Medicine

“A Fresh Perspective on the Covid-19 Numbers”

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Robert Prost emails:

I wanted to share with you, my take on the corona virus situation in the United States.
 
But first, a brief introduction. I am professor emeritus at the Medical College of Wisconsin in Milwaukee.
 
I have a PhD in Biophysics and spent my career in MRI-based research, mostly on brain tumors.
 
I check the Johns Hopkins’ website every day for the progress of the epidemic and I had a feeling about the numbers I’ve been seeing.
 
The website: https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 is very good.
 
The daily case number totals can be extracted by mousing over each plotted point in the graph in the lower right hand corner of the screen.
 
The curve at first looks daunting, it seems to be shooting straight up. But being at least in part a mathematician, I wondered about the velocity of this upward move in cases.
 
If the velocity was going up, the epidemic would be accelerating, the epidemic would be worsening. If going down, it would be getting better (slowing).
 
So I plotted the data and took the first derivative with respect to time. What it shows is that the velocity of the epidemic in the US is definitely slowing, and quickly.
 
While the number of confirmed cases continues to rise, it is rising more slowly. If there were a confounding effect from increased surveillance (more testing revealing yet more cases), the apparent velocity should be going up.
 
Instead, it is going down. So I believe the effect to be real, and thus I believe we are witnessing the beginning of the end of the epidemic. While this data says nothing about the potential for re-emergence in the fall or following spring, it does suggest that we have in fact, flattened the curve.

US Covid-19 Cases and Rate of Change

UPDATE: A follow-up email from Robert is posted here.

Stuff Is Going To “Fall Off The Truck”

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In my previous post I hinted that perhaps Mr. Cuomo doesn’t really need forty thousand ventilators for the Covid-19 crisis in New York. A lively and interesting discussion ensued and I thank the commenters for that.

Today I had on the Trump presser and I was doing other things until Trump said the following, (speaking of mask usage per day at a certain hospital) – and my ears perked up:

“How do you go from 10 to 20, to 300,000 — 10 to 20,000 masks to 300,000, even though this is different. Something’s going on, and you ought to look into it, as reporters,” Trump said.

As an aside, he really does speak in stream of consciousness, no? Anyways.

I love math problems and would like to see the actual numbers of staff/masks if those numbers exist – that could be interesting. Trump could have been fluffing the numbers a bit to make a point on something he has heard. But Trump isn’t stupid and brought it up for a reason.

Of course the Washington Post can’t have Trump doubting for a second that anyone in a democratic controlled area would…well…maybe…”borrow” some of the supplies – and they said that Trump was touting a “conspiracy theory”.

When the books are written about this episode, I am fairly confident that waste and fraud will be two of the more interesting aspects. Some of it will be on purpose, and some of it will be just because this is a large project run by the government.

Dueling Doctors

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In the blue corner, we have the joint statement on multiple patients on ventilators by the Society of Critical Care Medicine (SCCM), American Association for Respiratory Care (AARC), American Society of Anesthesiologists (ASA), Anesthesia Patient Safety Foundation (APSF), American Association of Critical”Care Nurses (AACN), and American College of Chest Physicians (CHEST) which recommends letting people die when spare ventilator reserves run out. And in the red corner, we have the VESper by Prisma Health fresh off of its recent victory to get regulatory approval under emergency use rules to allow ventilators to be used by up to four patients.

It is triage with its ugly logic of letting patients die vs hope and technical advancement to save everyone, live in the United States at Covid-19 virus hot spots across the nation. This may affect you personally so it is important that you know whether or not the hospital you might depend on to save your life has picked one side or the other in a thoughtful way.

Everybody could ask the question but it would be better if our press did ask and broadcast the answers. At the time of writing, they’ve had two days to do so. Are you informed on the issue? Are your neighbors? Is your hospital?

This lack of discussion is the death of journalism. This time ignorance can have deadly consequences for us all.

Ventilator Math

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So Andrew Cuomo says that they need up to 40,000 ventilators in New York City.

But “the number of ventilators we need is so astronomical,” Cuomo warned, pegging the “apex number” of ventilators that could be required in New York at 40,000.

So, I like math and I enjoy trying to suss out these types of problems. I’m assuming that a normal “joe” can’t just wake up and intubate someone, and that probably your run of the mill nurse who checks your blood pressure can’t either. I found this list of physicians in New York State as of 2019:

Psychiatry 6,759
Surgery 4,293
Anesthesiologists 4,262
Emergency medicine 4,560
Radiology 3,999
Cardiology 3,149
Oncology (cancer) 2,213
Endocrinology, diabetes, & metabolism 902
All other specialities 18,771
Total specialty 48,908

My guess is that at least half (more?) of these doctors probably aren’t able to intubate someone. So…I’m wondering (paging Dr. K), looking at these numbers of doctors that are up and running with their practice in the state of New York that are qualified, how would they even be able to use 40k ventilators? Maybe I am missing some legislation that would allow doctors from other states to practice in New York State right away. Perhaps it is easier than I think to intubate a patient and Joe Radiologist can do it. Anyone?

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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