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2020-03-29 8:59 AM
Official BT Coach
Subject: Report from the Front Lines in New Orleans
Below is a direct copy from a post over on SlowTwitch - https://forum.slowtwitch.com/forum/Slowtwitch_Forums_C1/Lavender_Room_F4/Report_from_the_front_lines_in_New_Orleans_P7183295/
There seems to be a great deal of distruct of anything the media is saying so perhaps a report from a doctor who is actually treating COVID-19 patients will be helpful. Some of this is very technical but it certainly conveys the dire circumstances facing our health care system.
(to clear up some apparent confusion: I am not involved in these stories, other than to be related to a doctor whose connections (that's her saying "my physician colleagues") brought this post to my attention. My apologies)
Their ICU is full and the suite usually used for endoscopy is full, all but one on ventilators. Their inpatient floor is full of COVID19 patients, and 4 of those needed emergency intubation and, since the critical care unit and endoscopy suite are full of intubated patients, they get sent from the floor to the ER to get the ventilator management they need.
Also, they are out of the usual sedating/pain relief meds they would use for these sick, ventilated patients and having to resort to other less commonly used drugs.
Chloroquine isn’t helping the sickest patients.
This is only the beginning. Please stay home. Trust the doctors and scientists. Plan on remoting in for Easter services. Don’t go to work if you don’t have to. Oh, and the doctors and governors need every ventilator they say they do. And don’t you dare suggest they’re “wasting” PPE.
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.
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.
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.
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.
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."
2020-03-30 7:03 AM
in reply to: k9car363
Subject: RE: Report from the Front Lines in New Orleans
Originally posted by k9car363
Very scary statistics on mortality rate of those that go on ventilators.
Started by Left Brain
Views: 224 Posts: 14
2020-02-13 5:26 AM Porfirio
Started by Rogillio
Views: 538 Posts: 20
2019-12-20 8:52 AM Left Brain
Started by Rogillio
Views: 274 Posts: 4
2019-04-23 9:13 PM Left Brain