Fear and Loathing, a Rat Flu Odyssey

[Core Shot]

Meemaw?

[idahospud]

This is disrespectful in the South. Mother is even worse.... Or so i hear

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No, no, no, that's what we're supposed to call our wives.

[KQ]

My son's mothers side is from Alabama and that's what i was told repeatedly. Not sure Alabama and North Carolina are the same but i am sure your grandmother had more decency and class than those of which i speak

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Oops - added this after you quoted:

Whatever... shouldn't have judged... just sounded/read weird to me. To each their own and we've got bigger fish to fry.......

Again... meant no offense. Should get off to bed anyway. Sleep is good for immune system!

[rideit]

No, no, no, that's what we're supposed to call our wives.

Ok, Mr. Pence.

[SirVicSmasher]

Oops - added this after you quoted:

Whatever... shouldn't have judged... just sounded/read weird to me. To each their own and we've got bigger fish to fry.......

Again... meant no offense. Should get off to bed anyway. Sleep is good for immune system!

Good night KQ

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[Core Shot]

CNN documentary from three years ago.
Eerie
Pandemic pandemonium

[KenJongIll]

CNN documentary from three years ago.
Eerie
Pandemic pandemonium

Yeah..was watching that. Eating a roast beef roll up...had to turn it off. Ebola ain’t pretty

[old goat]

My Grandmother was from North Carolina. My mother called her "Mom" and Grandma always referred to her mother (my great-grandmother) as "Mother." Maybe she'd been northern-ized from homesteading Montana.

Whatever... shouldn't have judged... just sounded/read weird to me. To each their own and we've got bigger fish to fry.......

[idahospud]

Ok, Mr. Pence.

Man, that guy scares me. He's like Skeletor but less personable.

Yeah..was watching that. Eating a roast beef roll up...had to turn it off. Ebola ain’t pretty

I haven't watched that, but at least for ebola the upside is that it kills so horribly and efficiently that it doesn't actually spread very well.

[Rideski]

Fucking cruise ship industry asking for a bailout before the problem is even barely underway, when they exacerbated the thing, and they aren’t even American companies.

[powpig]

The CDC is hiring Quarantine Officers

[Ted Striker]

Man, that guy scares me. He's like Skeletor but less personable.

Trump: I have the power!
Pence: YOU!? You will no longer stand between me and my destiny.
Trump: But I will! I told you that it's always between us.
Pence: I ache to smash you out of existence! To drive your cursed face from my memories forever!

[LongShortLong]

Your a moron. My wife's hospital is in crisis mode currently. Keep sucking trumps dick.

That's very, very bad. There's a roughly 10 day delay from getting infected to visiting the hospital. Meanwhile corona doubles every 3 days (some say 2). That means 3-5 doublings (8X-32X) worth are already sick. Just wait a few days and they'll need help.


http://staythefuckhome.com

[LongShortLong]

CDC Can't do calculations. They are way underplaying this.

[grinch]

"Herd immunity" WTF!?!? UK has lots its mind

https://twitter.com/JoshuaPotash/sta...330332160?s=09

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[bodywhomper]

"Herd immunity" WTF!?!? UK has lots its mind

https://twitter.com/JoshuaPotash/sta...330332160?s=09

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This is what I was asking about earlier. I don’t totally get it, and apparently, many experts don’t in Britain, either (I’m not a public health person). Many would say the same about our national “strategy.” I have not read what the UKs plan is to protect the vulnerable while the heard immunity is building.

And this

[powdork]

2-5%. But if the healthcare system is over run then much higher. Probably going to see that happen somewhere.

Today I wondering more about densely populated 3rd world countries. We’ve not heard much about India or Indonesia.


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You doctor types will understand more of this than me, since it get's fairly clinical, but this is from a Seattle Hospital (via a local guy (maggot) that I ski with and trust).
It's long and technical, short version: Seattle is turning into Italy, and affecting some young healthy folk too. And it's fucking up the hospital so regular sick, car crashes, etc are hosed too

CLINICIANS:

From a Seattle-based intensivist. Very helpful for clinicians preparing for their front-line barrage. Thanks for sharing from the hot zone.

This is from a front-line ICU physician:

* 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.

Plz share info.

actually it's pretty understandable after a couple reads for a somewhat smart layman
and sad. like the Bergamo Dr.'s letter but one day sooner.

[jono]

Thanks powdork. Couple things in there I've been wondering about as a layman: Remdesivir continues to sound promising and thoroughly red-taped; is there more to it than that, or is that just the sort of granular detail our decision-makers can't see?

Re: mask re-use, if that's inevitable, is heating any better than bleaching? If the virus dies around 70 C, a lot of materials may be more physically stable getting heated to 70 C dry than getting hit with a liquid. Of course, both are contrary to manufacturer's recommendations, at least for N95 masks (3M says storage max of 30 C and 80% RH). But if a mask has no foam in it, what is there that can't handle a little warm air?

Any of you dentists pop masks into the sterilizer?

[riser4]

RVers are roadside camping and pushing out the homeless campers in my neck of the woods. And I saw 2 other abandoned and trashed RVs at the roadside bt the highway. Hmmm.

Attachment 320348

Shitter's full.

[SKIP IN7RO]

WWMD, brother and fam (3 kids <5yo) are planning to come through my area on way back home since their trip to Durango was cut short. They want to go out for lunch and hang out for a little bit (all good under normal conditions). How far would you take the social-distancing? I am thinking they should go the fuck home asap and keep their 3 kids away from grandma and grandpa.

[rod9301]

WWMD, brother and fam (3 kids <5yo) are planning to come through my area on way back home since their trip to Durango was cut short. They want to go out for lunch and hang out for a little bit (all good under normal conditions). How far would you take the social-distancing? I am thinking they should go the fuck home asap and keep their 3 kids away from grandma and grandpa.

You're right

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[char_]

Does anyone have any good reporting on the hospitalization rate by age?

I see lots of reports on the fatality rate by age, but not hospitalization rate. I think people under 40 are thinking that they aren't even at risk of going to the hospital.

[char_]

WWMD, brother and fam (3 kids <5yo) are planning to come through my area on way back home since their trip to Durango was cut short. They want to go out for lunch and hang out for a little bit (all good under normal conditions). How far would you take the social-distancing? I am thinking they should go the fuck home asap and keep their 3 kids away from grandma and grandpa.

Strong chance you are going to look like a genius in a week.

[jono]

Strong chance you are going to look like a genius in a week.

And if not, thanks in advance!

[riser4]

What could go wrong? https://www.cnn.com/travel/article/c...day/index.html