Medical Discussion of Coronavirus

[Tangler]

1. I'm an inpatient physician
2. I'm a human, and no one knows the true incidence of SARS-COV-2

You left out the most important part:

3. you are our one only FLP! A truly unique and irreplaceable rascal that brings smiles to the faces of WCI readers with your wit, humor, and sarcasm!

[Tangler]

Pigs matter!

[Jaqen Haghar MD]

Of course everyone matters... you can't make it into a straw man. Nobody is sacrificing anyone. Nobody is going to get this COVID or any other disease on purpose, and nobody is going to give it to anyone else on purpose. I simply said no society in history would choose its young and healthy over its seniors.

The 'serious cases' among health, safety, and other workers - and young or middle age people in general - is terribly overblown, and we all know it. The stats are above... this thing can VERY rarely pose a serious threat to people under retirement age barring morbid obesity. Refer to the CDC study of 10k health care workers. Other US and international cohorts on UpToDate and similar all echo the same. The death % and hospitalized % will nose dive as more testing occurs, just like H1N1 or MERS or SARS rates did. COVID's USA and overall worldwide mortality percentage is going to be well under 1% and total body counts way under what was predicted by doom and gloomers. Those who succumb to COVID19 were basically beyond help since they were mostly drain-circling to begin with. Sad but true. Will there be rare exceptions? Sure. Do you make policy based on outliers? Nope.

I totally get not wanting to overload the system, but we created an entirely new problem by largely ignoring all other conditions in order to be myopic with a fetish for Corona. Bad move. Hospitals are NOT overloaded for the most part... nearly all have vents, ICU, etc available to greater degree than they usually do back in peak flu season annually. What they now don't have is revenue or the ability to help the 99% who haven't gotten Corona but are getting silent MI, CVA, etc at home due to missed Rx and missed appts. Warnings of a high current importance of public health tactics of hygiene, distance, and other common sense flu season stuff like not attending work sick and senior wearing mask or isolating would have sufficed fine for COVID19.... as if did in other nations.

However we handle it, we will see shutdown resulting in more and more people running out of their meds due to finances and lack of access, more and more folks going depressed and much worse psych, nobody doing screen tests or labs or cleanings, etc. It is like no more service checks or new filters or oil changes or tire rotations or spark plug swaps for American health... works fine, until it doesn't. That is the entire reasoning for all of the evidence-based specialty and primary care guidelines we are now neglecting. You always see a bit of that stuff with people running out of Rx and being non-compliant with screenings and f/u (and it makes for severe admits and big problems later), but now it will start to be a ton with essentially zero preventative care for medical, dental, optho, podiatry, PT, social work, etc etc etc. Time will tell. It already is.

I think there is something to this line of thinking. I’ve had some young patients get pretty sick, and some elderly ones pass, and I’ve DC’d a bunch that did fine. The purpose of social distancing was to prevent the hospitals from getting overwhelmed. It worked.

Right now the hospital is just empty. The ED volume is beyond low. We’ve cut more than 50% of the usual coverage hours. Everyone is working less than half time in the ED. We’ve pretty much furloughed a couple of our ED docs. I work in one of the counties with the highest concentrations of cases in the state. This is going to be a bad year. I worry that it will not correct anytime soon.

[White.Beard.Doc]

The 'serious cases' among health, safety, and other workers - and young or middle age people in general - is terribly overblown, and we all know it.

I guess you are saying somehow this Covid thing is overblown. It is shocking to me that you feel that way.

My former ED colleague and friend is dead. And two other employees in the hospital where I work are dead. Yes, my former physician colleague recently turned 60. But he was active, full of life, working full time in the ED. This disease kills people, more on the older side, but on the younger side as well. I have seen it, up close and personal, with my own eyes. On our many bad days we have had deaths occurring repeatedly, all day and all night, around the clock, "rapid response, code 99, rapid response", all day and all night long, over and over and over. Our regular morgue is full, our accessory morgue is full, and the refrigerated truck is full, bodies, dead bodies, everywhere.

Have you been in a hospital where the ED, the floors and the ICU are crushed like never before in any of our lifetimes? Or are you out in some rural area, isolated from what is going on? If our community had taken no action to try to mitigate this health care disaster, the health care workers would have mutinied by walking out, shutting down the hospitals. We would have anarchy, without functioning hospitals, no health care safety net, no civil society, every person left to fend for themselves. Is that what you are advocating?

[ENT Doc]

I guess you are saying somehow this Covid thing is overblown. It is shocking to me that you feel that way.

My former ED colleague and friend is dead. And two other employees in the hospital where I work are dead. Yes, my former physician colleague recently turned 60. But he was active, full of life, working full time in the ED. This disease kills people, more on the older side, but on the younger side as well. I have seen it, up close and personal, with my own eyes. On our many bad days we have had deaths occurring repeatedly, all day and all night, around the clock, "rapid response, code 99, rapid response", all day and all night long, over and over and over. Our regular morgue is full, our accessory morgue is full, and the refrigerated truck is full, bodies, dead bodies, everywhere.

Have you been in a hospital where the ED, the floors and the ICU are crushed like never before in any of our lifetimes? Or are you out in some rural area, isolated from what is going on? If our community had taken no action to try to mitigate this health care disaster, the health care workers would have mutinied by walking out, shutting down the hospitals. We would have anarchy, without functioning hospitals, no health care safety net, no civil society, every person left to fend for themselves. Is that what you are advocating?

What is your exit strategy?

[fatlittlepig]

Sorry FLP, I would be pretty sad if I was negative, even though we don't know what it means in terms of immunity. Some Ig seems better than no Ig, but I am just a caveman anesthesiologist, so what do I know?!

Yes, of course I was hoping the G line would materialize. I have enough testing capacity to repeat in several months and again in several months etc.

[fatlittlepig]

What are you talking about. Plenty of healthy people are getting real sick and even dying. I am in a relatively low impact area and I have about a dozen patients who tested positive. 4 hospitalized. 2 are still intubated. Both in their 50s. One guy intubated for over 3 weeks now yes he is obese and has well controlled DM but he was by no means circling the drain. He was likely planning on working another decade.

The other guy was in excellent health. Remote history of smoking. Nothing else. Not fat. No metabolic syndrome. Takes no meds. Normal guy with a normal job. Mid 50s. Scares the sh!t out of me.

It is a small sample size for sure but it can cause very significant morbidity and mortality in healthy folk. And we do not know what the common denominator is.

You have a dozen of your own patients that tested positive? That seems like a lot.

[G]

Yes, of course I was hoping the G line would materialize.

can't quite think of anything pithy....

[StarTrekDoc]

This will be the last time I say this: the POC serology tests are trash. If it's negative, you're likely negative. If it's positive, you're still probably negative. The new elisa assays on the chemistry lab immunoanalyzers are much better but in a low prevalence population, your PPV is still likely to be so low that a positive test isn't definitive proof you've been exposed. Serology testing will never be this near 100% sensitivity and specificity test. It's not like a molecular test or ion electrodes.

We will need a balance of science AND good governance to get us through this and America back on its feet.

I wouldn't quite say trash; NPV is quite strong even with the current low prevalence. PPV is going to get a lot better when we hit 10-20% prevalence. -- and that's the 1st generation tests.

@WBD - I'm sorry to hear about the direct loss you've suffered. This is what folk protesting need to see and understand. We came dangerously close to anarchy if the stay-at-home meausures weren't enacted when they were. The N0 was probably way beyond 4 with the amount of hindsight asymptomatic spread out there and if we had waited another week it would have overwhelmed our major cities.


Cellex was the first on out there but its sens and spec are in-line with the reported ones out of china being brought in that scanwellhealth is using with Wake Forest and we are using CLIA testing with Diazyme that has about the same clinical sens and spec numbers. -- Still PPV is low so wouldn't hang a positive IgG and go crazy with no PPE.

[Tim]

Tangler
The purpose was to lower the curve to keep from overwhelming the hospitals. The hard stop on “electives” was necessary to keep your hospital afloat. At what point will you release an OR for and organ transplant from a relative.? At what point will you release an OR for a cancer related procedure? At what point will you release an OR for a knee or hip replacement? Does it make a difference if it is an adolescent or a senior citizen?
I empathize with your situation. The PPE, OR’s and 10 other hospitals in Texas are prohibited by law from providing needed services. They sit idle and the patients suffer or get worse.
Would you consider a preferable answer is to get you the equipment you need or are you more comfortable telling the family that their brother passed without the transplant and tell the husband and children they lost their mother in towns 100’s of miles away? By no means am I meaning to throw a guilt trip on you. Elective is basically anything that can wait 24 hours. It’s been 30 days. I 100% agree with your points about every patient and provider mattering.
There are so many layers in this onion. Elective isn’t the right answer ramping up. I hear the distrust of segments of the healthcare systems just going for the revenues. A hard stop state wide won’t work either. Your past, current and future patients are fortunate to have you. Stay healthy.

[Lordosis]

You have a dozen of your own patients that tested positive? That seems like a lot.

I know. I went looking back to see if they were in recently and if my office was the ground zero but j could not find a connection that made sense. The vast majority are hospital employees. I seem to have a large chunk of healthcare workers on my panel. I also am a family physician so 5 of my positive cases was a couple and their 3 kids. Only the parents were tested but the kids had symptoms so I just assumed...

Luckily I have not seen any children with anything worse then a moderate flu.

[Antares]

My colleague - a psychiatrist in NY who deals especially with the NYC orthodox Jewish community has at least 25 positive/sick patients in his practice. I’ll spare you the details, but it’s pretty awful. I only have 4 in my (relatively small) psychiatric practice, but 20ish in my circle of friends, patients, acquaintances. One friend is dead, one miraculously is finally off a respirator after three weeks, remains to be seen what her quality of life will be, etc. I’m 61. I have a lot of energy. I have goals, and teenaged kids. Not anxious to die yet. Don’t tell me I’m expendable. Neither is my 85 year old mother. We all still have a future.

[Otolith]

COVID has hit cities and communities differently. My community has prepared aggressively for a surge that has not happened while colleagues in different parts of the country were unable to prepare. Social distancing effect is dependent on the intersect of: time initiated, population density, and initial community burden of COVID.

Treating all of the country the same doesn't make sense....

[Tangler]

Tangler
The purpose was to lower the curve to keep from overwhelming the hospitals. The hard stop on “electives” was necessary to keep your hospital afloat. At what point will you release an OR for and organ transplant from a relative.? At what point will you release an OR for a cancer related procedure? At what point will you release an OR for a knee or hip replacement? Does it make a difference if it is an adolescent or a senior citizen?
I empathize with your situation. The PPE, OR’s and 10 other hospitals in Texas are prohibited by law from providing needed services. They sit idle and the patients suffer or get worse.
Would you consider a preferable answer is to get you the equipment you need or are you more comfortable telling the family that their brother passed without the transplant and tell the husband and children they lost their mother in towns 100’s of miles away? By no means am I meaning to throw a guilt trip on you. Elective is basically anything that can wait 24 hours. It’s been 30 days. I 100% agree with your points about every patient and provider mattering.
There are so many layers in this onion. Elective isn’t the right answer ramping up. I hear the distrust of segments of the healthcare systems just going for the revenues. A hard stop state wide won’t work either. Your past, current and future patients are fortunate to have you. Stay healthy.

I hear what you are saying. I think we actually agree. My colleague did a heart/kidney transplant combo last friday. Those cases are going, but EVERY case has to be looked at closely and with great input from many people. The idea of needing a heart or you die, sure go. But what if you have been on a LVAD for 3 years waiting on a heart? You are at home and walk around your yard and neiborhood with a mask and you are doing "ok". Do you want to spend a week in my hospital recovering from a heart transplant with tons of immunosuppressive meds in your system and nurses and docs who care for covid patients rounding on you and examining you and chainging your dressing and stripping your chest tubes ? My hard stop is for the stupid crap like yearly GYN, Derm, plastics, knee scope, screening colonoscopies.
So for me it boils down to this:
Emergency (ex bowl obstruction) Go, now.
Urgent: well, how urgent? is it a 94 year old with aortic stenosis for a TAVR? How much covid is in your hospital? How bad is the aortic valve? I would stay home if I was that patient and wait a few months. On the other hand if you have breast cancer and you are 44 with 4 kids, I would do that ASAP and then get the ************************ out of the hospital.
Elective: Nope, not worth it. Sorry, not until we get a handle on this thing. The boob jobs, back pain surgery on an obese dude and the total knee can wait another month and then we can see what things look like.
I think my main thing was the idea that this thing is somehow "overblown" well, sorry, it is not.
Exit strategy: survive on the "fat of the land = stored up stuff" for a few more weeks and then reassess. See what the world looks like then. Do we have effective therapy and better testing? Can we determine (even with some doubt) if someone has some antibodies and has "potential" immunity? How is the supply of PPE? Are the administrators still enjoying plenty of gourmet coffee in their office bunkers? (OK that is a joke).
Ok, I gotta go check my equiptment and see if anyone is floundering in the units.

[CordMcNally]

Not anxious to die yet. Don’t tell me I’m expendable. Neither is my 85 year old mother. We all still have a future.

Did somebody say you were expendable and I missed it?