The Official CORONAVIRUS oh *&^! thread. Time to start stocking up on food?

[DomRRTtoPA]

11 hours ago, Reality Check 2 said:

I know we try to stay out of politics here but I am livid.

Trump is a moron and endangering public health with his lies, diversions and complete lack of any knowledge of how to handle this. 

He has flat out LIED about this illness and FAILED to follow medical professionals advice. 

He FIRED the pandemic team and now closed all the Coronavirus meetings as classified, excluding folks who actually know what to do.

Not enough tests, NOT testing people, not acting soon enough..... 

How do we, the medical professionals function with this dismal excuse for leadership?

Seems like a third reality check might be needed in this case. Nothing you said has any basis in fact, you are allowing your political leanings to affect your judgment. If you look at the response to covid19 compared to any other outbreak since the beginning of this country you could only objectively say that this administration has shown decisive action, been proactive, and highly effective in implementing the public health measures that are proven to combat the disease.  No amount of wailing, nay saying and internet trolling can ever change the fact that no President has ever implemented measures and made the public aware as quickly as the one we have now. 

[Cideous]

27 minutes ago, DomRRTtoPA said:

Seems like a third reality check might be needed in this case. Nothing you said has any basis in fact, you are allowing your political leanings to affect your judgment. If you look at the response to covid19 compared to any other outbreak since the beginning of this country you could only objectively say that this administration has shown decisive action, been proactive, and highly effective in implementing the public health measures that are proven to combat the disease.  No amount of wailing, nay saying and internet trolling can ever change the fact that no President has ever implemented measures and made the public aware as quickly as the one we have now. 

Keep drinking the coolaid.....

Edited March 12, 2020 by Cideous

[DomRRTtoPA]

 

41 minutes ago, Cideous said:

Keep drinking the coolaid.....

The blue Kool-Aid or the red? Give me just 1 example and you can change my mind. Unlike others I pride myself on understanding facts.

[rev ronin]

Guys, can we focus on the disease at hand, not the political leadership or lackthereof?

Diseases don't care who's in the White House, and past action/inaction can't be changed now.

[DomRRTtoPA]

I treated my first covid19 patient today so my anxiety over some of the nonsense is high. Testing was readily available with a 24 hour turn around at the state health dpt. Pt has multiple comorbidities and has developed ARDS, pretty stable condition today FiO2 is at 55 PEEP 12 but trending in the right direction. Take care and stay safe.

[mgriffiths]

2 hours ago, ShakaHoo said:

At what point do we start re-investing in the stock market?!?!?  Is this just getting started?

Some would say that you are trying to "time the market," and "time IN the market" is better.  While I would say this is usually true, I think this is different.

I haven't been putting anything into the market right now.  Partially because I didn't have the cash when this all started, but also because I think this is only going to get worse.  It really only seems to be starting in the USA, plus have we really had the full effect yet of the significant drop in Chinese manufacturing for USA assembly?  I don't think so.

Sports seasons are just now being cancelled.  Schools are just now closing.  Conferences are just now being cancelled/rescheduled.  The list goes on...and on...and on...which is GOOD from a pandemic perspective, but terrible for our economy.

The question is how quickly will things recover once this is over?

[cbrsmurf]

I agree with Rev.  I'm all for deleting political posts.  There's nothing you can do about who is in charge of the government now.  All you can do is vote in November... unless they suspend the elections.

 

Some updates:

WHO has declared this a global pandemic.

President Trump has implemented a travel ban from Europe sans UK, but appears only to apply to foreign citizens, not US citizens.

120 severely ill patients are being trialed on remdesivir.

Study regarding stability of virus on various surfaces and possible aerolization:

https://www.medrxiv.org/content/10.1101/2020.03.09.20033217v1

Emcrit resource:

https://emcrit.org/ibcc/COVID19/

CDC guide for health professionals:

https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html

[medic25]

23 minutes ago, DomRRTtoPA said:

I treated my first covid19 patient today so my anxiety over some of the nonsense is high. Testing was readily available with a 24 hour turn around at the state health dpt. Pt has multiple comorbidities and has developed ARDS, pretty stable condition today FiO2 is at 55 PEEP 12 but trending in the right direction. Take care and stay safe.

Must be nice to have testing readily available.  We still can't test anyone who isn't being admitted, and need to jump through a host of hoops with public health to even try and make this happen.  I've had colleagues in the ED with high-risk patients who were denied testing by the health department.  We should have been prepared for this is a nation well before now, but instead we are scrambling to catch-up.

[cbrsmurf]

9 minutes ago, DomRRTtoPA said:

My patient was not tested until their condition became critical and IMO it was completely unnecessary until then. It was getting to the point where we were able to R/O everything else. The diagnosis does not change the treatment as the treatment in 100% of the cases at this time is symptom management. I heard this morning that there has been some promising results with testing remdesivir on animals, hopefully we can fast track that and we can all move on. 

The only way we are going to beat this virus in the short term is through public health management, so you might want to trust in that when they deny you a diagnostic or be miserable until its over. I learned quite a bit about public health in my undergrad and you can only be so proactive in preparing for disaster before people start calling you crazy. So although I acknowledge a certain degree of reactivity, I can not be convinced that it is atypical under the circumstances.

Completely disagree.  One of the main reasons China has been able to contain the virus as well as other countries such as Singapore and Taiwan was the widespread use of testing.  With testing and actually identifying regional exposure, proper preparation and policies can be designed, planned and implemented.  The reason our health department and CDC has been denying tests is the poor capacity for testing capability, essentially managing a limited resource.  Once the ability to test ramps up, the pushback and threshold for testing will decrease.  This is already  happening in Washington, where UW has had a significant ramp up of testing capability.

[polarbebe]

 

2 hours ago, cbrsmurf said:

Completely disagree.  One of the main reasons China has been able to contain the virus as well as other countries such as Singapore and Taiwan was the widespread use of testing.  With testing and actually identifying regional exposure, proper preparation and policies can be designed, planned and implemented.  The reason our health department and CDC has been denying tests is the poor capacity for testing capability, essentially managing a limited resource.  Once the ability to test ramps up, the pushback and threshold for testing will decrease.  This is already  happening in Washington, where UW has had a significant ramp up of testing capability.

This. 
 

Without testing and appropriate surveillance (those with risk factors) you can’t quarantine, make policies effectively, deploy resources most efficiently.  Need to “flatten the curve”.

South Korea was able to limit the spread by performing over 220,000 tests.  The US? As of 3/10 performed about 11,000 tests.  CDC really screwed up.

Italian intensivists have run out of ventilators (making decisions on allocations of limited resources such as vents, basically mass casualty triage in the ICU) and are treating ICU patients in the corridors.  Basically what happened also at ground zero (Wuhan).  

https://www.google.com/amp/s/www.euronews.com/amp/2020/03/12/coronavirus-italy-doctors-forced-to-prioritise-icu-care-for-patients-with-best-chance-of-s
 

I read a post from an intensivist from Seattle that one ICU is only COVID-19 patients and med/surg for stable COVID-19 and end of life care.  Haven’t been able to confirm this from other sources though.  
 

The same post also said most death from cardiac arrest not hypoxia/ARDS... ? Due to possible sepsis cardiomyopathy or viral myocarditis with normal EF reduced to ~10% several days later.  Mixed shock states of sepsis plus cardiogenic = death.  
 

NY state has guidelines of allocation of ventilators:

https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf
 

SCCM have made their Fundamentals of Disaster Management modules for free.   Highly encourage everyone to watch them:

https://www.sccm.org/disaster
 

Lastly, I recommend everyone get their affairs in order and make sure your family is taken care of in case something happens to you...  
A NJ PA is on high-flow NC due to COVID-19 (you can google him, he has been all over the press).

Stay safe.  

 

Edited March 12, 2020 by polarbebe

[DomRRTtoPA]

PCR testing is not cheap($3000), it is not fast(24hrs labor intensive), it is not accurate(A CT scan has a higher level of accuracy) and it does not change the treatment plan(symptomatic treatment). Even the new IgM/IgG rapid tests have limitations and it is recommended to validate results with PCR. China is the largest producer of chemicals in the world, they have the supply of the reagents needed for mass scale PCR testing. To say that the US and every other country was unprepared is nonsense, you simply can not prepare for a pandemic of this magnitude without wasting billions annually to stockpile chemicals with costly expiration dates or producing them yourself with high startup costs. We rely on other countries for goods because we thrive as a result, who would have thought that relying on an oppressive dictatorial regime for cheap labor costs would be bad for us during a world crisis? 

I thought that I was clear that I was separating the necessity for testing for medical treatment from public health by mentioning "The diagnosis does not change the treatment as the treatment in 100% of the cases at this time is symptom management." in one paragraph then "The only way we are going to beat this virus in the short term is through public health management" in the next.  I guess where I erred was in saying the testing was "completely unnecessary" when I meant to say completely medically unnecessary for the treatment of patients, which is where I am trying to keep my focus. I tend to trust the government and the experts working for the CDC when it comes to knowing what is best during a crisis. They have determined the value of PCR testing for covid19 and its much less than what you all are claiming. Its not a perfect system and its easy to make mistakes but its what we have.

[ohiovolffemtp]

I have seen two treatment suggestions in addition to symptomatic management and antivirals:

• ACE inhibitors: statements to the effect that somehow coronaviruses attack the lungs via angiotensin receptors
• High dose vitamin C - from the same folks that like it for sepsis

Anyone have any thoughts on either of these?

[Joelseff]

I'll just leave this here...

Sent from my SM-G975U using Tapatalk

[MediMike]

The suggested entry point is via the ACE2 receptor rather than anything to do with ACE itself.  Lancet had a brief piece pointing out that there is actually upregulation of the ACE2 receptor in patients who utilize ACEi /ARBs potentially INCREASING their risks.  Theoretical reason for why individuals with comorbidities such as HTN/NIDDM/IDDM etc. may have worse outcomes (as they are the ones most commonly on such meds)

In regards to VitC...So far evidence hasn't been in favor of the OJ.  VITAMINS and CITRUS-ALI didn't show anything (ok CITRUS-ALI had a mortality benefit but it was a secondary outcome with a failed primary so take what you will out of that).  Have heard that China may be doing  high dose trial and there are several proposals in the works on clinicaltrials.gov

[mgriffiths]

5 hours ago, Joelseff said:

 

 

I'll just leave this here...

Sent from my SM-G975U using Tapatalk
 

 

"Two garbage bags...my shoes have come loose..." - I'm sorry, but that is funny.

[cbrsmurf]

Over 1000 in Italy dead, CFR estimated to be higher than in Wuhan. 

[sas5814]

Yesterday my wife and I were grocery shopping and there was no TP or bleach in the store. There had, at that time, been no confirmed cases in our area. This morning we had our first 3. I can only imagine the craziness that is about to start

[Cideous]

18 minutes ago, sas5814 said:

Yesterday my wife and I were grocery shopping and there was no TP or bleach in the store. There had, at that time, been no confirmed cases in our area. This morning we had our first 3. I can only imagine the craziness that is about to start

Stopped by Sams yesterday to grab a few things and it looked like a war zone.  Not one cart and basically people everywhere fighting over supplies.  I just stood there for a second, took it all in, then turned around and walked out.

 

If this is a "Hoax"....it's quite the effective "Hoax". 

[cbrsmurf]

Samples can be sent to University of Washington for testing if your local health dept can't/won't test:

https://testguide.labmed.uw.edu/public/view/NCVQLT?tabs=no

[cbrsmurf]

21 hours ago, DomRRTtoPA said:

PCR testing is not cheap($3000), it is not fast(24hrs labor intensive), it is not accurate(A CT scan has a higher level of accuracy) and it does not change the treatment plan(symptomatic treatment). Even the new IgM/IgG rapid tests have limitations and it is recommended to validate results with PCR. China is the largest producer of chemicals in the world, they have the supply of the reagents needed for mass scale PCR testing. To say that the US and every other country was unprepared is nonsense, you simply can not prepare for a pandemic of this magnitude without wasting billions annually to stockpile chemicals with costly expiration dates or producing them yourself with high startup costs. We rely on other countries for goods because we thrive as a result, who would have thought that relying on an oppressive dictatorial regime for cheap labor costs would be bad for us during a world crisis? 

I thought that I was clear that I was separating the necessity for testing for medical treatment from public health by mentioning "The diagnosis does not change the treatment as the treatment in 100% of the cases at this time is symptom management." in one paragraph then "The only way we are going to beat this virus in the short term is through public health management" in the next.  I guess where I erred was in saying the testing was "completely unnecessary" when I meant to say completely medically unnecessary for the treatment of patients, which is where I am trying to keep my focus. I tend to trust the government and the experts working for the CDC when it comes to knowing what is best during a crisis. They have determined the value of PCR testing for covid19 and its much less than what you all are claiming. Its not a perfect system and its easy to make mistakes but its what we have.

Again, I disagree.  Preparation, just like any natural disaster, would have helped.  Yes, it would've been expensive, but now it's going to be way more expensive in the long run because we were underprepared.  

 

Furthermore, PCR testing ain't that expensive or hard; I used to do it for years before becoming a PA.  You do a little processing and then let the PCR run on its own and the computer spits out the results.  The reason PCR is expensive in general is the R&D costs to identify nucleotides/genes, validate, and patent testing.  It will provide rule-in/out of disease, especially when the patient has mild symptoms and you can manage/watch/quaratine with those results (plus you aren't blasting someone with ionizing radiation just to screen someone).

 

CDC and government are not limiting testing because they don't think it's needed.  They just don't have the capability at this time.  Why do you think they are desperately ramping up testing capability if it's not needed?

[EMSGuy1982]

Man, a career change to occ med is really tempting because UC is a nightmare right now....

[Cideous]

30 minutes ago, EMSGuy1982 said:

Man, a career change to occ med is really tempting because UC is a nightmare right now....

Better do it fast.

[mgriffiths]

3 hours ago, EMSGuy1982 said:

Man, a career change to occ med is really tempting because UC is a nightmare right now....

As a FM PA who recently transitioned to ortho, I have been getting calls left and right about covering in our UCs.  We are extending hours and creating a bit of "covid-19" clinic.  I've told them to please only use me as last resort due to my pregnant wife at home.  This isn't exactly something I want to bring home.  The result was I have been conscripted to cover next week...  Pretty upsetting when they are cancelling at physicals and well-child visits...pretty much all of the FM and IM providers should be more than available considering any patient with a fever and respiratory symptoms is being sent to the "covid-19" clinic.

[ShakaHoo]

14 hours ago, EMSGuy1982 said:

Man, a career change to occ med is really tempting because UC is a nightmare right now....

I work in Occupational Medicine.

1)  All hospital employees who believe they have an exposure are to be evaluated by Occupational Medicine.  This is done either an in-person visit, or a telephone consultation.  Needless to say, we are dealing with a large amount of this.  

2)  Any hospital employee who is quarantined, or out of work with "Corona Like Symptoms" needs to be seen and evaluated by Occupational Medicine prior to returning to work.

3)  Local businesses have been calling us for guidance non-stop.  They are all requesting that their employees who are quarantined or out of work with upper respiratory symptoms be seen and cleared by our office prior to returning to work.

 

Not quite as tedious or dangerous as working in Urgent Care or the Emergency Room (I previously worked in Urgent Care), but certainly high volume with its own stressors.  

[True Anomaly]

Community spread is here.  If it’s not already in your backyard, it’s coming soon.

In my opinion, it is at the point that the availability of testing should be guiding evaluation and management.  If someone shows up to an ER and If you As the evaluating PA don’t have ready access to testing, then unless they are truly in extremis and needing of supportive care- ie, ventilatory support- then they get DISCHARGED and advised to quarantine.  

If testing is available, then by all means test in order to establish the cohort and potential for exposure.  But even if they test positive, they’re not staying in the hospital.  So....off to home you go anyway

Most places, mine included, have ready access to a respiratory PCR panel (it’s amazing what you find you have access to in times like this) which tests for just about every respiratory virus and even a few bacteria.  Although a positive on that PCR doesn’t mean rule out a co-infection, it certainly makes it far less likely that you have COVID- and at this point I think a valid clinical decision can be made.

Bottom line- the current triage process for asking about symptoms and possible exposure to a know patient is unhelpful.  If they don’t have it now, they likely will soon. Holding the dam for just a few more days/weeks until testing become much more widely available is going to be the hardest part