A fairly long smattering of Health Care workers reports ON THE FRONTLINE:
RR findings in general have little correlation with disease severity in pneumonia, and that goes for COVID as well. A patient <65 who isn't hypoxic or hypotensive with a RR <30 essentially never needs to be admitted for pneumonia outside of unique circumstances (regardless of imaging), and even then it's usually "just in case". I will say this disease does make one hesitate because of its unique course, but there are predictors other decompensation as you said that can guide you.
I don't love the Plaquenil option and the data sucks to be honest, but I have used it some. Remdesivir really seems to work well in the severe cases from my anecdotal perch.
Also, some of these patients have incredible IL-6 levels. I've never seen numbers this high even in my AIDS patients with KICS. One guy had a level above assay which were pretty sure has never been reported by our lab before.
Obviously we dont know what they were for Spanish flu patients 100 years ago but the cytokine storm was the hallmark of that disease. We're seeing something similar here. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Patients requiring supplemental oxygen beyond regular nasal cannula, which in COVID usually ends up being a ventilator. We don't really try NIPPV as the OP said because it doesn't help much and risks aerosolizing the virus. I've had one patient saved from a vent by high flow nasal cannula, which in terms of pure oxygen delivery is the most we can provide prior to intubation, but generally these people are either on NC or getting intubated because the hypoxia becomes so profound so quickly if they crash. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I've got several doc friends in NOLA that are giving identical stories. The kind of stuff you and they are talking about are things I'd never have expected to see as a physician. I went from seeing none of these patients, to 10 of them in the last 2 days. All of them so far mild. I'm sure that this will change in the next day or two. As i told some of my colleagues, based on the number of mild cases I'm seeing, **** is about to hit the fan. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ San Antonio. I think they state that we reportedly have only 67 confirmed cases currently, however, I can tell you that the large majority of patients that likely have it are being sent home without testing. I have seen 2 confirmed cases myself. Another 8 that either have a confirmed close contact with a +individual, labs and imaging results that are classic for the CV, or a very concerning travel history and symptoms that are consistent with it. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Hang in there. Unfortunately, I am hearing stories similar to this in areas around New Orleans. Let's hope things get better. Praying for you. This virus is just a bad monster. Once you go into cytokine storm it is so hard to survive. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ People asking about the hydroxycholoroquine combination, once you are this sick it is very unlikely to help. Way too much viral replication and inflammation has already occurred. It's purpose the way I see it is for us doctors in the community to get it started as soon as possible to hopefully slow down viral replication and inflammation so they never get to ventilator stage. Also hopefully it will be proven to successful in prophylaxis to protect the physicians l from getting too much viral exposure. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Based on what I'm hearing from colleagues in peds ID it seems like asthma is the theme of severe presentations under 20. Kids with asthma are the ones getting intubated, but thankfully this is more related to reactive airway disease and less so parenchymal lung disease. It basically causes a severe asthma exacerbation which is easy enough to fix once they're intubated. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Another day, another 5 seen, 2 are confirmed, the other 3 told they should assume they have it. Our hospital system is about to run out of rapid test kits and the local health department has asked us to no longer send them swabs from patients that are being discharged (that was apparently a thing for about 4 days before they were so inundated with swabs that they had to stop it). ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ All the cases so far have remained mild, thankfully, although I suspect most are early in the disease process. Ages range from 20-80+. Can't rely on the chief complaint to be the typical viral syndrome, as I have had one who came in for abdominal pain and another was an older gentleman with altered mental status. Many of them don't have fever. Several of them have pretty unremarkable lab work, although many have several of the typical lab or imaging abnormalities. Many of these patients are being seen by healthcare workers w/o proper PPE due to atypical complaints. One of the confirmed patients was brought in by EMS without any PPE on whatsoever, although I don't think they realized that this patient was at risk for having it. Unfortunately, after talking with some of my local EMS friends, they are getting absolutely no education regarding ways to protect themselves, and who they should suspect this in, at least according to them. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ On another note, I'm having to limit the quantity to dispense on certain inhalers and other maintenance medications for chronic conditions. We are having a lot of medications go on backorder and we just don't know when more will be coming. So you may see more drug change requests from pharmacy. Also, since a lot of physicians are on this thread just a heads up as of 3-20-2020:
1 TITLE 22 EXAMINING BOARDS 2 PART 15 TEXAS STATE BOARD OF PHARMACY 3 CHAPTER 291 PHARMACIES 4 SUBCHAPTER A ALL CLASSES OF PHARMACIES 5 291.30. Medication Limitations. 6 No prescription or medication order for chloroquine, hydroxychloroquine, mefloquine, or 7 azithromycin may be dispensed or distributed unless all the following apply: 8 (1) the prescription or medication order bears a written diagnosis from the prescriber consistent 9 with the evidence for its use; 10 (2) the prescription or medication order is limited to no more than a fourteen (14) day supply, 11 unless the patient was previously established on the medication prior to the effective date of this 12 rule; and 13 (3) no refills may be permitted unless a new prescription or medication order is furnished.
https://www.pharmacy.texas.gov/files_pdf/291.30.pdf - https://www.pharmacy.texas.gov/files_pdf/291.30.pdf
If you get a call about these medications from pharmacy this is why. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Just heard from a buddy who is at Mt. Sinai in NY that they just adopted a mandatory DNR policy for COVID patients if via 2 physician consent it is determined a patient is unlikely to survive no matter what is done. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I know first hand much of what the administration is stating in these pressers is false, because I see things to the contrary at my own facilities. I voted for Trump but it's extremely frustrating listening to him and those around him telling the American people things that just aren't true.
Most major medical centers already have or are drafting plans with their legal departments for this scenario.*DNR* It's going to be implemented at more than a few before this is done. There are even medical and ICU directors at major institutions ON THE RECORD stating as much. Anything said to the contrary is, at best, misleading. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
Apparently the hospitals in NY are also starting run short on commonly used ICU meds, such as pressors and sedation. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ I am ER, trained at the Lake in BR
We are doing plaq/azithro in the ICU....obviously we have the ability to keep them on the monitor if they go into Torsades. Agree, I am not testing anyone unless they are admitted. I am sorry, but I am not putting my nursing staff at risk for a mildly symptomatic patient to whom the treatment does not change,
Intubation wise, trying to minimize risk as best as possible. I have the vent set up before hand, minimize bagging, have them on 100% NRB until RSI. Then I am pushing paralytic before hand to minimize sedation time. Tube them w glidescope and immediately put them on vent to decrease open circuit time. Can do this <90 sec if prepared. ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
------------- 'A man who does not think and plan long ahead will find trouble right at his door.' --Confucius
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