There are, of course, many items that could be placed in a risk register for our ongoing management of COVID-19. I find myself drawn to those categorizable as, or perhaps triggered by, human perception and behavior. By way of limiting the scope of this post to reasonable attention spans, here are my current top 3:
Law Enforcement
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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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.
Going, Going. Gone
The credibility of the mainstream press establishment is shimmering into nothingness, like the last bit of winter snow after a week of warm spring days; just as our respect and trust for such federal bureaucracies and establishments like the FBI are similarly evaporating. While acknowledging and accepting that such establishments are operated by mere mortals, with all the weaknesses and moral failings that ordinary human beings are heir to, and grudgingly accepting the understanding that the establishment news media trends strongly to the left in political sympathies … look, we can accept all that and a certain degree of human bias, but what’s getting hard to swallow of late is the sheer, mind-numbing, flaming incompetence of them all. Which might be a blessing, for terrifying competence on the part of our current Ruling Class and their minions would make protesting or opposing them that much more difficult. Instead, as Kirk so memorably put it last week,
“What we have is, instead, an aristocracy of dunces, men and women who tell the rest of us how smart they are, and then screw up the entirety of civilization based on fantasies they’ve come up with. The rest of us need to start recognizing that the emperor not only isn’t wearing any clothes, he’s drunk off his ass and waving his wing-wang in our faces. The people who’ve flim-flammed their way into power are all dangerously inept and terminally deluded. If you doubt me, open your eyes and look around yourself: Is there anything, anything at all that these soi-disant “elites” have gotten right in the last century? Anything at all?”
Jeffrey Epstein’s Death in Federal Custody, the Suicide of Federal Government Credibility
The announced “death by suicide” of Pedo-Pimp to the Powerful Jeffrey Epstein in Federal government custody while;
- On a 24/7 suicide watch,
- After his first “suicide attempt,” in late July, and
- Before there was any time for a real autopsy…
…is such utter horse manure as to utterly destroy any shred of credibility of the Federal government.
That Federal Attorney General Barr first called for an FBI investigation of Epstein’s death — to deafening loud round of public rasp-berry’s.
Then he followed that credibility destroying knee jerk response near seconds later by saying the Department of Justice Inspector General would conduct the investigation — given the non-prosecution of so many in the DoJ & FBI after the IG caught them red handed leaking FISA surveillance sources and methods to the press — amounts to an “Eff-U” slap in the face to the General Public.
This is pure “Pravda Reporting on Chernobyl” territory. It’s all about elite posturing and “Face” while the radioactive pile burns.
America functions on the consent of the governed. This requires the government be credible through elite replacement by elections as well as the fair administration and enforcement of justice for both the powerful as well as the least of us.
The circumstances of Mr Epstein’s death are such that I’ve completely lost any faith in the concept of “Justice” that in any way involves the institutional FBI or Department of Justice.
I hate saying that because it leaves us here:
“Those who make peaceful change impossible make violent change inevitable.”
That Rubicon has now been crossed. G-d help the people of these United States.
Please comment and tell me I’m wrong. I’m in the mood to be lied too.
When the Saxon Began to Hate
It was not part of their blood,
It came to them very late,
With long arrears to make good,
When the Saxon began to hate.
I have often jokingly wished that some kind of secret sign existed, like a Masonic emblem or peculiar handshake by which those of us conservatives who do not go about openly advertising our political affiliations to all and sundry might discretely identify a kindred spirit. Those of us in the real world have friends, neighbors, and co-workers who range across the political spectrum; Traditional good manners and consideration for those who didn’t share your beliefs once dictated a degree of ambiguity regarding political leanings, sexual orientation, and religious beliefs. This sense of discretion owed more to conventional good manners rather than cowardice, although a disinclination about being bashed about the head by a member of the Klantifa, harassed out of a restaurant, or a Twitter campaign to get one fired from employment are lately a very real possibility as a result of overtly advertising ones’ conservative sympathies.