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  #1901  
Old 29 March 2020, 13:00
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Armed vigilantes in Maine chop down tree, block driveway to force neighbor to self-quarantine amid coronavirus pandemic

https://www.foxnews.com/us/maine-cor...bor-quarantine

Shit getting Mad Max.
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  #1902  
Old 29 March 2020, 14:22
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This is only a short ways from my home. To the Islander's defense, it is reported that they asked them to leave nicely before blocking their driveway. ;-)
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  #1903  
Old 29 March 2020, 14:24
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Quote:
Originally Posted by GPC View Post
Armed vigilantes in Maine chop down tree, block driveway to force neighbor to self-quarantine amid coronavirus pandemic

https://www.foxnews.com/us/maine-cor...bor-quarantine

Shit getting Mad Max.
Do-gooders
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  #1904  
Old 29 March 2020, 14:28
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Originally Posted by tim416 View Post
This is only a short ways from my home. To the Islander's defense, it is reported that they asked them to leave nicely before blocking their driveway. ;-)
Perhaps, but what a slippery slope.
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  #1905  
Old 29 March 2020, 14:43
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Well, this new shelter in place for four weeks by Gov. Evers which appears to allow everything except eating, drinking and worshiping together, I conclude that it is quite a bunch of hogwash! I tried to go fishing on Friday! It was assholes and elbows at every public access along a 15 mile stretch of river(not the Mississippi) and every trailhead was packed with cars and bikes and strollers and dogs! Walmart , Home Depot, were also packed! So much for covid-19 mitigation! I did not even try to wet a line!
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  #1906  
Old 29 March 2020, 15:18
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Esteemed medical professionals, I have come across a few articles that suggested a possibility of correlation between the immune response to COVID-19 and Bacillus Calmette-Guťrin vaccine. What are your thoughts on that?

Here is a link to one of these articles:

https://www.sciencealert.com/austral...s-get-it-first
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  #1907  
Old 29 March 2020, 16:44
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This was released an hour ago. They think itís airborne. This changes things.


Transmission Potential of SARS-CoV-2 in Viral Shedding Observed at the University of Nebraska Medical Center
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  #1908  
Old 29 March 2020, 17:45
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If national leaders, including the medical experts who are guiding our response, don't come out and endorse this report you're getting a vacation.

We've been pretty lenient on much of the hysterical crap thrown up as fact, but posting something with the statement "this changes things" is ridiculous.
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  #1909  
Old 29 March 2020, 18:02
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Quote:
Originally Posted by Silverbullet View Post
If national leaders, including the medical experts who are guiding our response, don't come out and endorse this report you're getting a vacation.

We've been pretty lenient on much of the hysterical crap thrown up as fact, but posting something with the statement "this changes things" is ridiculous.
SB I agree with you just bad info

I opened the web link. THIS is the best part of it all


This article is a preprint and has not been certified by peer review [what does this mean?]. It reports new medical research that has yet to be evaluated and so should not be used to guide clinical practice.
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  #1910  
Old 29 March 2020, 18:34
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For those working in affected areas, either in the field or in hospital, what are you seeing as far as patient presentation?

We've seen a (small) uptick in cases here that generally fit what is being said about how the virus progresses, though I don't know that all have been positive- some were and some weren't my patients.

Specifically: hypoxia in people who weren't short of breath and (sometimes) had clear lung sounds.

Very difficult to ventilate once intubated- early ARDS.

Not usually volume depleted or shocked...maybe dehydrated at best.

Not always febrile but more often with body aches.

If they get sick a rapid onset (2-3 days) from mild to severe.

This squares with a lot of what I've been able to find so far but again, not a lot of first hand experience at this point.
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  #1911  
Old 29 March 2020, 19:25
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Originally Posted by Silverbullet View Post
If national leaders, including the medical experts who are guiding our response, don't come out and endorse this report you're getting a vacation.

We've been pretty lenient on much of the hysterical crap thrown up as fact, but posting something with the statement "this changes things" is ridiculous.
Just because a virus can exist in aerosol form (airborne transmission) doesnít mean that it is clinically significant. This paper shows that, under the conditions of a hospital room, there is likely airborne transmission of viral particles.

For practical purposes, it doesnít mean that much to the average citizen. The transmissibility of this virus is already known, and it isnít super contagious. For every case of the Rona, it produces 2-3 new cases. Compare that to measles, which is the most-contagious bug we know of, at 15-20 new cases for each case of measles. Measles is small and hearty, and can stay suspended in air for hours after being sneezed out of an infected person.

This paper may prompt hospitals to place Corona patients in airborne isolation, but I frankly doubt it. I think airborne precautions are appropriate when intubating a patient, proning (flipping) a patient, or suctioning airways. Hospitals are already doing this.

The paper is interesting, but it isnít a game changer. Again, we know how transmissible the disease is, and it isnít on a par with truly ďairborneĒ diseases. The Rona is sparingly airborne, but barely and only under ideal conditions.

V/R,
Danny
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  #1912  
Old 29 March 2020, 19:27
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From an 18D friend:

Details from an ER MD in New Orleans, and a grim reality sweeping the nation. We all need to come together, as Americans, and help our fellow Americans through this pandemic.

For my physician friends and medical providers:
-----------------
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."
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  #1913  
Old 29 March 2020, 19:42
AKAPete AKAPete is offline
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Quote:
Originally Posted by Purple36 View Post
From an 18D friend:
Your post
Seen that post popping up in a number of places on the net.
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  #1914  
Old 29 March 2020, 19:50
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Quote:
Originally Posted by Silverbullet View Post
If national leaders, including the medical experts who are guiding our response, don't come out and endorse this report you're getting a vacation.

We've been pretty lenient on much of the hysterical crap thrown up as fact, but posting something with the statement "this changes things" is ridiculous.

My apologies. I didnít convey whatís in my head from a healthcare perspective. Initial guidance was to treat them like an airborne isolation patient. That is what we have done and continue to do at my facility. The Covid patients that come to our critical care unit are in negative pressure rooms. We use N95 or the CAPR helmet only for those patients. The rule out or less symptomatic patients are on the Covid unit that is all negative pressure. CDC then scaled back and said the patients only need contact+droplet. Some hospitals are treating them with only surgical masks and gowns. If this study or similar is correct then the guidelines need to be changed back to N95 quickly.
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  #1915  
Old 29 March 2020, 19:51
19MIKE 19MIKE is offline
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Quote:
Originally Posted by Chesie View Post
The paper is interesting, but it isn’t a game changer. Again, we know how transmissible the disease is, and it isn’t on a par with truly “airborne” diseases. The Rona is sparingly airborne, but barely and only under ideal conditions.

V/R,
Danny
I'm a layperson. What are 'the truly "airborne" diseases'? And if it's not comparable...why is it seem to be spreading so fast??
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  #1916  
Old 29 March 2020, 19:56
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Originally Posted by Jakers View Post
For those working in affected areas, either in the field or in hospital, what are you seeing as far as patient presentation?
This seems to be a good cliff note version thatís been going around and updated as the data changes
link
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  #1917  
Old 29 March 2020, 20:02
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Originally Posted by 19MIKE View Post
I'm a layperson. What are 'the truly "airborne" diseases'? And if it's not comparable...why is it seem to be spreading so fast??
SARS, tuberculosis, chickenpox, measles...

It really is a continuum, which is why most places are using a hybrid of PPE for both airborne and droplet precautions.

We've known for a while that there are elements of this that are similar to airborne-spread illnesses like how long it can live on certain surfaces.

If it is confirmed that there is an airborne component, I would not be surprised.
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  #1918  
Old 29 March 2020, 20:09
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Not me. I think I'm off the airborne boat.
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  #1919  
Old 29 March 2020, 20:56
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Quote:
Originally Posted by Chesie View Post
...This paper shows that, under the conditions of a hospital room, there is likely airborne transmission of viral particles.

For practical purposes, it doesn’t mean that much to the average citizen.... For every case of the Rona, it produces 2-3 new cases....

...I think airborne precautions are appropriate when intubating a patient, proning (flipping) a patient, or suctioning airways. Hospitals are already doing this.

The paper is interesting, but it isn’t a game changer. Again, we know how transmissible the disease is... The Rona is sparingly airborne, but barely and only under ideal conditions.
Concur with the above excerpts from Chesie's post.

Overall, the article is confirming things that we already thought and have seen / been practicing based on other limited information.

The most important take-away is quoted below. May cause some additional people to wear masks and gloves when out in public.

The article has now been SOCNET peer-reviewed

Quote:
Taken together these results suggest that virus expelled from infected individuals, including from those who are only mildly ill, may be transported by aerosol processes in their local environment, potentially even in the absence of cough or aerosol generating procedures. Further, a recent study of SARS-CoV-2 in aerosol and deposited on surfaces, indicates infectious aerosol may persist for several hours and on surfaces for as long as 2 days.
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Last edited by O_Pos; 29 March 2020 at 21:02.
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  #1920  
Old 29 March 2020, 21:01
F18Wub F18Wub is offline
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Originally Posted by Jakers View Post
For those working in affected areas, either in the field or in hospital, what are you seeing as far as patient presentation?

.
My department hasn't had a lot of these yet, but town next to us has, including two clusters in nursing homes. One thing they've related to us is a lot of their inital exposures (resulting in multiple guys getting quarantined) involved falls. They got burned by a couple of them. The EMS System directives change almost daily, as with the PPE, but for the forseeable future, nebulizers are completely out, CPAP is a no go on suspected Covid pt's, they are telling us to ventilate as best as possible, but don't be afraid to intubate if you see it going that way early.

The PPE thing has been frustrating. We've settled on all patients get surgical masks right off the bat, one person will interview, get a temp and go from there. The PPE of choice for us has landed on N95's for us, with gloves and eye protection, going to gowns if they are under suspicion. I've been doing the research on the supply chain thing for N95 substitutes, its not pretty. I saw on FB that Oklahoma City has gone to SCBA for EMS calls. I can see it heading that way if this goes a long time with limited N95 availability. One thing of note is that a lot of the FD exposures to this has come from not putting a mask on the patient, I'd venture a guess to say that the pt's weren't presenting normally, but became symptomatic and tested positive later, leading to the isolation of the crews.
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