Coronavirus

Crossed the six-figure threshold for confirmed cases in the US today.

Good riddance:

thehill.com/homenews/senate/489788-cruis...avirus-stimulus-bill

My boys' school just announced online classes for the remainder of the year. 8-11 in the morning and 1-4 in the afternoon.

One of my boys looked pissed off when he found out. He's been lying around the house playing videogames for two weeks, and when heard about the class hours he asked, "what if I don't want to do school work during those hours? What if I don't want to do school work until 10?" The kid was serious. He's been sleeping until 11 during the hiatus.

I am SO telling his kids about this 25 years from now. People will have dramatic stories about the plague years and I'll be throwing my boy under the bus with his kids, about how hard he had it with his school schedule.

"Well Ryan" I said, "I can email Dr. Arlotto and ask if he can change the hours to better suit your sleep schedule." Arlotto is the superintendant of schools for Anne Arundel County, and he frequently says that he'd like to hear from us. I think tonight's the night to take him up on that.

Apparently rolling onto one side and pressing the power button on his PC at 7:58am is too much of a stretch for my boy's current sleep schedule.

Speaking as someone delivering e lessons, my school is VERY concerned about the extra stress being laid on the students to do these lessons and has emphasised to all teachers that there are to be NO sanctions applied for not completing work during this period.

I agree with this, I find it incredibly stressful (due to wife trapped in Ukraine) and I cannot imagine what kids are going through, exposed to the constant apocalyptic news reporting.

ThirstyMan wrote: Speaking as someone delivering e lessons, my school is VERY concerned about the extra stress being laid on the students to do these lessons and has emphasised to all teachers that there are to be NO sanctions applied for not completing work during this period.

I agree with this, I find it incredibly stressful (due to wife trapped in Ukraine) and I cannot imagine what kids are going through, exposed to the constant apocalyptic news reporting.

Interesting insight, thanks.

Our official statewide lockdown started at midnight. There is a long list of essential industries, such that supposedly 80% of Minnesota businesses are not shut down. But people here have been taking coronavirus seriously for at least the last two weeks, so traffic is almost non-existent this morning. I think a lot of people are working from home (though not on a Saturday morning).

I went to the grocery store this morning, and once again they were slammed by idiot horders. Fucking morons don't understand that the grocery stores will not be shutting down, so there is no need to horde. So toilet paper, kleenex, and paper towels are again completely sold out. Most of the rest of the store was pretty normally stocked, with odd exceptions. No carrots, period. Some bananas still sold in the usual bunches, but most were being sold as single bananas. Bread, milk, eggs, and rice are still mostly sold out.

This situation has revealed interesting differences in grocery store supply chain quality in our area. We don't go to Safeway regularly but they obviously have the best supply chain infrastructure so we're going now. Even got Tylenol yesterday.

We are about to move our students to optional pass/fail, which the faculty senate is finalizing with the adminstration. So that's very good.

Wasn't it Msample who posted that supply chain article a few pages back? I think that's a more likely explanation for difficulties in keeping things stocked than hoarders. The other option, if you have it, is to do what Gary mentions and go to smaller places. We have a store called Meijer in the Midwest which is like a lesser version of Wal-Mart; a family-owned "superstore" that has groceries, clothing, hardware, etc. They've had enormous stocking problems for the past month, as basic things like cleaning supplies, eggs, and paper products keep disappearing. Meat was a real problem for a couple weeks, too.

In contrast, they have a smaller division called Fresh Thyme, which carries mostly organic products from smaller producers. Every time I've been there, they've had zero supply issues except for one item: toilet paper (which is still the weirdest phenomenon.) They do carry regular produce/meat/eggs/bread alongside the organic stuff, but I think the popular perception is so strong about there only being organic and, thus, more expensive stuff there that they haven't been hit with the impact of heavier shopping that the larger stores have. Similarly, I found bleach and a couple other cleaning products at a smaller drugstore nearby because a lot of people don't think about getting groceries from drugstores.

Fascinating/disturbing stuff from an ER doc in New Orleans: [Just FYI: Cytokine storm is a dangerous immune system response where the system starts attacking organs; DKA is diabetic ketoacidosis, where the blood sugar is so out of control that the blood begins becoming acidic]

"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."

ThirstyMan wrote: Speaking as someone delivering e lessons, my school is VERY concerned about the extra stress being laid on the students to do these lessons and has emphasised to all teachers that there are to be NO sanctions applied for not completing work during this period.

I agree with this, I find it incredibly stressful (due to wife trapped in Ukraine) and I cannot imagine what kids are going through, exposed to the constant apocalyptic news reporting.

I wish I could get this message across to my educational "leaders".

Apparently we can't afford to drop the ball on outcomes etc FFS

We're hitting the exponential part of the curve here in the Philippines. When we went under lockdown two weeks ago, we were at 200-300 cases. Now it's up to 1400 and climbing. I suspected the count at the beginning was low, and I still suspect as much. I still don't think people are taking this very seriously here, and there's no infrastructure in place to make people take it seriously.

It's looking very much like our trip back to the States that we had planned for this summer will almost certainly not happen. I'm trying to look on the bright side of that, but it's not easy.

And driving into the CBD today, I saw something that made my blood boil.

In front of New Orleans City Hall, there's a park called Duncan Plaza.

It was full of people, not practicing social distancing.

I also read an article in the Gothamist.com with pictures of people in NYC parks doing the exact same thing, kids playing soccer.

Fuck you, assholes. You get what you deserve. Especially for those fuckwits in Duncan Plaza.

Rliyen wrote: And driving into the CBD today, I saw something that made my blood boil.

In front of New Orleans City Hall, there's a park called Duncan Plaza.

It was full of people, not practicing social distancing.

I also read an article in the Gothamist.com with pictures of people in NYC parks doing the exact same thing, kids playing soccer.

Fuck you, assholes. You get what you deserve. Especially for those fuckwits in Duncan Plaza.

Both Florida and Texas are restricting travelers from Louisiana:

www.houstonchronicle.com/news/houston-te...r-covid-15164996.php

Both states will probably relax their restrictions once they hit a critical mass of their own cases of coronavirus this week. In fact, Florida already has more cases of coronavirus than Louisiana, and Teaxs will likely catch up to Louisiana soon.

Shellhead wrote:

Rliyen wrote: And driving into the CBD today, I saw something that made my blood boil.

In front of New Orleans City Hall, there's a park called Duncan Plaza.

It was full of people, not practicing social distancing.

I also read an article in the Gothamist.com with pictures of people in NYC parks doing the exact same thing, kids playing soccer.

Fuck you, assholes. You get what you deserve. Especially for those fuckwits in Duncan Plaza.

Both Florida and Texas are restricting travelers from Louisiana:

www.houstonchronicle.com/news/houston-te...r-covid-15164996.php

Both states will probably relax their restrictions once they hit a critical mass of their own cases of coronavirus this week. In fact, Florida already has more cases of coronavirus than Louisiana, and Teaxs will likely catch up to Louisiana soon.

I read that, and they're right to do so. Florida is stopping anyone from New York, too.

Broward County had their own stupidity over the weekend. I95 got shut down because idiots wanted to party on the highway. Literally stopped their cars and were dancing around. Paste eaters, all of them.