Immigration

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

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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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Books That I Cannot Wait Not to Read

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Amanda at Mad Genius Club posted last week with some musings on the current publishing scene er, that is what I took to calling the Literary Industrial Complex, back when I first went indy around 2008 Indy Publishing that is. When people ask me who my publisher is, I look at them loftily, and reply, “I own the publishing company!” Which I do a nice little small enterprise that I came into as junior partner, and which the original founder sold to me when she regretfully concluded that she could no longer carry on. We do other authors’ books, as well as my own; regional and small-press stuff, nothing which would ever excite the interest of the Literary Industrial Complex or the minions thereof. No point to it at this late date; as one of the other indy authors I associated with at the time often repeated “If readers love-love-love the book, they don’t really care who published it.”

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Why I Do Not Care for Ilhan Omar

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Oh, let me count the ways first, a purely visceral and visual reaction: she’s a snake in a trendy head-scarf. Reminds me of the internet meme of Momo, actually. And the fact that she is a particularly nasty bigot and vocal anti-Ordinary American, and Jew-hater, and might very well have both perpetuated and benefited from immigration fraud.
And … Somali.

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Fixing the border facility crisis

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It’s useful to review how to fix conditions of overcrowding in a facility. There are two fixes available.

1. You build more capacity
2. You increase training and oversight of the personnel running the facilities if they’re not behaving adequately

Both of these fixes require more money allocated by Congress. It helps when the Executive requests more funding but Congress doesn’t require it.

Go look at the legislative history. President Trump asked for more funds, Congress turned him down. It wasn’t his own party that denied him, it was the Democratic delegation that was against relief.

President Trump sought to work around the restrictions by declaring an emergency and using military construction money. It was left wing advocates who went to court to fight Trump, preventing him from building more facilities.

The left wing solution is to cause so much suffering so that our hearts break and we stop enforcing the law.

That’s cruel. It’s cruel on purpose.

Congresswoman Alexandria Ocasio-Cortez alleges misbehavior by camp personnel. She is one of a small select group, just 535 people strong who could directly improve the situation by introducing legislation that would force improvements in behavior. She has yet to introduce any.

The Congresswoman is a prominent part of the cruelty agenda.

In a normal country, hard questions would be asked by the mainstream media of those who have recently been part of this cruelty agenda.

Telemigration

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It has often been asserted that the US doesn’t need to worry overmuch about our position in Manufacturing, because Services are the future and that is where we will have the most competitive advantage.  And, indeed, the balance of trade in services is more favorable than that in the goods-producing industries: for 2018, exports of services totaled $821 billion, whereas imports of services were only $557 billion.

However, while imports of services are today small compared with imports of goods, which for 2018 were almost $2.7 trillion, it would be a mistake to conclude that services businesses and services jobs are immune to offshoring.  Indeed, for many types of services, offshoring/exporting is easier than the offshoring/importing of goods:  there are no transportation issues, and, in the case of imports to the US, there are no tariffs at all.

Telemigration…the term was introduced by Richard Baldwin in his book The Globotics Upheaval…is the ability to have remote workers doing things that previously would have required their physical presence.  Obviously, the ability to do this has been greatly enhanced by the availability of the Internet and other forms of high-bandwidth low-cost communications.  Today, medical images and legal documents are being reviewed in low-cost-of-labor countries.  Software is being developed for American companies in countries around the world.  Offshoring of clerical operations has been practiced by US firms for a couple of decades, and, of course, the offshoring of customer service is common.

Baldwin also argues that telemigration will be greatly enhanced by the availability of machine translation technology, especially Google Translate.  I think he may be overstating the case here–from what I’ve seen, the quality of GT translations is highly variable.  Not sure how well this approach would work in facilitating the interaction that is often required among team members to create something or solve a problem, and I am sure I wouldn’t want to trust it exclusively for something like, say, translating the functional specifications for a life-critical avionics system to be programmed by non-English speakers.

But there are a lot of English-speakers in the world, and a lot of activities in which fluency in a common language is not essential.

One area in which a lot of telemigration seems to be occurring is in software development and maintenance.  Here for example, is a company which acquires application software companies and offshores much of the ongoing work (which presumably includes incremental product enhancements as well as problem-fixing) to contract programmers: company’s chief recruiter asserts that  the current cloud wage for a C++ programmer is $15 an hour. As the Forbes article notes, that’s what Amazon pays its warehouse workers.  (Well, at least in the US–and $15/hour for a programmer in, say, India is surely worth a lot more than $15/hour in this country.)  What makes this story particularly interesting is that the founder/CEO of the company was noted, in his earlier incarnation in a different software business, for paying software people very well indeed and going to great lengths to recruit them.

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