Coronavirus (No politics)

[Grudenator]

This is a DA tweet. We have the best healthcare system in the world.
Nobody fighting this will have bigger numbers than China. Just because they severely underreported numbers doesn't make this true.

We have access to some of the best healthcare, but you better have the best insurance or be willing to go bankrupt for it.

 

[ButchPlz]

He isn’t wrong though. American healthcare isn’t great. I work in healthcare and it’s a very crooked, money grabbing business.

We spend more money on healthcare because politicians on both sides of the aisle have destroyed any semblance of a free market there via regulation, meaning only wealthy corporate hospitals and large insurance companies get a chance to thrive.

He's still wrong. We don't have more cases than China. But that Goo guy is a fake doctor so I guess you can't expect much.

 

[InVOLuntary]

Sad but true

Lutz

 

[vols50]

and short two bullets

4 bullets, always double tap, just in case.

 

[Coug]

We have access to some of the best healthcare, but you better have the best insurance or be willing to go bankrupt for it.

Bankruptcy it is. 2 or 3 weeks on a vent in the ICU?! Only a 1 percenter could pay that back.

 

[BigOrangeAl 1979]

They are saying another 3 weeks before we hit the peak of this

 

[davethevol]

They are saying another 3 weeks before we hit the peak of this

Don’t trust much of what anyone is saying at this point.

 

[VolnJC]

 

[InVOLuntary]

This making its way around social media. From an ER doctor in New Orleans I believe:

These are not my words but are very informative from an ER physician in New Orleans. One of my ENT friends graduated with him from Medical school. A lot of this information is counterintuitive on how we usually treat respiratory failure and pneumonia. Thought you guys might enjoy it.

(Copy and pasted from a private group)this is a really interesting read and breakdown of covid for this U.S. facility.

"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."

 

[bag12day]

4 bullets, always double tap, just in case.

I practice alot on my own range... Double tap not required. Chinese ammo quality might require 3-400 to do the job but not sure if NK makes their own.

 

[BigOrangeAl 1979]

Don’t trust much of what anyone is saying at this point.

. When do you think a vaccine at the earliest will be ready ?

 

[vollygirl]

I practice alot on my own range... Double tap not required. Chinese ammo quality might require 3-400 to do the job but not sure if NK makes their own.

But how's your cardio?

 

[bag12day]

But how's your cardio?

Lol well lets just say if you see me running try to keep up cause something really bad happened behind me. Between growing our food, hunting, fishing, fire dept training (slow cardio for us old timers), chasing calfs and running my business into the ground I'm cardioed out. No time for a gym.

 

[Grudenator]

Bankruptcy it is. 2 or 3 weeks on a vent in the ICU?! Only a 1 percenter could pay that back.

I wasnt just talking about coronavirus/ICU specifically, just healthcare in general. Why should a maintenance medication cost someone $300+ a month?

 

[hog88]

969 died in Italy yesterday crazy and sad how bad that country is getting hit by this. Imagine all the wealth of knowledge being lost.

Sucks to have a crappy healthcare system.

 

[Orangeredblooded]

He isn’t wrong though. American healthcare isn’t great. I work in healthcare and it’s a very crooked, money grabbing business.

More so in the insurance part, I work in healthcare also.

 

[ButchPlz]

More so in the insurance part, I work in healthcare also.

You can't put it all on insurance. The hospital here can be basically summarized as 'evil empire'.

 

[ButchPlz]

I wasnt just talking about coronavirus/ICU specifically, just healthcare in general. Why should a maintenance medication cost someone $300+ a month?

Because Americans are assuming every cost of research and development that goes into each drug, rather than that cost being spread around the world.

 

[vollygirl]

Lol well lets just say if you see me running try to keep up cause something really bad happened behind me. Between growing our food, hunting, fishing, fire dept training (slow cardio for us old timers), chasing calfs and running my business into the ground I'm cardioed out. No time for a gym.

Have you seen the movie Zombieland?

 

[VolnJC]

Because Americans are assuming every cost of research and development that goes into each drug, rather than that cost being spread around the world.

I was going to add that point....Americans pay for the ingenuity that gets basically given away to other countries...also we have bankruptcies and lawsuit liabilities added to every bill

 

[Orangeredblooded]

You can't put it all on insurance. The hospital here can be basically summarized as 'evil empire'.

I didn’t, hence the more so and not all. The amount of “if you scratch my back, I’ll scratch yours” I’ve seen between provider and compensation from Insurance, is the main reason I got out of that side of it. Providers have to word their diagnosis and procedures a certain way to get compensated at the level of their care.

 

[ButchPlz]

I didn’t, hence the more so and not all. The amount of “if you scratch my back, I’ll scratch yours” I’ve seen between provider and compensation from Insurance, is the main reason I got out of that side of it. Providers have to word their diagnosis and procedures a certain way to get compensated at the level of their care.

The hospital here treats its healthcare-worker employees very badly, and very much operates in the 'doctors all must see X patients per day or be fired' vein. They have absolutely massive turnover, but they're the only game in town and the local government is in their pocket (literally, in many cases) so they get to make the decisions.

 

[Power T-Rev]

Compared to other countries our healthcare is overall better. You can complain about it, but I'm glad I live in the US and not Italy or Spain

 

[Orangeredblooded]

The hospital here treats its healthcare-worker employees very badly, and very much operates in the 'doctors all must see X patients per day or be fired' vein. They have absolutely massive turnover, but they're the only game in town and the local government is in their pocket (literally, in many cases) so they get to make the decisions.

As I said, I’ve seen both sides and why I got out, I could debate with you on Insurance billing and coding on the flagrant miss use on both sides, whether it be healthcare wording their diagnoses and procedures a certain way to get the max compensation, (a few do that, not all) or the insurance part of weeding through the claims and policing through the claims that might be overreaching and still make profit, it the exactly why I went back into the food industry now, less stress.

 

[ButchPlz]

As I said, I’ve seen both sides and why I got out, I could debate with you on Insurance billing and coding on the flagrant miss use on both sides, whether it be healthcare wording their diagnoses and procedures a certain way to get the max compensation, (a few do that, not all) or the insurance part of weeding through the claims and policing through the claims that might be overreaching and still make profit, it the exactly why I went back into the food industry now, less stress.

I'm not arguing with you, I know it's both sides. You've got people on both sides that argue hurr durr this is how free markets work but the reality is, healthcare is not a free market at all.