Medical Discussion of Coronavirus

[Zaphod]

We just finished recruitment of a randomized study with toci and another ongoing with resdemivir. No steroid or hydroxy in any case. Results not released, but rumor says both appear favorable.

I agree the key is to prevent cytokine storm. It will probably need larger studies of positive and screen and treatment within positive to take and turn off the response early....not when it's happening already.

That's why I'm interested in a particular subgroup to follow.....those already on immunomodulation.....that get covid....how do they fair? Lower admission rates? Lower ICU and mortality endpoints?

This would be helpful, could get a large sample with ease, and possibly enough to make some inferences.

I guess right now these are the questions to ask. What are the things we'd like to know and given its so widespread where is this data already available and how do we obtain it?

[FIREshrink]

That makes sense for folks admitted to the hospital... Already in that second phase and at that point needing to modulate the overwhelming immune response.

[nephron]

Has anybody noticed how easy it is to publish anything with COVID-19 these days? The NEJM keeps publishing these small case series and peoples opinions on things. I think that if I had 100 testing kits, I could get into the NEJM, maybe just by documenting the number of asymptomatic healthcare providers or looking at the incidence of COVID-19 in patients that come in for unrelated issues. I feel bad for people doing actual research, a cure for lung cancer would probably not get published right now in the midst of all this covid-19 business. I think that COVID-19 is one of the idea diseases to study and publish on, it is widely prevalent, and people don't seem to know that much about it. You could probably get something into JAMA if you wrote something up on people who have stubbed toes who also have COVID. If I was trying to publish something, I would probably put a COVID spin on it, like maybe dialysis access in COVID patients.

[nephron]

Are people rounding on COVID patients doing physical exams on their COVID patients? I feel guilty for wasting PPE on a worthless exam, but I would also feel guilty for making the dialysis RN spend several hours with the patient if I would not go into the same room with them.

[FIREshrink]

Generally trying to limit to only one doc visit per day per patient. So psych is by tele, ID by chart review, etc .

[PedsCCM]

Same here. Our ICU attending does the exam and all other specialists have some addendum about the physical exam being deferred due to PPE/pandemic concerns

[Max Power]

Quick update: So far my hospital is 8 deaths, 3 survivals, 21 currently in ICU. This is in a flyover state with <1% of the cases of NYC alone. Easily the worst death was a 32 year old-admission to death in 18 hours, with fear in her eyes the whole time as she struggled to breathe and I lied to her, telling her everything was going to be ok. It's going to be hard to unsee.

Using hydroxychloroquine/azithro on most patients, but I would say it doesn't make a bit of difference. Maybe earlier in the course of illness? Hard to know. No resdemivir available here, no convalescent serum. Tocilizumab for 2 patients; one seems better, one is worse.

I feel like I'm fighting a guerilla war, with an unseen enemy that is nowhere and everywhere. Is that cashier infected? What about that nurse? It's the stress of never, ever feeling safe that wears us down. I will keep putting one foot in front of another, and scrubbing, and scrubbing, and scrubbing.

This is roughly the same as my experience... it hits some vulnerable pts bad, and for those, the protocol meds don't seem to do much unless they are a healthy-ish 50-70yo person with a productive cough that gets bact pneumonia near the end of the COVID weeks.

We had a 34M who was on ICU vent for a bit, 400+ lbs still (despite losing a few dozen pounds inpt), and is d/c home quarantine now. I can't imagine your 32F wasn't a smoker, chemo, Dm1 uncontrolled, morbid obese, etc type? If she was healthy - or even healthy-ish, you need to publish the case study of a COVID19 death that young.

I don't get the fear factor, though... the precautions and tx for this are simple and 98% the same as swine flu or TB or anything communicable. It is unfortunate, and second wave of COVID19 this fall will potentially be even tougher, but I can't really say I have seen one person under 50 get a seriously ill from this or one person under 75 without serious comorbid factors who died (aside from in rumors... which have all turned out false). I'm no spring chicken, and I was offered to mostly work in the minor ER side (declined, said keep schedule per usual), but I just don't understand all the healthy and young-ish RNs and even some docs trying to weasel out of the job or obsessed with over-the-top PPE and washing/disinfection over something that's relatively mild for the vast majority of those who get it. I would much rather get this Corona than MRSA, VRE, Cdiff, Hep, HIV, CRPS, intra-artic fx, meningitis, etc etc etc etc that we deal with every day. Maybe my views will change. Dunno

[fatlittlepig]

This is roughly the same as my experience... it hits some vulnerable pts bad, and for those, the protocol meds don't seem to do much unless they are a healthy-ish 50-70yo person with a productive cough that gets bact pneumonia near the end of the COVID weeks.

We had a 34M who was on ICU vent for a bit, 400+ lbs still (despite losing a few dozen pounds inpt), and is d/c home quarantine now. I can't imagine your 32F wasn't a smoker, chemo, Dm1 uncontrolled, morbid obese, etc type? If she was healthy - or even healthy-ish, you need to publish the case study of a COVID19 death that young.

I don't get the fear factor, though... the precautions and tx for this are simple and 98% the same as swine flu or TB or anything communicable. It is unfortunate, and second wave of COVID19 this fall will potentially be even tougher, but I can't really say I have seen one person under 50 get a seriously ill from this or one person under 75 die (aside from in rumors... which have all turned out false). I don't understand all the healthy and young-ish RNs and even some docs trying to weasel out of the job or obsessed with over-the-top PPE and washing/disinfection over something relatively mild for the vast majority of those who get it. I would much rather get this Corona than MRSA, VRE, Cdiff, Hep, HIV, CRPS, intra-artic fx, etc etc etc etc. Maybe my views will change. Dunno

Of course you would rather get mildly asymptomatic SARS-cov-2 than cdiff or MRSA bacteremia but would you rather get moderate to severe covid 19 than cdiff?

[pulmccMD]

Hello to all.
Not much new to post here--seeing less cases, but still several getting intubated and most not doing well.
Have had about 1 extubation to every 4-5 deaths. We throw the kitchen sink at them-one of the ID docs tries something, critical care tries something, etc, etc.
Not sure if any of it works, or are we doing harm.
Lately we have been considering starting Ivermectin.
I have been busy making putting in dialysis catheters--one day the creatinine is less than one, then the next day it's over 3. Geez..

Question to the group--have y'all trached anybody yet because they can't come off the vent?? My partners and I are discussing what to do with some of the 50-60 yr olds, who are basically stuck. Have been reading about some centers doing early tracheostomies, and some not. I know that we most likely get push back from our ENT/Surgery colleagues. We do some percutaneous tracheostomies, but a lot of these patients are morbidly obese.

Thanks to all, and for those that celebrate Easter, Happy Easter to all and to y'alls families.

[Panscan]

Has anybody noticed how easy it is to publish anything with COVID-19 these days? The NEJM keeps publishing these small case series and peoples opinions on things. I think that if I had 100 testing kits, I could get into the NEJM, maybe just by documenting the number of asymptomatic healthcare providers or looking at the incidence of COVID-19 in patients that come in for unrelated issues. I feel bad for people doing actual research, a cure for lung cancer would probably not get published right now in the midst of all this covid-19 business. I think that COVID-19 is one of the idea diseases to study and publish on, it is widely prevalent, and people don't seem to know that much about it. You could probably get something into JAMA if you wrote something up on people who have stubbed toes who also have COVID. If I was trying to publish something, I would probably put a COVID spin on it, like maybe dialysis access in COVID patients.

In contrast to China where their federal government has to approve any research on covid before it is allowed to be submitted for publication.

[fatlittlepig]

My outlook on Covid-19 is quite gloomy. There are 500K confirmed cases in the US, let’s assume that figure is off by a factor of 10 due to lack of testing and asymptomatic carriers. So 5 million/350 million, 1.5% of US population is either infected or recovered. Therefore 98.5% of US population remains naive to the virus. With a vaccine 12-18 months away, we are supposedly going to mitigate, test/contact trace/isolate in the meantime. They promised widespread testing, that’s not here. They promised widespread serological tests, where are they? Who will be doing contact tracing for the entire US population? Where will people be isolated? Who will coordinate this. It’s a total joke.

[pulmdoc]

https://www.medscape.com/viewarticle/927976

This is the reason for the fear. I count 65 names on this list age <50; I count 11 names age <30. This is not just a disease of the old and weak; young healthy people can die of it, too. When they do, we are powerless to stop it. Mortality if you are sick enough to need a vent runs 70-80% for all comers, even in the 18-49 age group its at least 50%. Of course you wouldn't be afraid if you knew you would be asymptomatic or have mild disease, but being young and strong is not protection, and to suggest otherwise is foolish. If you haven't seen any young healthy people fighting for their life, you haven't seen enough cases yet.

[billy]

This is roughly the same as my experience... it hits some vulnerable pts bad, and for those, the protocol meds don't seem to do much unless they are a healthy-ish 50-70yo person with a productive cough that gets bact pneumonia near the end of the COVID weeks.

We had a 34M who was on ICU vent for a bit, 400+ lbs still (despite losing a few dozen pounds inpt), and is d/c home quarantine now. I can't imagine your 32F wasn't a smoker, chemo, Dm1 uncontrolled, morbid obese, etc type? If she was healthy - or even healthy-ish, you need to publish the case study of a COVID19 death that young.

I don't get the fear factor, though... the precautions and tx for this are simple and 98% the same as swine flu or TB or anything communicable. It is unfortunate, and second wave of COVID19 this fall will potentially be even tougher, but I can't really say I have seen one person under 50 get a seriously ill from this or one person under 75 without serious comorbid factors who died (aside from in rumors... which have all turned out false). I'm no spring chicken, and I was offered to mostly work in the minor ER side (declined, said keep schedule per usual), but I just don't understand all the healthy and young-ish RNs and even some docs trying to weasel out of the job or obsessed with over-the-top PPE and washing/disinfection over something that's relatively mild for the vast majority of those who get it. I would much rather get this Corona than MRSA, VRE, Cdiff, Hep, HIV, CRPS, intra-artic fx, meningitis, etc etc etc etc that we deal with every day. Maybe my views will change. Dunno

In NJ two EMTs died a week apart from each other- one was 24, other was mid 30s https://www.nj.com/coronavirus/2020/...irus-dies.html I don't know if they had serious co morbidities. Anecdotally a healthy physically fit 30 yr old died at my hospital from it- not obese. Yes the majority of the 20-40 yr olds will do just fine with this, but we don't have a magic 8 ball to tell us which ones wont. Although I'll admit I am shocked when I have to intubate a young pt who's not obese for this as it seems to be a common co-morbidity among the younger patients who crash.

[Tim]

pulmccMD
”Lately we have been considering starting Ivermectin.”
If you do, please post results. IM me if you prefer.
Thank you.

[G]

https://www.medscape.com/viewarticle/927976

This is the reason for the fear. I count 65 names on this list age <50; I count 11 names age <30. This is not just a disease of the old and weak; young healthy people can die of it, too. When they do, we are powerless to stop it. Mortality if you are sick enough to need a vent runs 70-80% for all comers, even in the 18-49 age group its at least 50%. Of course you wouldn't be afraid if you knew you would be asymptomatic or have mild disease, but being young and strong is not protection, and to suggest otherwise is foolish. If you haven't seen any young healthy people fighting for their life, you haven't seen enough cases yet.

Well, h3ll...I prefer the ignorance is bliss approach, but thanks for the link. It puts my self-pity over my respirator-rash in perspective.

RIP.