This was posted (re-posted from another group) by a friend who is an RN and retired last year from the ER. Although I can understand some of the lingo, if one of the Docs on the forum could break it down a little it would be appreciated.
Thanks

"Repost from another group. Interesting read.

"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.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."

Well, NOAA had to get involved.

quote:

Originally posted by Skins2881:
RI setting up checkpoints and having people entering state self quarantine.

This is a Nonissue....Nobody wants to go to Rhode Island anyway!

quote:

Originally posted by thunderson:
This was posted (re-posted from another group) by a friend who is an RN and retired last year from the ER. Although I can understand some of the lingo, if one of the Docs on the forum could break it down a little it would be appreciated.
Thanks

Yeah, got any type of link or source?

quote:

Yeah, got any type of link or source?

Yes, I do..but you can't have it. I have known the person who posted this for 45 years. Now do you care to add your medical opinion as that is what I asked for?

quote:

Originally posted by Balzé Halzé:
Hehe. "'Half' Whitmer." Love it.

Now she is complaining vendors won't worn with her because of Trump. Basef innher track record she tried to muscle them and they told her to pack sand.

The other day she told us 1 hospital got (I think) 700k masks but that won't last a single shift, not enough, need more. Are they brewing coffee in these damn things???

https://www.msn.com/en-us/news...lWERQ5_-kwwmwSKRMQ84

quote:

Originally posted by thunderson:

quote:

Yeah, got any type of link or source?

Yes, I do..but you can't have it. I have known the person who posted this for 45 years. Now do you care to add your medical opinion as that is what I asked for?

I read all of it, very informative and anyone in the medical field can tell its not BS. Thanks Thunderson.

The just-launched Apple application for self-screening of COVID-19. Download free from the App Store onto your device, or try it online.

quote:

Originally posted by highroundcount:

quote:

Originally posted by parabellum:
2.2 million dead in the US? I'm telling you- some of these people who are making these ridiculous predictions just need to be hung. Coronavirus is not damaging this nation; hysterical, posturing, egotistical, incompetent know-it-alls with an agenda are damaging this nation.

The antidote is hemp, properly knotted and utilized.

Do any of you honestly think for one single second that such an estimate is anything more than fantasy? And we're listening to these boobs?? I don't care how many degrees they have or how well-regarded they are in their field. A prediction of 2.2. million US deaths from this bug is outrageously false.

Oh, but now, you see, we've "taken the necessary precautions", so he can now "downwardly revise" this figure. Oh, come on. You are fooling a lot of people but you are not fooling all of us.

All this is a test run.....all I've to say at this point.

Pure sadness

Nora O'Donnell on CBS interviewed a weeping female Chicago ER doctor, (and Democrat donor, no doubt), who stated all the doctors she knows are almost out of supplies, running on no sleep, have overflowing ICU wards, having to put patients in hallways, and are skyping it their children because it "might be the last time," and are all filling out their wills because this virus is going to be taking the lives of so many health care officials. This IMMEDIATELY following Trump's press conference where it was revealed that there is no scenario where so many will die, and after revealing that thousands of empty ICU rooms still exists in hospitals in New York alone.

The media really is pushing this.

The truth will find its way out. This business has affected most of the people on the planet. Gonna be kinda hard to keep the bullshit flowing. Most everyone has a personal stake.

I look at these marathon press briefings the President is holding each day and I try to imagine how much wose this situation would be with that stuttering clusterfuck of a prevaricating kiddie diddler Biden up there instead.
President Trump has hit his stride and he is leading the nation quite effectively through this nonsense, and ol' Dementia Joe looks exactly what he is- a doddering, senile old man with delusions of grandeur.

Interesting that they're activating the non-active reserves. We're seeing a concentration of infections in specific large, urban areas; I wonder if they're putting together some combination of medical, logistical and maybe engineering/construction groups to go there.

On a side note, sending in federales of some kind might provide an alternative source of information to Nora O'Donnell.

The military is starting to feel the effects too... An entire carrier on lockdown. Various servicemembers out sick across the country. Etc.

So part of it may just be to fill the gaps left by the anticipated percentage of sick active duty folks.

quote:

Originally posted by Il Cattivo:
Interesting that they're activating the non-active reserves. We're seeing a concentration of infections in specific large, urban areas; I wonder if they're putting together some combination of medical, logistical and maybe engineering/construction groups to go there.

Hopefully to build a very very large wall around NYC... didn't they make a movie about that...?

quote:

Originally posted by RogueJSK:
The military is starting to feel the effects too... An entire carrier on lockdown. Various servicemembers out sick across the country. Etc.

So part of it may just be to fill the gaps left by the anticipated percentage of sick active duty folks.

No more so than anyone else.

An Aircraft Carrier is like a small, mobile NYC, 4-5K people living in the size of a couple of football fields several stories deep. Lots of steep ladderwells to get around (very few elevators and those are for heavy equipment / weapons / etc), everyone has to use hands to get up and do. Not surprising at all it is racing around a carrier. But carriers are used to 'the hacks' that everyone gets all the time on deployment. Colds make the rounds, its just what it is.

The regular stateside military is just as pissed as the rest of us - no travel orders, no leave outside of 50 miles. We have moved operations to outside their bases to support them. Our on site personnel are still working on base if their jobs require it or telecommuting.

But there is no wide ranging infections in the military, don't let yourself be fooled. 99% of the impact is the same self inflicted shotgun blasts we have been doing to ourselves, only the military actually make their people follow the rules, unlike civilians.

quote:

..didn't they make a movie about that?

Yep. And no matter how many times I watch it, all I ever seem to remember is Adrienne Barbeau.

quote:

So part of it may just be to fill the gaps left by the anticipated percentage of sick active duty folks.

Hopefully they'll give folks who got knocked out of work some kind of shot at volunteering first.

quote:

Originally posted by Il Cattivo:
Hopefully they'll give folks who got knocked out of work some kind of shot at volunteering first.

We are actually in a different boat, several of my part time guys can't travel now for our civie company because they can't take local reserve military orders / drills if they leave the area to work for us unless they do a 14 day QT - and while our work is continuing, they can't risk losing the Reserve money, so they have 'self sidelined' from work and taken reserve orders - with the hopes it'll only be a month or so until they can return to work for us.

quote:

Originally posted by thunderson:

quote:

Yeah, got any type of link or source?

Yes, I do..but you can't have it. I have known the person who posted this for 45 years. Now do you care to add your medical opinion as that is what I asked for?

Did this person write that or repost it?

on p248, ChicagoSigman posted a vimeo that is long but very informative

Free money everywhere on the floor! Run, run RUN and get it before someone else does!!!!