OT: from ICU doc in Seattle

OT: from ICU doc in Seattle

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  • This is from a front-line ICU physician in a Seattle hospital. It’s pretty dense and directed towards physicians/healthcare workers but it just highlights why we have to slow the infection down. Keep in mind I’ve seen accounts from doctors in Italy where the situation is far more dire.

    This is his personal account:

    * we have 21 pts and 11 deaths since 2/28.
    * we are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen.
    * US has been past containment since January
    * Currently, all of ICU is for critically ill COVIDs, all of floor medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New resp-sx pts Pulmonary Clinic offshoot is open
    * CDC is no longer imposing home quarantine on providers who were wearing only droplet iso PPE when intubating, suctioning, bronching, and in one case doing bloody neurosurgery. Expect when it comes to your place you may initially have staff home-quarantined. Plan for this NOW. Consider wearing airborne iso PPE for aerosol-generating procedures in ANY pt in whom you suspect COVID, just to prevent the mass quarantines.

    * we ran out of N95s (thanks, Costco hoarders) and are bleaching and re-using PAPRs, which is not the manufacturer's recommendation. Not surprised on N95s as we use mostly CAPRs anyway, but still.

    *terminal cleans (inc UV light) for ER COVID rooms are taking forever, Enviro Services is overwhelmed. Bad as pts are stuck coughing in the waiting room. Rec planning now for Enviro upstaffing, or having a plan for sick pts to wait in their cars (that is not legal here, sadly).

    * CLINICAL INFO based on our cases and info from CDC conf call today with other COVID providers in US:
    * the Chinese data on 80% mildly ill, 14% hospital-ill, 6-8% critically ill are generally on the mark. Data very skewed by late and very limited testing, and the number of our elderly pts going to comfort care. - being young & healthy (zero medical problems) does not rule out becoming vented or dead - probably the time course to developing significant lower resp sx is about a week or longer (which also fits with timing of sick cases we started seeing here, after we all assumed it was endemic as of late Jan/early Feb). - based on our hospitalized cases (including the not formally diagnosed ones who are obviously COVID - it is quite clinically unique) about 1/3 have mild lower resp sx, need 1-5L NC. 1/3 are sicker, FM or NRB. 1/3 tubed with ARDS. Thus far, everyone is seeing: - nl WBC. Almost always lymphopenic, occasionally poly-predominant but with nl total WBC. Doesn't change, even 10days in. - BAL lymphocytic despite blood lymphopenic (try not to bronch these pts; this data is from pre-testing time when we had several idiopathic ARDS cases) - fevers, often high, may be intermittent; persistently febrile, often for >10d. It isn't the dexmed, it's the SARS2. - low ProCalc; may be useful to check initially for later trending if later concern for VAP etc. - up AST/ALT, sometimes alk phos. Usually in 70-100 range. No fulminant hepatitis. Notably, in our small sample, higher transaminitis at admit (150-200) correlates with clinical deterioration and progression to ARDS. LFTs typically begin to bump in 2nd week of clinical course. - mild AKI (Cr <2). Uncertain if direct viral effect, but notably SARS2 RNA fragments have been identified in liver, kidneys, heart, and blood.
    * characteristic CXR always bilateral patchy or reticular infiltrates, sometimes perihilar despite nl EF and volume down at presentation. At time of presentation may be subtle, but always present, even in our pts on chronic high dose steroids. NO effusions. CT is as expected, rarely mild mediastinal LAD, occ small effusions late in course which might be related to volume status/cap leak.
    * Note - China is CT'ing everyone, even outpts, as a primarily diagnostic modality. However, in US/Europe, CT is rare, since findings are nonspecific, would not change management, and the ENTIRE scanner and room have to terminal-cleaned, which is just impossible in a busy hospital. Also, transport in PAPRs. Etc. 2 of our pts had CTs for idiopathic ARDS in the pre-test era; they looked like the CTs in the journal articles. Not more helpful than CXR. - when resp failure occurs, it is RAPID (likely 7-10d out from sx onset, but rapid progression from hospital admit). Common scenario for our pts is, admit 1L NC. Next 12hrs -> NPPV. Next 12-24hrs -> vent/proned/Flolan. - interestingly, despite some needing Flolan, the hypoxia is not as refractory as with H1N1. Quite different, and quite unique. Odd enough that you'd notice and say hmmm. - thus far many are dying of cardiac arrest rather than inability to ventilate/oxygenate. - given the inevitable rapid progression to ETT once resp decompensation begins, we and other hosps, including Wuhan, are doing early intubation. Facemask is fine, but if needing HFNC or NPPV just tube them. They definitely will need a tube anyway, & no point risking the aerosols. - no MOSF. There's the mild AST/ALT elevation, maybe a small Cr bump, but no florid failure. except cardiomyopathy. - multiple pts here have had nl EF on formal Echo or POCUS at time of admit (or in a couple of cases EF 40ish, chronically). Also nl Tpn from ED. Then they get the horrible resp failure, sans sepsis or shock. Then they turn the corner, off Flolan, supined, vent weaning, looking good, never any pressor requirement. Then over 12hrs, newly cold, clamped, multiple-pressor shock that looks cardiogenic, EF 10% or less, then either VT->VF-> dead or PEA-> asystole in less than a day. Needless to say this is awful for families who had started to have hope. - We have actually had more asystole than VT, other facilities report more VT/VF, but same time course, a few days or a week after admit, around the time they're turning the corner. This occurs on med-surg pts too; one today who is elderly and chronically ill but baseline EF preserved, newly hypoTN overnight, EF<10. Already no escalation, has since passed, So presumably there is a viral CM aspect, which presents later in the course of dz. - of note, no WMAs on Echo, RV preserved, Tpns don't bump. Could be unrelated, but I've never seen anything like it before, esp in a pt who had been HD stable without sepsis.

    Treatment -
    *Remdesivir might work, some hosps have seen improvement with it quite rapidly, marked improvement in 1-3 days. ARDS trajectory is impressive with it, pts improve much more rapidly than expected in usual ARDS.
    *Recommended course is 10d, but due to scarcity all hosps have stopped it when pt clinically out of the woods - none have continued >5d. It might cause LFT bump, but interestingly seem to bump (200s-ish) for a day or 2 after starting then rapidly back to normal - suggests not a primary toxic hepatitis.
    *unfortunately, the Gilead compassionate use and trial programs require AST/ALT <5x normal, which is pretty much almost no actual COVID pts. Also CrCl>30, which is fine. CDC is working with Gilead to get LFT reqs changed now that we know this is a mild viral hepatitis.
    -currently the Gilead trial is wrapping up, NIH trial still enrolling, some new trial soon to begin can't remember where.

    *steroids are up in the air. In China usual clinical practice for all ARDS is high dose methylpred. Thus, ALL of their pts have had high dose methylpred. Some question whether this practice increases mortality.
    *it is likely that it increases seconday VAP/HAP. China has had a high rate of drug resistant GNR HAP/VAP and fungal pna in these pts, with resulting increases mortality. We have seen none, even in the earlier pts who were vented for >10d before being bronched (prior to test availability, again it is not a great idea to bronch these pts now).
    - unclear whether VAP-prevention strategies are also different, but wouldn't think so?
    - Hong Kong is currently running an uncontrolled trial of HC 100IV Q8.
    - general consensus here (in US among docs who have cared for COVID pts) is that steroids will do more harm than good, unless needed for other indications.
    - many of our pts have COPD on ICS. Current consensus at Evergreen, after some observation & some clinical judgment, is to stop ICS if able, based on known data with other viral pneumonias and increased susceptibility to HAP. Thus far pts are tolerating that, no major issues with ventilating them that can't be managed with vent changes. We also have quite a few on AE-COPD/asthma doses of methylpred, so will be interesting to see how they do.

  • Discussion
  • Fake news. You trust people just because they have MDs and
    Ph.Ds and years of relevant experience and ignore the people here who know it is mere hype just because the peop!e here have no education, training, experience or common sense.

    You know what they call people who trust public health experts more than ignorant rednecks?

    This post was edited by Crawling King Snake 2 months ago

  • My daughter is in Oak Harbor, WA. Her first job as a clinical pharmacist was at Kirkland, WA at Evergreen Health. That's where the first coronavirus fatalities showed up. The state of Washington is in total disarray she said.
    Needless to say I have my concerns.

    This post was edited by oldschooleer 2 months ago

  • Here is another account from a doctor in Italy. This is more in civilian vernacular

    COVID-19: FELLOW DOCTORS - LEARN FROM THE ITALIAN MISTAKES AND FIRST WIN OVER THE MEDIA AND POLITICS AND THEN INSIDE THE HOSPITAL

    Dear fellow colleagues,
    I would like to make a plea and explain to all of you the situation that is currently going on in my country in order for you to face this serious pandemic in the best possible way.
    In Italy, we have now understood that we are facing the worst health emergency in the history of modern medicine. China and other Asian countries have faced this pandemic with promptness and exceptional rigor that Italy has not been able to show..
    Our Chinese colleagues have published precise and clear case reports, reviews and data that have been severely underestimated in Italy.
    The situation here in Italy has been clear only when many hospitals were saturated and containment measures were put into action late.
    This virus does not respect boundaries and frontiers and needs to be addressed as a global problem.
    Everyone needs to be clear about the situation in order to face the problem in the best possible way that will probably affect your country too.
    SARS-CoV-2 is a highly contagious virus with a fairly long incubation period (about 5-6 days on average) during which the infected subjects can already be infectious. Most infected patients develop mild and non-crippling symptoms that result in an underestimation of the problem.
    A significant proportion of patients develop pneumonia which can precipitate unpredictably causing hypoxia difficult to take handle.
    This is the real critical issue around COVID-19: most of these SARS patients can be saved with orotracheal intubation and intensive care treatment with a huge commitment and resources for a long period of time (about 2 to 6 weeks).
    However, a small percentage of patients die despite intense treatment and the first ones to succumb are the weakest and oldest patients.
    This will create a large group of individuals with mild symptoms and preserved autonomy that are capable of spreading the infection and of communicating to the outside world that they are in good clinical condition.
    In the meantime, a percentage of patients that is not very small (10-15 %) will be intubated in intensive care and will not be able to testify to the world that the situation is serious and critical.
    The first to die will be the most fragile and elderly people.
    Such a scenario will lead the public to believe that COVID-19 is a virus that is not to be feared because it kills only few people whose health is already compromised.
    The situation becomes clear to everyone only when intensive care units are saturated and doctors have to start choosing who will be intubated and who will not be, with a significant increase in the number of deaths.
    In order to limit the death toll, the costs to the health system and the economic impact, it is necessary to begin containment measures well before the saturation of intensive care. This concept has become clear in China, but not in Italy.
    Intensive care hospitalisation occurs at least 10 days after the infection, therefore containment measures have an effect on the inflow of critically ill patients at least 10 days later.
    The high contagiousness makes this virus spread rapidly and in 10 days there can be thousands of people infected.
    All of us physicians can work at best with precise diagnoses and exhausting shifts both in wards and in the intensive care unit.
    Our actions will certainly help save lives but only the media and public health measures of early containment can help save thousands of lives.
    Containment measures definitely have a substantial economic impact and many will try to impede them but they are inevitable. Even if the Government does not impose economically drastic measures, fear will still harm the economy later on.
    Adequate containment will slow down the inflow of critically ill patients giving you time to intubate and discharge them and, thus, reduce mortality by one tenth.
    The advice I wish to give you is to prepare yourselves both from a clinical and infrastructure point of view, and in the meantime to stress the media and politics in order to take immediate drastic containment measures. This way the number of deaths will be decreased by thousands.
    We now find ourselves working in difficult conditions and we are conscious that the worst is yet to come. We regret not taking containment measures earlier.
    Please note that I am open to any suggestions from my Italian colleagues to improve this letter.
    Should you require any information or further clarification, please do not hesitate to contact me.
    Good luck to all of you
    Francesco Pilolli MD, ENT, Niguarda Hospital, one of the biggest COVID-19 Hubs in Italy.
    No photo description available.

  • wvskip said... (original post)Here is another account from a doctor in Italy. This is more in civilian vernacularCOVID-19: FELLOW DOCTORS - LEARN FROM THE ITALIAN MISTAKES AND FIR...


    If that doesn't open everyone's eyes, I don't know what will.
  • Crawling King Snake said... (original post)Fake news. You trust people just because they have MDs and Ph.Ds and years of relevant experience and ignore the people here who know it ...

    Post of the year. Why would you trust a doctor who has dedicated his/her whole life treating people when you can trust an A$ Clown who lies about the numbers because he only cares about the stock market????

  • Pound salt.

  • I want to see Venn Diagram of who thinks this is a media hoax and tRump Supporters.

  • NMEER said... (original post)I want to see Venn Diagram of who thinks this is a media hoax and tRump Supporters.

    Just one large circle

  • 50% of the infections in Italy required hospitilization

  • NMEER said... (original post)I want to see Venn Diagram of who thinks this is a media hoax and tRump Supporters.

    What is tRump?

  • In case you're wondering, you do not want to be on a ventilator. A lot of people (who are obviously in medical crisis before they are intubated) never come off them alive, so they don't get to tell you about the experience.

    I was on a ventilator for about five days following a lengthy vascular procedure about 3 1/2 years ago. It is damn scary, and you can't communicate well to explain your side of things because you have a tube down your throat and may be sedated as well. I have more on the subject, but doubt anyone wants to hear it.

    I would take a little inconvenience and voluntary isolation for about ten or twelve years before I would voluntarily undergo intubation and a vent.

  • A lot of medical jargon and then you get to the end and reveal your political *********.

    Want to see the real **** clowns? Look in the mirror.

    Why do you think President Trump put the travel ban on China as soon as they refused to let our experts help them?? China hid the thing from day one!!!

    The politicizing of this thing really pisses me off.

    This post was edited by Sg44gold 2 months ago

  • Sg44gold said... (original post)A lot of medical jargon and then you get to the end and reveal your political *********. Want to see the real **** clowns? Look in the mirror. Why ...

    Since 100% of what the Stable Genius says/does is politicized, I think it has rubbed off a little on people that normally do not do that:)

  • Sg44gold said... (original post)A lot of medical jargon and then you get to the end and reveal your political *********. Want to see the real **** clowns? Look in the mirror. Why ...

    China is blaming our military for bringing it over there and infecting their ppl.

  • Sg44gold said... (original post)A lot of medical jargon and then you get to the end and reveal your political *********. Want to see the real **** clowns? Look in the mirror. Why ...

    Where did I get political?

  • RADFORDEER said... (original post)Post of the year. Why would you trust a doctor who has dedicated his/her whole life treating people when you can trust an A$ Clown who lies abou...

    Which assclown are you talking about? The one that halted all travel from China to stop this from spreading? The one that asked the Senate to pass a bill to support the containment of this virus? The one that halted all travel from Europe and Middle East countries where this has rampantly spread? Or the one that is calling him a xenophobe because he is keeping infected people out of the U.S.

  • ButlerEER said... (original post)Which assclown are you talking about? The one that halted all travel from China to stop this from spreading? The one that asked the Senate to pass ...

    Probably the one that claimed the virus was just a hoax at his political rally then 12 days later tried to blame Obama for the country’s lack of preparedness.

  • Kilabeas said... (original post)Probably the one that claimed the virus was just a hoax at his political rally then 12 days later tried to blame Obama for the country’s lack of pr...

    LIARuser generated

  • oldschooleer said... (original post)My daughter is in Oak Harbor, WA. Her first job as a clinical pharmacist was at Kirkland, WA at Evergreen Health. That's where the first c...

    Hope your Daughter is okay

  • Or maybe the one that yells “fake news” whenever someone says something that makes him look bad.

  • Kilabeas said... (original post)Or maybe the one that yells “fake news” whenever someone says something that makes him look bad.

    That has been debunked a million times bud, try and keep up.

  • ButlerEER said... (original post)Which assclown are you talking about? The one that halted all travel from China to stop this from spreading? The one that asked the Senate to pass ...

    All well past when he should have done so

    well past

  • Trump Train said... (original post)That has been debunked a million times bud, try and keep up.

    Speaking of fake news...

  • Kilabeas said... (original post)Speaking of fake news...

    Verdict: False

    In these trying times, we must turn to the greatest document in the history of the world to promise freedom and opportunity to its citizens for guidance. Find out more now >>

    Trump referred to “politicizing” of the coronavirus by Democrats as “their new hoax.” He did not refer to the coronavirus itself as a hoax.

    Throughout his speech, Trump reiterated that his administration is taking the threat of the coronavirus seriously.

    Now back to your PMSNBC now fool.

  • wvskip said... (original post)50% of the infections in Italy required hospitilization

    That's because Italy has the oldest population in all of Western Europe.