
while traveling to tropical regions where the disease is endemic. It is
also used to treat amoebic liver abscesses when other drugs used for
such infections are not working. These drugs also mildly suppress the
immune system, which is why they are used as part of the treatment of
some autoimmune disorders, such as lupus erythematosis or rheumatoid
arthritis.
One thing that should be understood is that these are not
entirely benign drugs. They have a number of side effects and adverse
reactions. In addition to more mild side effects, such as nausea,
headache, loss of appetite, and diarrhea, there are two more severe
potential side effects. One is that long term use of these drugs can
damage the retina and lead to macular degeneration, which is why
patients taking these drugs long term need regular ophthalmological
examinations. They can also affect the heart by prolonging the QT interval and also lead to drug-induced torsade de pointes, a potentially lethal ventricular tachycardia.
The other drug in the combination, azithromycin
(trade names Zithromax, Azithrocin, and others), is a common
antibiotic, used to treat a number of infections, ranging from ear
infections, to strep throat, pneumonia, and a number of sexually
transmitted infections, including chlamydia and gonorrhea. It’s commonly
prescribed as a “Z-Pak,” to be taken for five days, and it’s widely prescribed.
It can also be used to treat malaria. It has few adverse side effects,
but it shares one with hydroxychloroquine: QT-segment prolongation.
Indeed, the FDA issued a warning
in 2013 that azithromycine “can cause abnormal changes in the
electrical activity of the heart that may lead to a potentially fatal
irregular heart rhythm.” The warning further cautioned that people with
certain pre-existing conditions are at particular risk, such as those
with QT interval prolongation, low potassium or magnesium levels, a
slower than normal heart rate, or those who use certain drugs to treat
abnormal heart rhythms.
A number of doctors on Twitter were alarmed at the suggestion that
two drugs that can affect heart rhythm be taken together without much
stronger evidence that they were effective....
When asked if he would make the decision to loosen social-distancing
recommendations even if it went against the advice of federal public
health officials, Trump said: “If it was up to the doctors they might
say shut down the entire world.”
The US at time of posting has had over 43,000 cases, some 550 deaths, with 1000 in serious or critical condition.
Q: You’re standing there saying nobody should gather with more than 10 people and there are almost 10 people with you on the stage. And there are certainly more than 10 journalists there asking questions.
A: I know that. I’m trying my best. I cannot do the impossible.
Q: What about the travel restrictions? Trump keeps saying that the travel ban for China, which began 2 February, had a big impact on slowing the spread of the virus to the United States and that he wishes China would have told us 3 to 4 months earlier and that they were “very secretive.” (China did not immediately reveal the discovery of a new coronavirus in late December 2019, but by 10 January, Chinese researchers made the sequence of the virus public.) It just doesn’t comport with facts.
A: I know, but what do you want me to do? I mean, seriously Jon, let’s get real, what do you want me to do?
That was from an interview with Dr Fauci,director of the National Institute of Allergy and Infectious Diseases and apparently nanny to the toddler in chief in Science Magazine
Brazil’s far-right president, Jair Bolsonaro,
has accused his political foes and the press of purposefully “tricking”
citizens about the dangers of coronavirus, as Latin America braced for a
spike in the number of deaths.
The pandemic has claimed nearly 15,000 lives
across the globe and looks set to exact a deadly toll on Latin America
in the coming weeks, with many regional governments closing borders and
shutting down major cities in a desperate bid to limit the damage.
But Bolsonaro has resisted such drastic measures, dismissing media
“hysteria” over coronavirus and calling the illness “a little flu”.
In a tetchy television interview
on Sunday night Bolsonaro again downplayed the pandemic and attacked
the governors of key states including Rio de Janeiro and São Paulo who
have ordered residents to stay at home and are imposing quarantines.
“The people will soon see that they were tricked by these governors
and by the large part of the media when it comes to coronavirus,”
Bolsonaro said, as his own health officials announced 25 deaths and
1,546 cases of coronavirus in Brazil.
As the National President of the Pharmaceutical Society of Australia
(PSA) representing Australia’s 32,000 Pharmacists, we are providing this
open letter to all Australian prescribers regarding the Prescribing hydroxychloroquine for COVID-19.
On the background of some promising data showing the effectiveness of
hydroxychloroquine for the treatment of COVID-19 and with President
Trump’s announcement yesterday, 20 March 2020, that the drug hydroxychloroquine may
support the care of patients affected by COVID-19, Australian community
pharmacies have seen unprecedented demand for the drug.
PSA is receiving reports from Australian pharmacists that they are
receiving prescriptions from: doctors prescribing for other doctors and
their families; as well as dentists prescribing to the community and
their families; Non-medical prescribers prescribing bulk amounts of the
drug. If this medication does indeed have the efficacy that we would
desire against COVID-19 then it needs to be prescribed and used
judiciously. The stock of this medication needs to be managed
effectively and utilised for those who may genuinely need it.
Our strong advice to pharmacists at this point in time, until further
advice is available, is to refuse the dispensing of hydroxychloroquine
if there is not a genuine need, and that need is for those indications
for what it is approved for – inflammatory conditions or the suppression
and treatment of malaria The current stock of hydroxychloroquine needs
to be managed sensibly, it needs to be available for those who are
currently being prescribed this medicine, and it may also be needed for
treatment of COVID-19 in the future. We are urging pharmacists to manage
their existing stock if they have it sensibly, ensuring those who are
currently prescribed the medicine have an existing supply.
PSA will continue to work with the Minister for Health and the
Therapeutic Goods Administration (TGA) with regards to the appropriate
management of national stockpiles and medicines stock in Australia. PSA
would like to keep safe any stock of hydroxychloroquine held in local
pharmacies – so it is available to treat patients who genuinely need
this medicine. The only way this is possible is for prescribers to not
write prescriptions for this medicine as a ‘just in case’ measure and
for pharmacists to refuse the supply outside of these indications at
this point in time.
While the data may not yet be clear, if hydroxychloroquine is shown
to be effective for COVID-19, we want every dose available to treat
those who may require it.
Yours sincerely,
Associate Professor Chris Freeman
PSA National President
The
outbreak of the respiratory virus began in China and was quickly spread
around the world by air travelers, who ran high fevers. In the United
States, it was first detected in Chicago, and 47 days later, the World
Health Organization declared a pandemic. By then it was too late: 110
million Americans were expected to become ill, leading to 7.7 million
hospitalized and 586,000 dead.
That
scenario, code-named “Crimson Contagion” and imagining an influenza
pandemic, was simulated by the Trump administration’s Department of
Health and Human Services in a series of exercises that ran from last
January to August.
The simulation’s sobering results — contained in a draft report dated October 2019
that has not previously been reported — drove home just how
underfunded, underprepared and uncoordinated the federal government
would be for a life-or-death battle with a virus for which no treatment
existed.
The draft report, marked “not to be
disclosed,” laid out in stark detail repeated cases of “confusion” in
the exercise. Federal agencies jockeyed over who was in charge. State
officials and hospitals struggled to figure out what kind of equipment
was stockpiled or available. Cities and states went their own ways on
school closings.
Many of the
potentially deadly consequences of a failure to address the shortcomings
are now playing out in all-too-real fashion across the country.
I'd say "Remember in November", but by then a million Americans (at least) will have died, and holding any Free and Fair election would be impossible. Anything involving massed crowds in polling booths and lines to get in them would be dangerous lunacy, so if elections are held at all, the way of doing them will have to change radically.
Those who criticised Trump for his action in banning travellers from China were wrong, and should admit it. If they don't, they are not to be trusted.
Those who now criticise the measures being taken far too late are not to be trusted.
Those who believe the obvious untruths continually being spouted by the GOP and Trump - you are responsible for this being as bad as it's going to be. Not for the first million deaths perhaps, half a million would have died even if everything had been done right. But for the millions after that, because Reality wins in the end, and the Con game finishes eventually.
We were living in trees when they met us. They showed us each in turn
That Water would certainly wet us, as Fire would certainly burn:
But we found them lacking in Uplift, Vision and Breadth of Mind,
So we left them to teach the Gorillas while we followed the March of Mankind.
We moved as the Spirit listed. They never altered their pace,
Being neither cloud nor wind-borne like the Gods of the Market Place,
But they always caught up with our progress, and presently word would come
That a tribe had been wiped off its icefield, or the lights had gone out in Rome.
With the Hopes that our World is built on they were utterly out of touch,
They denied that the Moon was Stilton; they denied she was even Dutch;
They denied that Wishes were Horses; they denied that a Pig had Wings;
So we worshipped the Gods of the Market Who promised these beautiful things.
We estimate 86% of all infections were undocumented (95% CI: [82%–90%]) prior to 23 January 2020 travel restrictions. Per person, the transmission rate of undocumented infections was 55% of documented infections ([46%–62%]), yet, due to their greater numbers, undocumented infections were the infection source for 79% of documented cases.
Actually, I am a Rocket Scientist.
Also hormonally odd (my blood has 46xy chromosomes anyway) and for most of my life, I looked male, and lived as one, trying to be the best Man a Gal could be. Anyway, in May 2005 that started changing naturally for reasons still unclear, and I'm now Zoe, not Alan : happier and more relaxed not to have to pretend any more.
UPDATE - reason now identified as the 3BHSD form of CAH.
This blog, written by a rocket scientist, is a fascinating collection of information, both personal and scientific, regarding intersex, transsexualism and related psychosocial and psychosexual issues. ... It is erudite and heartfelt. Just read the posts about the passport issue. You won't know whether to laugh, weep or crawl into a ball and rock gently in a corner - an amazing person. - David --- The reason I so appreciate bright, perceptive people - as opposed to ideologues whose intelligence does little to illuminate - is that they manage to both instruct and learn with a certain grace. Among such rarities in the transblogosphere is Zoe, whose direct speech and clear humanity always make her worth reading, even if one doesn’t always agree with her every conclusion. - Val --- The following is a request for permission to archive your A.E.Brain blog site which we have wanted to do for several years... The Library has traditionally collected items in print, but it is also committed to preserving electronic publications of lasting cultural value.... Since (1996) we have been identifying online publications and archiving those that we consider have national significance.... We would like to include A.E.Brain blog site in the PANDORA Archive... -Australian National Library
