Texas Aggie Doctor Reports — Clinical Pearls Covid 19 for ER practitioners

The following information is from a front line ER doctor using the handle of ‘nawlinsag’ on a Texas Aggie web site.  I’ve included the link below. I’ve also included the complete text of his post in full in hopes medical professionals and lay people could get the most benefit from his observations of the course of COVID-19 in a small front line Louisiana hospital.

Short form: This is not the flu.  It is a horror show of death and disablement that is crowding out all other medical care including an immediate downgrade of life saving cardiac care.  Only on in seven people put on ventalators in this hospital is surviving, and then only after 10-t0-12 days of ventalator support.

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https://texags.com/forums/84/topics/3102444?fbclid=IwAR3s13SRnw7YNgtu-7LZyrMUSMIRRWScU67lwbuwZM8fna-6R8k4tqrtO3w

I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.

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.

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Ventilator manifold can quadruple number of people on ventilation

A paper published in 2014 documents the invention of a ventilator manifold which can lead to up to 4 people sharing a ventilator.

Ventilator manifold for disaster surge usage

You can find the paper here and an article describing the invention here.

Does anyone know the regulation that is stopping us from printing these manifolds and reducing the death toll from a local overwhelmed medical system? A lot of people are rightly worried about our ventilator situation. Something that quadruples system capacity would be a godsend.

Update: This is deemed a method of desperation with numerous problems that can lead to worse patient outcomes in this joint statement by six US medical associations. They really don’t like it.

This is not stopping innovators like Prisma Health from developing ways to have multi-user ventilators.

Update 2: New York has approved ventilator splitting as they purchase 7,000 more ventilators. Federal ventilators are also starting to arrive, all 400 of them.

China Virus

Seriously, I do wonder if there isn’t a strong antipathy against all things Official-Mainland-Chinese/ Chinese Communist Party and all its works building among Americans, in the wake of the almost-universal infection by the Wuhan Corona-virus epidemic. I mean – the damn plague started there, despite what all the official CCP agencies and bodies, and their sympathizers and hired media can and will insist. Bungling containment, concealing practically everything about the epidemic (the third devastating epidemic originating in China, by the way, the swine flu and the H1N1 virus being the first two) and then having the unmitigated gall to blame it on the United states – that takes the absolute cake, as far as I am concerned. It reminds me of the books I absorbed, growing up; most by English and American authors of the mildly popular sort (some fiction, some non) and dating anywhere in the first half of the 20th century whose detestation of Germany and Germans hung in the atmosphere of those books like a particularly dank fog. It was an almost visceral dislike, for all that we generally had been inclined favorably towards Germany before the turn of the previous century. Martin Luther, Johan Sebastian Bach, the Brothers Grimm, Schumann, Beethoven, Goethe, scientific, technological and medical advances all flowed to the rest of Europe and to the Americas, making us all the richer for it – but German ‘frightfulness’ in World War I, and the horrors inflicted by Nazi Germany burned through that enormous fund of respect and favorable opinion, leaving a very bad taste in the mouths of those old enough to have been exposed to them, either directly or at first and second remove. That bad taste may only now be fading with regard to Germany, but I wonder if it isn’t now about to be replaced with burning resentment of China, or at the very least, the Chinese Communist Party.

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Covid-19 Weekend Update/Random Thoughts

This morning I went on a long hike up at Devil’s Lake State Park. It was chilly, but there was no wind, which made it absolutely wonderful. I took the “hard” way, meaning I went up and down the bluffs twice as I made my way around the lake. The photo above is from the west bluff. There was hardly anyone there, which was eerie and peaceful, as this is Wisconsin’s most popular state park and I have never seen it so devoid of people. You could hear the ice heaving and breaking on the shore, and I heard some interesting birds making calls that I don’t typically get to hear. The migration is in full swing. During this time I prayed, meditated and got my workout in. I am very glad I did it after a long week.

During the drive back, I noticed that a lot of farmers were spreading. The cycle of life continues here behind the cheddar curtain.

So, some random Covid thoughts. I have enjoyed Governor Cuomo bitching and griping for help over the past week. What a whiner. Hey Cuomo – who has run New York for the past, ever? Maybe you should look in the mirror before you start playing politics. Same goes for Lori Lightfoot. Hopeless.

My Illinois facility will remain open during the “stay at home” order issued by Gov. Pritzker as HVAC is an “essential business”. While I typically loathe anything this man does, he did a nice job with the presser yesterday, I will admit. Contrast that with Lori Lightfoot, who bitched and whined about the lack of federal response. There is one bit of hilarity in Pritzker’s “stay at home” order (yes, I read the whole thing). Can you tell me which one of these things is different from the other?

Section 12 (h)
Definition of Critical Trades
Building and Construction Tradesmen and Tradeswomen, and other trades including but not limited to plumbers, electricians, exterminators, cleaning and janitorial staff for commercial and governmental properties, security staff, operating engineers, HVAC, painting, moving and relocation services, and other service providers who provide services that are necessary to maintaining the safety, sanitation, and essential operation of residences, Essential Activities, and Essential Businesses and Operations.

Oh yea, he kept the pot shops open too.

I am refreshed and pleasantly surprised by the State of Wisconsin coming forward with a united front and saying that there will be no “stay at home” order (otherwise known as government overreach). At least for now.

I stopped at a convenience store on the way home and picked up a dozen eggs. They were $1.49 and there were plenty of them.

Well, that’s about all I got. Hope everyone had half as good a day as I did. Let me know what you are seeing/feeling in your neck of the woods.