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  • This has been shared in a few places. The author is fine with sharing, just cut and paste: excellent and scary info from Intensivist (ICU doctor) front line Seattle, perhaps a colleague of White.Beard.Doc.

    * 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.

    Comment


    • Originally posted by formerly_cn View Post
      MPMD reasonable take but it's better to be proactive than reactive. Cancelling conferences, social distancing, restricting travel IS the right thing. Rumblings of this Sunday/Monday earlier this past week - whitebeard and many others in news were loud and clear. That is my issue. People saying oh couldn't have know etc etc , no, terrible reason. As docs our job to look at what has worked in china and situation in Italy and do lockdown to slow the spread; not use "hey young people don't die from this" to propogate the spread of this continuing as usual. The faster we control it and reduce the incidence the faster we get back to normal life.

      Anyways, going back to work. For Rads here, a nice case compedium of confirmed Corona cases with CT finding

      https://coronacases.org/forum/resear...onacases-org-1

      I caught one yesterday with similar findings, covid testing pending (pt in ICU , 50 yo NO comorbities). Coming back from your in Europe mid February. I'll update when test results come back.
      Positive !!!

      48 hr turn around time for in house PCR test (sent in early Friday morning )

      I have been refreshing to check if CT imaging was anything. Sensitive for sure . Checked chart on patient, clinically worse today than yesterday.

      Anyways, I'm gonna go rest. Wild.

      Comment


      • Kentucky has said no more elective procedures after Weds. Pretty crazy, but our governor has been on top of this.

        I dont know what I'll be doing, since almost everything is elective for us, but we'll see.

        Comment


        • Originally posted by formerly_cn View Post

          Positive !!!

          48 hr turn around time for in house PCR test (sent in early Friday morning )

          I have been refreshing to check if CT imaging was anything. Sensitive for sure . Checked chart on patient, clinically worse today than yesterday.

          Anyways, I'm gonna go rest. Wild.
          I certainly may be misinterpreting as a not-a-doc, but are you excited to have a positive result? Is that typical?
          Our passion is protecting clients and others from predatory and ignorant advisors. Fox & Co CPAs, Fox & Co Wealth Mgmt. 270-247-6087

          Comment


          • Originally posted by jfoxcpacfp View Post

            I certainly may be misinterpreting as a not-a-doc, but are you excited to have a positive result? Is that typical?
            I am not positive, the CT I read with features of coronavirus was positive on lab of the first Corona patient at our hospital. I am not showing excitement but rather that CT was sensitive and I suggested it on report. I feel terrible and took voluntary call Friday/Saturday to help with some back log CTs.

            And speaking of all of this, the other thread got nuked
            We can't be critical I suppose. Censorship at its best. Disappointing.

            Comment


            • ACEP announces two ED docs one in WA one in NJ critical condition w covid

              https://www.acep.org/corona/covid-19...quis-md-facep/

              Comment


              • Originally posted by jacoavlu View Post
                ACEP announces two ED docs one in WA one in NJ critical condition w covid

                https://www.acep.org/corona/covid-19...quis-md-facep/
                Thanks for sharing . Sad and concerning. News of docs and health care workers dying on front lines D(china and Italy). Hope they are taken care of and recover.

                Comment


                • Originally posted by Zaphod View Post
                  Kentucky has said no more elective procedures after Weds. Pretty crazy, but our governor has been on top of this.

                  I dont know what I'll be doing, since almost everything is elective for us, but we'll see.
                  It's sad I have to pray for my state and governor to do what our hospital CEO doesn't have the courage / smarts to do... (I guess that applies to me as well since I don't have the stones to not show up for my elective / non-emergent work tomorrow)

                  Comment


                  • Originally posted by formerly_cn View Post

                    I am not positive, the CT I read with features of coronavirus was positive on lab of the first Corona patient at our hospital. I am not showing excitement but rather that CT was sensitive and I suggested it on report. I feel terrible and took voluntary call Friday/Saturday to help with some back log CTs.

                    And speaking of all of this, the other thread got nuked
                    We can't be critical I suppose. Censorship at its best. Disappointing.
                    Hopefully efforts to bury an incredibly bad decision won't snowball into a further bad decisions to hide and cover up positives among the attendees, which will only massively exacerbate this disaster. Attendees and the community need to ensure this doesn't happen. People need to have the relevant information. The potential negative consequences from a failure to disseminate info could be catastrophic.

                    Comment


                    • Originally posted by VagabondMD View Post

                      This has been shared in a few places. The author is fine with sharing, just cut and paste: excellent and scary info from Intensivist (ICU doctor) front line Seattle, perhaps a colleague of White.Beard.Doc.

                      * 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.

                      Isn't it strange that washington has such severe cases compared to the rest of the country, and so many of specifically related to the one nursing home? it seems like we aren't really seeing similar trajectories in the rest of the country

                      Comment


                      • ^^^ it was probably there first, or earlier. Lots of back and forth travel w Asia

                        Comment


                        • why isn't california seeing a similar pattern, I would expect quite a bit more back and forth there. I think the multiple strain idea may have merit

                          Comment


                          • Originally posted by Panscan View Post


                            Isn't it strange that washington has such severe cases compared to the rest of the country, and so many of specifically related to the one nursing home? it seems like we aren't really seeing similar trajectories in the rest of the country
                            Not sure where in the country you are. My rad buddy in Denver saw five cases last night alone. Many hospitalized are under 60, including husband and wife in ICU on vents 2 weeks after daughter returned from studying in Italy.

                            Comment


                            • 5 confirmed cases, or 5 nonspecific groundglass cases?

                              It just seems like if you look at the big picture, comparing states to states and then putting their population and likely mobility of the given resident into context that it doesn't make much sense distribution wise

                              Comment


                              • Here’s a post from a frontline physician in Seattle:

                                I hesitate to write my perspective on the front lines but this has been a long week. My heart is breaking for all the disruption this is causing but I am also bracing myself for what may come. Patients suffering from COVID are in every hospital in Seattle. They require an unprecedented level of care to manage the disease while trying to protect heath care workers from exposure and further spread. It can take 15 mins just to suit up to enter a room safely. At UW, we are preparing for war. The ICUs and wards are filling with patients that may be here for 3 weeks average. Yes, most infected in the community will have mild symptoms. But the unlucky 10-15% that require hospitalisation need the highest acuity care in order to have a chance to survive. Adding 5 to 10 high acuity patients to each hospital per day is what could bring our health care system to a standstill as it will push out all other medical care. Those of us in health care can’t work from home - Fighting COVID is our new normal in the face of trying to care for patients with cancer, having babies, needing emergency surgery etc. This is why we need to enact serious societal change to limit our exposure. Pleas don’t wait for it to personally affect you or someone you love to take it seriously. In spite of those ominous words, I am hopeful the flattening is coming our way soon! I am so grateful to work at UW where the smartest most dedicated people are trying to solve this.

                                Comment

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