More on the virus

Sorry, Jreboll, that was meant to be a thumbs up.

I'm sorry for your loss, B, may your family find peace and your brother rest in peace. Very sad.

Both China and Italy have documented cases of pts 4 days into recovery after weeks of battling the virus to suddenly succumb.

This is some disease and when they say stay home, isolate, and take all precautions to avoid contagion they know what they're talking about. Avoidance seems to be the only sure thing.

Thank you guys.. yes it is very sad for hi wife and kids..Not sure what killed him exactly,the fibro and washing may have been too much but if he was not to come out whole it is better this way for him.. What a mess this virus is.. and still some peopleare not taking it seriously..

According to some stat, Mexico has the lowest compliance percentage with only 35.4 % compliance with the safety regulations. That's about what I'm seeing in SA. If that.

You have seen nothing until you see people in Chiapas. Several towns had their passion procession . In Venustiano Carranza 5000 people attended.
The main food market is busy very few people have masks there.. The only people who have gloves or one glove are the guys from the tortillera.

When it picks up here it s going to be really bad.. I am trying to get out by next sunday..

So, are you milling around among them???

I have a feeling we are going to be in for a very long run here in MX. Maybe a couple of years. We are still in the denial stage!

The government here has the ability to become as draconian as what happened in China.. Behavior will change very quickly when whole families start getting it.. the patrons & abuelas suffer & then pass in their arms.. heart-wrenching disease of maybe 7 days duration.  The strong Catholism need for proper burial, ritual here could overwhelm the churches, mourning taken to the streets, overwhelming grief.. No trust in Medical System, w nurses NOW being attacked on buses, street, accused of spreading it.. whoa.  Look at Ecuador now - bodies in the street.  Emotions on the pitch will be high.

Even if us Expats are dodging the bullet, we will feel such fear, sadness here, need masks for every day of the week, til the end of the year. Our curve is starting now, 2 months behind the US. So we are in for it till mid June, then baptismal rainy season. Don't think many TXsunbirds will be arriving, so very quiet July-Sept.  Mexico is VERY concerned about the millions of $$ that tourism/pensioners bring - critical to the economy besides oil & US worker remittances: all 3 legs of that stool doing poorly now.

What is unsettling is the reports of people who recover, but turn positive again. it suggests antibody dev isn't stable en vivo, much less en vitro, so vaccine development for CV could be delayed. So now is the time to eat your veggies, build cardiovascular & lung capacity for physical health. Hope is our new 4 letter word.

My condolences Bridgette.

They just invoked the dry law. No booze anywhere for a few weeks.

Was there a start and end date?

more hoarding coming up..

I think from immediately until April 30th?

I just read starting Monday so time to stock up.

Nope it is effective immediately. Just got back from Wal-Mart.

Mexico is reporting 4219 cases this morning. 1772 have recovered.

I wish they would do random testing then we would really know how many have recovered.

Yeah the numbers don't add up but that is what they are reporting. We may never know the full extent. Let's just try and keep it out of our little community. Locking it down was a great step forward. Kudos to el presidente of Chapala who has been very proactive.

MY COWORKERS PLEASE READ

Copied from another group. Hope this helps!


“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."

Chilling.

SunFan

Wow, that was intense, great report. Learned more than all the other anecdotal shit we’ve been hearing. That put to rest plaquenil use. And the peep required, that’s high. I’ve got thrombocytopenia so I don’t know how it would affect me. Stay away from steroids( for those using Flonase). Watch fluids(very important). Azithromycin is ok but didn’t mention zinc. I’ve had elevated lft’s in the past so I better watch it.
Interesting that he mentioned the use of tpa.

Like SF said, chilling! Agree, excellent report and highly educational.

I have chronic leukopenia and would not expect to do well. Don't think I will go to a hospital.

What is the takeaway from this article? Stay the F#$@K home!

Do they use ECMO or do they let it go if people on respirators do not do well?

I would guess for us old farts at Lakeside the chances of even getting on a respirator are pretty low. I'm sure they'll triage candidates.

SunFan

ECMO is a very expensive procedure. Round the clock personnel for just one patient when there’s a health crisis going on is unreasonable.

well they use ECMO in France, not sure in what cases. My brother was on such a system for more than a week but then it is a military hospital so it may be why.. I was just curious if that was comon or not..

This ECMOConcept started around 1970. It’s sort of like a heart-lung machine. Blood is drained from the femoral vein, oxygenated with a membrane oxygenator and returned back through the femoral artery. It is not done as often anymore because of the man hours involved and the benefit/risk ratio doesn’t make it worthwhile.

He got a stapf infection on it and then the blood thinners made him hemorrage and then as they change the dosis the filters got stuck.. , yes that system has a lot of risks besides being expensive. It was a last ditch effort as hs lungs were showing sign of a slight recovery.. but in the end the virus won..