Middle East

In the Field

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Sometimes, long after first reading a book or watching a movie and enjoying it very much, I have come back to re-reading or watching, and then wondering what I had ever seen in that in the first place. So it was with the original M*A*S*H book and especially with the movie. I originally read the book in college and thought, “Eww, funny but gross and obscene, with their awful practical jokes and nonexistent sexual morals.” Then I re-read after having been in the military myself for a couple of years, and thought, “Yep, my people!”

The movie went through pretty much the same evolution with me, all but one element and that was when I began honestly wondering why the ostensible heroes had such a hate on for Major Burns and the nurse Major Houlihan. Why did those two deserve such awful, disrespectful treatment? In the movie they seemed competent and agreeable enough initially. In the book it was clear that Major Burns was an incompetent surgeon with delusions of adequacy, and that Major Houlihan was Regular Army; that being the sole reason for the animus. But upon second viewing of the movie, it seemed like Duke Forrest, Hawkeye Pierce and Trapper John McIntyre were just bullying assholes selecting a random target for abuse for the amusement of the audience.

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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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SARS-CoV2/COVID-10 Update 3-5-2020 — “As long as you remember to keep breathing and don’t fall asleep, it’s basically just like the flu.”

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Issues covered will be on COVID-19 spread, World Headlines, the 3-4-2020 Seattle Public Health Press conference, World Headlind Summary,  Corruption at the WHO, Bad and good news COVID-19 medical developments. the Political/Demographic Implications of COVID-19 for the Gov’t  Elites, and the social media and videos COVID-19 tracking source section.

Top line, There are currently 97,138 confirmed COVID-19 cases worldwide, including 3,351 fatalities as of the March 5, 2020, at he 4:48pm ET time hack on the BNO News corona virus tracking site (https://bnonews.com/index.php/2020/02/the-latest-coronavirus-cases/) There are 80(+) and growing umber of nations including China plus three “Chinese special administrative regions” (Macao, Hong Kong and Taiwan) that have reported COVID-19 infections. China, Taiwan, Hong Kong, Japan, Thailand, Singapore, Italy, Iran, Germany, R.O.K. and the USA all appear to have local, or endemic, spread of the disease. Russia, Egypt, and Columbia appear to have joined the endemic spread list as well due to airports in the UAE and elsewhere picking up air travelers originating from those nations as sick with COVID-19.

WORLD HEADLINE SUMMARY (3/5/2020)

o New Jersey confirms first presumptive case
o NY state cases double to 22
o Seattle closes 26 schools
o Pentagon tracking 12 possible COVID-19 cases
o Illinois reports 5 more cases
o NYC reports 2 more cases, raising total to 4
o Italy postpones referendum vote; death toll hits 148
o WHO’s Tedros: “Now’s the time to pull out the stops”
o Tennessee confirms case
o Nevada confirms first case
o New Delhi closes primary schools
o EU officials weigh pushing retired health-care workers back into service to combat virus
o Italy to ask EU for permission to raise budget deficit as lawmakers approve €7.5 billion euros
o Beijing tells residents not to share food
o 30-year-old Chinese man dies in Wuhan 5 days after hospital discharge
o Cali authorities tell ‘Grand Princess’ cruise ship not to return to port until everyone is tested
o Global case total passes 95k
o Lebanon sees cases double to 31
o France deaths climb to 7, cases up 138 to 423
o EY sends 1,500 Madrid employees home after staffer catches virus
o Trump says he has a “hunch” true virus mortality rate is closer to 1%
o Switzerland reports 1st death
o South Africa confirms 1st case
o UK chief medical officer confirms ‘human-to-human’ infections are happening in UK
o UK case total hits 115
o Google, Apple, Netflix cancel events
o HSBC sends research department and part of London trading floor home
o Facebook contract infected in Seattle
o Microsoft, Google, Amazon, Netflix cancel events and/or ask employees to work from home
o Netherlands cases double to 82
o Spain cases climb 40, 1 new death
o Belgium reports 27 new cases bringing total to 50
o Germany adds 87 cases bringing total to 349

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SARS-CoV2/COVID-19 Evening Update 2-25-2020: The Pandemic Hide the Name & Blame Games

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The themes of this update will be on issues of COVID-19 spread, World Headlines, border closings, the CDC news conference, developments with fomite spread, how American Public Health institutions build a liablity law suit proof diagnostic test and how that limits tests for community spread and a new recommended COVID-19 sites, social media and videos section.
 
Top line, There are currently 80,420 confirmed COVID-19 cases worldwide, including 2,710 fatalities as of the 24 February 2020 at 5:24 p.m. ET time hack on the BNO News corona virus tracking site (https://bnonews.com/index.php/2020/02/the-latest-coronavirus-cases/) There are 39 nations including China plus three “Chinese special administrative regions” (Macao, Hong Kong and Taiwan) that have reported COVID-19 infections. China, Taiwan, Hong Kong, Japan, Thailand, Singapore, Italy, Iran and R.O.K. all appear to have local, or endemic, spread of the disease. Italy has spawned further spread in Spain proper, it’s Canary Islands possession, Austria, Germany, and possibly Croatia. And now Brazil in South America and Algeria reporting a case signals North West Africa have added two new regions to the Pandemic spread list. The virus has spread from Asia to Europe, North America, Australia and Africa.
 
All of the above meets the pre-COVID-19 WHO standard for a “Pandemic” that requiring endemic spread in multiple nations in multiple WHO regions. However, the WHO just decided that it was time to retire the term “Pandemic” because…something…[insert reasons here]. The WHO statement for doing so was a master piece of unintelligible double talk that boils down to “Lets not scare the “Normies” and set off more “Run, Hide & Hoard” panics like seized Italy, ROK and Singapore in the last few days. Meanwhile the WHO is cheering-on China’s “Hospice-Prison system for the infected” Quarantine as a “Model” in aiding China’s restarting the World economy.
ITALY COVID-19 Confirmed Cases and Deaths 25 Feb 2020
ITALY COVID-19 Confirmed Cases and Deaths 25 Feb 2020
 
World Headline Summary
o WHO warns the rest of the world “is not ready for the virus to spread…”
o CDC warns Americans “should prepare for possible community spread” of virus.
o San Francisco Mayor declares state of emergency
o Later, CDC says pandemic not a question of it, but when
o Brazil may have South America’s first coronavirus case
o Germany confirms 2nd case on Tuesday, brings total to 17
o Italy cases spike to 322; deaths hit 10
o Japan’s Shiseido tells 8k employees to work from home
o Trump Economic Advisor Kudlow tries to jawbone stock markets higher
o HHS Sec. Azar warns US lacks stockpiles of masks
o Italy Hotel in Lockdown After First Coronavirus Case in Liguria
o Algeria confirms 1st case
o First case in Switzerland
o Kuwait halts all flights to Singapore and Japan
o Iran confirms 95 cases, 15 deaths
o First case in Austria
o Spain reports 7 cases in under 24 hours, including in Madrid, Canary Islands, Barcelona
o Iran Deputy Health Minister infected with Covid-19
Pandemic Border Closures
Turkey, Iraq, Kuwait, Afghanistan, Pakistan, Turkmenistan, Georgia, Armenia, and UAE blocked border crossings by Iranians.
Russia, North Korea and Vietnam are blocking border crossings from China
Austria and Switzerlan are blocking border crossings from Italy.
El Salvador on Tuesday announced it would prevent entry of people from Italy and South Korea.
 

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COVID-19/SARS-CoV2 Update 2-23-2020 — When the “New Versailles Class” Meets Reality Without Privilege

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The themes of this update will be on issues of COVID-19 spread, testing, public health institutional credibility, some e-mails evaluating the CDC and our elites, and my personal analysis of same after the top line infection numbers and headlines.

The SARS-CoV2 virus and it’s COVID-19 virgin fields infection seems to have a top line R(0) of between three and 6.7 — that is one person infects near seven people on average — because there are repeated “super spreader” events where one person slimed an institution with a lot of close contact and then the fomite contamination of that institutional setting causes everyone present to get the disease. Examples thus far include the Diamond Princess Cruise ship, a pair of prisons in China, and multiple hospitals in China and now South Korea. The rate of growth of the COVID-19 pandemic is such that we will be fighting it on a very large scale in a few weeks (no more than 10) in every nation world wide with the public and private medical institutions, societal resources, and people we have right now, with all their flaws. And not what we wish they were, but will never have. There simply isn’t going to be time and energy for blame games when issues of daily survival break upon us all.

Top line, there are currently 78,986 confirmed COVID-19 cases worldwide, including 2,468 fatalities as of 23 February 2020 at 11:52 a.m. ET on the BNO News corona virus traking site (https://bnonews.com/index.php/2020/02/the-latest-coronavirus-cases/) China, Taiwan Hong Kong, Japan, Thailand, Singapore, Italy, and Iran all appear to have local, or endemic, spread of the disease. See multiple charts attached and headline summary

Bar Chart of World COVID-19 Infections as of 23 Feb 2020
Bar Chart of World COVID-19 Infections as of 23 Feb 2020
Bar Chart of World Qide COVID-19 Infections Without China and the Diamond Princess Cruise Liner
Bar Chart of World Wide COVID-19 Infections Without China and the Diamond Princess Cruise Liner

World Headline Summary:

o Italy confirms 3rd death and cancels last 2 days of carnivale in Venice as cases soar above 100
o 4 more cases confirmed in UK
o 200 Israelis quarantined
o Japan confirms more cases
o Japanese Emperor expresses hope for Tokyo Games (fat chance)
o ROK Gov’t total cases above 600
o Trump says US has everything ‘under control’ as he asks Congress for more money (I call B.S. below)
o EU’s Gentiloni says he has ‘full confidence’ In Italian health officials
o Turkey, Pakistan close borders with Iran as confirmed cases soar
o Global Times (Chinese Gov’t news source) says virus may not have originated at Hunan seafood market
o Axios reports shortages of 150 essential drugs likely. (Most source in China)

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