Coronavirus in the US

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This is true for many medical recommendations, though. Our medical community has decided (maybe rightfully so) that the general American public is too dumb to follow anything more complicated than a simple sentence. So they decline to make recommendations that require critical thinking, if/then scenarios or complexity. Recommendations are kept simple and absolute, even if that means a reasonable subset of indicators are not communicated so people can decide what fits their personal situation.

I will search for it, but there was a very interesting article about this written by one of the doctors who participated in the discussions over how to phrase the recommendations regarding alcohol consumption. At the time, there were a reasonable number of studies that indicated moderate alcohol consumption reduced the rusk of certain conditions/diseases. But “moderate” was complicated to define, differed for men and women, plus there was the fear that people wouldn’t read/comprehend/follow the details of what moderate meant and would just take the recommendation as a blanket endorsement of all drinking. So the decision was to not recommend any drinking, even though their evidence clearly indicated a benefit for certain amounts of drinking.

IMO, it’s the same issue with the masks. The American health officials do not trust Americans to have enough brain cells to understand and follow a very simple directive. That doesn’t mean the absolute best advice is that nobody but healthcare workers should ever wear a mask, it means that’s the simplest advice they could come up with that’s understandable by the public.

It’s frustrating to live in a society where the medical community has so little regard for the intelligence of the average citizen that it would rather KISS at the expense of giving detailed, complicated, comprehensive information to the public.

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https://www.nytimes.com/2020/03/28/us/politics/coronavirus-second-homes.html

This is another story about one area’s attempt to keep away people with second homes and holiday visitors. The state is mine, Wisconsin. The unwelcome attitude bothers me, but I understand it from the point of view of trying to prevent pressure on local health-care facilities.

“Health officials said the main hospital had capacity for 25 patients and could surge up to only about 50 if needed. Just four intensive care beds were available. Nurses had been beckoned to staff a local hotline that was being inundated with worried callers.”

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I don’t even know why we bother to list the numbers from China when it is clear how inaccurate they are. I mean , they have 1.4 billion people and only 80 something thousand cases , 3000 deaths ? Their leaders must really think that the world is made out of idiots. I feel bad for the poor Chinese people who have to live under such tragic circumstances.
Regarding the masks, if you cough or have any respiratory symptoms, it is best to use it, any regular mask will do. If you use only for protection, it may help by changing your behavior ( prevents from touching the nose and mouth ) or if somebody in proximity keeps coughing, otherwise it is not very useful and you waste resources.
For procedures that generate a lot of particles ( specimen collection and especially intubation )N95 and face shield are best.

11704

The average person doesn’t know how to use masks. I saw someone on TV helping out with the food line. He had a surgical type mask on. Problem was he had a huge beard.

When my dad was on a mine rescue team they had a no beard policy. Can’t get a good seal with the air masks.

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…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…
this article very long so I edited it will post link

, 3/25/20

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.

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.

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.

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http://texags.com/forums/84/topics/3102444
link for above

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@Charlotte44 Thanks for such a detailed info post.

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Thank you Charlotte. That’s the best, most comprehensive description I’ve seen of the disease, its progression, and current treatment protocols.

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I share some of your skepticism about the Chinese numbers, but I’m also skeptical about the numbers here in the US. Every state and municipality has different testing standards, and tests at different speeds. The turnaround times are also very different in different locations. There’s no central repository of data and CDC has given up on aggregating the numbers, as local data are collected and reported differently. It’s highly conceivable the actual number of infected in this country is multiple times of the reported number.

In China, the actual number of infected, and perhaps deaths, were also possibly multiple times of the reported numbers. If that’s true, doesn’t that mean they’ve done even better job controlling the spread, given that normalcy is gradually returning over there?

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They were right. We are idiots. WHO gave out a medal to China for doing a good job. Actually, we are worse idiots.

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Why is that? I have a friend who has a heart issue. The virus may present through the heart.

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Some good news since we need it. Italy may be free of new cases by middle of May.

https://www.msn.com/en-us/news/world/italy-could-be-free-of-new-covid-19-cases-by-may-16-experts-predict/ar-BB11XLll?li=BBnb7Kz&ocid=mailsignout

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I supposed they should get a medal from their own people, but a hammer from the rest of the world.

If they communicated clearly and loudly and provided visibility and transparency to the severity of the problem, how easy it is to spread, how their people have traveled to the US and the rest of the world…Then maybe the rest of the world would have more time to react and prepared and take it more seriously? Maybe, maybe not. But we would never know since they lied so much.

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Re masks: at the grocery store yesterday I was interested to note that every young couple shopping were wearing masks. Not the older people. Remember when you see a citizen wearing a mask they could easily be left over from a painting job, home DIY job as those masks were available at HD until recently. People reuse them. Whether that works or not. Or whether they are worn correctly or not.
Also I went to walk in clinic just a few weeks ago and they were requiring you to put on a paper mask. We saved ours. Not everyone wearing a mask is a hoarder.

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I agree. Where is the detailed info like the US doctor above? Where are the studies? They should have been shouting this from the rooftops to WHO and others. Shame on the Chinese for not only lying about the infections in the beginning, their case numbers throughout, but also not being forthcoming about the process. I still think governments should be nice to them for the time being so they can share anything they might have regarding anti-virals, cures etc…

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One grocery chain put out a request that only one person in a household shop…not the whole family r even a couple. Their message…one carriage one person.

I agree.

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I got very suspicious about the Chinese numbers when the patients in one of the first studies had a very low % if smokers. Given China’s very high smoking rate, that selection would not be representative of the entire population… I suspect that was possibly due to giving hospital admissions priority to certain people… I will stop at that because it is just my speculation.

I expect that when the dust eventually settles, a lot of publications will bite the dust. The Retraction Watch will have a field day.

https://retractionwatch.com/2020/03/28/weekend-reads-why-coronavirus-papers-need-a-warning-label-scientists-correct-the-record/

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[QUOTE=""]
worldwide 86% of covid 19 patients that go on a vent die<<<<<<<https://texags.com/forums/84/topics/3102444

[/QUOTE]

This goes back to this overhyped notion of having the public focus on vents as a product we are short of. Maybe it is part of the ADD of the public that they can’t really process this sort of information. It won’t really matter how many vents are produced now.

Death plans;
https://www.telegraph.co.uk/news/2020/03/27/elderly-coronavirus-patients-should-talk-families-whether-want/

Other than the bit about having a choice about getting an ICU bed (that won’t be a thing) Families need to have some drugs at home to make people comfortable when they can die at home, there will be no hospice nurse, we need to be able to tool family members to be able to access and administer such drugs.

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What the physician in New Orleans describes in the same as what my ICU friends are describing. Lungs sound relatively clear and the patient is breathing over 30 times/minute with low oxygen. The ARDS survival chances seems to be same as with other causes of ARDS : if you are young and healthy, you are more likely to make it. If you are old and/or have other medical issues, you have much lower chance.

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And now Chris Cuomo has it.