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  #1901  
Old Today, 09:32
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Quote:
Originally Posted by Devildoc View Post
I'm at home, so don't have all the numbers with me. A couple points. I think we just went over 2000 deaths, and we went from 1,000 to 2,000 in the matter of a few days. If that is the case, that is a logarithmic jump. Of course we're only into one week or so of the whole mandatory quarantine bullshit, so we will know how well it is working in another week or so.
If it's less than 60K, Panic = Fail.

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Originally Posted by Devildoc View Post
My third point would be, urban clusters are screwed, and if you look at the numbers of both infected, hospitalized, and the fatality case rate by urban center I think (again all of my stuff is at work) statistically it is presenting worse than the flu. That said, that's in what, three cities? Maybe four.
When you get the exact data that I can check against Influenza (at any time, but we'll use 2017/2018 since we didn't go full retard for that massive kill off), post it up.
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COVID-19 Deaths: 2,229
2018 Handgun Murders: 6,603
Annual Stair Fall Deaths: 12,000

Economy Wasn't Destroyed For:
2009 "Swine Flu" Deaths: 12,000
2017/2018 Influenza Deaths: 61,000

"From 12 April 2009 to 10 April 2010, we estimate that approximately 60.8 million cases (range: 43.3–89.3 million), 274,304 hospitalizations (195,086–402,719), and 12,469 deaths (8,868–18,306) occurred in the United States due to H1N1".

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  #1902  
Old Today, 09:44
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Urban Clusters!!!!! Just like Influenza...

2014/2015 Influenza Season (Study only went to 2016)
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United States - Pop ~331 Million.

"Team Apocalypse"

COVID-19 Deaths: 2,229
2018 Handgun Murders: 6,603
Annual Stair Fall Deaths: 12,000

Economy Wasn't Destroyed For:
2009 "Swine Flu" Deaths: 12,000
2017/2018 Influenza Deaths: 61,000

"From 12 April 2009 to 10 April 2010, we estimate that approximately 60.8 million cases (range: 43.3–89.3 million), 274,304 hospitalizations (195,086–402,719), and 12,469 deaths (8,868–18,306) occurred in the United States due to H1N1".

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  #1903  
Old Today, 10:08
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I'm a bit surprised (in a good way) to see this mentality from Sweden, of all places. No idea if it's the right move or not for this situation, but I definitely like the mentality.

https://www.theguardian.com/world/20...and-carries-on

Quote:
While every other country in Europe has been ordered into ever more stringent coronavirus lockdown, Sweden has remained the exception. Schools, kindergartens, bars, restaurants, ski resorts, sports clubs, hairdressers: all remain open, weeks after everything closed down in next door Denmark and Norway.

Universities have been closed, and on Friday, the government tightened the ban on events to limit them to no more than 50 people. But if you develop symptoms, you can still go back to work or school just two days after you feel better. If a parent starts showing symptoms, they’re allowed to continue to send their children to school.

It has only been in the past couple of days that the death toll has started to increase significantly, rising by a third in a single day on Thursday and Friday, with 92 people now dead and 209 in intensive care. As he announced the tighter restrictions on Friday, the prime minister, Stefan Löfven, warned that the coming weeks and months would be tough.

But he defended the decision not to implement the tighter restrictions seen in Denmark, France and the UK. “We all, as individuals, have to take responsibility. We can’t legislate and ban everything,” he said. “It is also a question of commonsense behaviour.”

Anders Tegnell, Sweden’s state epidemiologist, believes it is counterproductive to bring in the tightest restrictions at too early a stage. “As long as the Swedish epidemic development stays at this level,” he tells the Observer, “I don’t see any big reason to take measures that you can only keep up for a very limited amount of time.”
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Last edited by KS11; Today at 10:17.
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  #1904  
Old Today, 10:25
jportal50 jportal50 is offline
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Quote:
Originally Posted by The Fat Guy View Post
I don't think Dems see it as a threat as much as they see it as a tool to victimize their consituency.
Bingo. X1000
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  #1905  
Old Today, 10:42
Devildoc Devildoc is offline
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Quote:
Originally Posted by Polypro View Post
Urban Clusters!!!!! Just like Influenza...

2014/2015 Influenza Season (Study only went to 2016)
Okay and I'm not trying to be obtuse, maybe I'm not properly caffeinated, but I'm not seeing your point. Actually your point reinforces my point which reinforces everything we know about disease transmission and that it goes up in urban centers.

Already we are starting to see in these urban centers a nod towards saturation in the hospitals. The pace of which does not match the pace of influenza admissions, since all of this has been within two to three week..

Again we will know more in a week.
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  #1906  
Old Today, 11:08
racing_snake racing_snake is offline
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The part I don't believe is that we don't have large stockpiles of PPE somewhere, especially since it's coming out that we sent 16 tons to China in February, and Canada did as well. I also think they're calling up the IRR not to assist, but basically to isolate them so it doesn't affect military readiness. The same reason most police officers are only responding to life & death situations, a matter of readiness. I think the lethality of it doesn't justify the shutdown of everyday life. I've also been deemed *essential* & what if I've seen is more people out than ever in small groups. Instead of being able to go to the grocery once a week the panic has driven people to go every few days which maximizes exposure to it. Think about how drastically they could drop the spread if they issued everyone an n95 mask with that $1200 check, a reusable one that you could clean. To me this is definitely about pushing everyone into panic mode to see how draconian they can get, & what they can get away with passing just like after 911. Also, which politician is going throw themselves on the sword, & say things can go back to normal? How long does it last?
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  #1907  
Old Today, 11:33
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Quote:
Originally Posted by Justaclerk View Post
Can any of our Docs, RNs or EMTs serving in emergency rooms or treating and transporting the sick share their triage protocols? I shudder at the thought of having a STEMI during this period.
Cath lab brought a STEMI over to the ICU last Wednesday. Due to close proximity to the patient they are suiting up in their CAPR for all patients. Then they brought the patient over on a nasal cannula I voiced my concern from across the unit. I think they got the point.

Our numbers have exploded in a matter of days and we just had our first fatality. We don’t have the staff nor beds for much more and nowhere near hitting the top of the curve. Anesthesia is going to teach us to use their vents. I think we have enough vents for all the rooms and staff we have but we only have a 20 bed unit. Vented patients are staying on out unit and other Covid patients go to another unit for now.
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  #1908  
Old Today, 12:15
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Quote:
Originally Posted by racing_snake View Post
The part I don't believe is that we don't have large stockpiles of PPE somewhere, especially since it's coming out that we sent 16 tons to China in February, and Canada did as well. I also think they're calling up the IRR not to assist, but basically to isolate them so it doesn't affect military readiness. The same reason most police officers are only responding to life & death situations, a matter of readiness. I think the lethality of it doesn't justify the shutdown of everyday life. I've also been deemed *essential* & what if I've seen is more people out than ever in small groups. Instead of being able to go to the grocery once a week the panic has driven people to go every few days which maximizes exposure to it. Think about how drastically they could drop the spread if they issued everyone an n95 mask with that $1200 check, a reusable one that you could clean. To me this is definitely about pushing everyone into panic mode to see how draconian they can get, & what they can get away with passing just like after 911. Also, which politician is going throw themselves on the sword, & say things can go back to normal? How long does it last?
There was this report from a few weeks ago. This is a WAPO story grabbed from a non paywalled News site.

https://www.pressdemocrat.com/news/1...n-the-national
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  #1909  
Old Today, 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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  #1910  
Old Today, 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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  #1911  
Old Today, 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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  #1912  
Old Today, 14:28
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Quote:
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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  #1913  
Old Today, 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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  #1914  
Old Today, 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-Guérin 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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  #1915  
Old Today, 16:44
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This was released an hour ago. They think it’s 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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  #1916  
Old Today, 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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  #1917  
Old Today, 18:02
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Thumbs down

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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  #1918  
Old Today, 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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  #1919  
Old Today, 19:25
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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.
Just because a virus can exist in aerosol form (airborne transmission) doesn’t 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 doesn’t mean that much to the average citizen. The transmissibility of this virus is already known, and it isn’t 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 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
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  #1920  
Old Today, 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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