Fear and Loathing, a Rat Flu Odyssey

[skiballs]

https://www.cdc.gov/coronavirus/2019...iew/index.html

Interesting data, teetering on the edge, the way I see it.

[beaterdit]

Fucking depressing. Did he have any “comorbidities”? I haven’t read of any. 41....man.

None of us are gonna know without actually having the medical record, but based on what we've been seeing, I'm gonna guess that his "comorbidity" was simply an otherwise normally functioning immune system that, for whatever reason, went haywire when reacting to SARS Cov2 viremia.

Amputation prolly from a thrombotic event (blood clot) that killed circulation to the leg. Lungs prolly destroyed by widespread micro (or macro) thrombotic events. Subsequent badness (infections, etc) from end-organ destruction and inability to recover from them, despite the patient being otherwise young and healthy. This is only my edjumakated guess, so take my speculation with a healthy grain of salt.

I've mentioned several times upthread my belief that there is an autoimmune-mediated hyperthrombotic phenomenon whereby COVID19 kills many of the younger "healthier" patients (and likely older, sicker patients as well). My guess has been a form of catastrophic antiphospholipid antibody syndrome (CAPS), and indeed there's some clinical evidence that this might be the case.

The American Society of Hematology has a regularly updated precis regarding clinical thinking in the field.

Honestly the biggest risk factor for a severe case that I see is latinx ethnicity. The biggest common clinical risk factor among this group for us is Diabetes. *I think* Cordero falls into the latinx ethnicity, seems unlikely that he had diabetes but who knows. Man, it's hitting the latinx community hard here though. I don't have the actual numbers but in casual observation of my unit, of the severe cases with prolonged mechanical ventilation, about 80% of them are latinx. It's brutal. Lots of patients related to each other, husband/wife combo's, same common last names even if unrelated. Makes it confusing for us at times.

Also, the coagulopathies are definitely real, a lot of our patients have clots. We're doing what we call "prophylactic-plus" anticoagulation. Not therapeutic but larger than standard prophylactic doses of sub-Q heparin. Pretty interesting article here about some work one of my medical directors, has been doing. They've found a unique immune response causing lung damage and clots that we can possibly target for treatment.

My wife got a positive antibody test today. I had Covid like symptoms in late-December, she had a bad sore throat in mid-March, and she had something very similar to Covid toes in May. So who knows...

Crazy, are you gonna get tested? I imagine you're positive too.

I was negative for antibodies about a month ago and they don't plan to retest us yet. Three of our Nurses had contracted it as of last week. Maybe more by now. They're quarantining and testing us based on exposure to the those infected. For our hospital, high risk is defined as close contact, less than six feet, with one or both parties unmasked, for upward of 15 minutes. So basically eating lunch. We're not supposed to do that near people, or out on the unit at all but some have gotten sloppy. I'm frequently in charge and as crazy as it's been, I don't feel comfortable stepping off the unit to eat so I go to a corner 10+ feet away from everyone and warn them to keep their distance.

It's generally ramping up here in Salt Lake still. At least we have a county-wide mask mandate that seems fairly effective. I only see a couple people without in my grocery store. Went into El Tigre muffler shop the other day though and not a mask in sight. All latinx guys too. Hopefully they don't have to know me professionally. My Unit's 1/3-1/2 Covid these days. Initial mortality was 80% for our ventilated patients but since then we've done much better. We're holding at 25% since the beginning now so our numbers have been even lower in this continuing phase to make up for the initial numbers. Looks like nationwide it's dropped to about 35%, depending where you look, so we're doing well. We're not doing a lot that we haven't always done for bad ARDS, we're just doing a lot more of what we've always done. Chemically paralysing, proning people, high dose fentanyl drips, steroids. Seems our Hydroxychloroquine trial is over but we're still doing the Remdesivir, that's in really short supply though. Our go-to sedative for ventilated patients, propofol is really short too so we're doing other stuff randomly like ketamine drips and longer acting benzos. Usually we try to minimise that stuff, along with fentanyl drips but ya gotta do what ya gotta do.

Not sure what the status was on our 46 year old ECMO guy when I posted last but he made it, the third or fourth person in the world to do so. Two months out from discharge he's still on oxygen though, with a very low activity tolerance. Major permanent lung damage, might need a transplant someday.

As for me, I'm staying the fuck away from people if I can, and wearing a mask when around others in public. I have been mountain biking with a couple friends a bit, we drive separately and keep our distance on the trail. The political situation regarding masks (and other issues) here and around the country is shameful. WTF.

[ncskier]

What's amazing about this is that most layman thought, fuck, warm weather, at least the virus going dormant. And I thought that Florida starting slow may have been proof of that, since March is start of summer there. Well, here we are at the most godawful hottest time there (I lived there for a few years, it's unreal in summer) and this thing is just going off big time.

Maybe its the whole recirculating indoor air conditioning thing going on. Like the whole indoor recirculating air with heat on in New York earlier.

[MultiVerse]

Maybe its the whole recirculating indoor air conditioning thing going on. Like the whole indoor recirculating air with heat on in New York earlier.

Yeah, a Harvard infectious disease expert suggests air conditioning use across the southern U.S. may be a factor in spiking COVID-19 cases.

For a while Florida and other Southern states were doing well after reopening, accompanied by a lot of praise for the governors, so the recent surge is probably some combination of heat driving people indoors along with people letting their guard down after the lull in cases. Assuming another surge in America was invertible, the recent increase isn't all bad in the sense that a winter surge would be even worse when accompanied by influenza along with other infectious diseases.

https://news.harvard.edu/gazette/sto...-in-the-south/

Honestly the biggest risk factor for a severe case that I see is latinx ethnicity. The biggest common clinical risk factor among this group for us is Diabetes. *I think* Cordero falls into the latinx ethnicity, seems unlikely that he had diabetes but who knows. Man, it's hitting the latinx community hard here though. I don't have the actual numbers but in casual observation of my unit, of the severe cases with prolonged mechanical ventilation, about 80% of them are latinx. It's brutal. Lots of patients related to each other, husband/wife combo's, same common last names even if unrelated. Makes it confusing for us at times.

The same thing is happening in California and a lot of other places. Some of it has to do with people of color working in food plants, nursing homes or low-wage service jobs and then infecting other members of their oftentimes multigenerational household.

[Benny Profane]

Maybe its the whole recirculating indoor air conditioning thing going on. Like the whole indoor recirculating air with heat on in New York earlier.

Sounds good.

[Benny Profane]

Yeah, a Harvard infectious disease expert suggested that air conditioning use across the southern U.S. may be a factor in spiking COVID-19 cases.

For a while Florida and other Southern states were doing well after reopening, accompanied by a lot of praise for the governors, so the recent surge is probably some combination of heat driving people indoors along with people letting their guard down after the lull in cases. Assuming another surge in America was invertible, the recent increase isn't all bad in the sense that a winter surge would be even worse when accompanied by influenza along with other diseases.

Sure glad I waited on that Ikon pass.

[abraham]

Maybe its the whole recirculating indoor air conditioning thing going on. Like the whole indoor recirculating air with heat on in New York earlier.

Likely, I think I remember reading about how spreading was expected increase in places like Arizona and the south because of how much time people spend inside with AC in the summer. The whole 'the virus dies in warm temperatures' thing that I heard from a surprising number of people always seemed like bullshit wishful thinking to me. Human bodies are pretty warm themselves.

Honestly the biggest risk factor for a severe case that I see is latinx ethnicity. The biggest common clinical risk factor among this group for us is Diabetes. *I think* Cordero falls into the latinx ethnicity, seems unlikely that he had diabetes but who knows. Man, it's hitting the latinx community hard here though. I don't have the actual numbers but in casual observation of my unit, of the severe cases with prolonged mechanical ventilation, about 80% of them are latinx.

Interesting and concerning. Do you think it's diet related? Most of that side of my family eats decently and doesn't have everything with lard but it's been a concern in the past. Especially with a few aunt and older relatives who refuse to make adjustments to deal with doctor advice.

If it's not diet related I might have to have some serious calls with my little cousins about taking this seriously. Probably should do that anyway.

[Norseman]

I've read of the prevalence among latin ethnics, too, such as in the hard-hit agricultural counties of E. WA... but was under the impression it was perhaps more related to cramped housing and closer daily work and social contact habits/culture rather than physical health traits. But the links with diabetes and vascular health are sure interesting and basinbeater's anecdotal numbers are striking.

[Rideski]

Atlanta Mayor tests pos.

[The SnowShow]

Rob Katz doesn't care about mountain bikers.

Biking is nothing but a loss leader in his mind.

When it comes to Whistler, Trestle, and other profitable bike parks, just cover your eyes and yell "la la la bikes are too dangerous!" because that is the Vail Resorts Way(tm).

Or at least one can be easily forgiven for believing this based on the general management actions toward biking both now and in the past.

Fuck Vail Resorts.

I bought a Trestle pass (I'd usually just go over a few days a year) for the first time ever and will be buying Snowmass daypasses. Normal summer I'd have a Keystone season pass, make 2 trips to Whistler (I'll blame Trump not Katz for not getting Whistler), and at least 1 trip to CB bike park.

Keystone Beta: you can bike up service roads and there is a "bike at your own risk" sign in the base area, but there are "no uphill biking" signs at every intersection going up (as there normally would be) but "trail closed to bikes" signs at every trail going down. They are easily ignored. The fallen trees on the trails are less easily ignored, although some of them are mysteriously being cleared. At 2360ft of vert, one Keystone lap is all I got in me instead of 4-5 lift served laps. Makes me want an emtb.

With a ton of Keystone, CB and Vail riders having to hit Snowmass and Trestle, I bet that many do not come back as bike customers next year, and then Vail will just shut down their bike parks for good. Frankly, I'm surprised Vail corporate hasn't ordered Whistler to make A-Line and Freight Train "multi-use paths" and "biking slow zones."

I guess the Vail gondola is now open but for hiking only. WTF? That’s a slap in the face to mountain bikers. Makes no fucking sense.

Not that it matters much. Trestle is light years better.

[old goat]

Local post offfice today, staff not wearing masks. I just wanted to drop off and GTFO, counter lady yacking with customer in front of me. An old lady got in line behind me with no mask and she was crowding my marked space on the floor so I kept moving away, she kept crowding me. I was about to ask her stop, but she gave up and then it was finally my turn at the counter. 30 seconds later I was out. They should be set up to handle this. Stop penalizing the post office and run it like the government service it should be.

At the Post Office 4P today, 10 people in line, one clerk working, everyone masked and keeping their distance. The clerk was amazingly pleasant considering the circumstances and the late hour. The PO here can't hire anyone at the salary they pay. The woman in front of me was mailing off masks--very successful business for her judging by the number of packages she sent. The clerk said package volume was 4 times pre Covid.

[Cono Este]

I went to Best Buy today and the shelves were empty. I don’t know if it’s a supply chain issue, but the rep said it’s all online orders now.

The world will never be the same.


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[KQ]

Apparently things aren't going well in Britian with their attempt to reopen pubs.

Police slam 'disgusting inhuman thugs' who pelted officers with bottles and threatened them with knives as they tried to break up illegal block party in west London

'Crystal clear' that drunk people can't socially distance -- UK police officer

[east or bust]

I found it pretty ironic that both of my connecting stops were in some of the worst locations possible. Dallas/Ft Worth and Miami.

Miami is a really nice airport though. So huge it's easy to find an empty gate and chill. The worst is knowing there are people walking around carrying the covfefe. EWR to Miami had an empty row to myself. Miami to PHX was a full flight.

Also, wearing an N95 for 12 hours straight is not fun.

/endblog

[funkendrenchman]

Crazy, are you gonna get tested? I imagine you're positive too.
.

I’ll get tested next week. I’m a little skeptical of its accuracy but will trust it a bit more if we’re both positive. Her main exposure has been a knee surgery in April and lots of PT. My illness in December was right after a large Chinese group was in town. It was unlike any cold I’ve ever had. I tested negative for flu.

[Cono Este]

Today I walked to a store to buy some beer and they told me I could not come In without a mask. So I go home, drive back, go to another store, and now they want my mask off to buy alcohol.

Home brew?


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[KQ]

Today I walked to a store to buy some beer and they told me I could not come In without a mask. So I go home, drive back, go to another store, and now they want my mask off to buy alcohol.

Home brew?

Someone else here posted about having to remove their mask to buy beer. When I was at the store the other day buying wine I mentioned that to the clerk. She thought that was a strange request and said they had not been told to do that.

[Mr. Mike]

Atlanta Mayor tests pos.

how does that photo relate to the Atlanta mayor or covid-19?

[Tri-Ungulate]

Honestly the biggest risk factor for a severe case that I see is latinx ethnicity. The biggest common clinical risk factor among this group for us is Diabetes. *I think* Cordero falls into the latinx ethnicity, seems unlikely that he had diabetes but who knows. Man, it's hitting the latinx community hard here though. I don't have the actual numbers but in casual observation of my unit, of the severe cases with prolonged mechanical ventilation, about 80% of them are latinx. It's brutal. Lots of patients related to each other, husband/wife combo's, same common last names even if unrelated. Makes it confusing for us at times.

Good to hear from ya, S -- been wondering how you've been holding up.

We're seeing a lot of LatinX at our unit as well, but my own personal feeling is it's less the genetic or comorbidity determinants than the fact that they make up the bulk of the high risk population, with multigenerational family units, and working conditions that almost guarantee prolonged and extensive exposures, both likely leading to a high viral titre that we think is correlated to severity of disease. I mean, these folks often have to work day in and day out in places like meatpacking facilities (like the Provo outbreak) which represent multiples of risk over some upper middle class dude who can work remotely, then perhaps get exposed when he sits too close to a carrier for an hour at a bar. But yeah, totally agree that diabetes certainly doesn't help.

Also, the coagulopathies are definitely real, a lot of our patients have clots. We're doing what we call "prophylactic-plus" anticoagulation. Not therapeutic but larger than standard prophylactic doses of sub-Q heparin. Pretty interesting article here about some work one of my medical directors, has been doing. They've found a unique immune response causing lung damage and clots that we can possibly target for treatment.

Thanks for pointing me to the article. It ties in perfectly with my catastrophic antiphospholipid syndrome (CAPS) hypothesis, as CAPS and the neutrophil extracellular traps (NETs) they discuss in their Blood article are inextricably linked (nice open access review here). Hope Estelle is well, and glad Liz got first authorship. Hang in there.

[Norseman]

dude Tri-U, thank you for chiming in here occasionally with educated musings. it's refreshing and reassuring.

same to huckbucket and mofro of course, and the nurses and docs and first responders. your views are so valuable, hope you continue to post.

[Rideski]

how does that photo relate to the Atlanta mayor or covid-19?

[old goat]

Someone else here posted about having to remove their mask to buy beer. When I was at the store the other day buying wine I mentioned that to the clerk. She thought that was a strange request and said they had not been told to do that.

It would make sense if they were checking ID. Which brings up the possibility that we can all share season passes since they can't tell if we match the pass picture if we're wearing masks.

5 months into this thing and we still don't have enough testing https://www.nytimes.com/2020/07/06/u...-shortage.html or enough
PPE https://www.washingtonpost.com/local...4c6_story.html

The level of national incompetence is beyond staggering. Time for the 25th Amendment. Every day Trump stays in office more people die unnecessarily. Pence is no genius but he has enough brains to get out of the way and let the experts run the show. Being a second fiddle doesn't seem to bother him. I haven't heard much lately about whether we should trash the economy to let a few old people die. We tried to open quickly to save the economy and it didn't work. By now it should be clear to everyone that the economy can't be saved unless the pandemic is controlled.

[ate'em]

dude Tri-U, thank you for chiming in here occasionally with educated musings. it's refreshing and reassuring.

same to huckbucket and mofro of course, and the nurses and docs and first responders. your views are so valuable, hope you continue to post.

holy fuck yes

[bobz]

5 months into this thing and we still don't have enough testing https://www.nytimes.com/2020/07/06/u...-shortage.html or enough
PPE https://www.washingtonpost.com/local...4c6_story.html

Just speculating here, but part of the problem, you know, aside from how the president opposes more widespread testing and has said so, could be that testing tech and materials are mostly manufactured, distributed, administered, and reimbursed via private companies seeking to maximize revenues, meaning that the cost per test is surely a hefty multiple of what it could have cost if actually testing lots of people in order to beat the virus was among our society's higher priorities.

But then, even at exorbitant costs, the US could have and should have ramped testing capacity way up.

[Cono Este]

It would make sense if they were checking ID. Which brings up the possibility that we can all share season passes since they can't tell if we match the pass picture if we're wearing masks.

5 months into this thing and we still don't have enough testing https://www.nytimes.com/2020/07/06/u...-shortage.html or enough
PPE https://www.washingtonpost.com/local...4c6_story.html

The level of national incompetence is beyond staggering. Time for the 25th Amendment. Every day Trump stays in office more people die unnecessarily. Pence is no genius but he has enough brains to get out of the way and let the experts run the show. Being a second fiddle doesn't seem to bother him. I haven't heard much lately about whether we should trash the economy to let a few old people die. We tried to open quickly to save the economy and it didn't work. By now it should be clear to everyone that the economy can't be saved unless the pandemic is controlled.

No doubt the guy failed. He threw a Hail Mary pass with trillions and failed. People bought new cars.

But I think it goes deeper. The whole mask debate has me baffled. Lots of mixed messages 3 months ago, and I think they intentionally lied as there was no supply for the general public and did not want to create a panic . Which makes lifting the lockdown as supplies became available even more asinine.

I see failure on so many levels, and as the saying goes, when the govt says not to panic, it’s time to panic. Never trust the govt. rely on yourself.




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