Posted on 03/29/2020 4:18:02 AM PDT by Liz
“I am an Emergency Room MD in New Orleans, UNC 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 and taste, 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
Worldwide 86% of covid-19 patients that go on a ventilator 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 (hydroxy-chloroquine) 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.
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."
Yes this is a serious illness. It so far is not as bad as H1N1 was when it
came through. it may get there we will see. However it is not worth the rank panic and fearmongering running rampant through the country and on this board. I am so tired of nonmedical or long retired medical professionals from unrelated fields calling me names and a liar and breathlessly provided false information I could vomit. Everyone needs to go sit in the corner and take a deep breath, and to shut up if the are speculating and are not part of the solution. Thank you for your common sense comment.
I had to spend time looking up a bunch of the medspeak but it was worth it.
I agree with you.
For me, since I am basically lazy, it's a lot easier to do what it takes to NOT get it, than to deal with what it takes to recover or die if I have it.
So, Bubba pandered to queers
They will do fine. Most that need oxygen do not end up on vents, if they feel worse they can come back. You do what you have to. It is standard practice to admit everyone with meningitis to the hospital. The first year we had west Nile meningitis in our community I was sending 3-4 people a day with clinical meningitis home without even a spinal tap, They were fine. You do what you have to with what is going around In the community. I will say I live in one of the hot spots (not NY) and yes we have a fair number of Covid cases in house but our hospitals are largely empty. Other than woefully inadequate PPE we are doing fine.
As I was reading the article, it struck me that that this was written by a group of first/second year medical students who did some research then posted this to show how smart they are. ;o)
Heh.....you got that right.
It is telling, that NOT ONCE during her ill-fated 2016 campaign did Hillary mention the “fine work of Bill and the C/F.”
Funny, I had an extended conversation yesterday with a good friend who is also an ER physician in a small community in SE Ill.
His experience is somewhat at odds with this fellow on a couple of issues.
1. The percentage of serious cases requiring hospitalization and turning critical has been 90% mild/10%/3%.
2.His experience with the efficacy of HCQ/Z-Pac has been nothing short of impressive. He has been so pleased with the combo as an effective treatment that he’s begun prescribing it as a prophylactic for those most likely to be exposed.
Oh and btw, he has tested positive for the COVID-19 antibodies.
That's very true, and it has nothing to do with the practice of medicine.
I’ll say this. In all my years I never saw ONE ER doc come up to the ICU to see how his patient was doing. That’s not quite true. There was the prostitute with the tattoo of a heart and “Daddy” in it. They all came up to see her.
More knowledge acquired.
Thank you, FRiend.
May God keep watch.
Tatt
The multiple manifestations of the virus and its severity are indeed alarming.
They need to nail that down.....geography, medical history, contamination? What?
IMHO the social changes this disease will precipitate will be under pressure from every source. Doctors will be only one. Something tells me today’s doctors won’t be able to defend the profession.
You got that right. Just his claim of knowing how these patients did after admission does not ring true. They intubate them and send them up unless they are too busy to intubated and they leave it to us. Then on to the next patient. Particularly when they are as busy as this guy says
Can we assume the lady’s tattoo was on an unmentionable place?
LOL.
You, too. Stay safe.
Y/V/W.
No. It was right out there. Right deltoid.
No. It was right out there. Right deltoid. I’d tell you what she died from but it would be nasty.
Oh....OK.
I have been yelled at by some of the best surgeons there are as a function of where I trained. I can tell you that when they are yelling and screaming I politely ask them to finish their art project while I try the hell to save the patients life.
My favorite surgeon anesthesia quips:
1. Surgeon. Damn it patient is moving
Anesthesiologist. Good. That’s a sign you haven’t killed him yet
2. Surgeon. Where is the bleeding coming from
Anesthesiologist. No idea. But I am guessing it has some to do with that big knife you just used
3. Anesthesiologist. Where is the bleeding form
Surgeon. Not bleeding. Just oozing (asks for suture)
Anesthesiologist. Wow. I never learned how to suture oozing
4. Anesthesiologist. Case is canceled
Surgeon. You can’t cancel my case
Anesthesiologist. You are right. Anesthetic is cancelled. Feel free to proceed.
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