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Formerly DT: COVID-19 - Featuring Lots of Politics, now CR because political talk not going away

InkaUtexas

By InkaUtexas
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Uncle Boobs
Uncle Boobs

Against my better judgment and several beers deep, I have taken you up on this, potentially ending my streak of totally worthless posts. I have done 3 and 7 day averages only on the Worldometer data. 

Brisketexan
Brisketexan

Daughter’s home. A little PTSD, we’re picking up Whataburger to help.

Coelenterate Fuccboi
Coelenterate Fuccboi

Just try and imagine GreenspointTexas being the person to intubate you as you fight for your life against COVID-19. You’re laying there gasping for air while he chastises you for all the things you li

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Enchubben

Enchubben 5509

Posted
Posted
29 minutes ago, closetojumping said:

Fucking great. I just got settled in for two weeks of moderate isolation in Galveston and now the plague is here. Crossing my fingers that the pier amusement park is still riproaring and going!

 

At least you have Hummel’s down by Pirate’s cove. You could not drag me into the Kroger near 61st.

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Parliament

Parliament 14128

Posted
Posted

As a CDL holder, I can say the hours of service limits for truckers are rather cautious. States relax them on occasion for "crises" like propane shortages and such. (It's somewhat political.) In this case I think it's premature to do so, but still.

The risk of overtaxed truckers getting in accidents is much smaller than all the other things going on right now. Let's not worry about this.

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atomheartbevo

atomheartbevo 89408

Posted
Posted
1 hour ago, F250 said:

Talked to a buddy who works at HEB HQ. He said that yeah shit is crazy but the hoarding isn't new to them despite it happening on a bigger scale. They have protocols in place to keep the goods flowing but they need to get through this initial wave of hoarding first. Plenty of food to go around they just need people to stop buying a month's worth of toilet paper at one time. He also mentioned that the suppliers are throttling orders across the board but they are HEB so that shouldn't be a major issue.

Mentioned there is an effort to scale up curbside and other online services but the current hoarding is making things difficult.

They have decades of hurricane and other natural disaster data to pull from.    

Curbside is showing free for us, but Tuesday is earliest we could get a slot.  

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justhookit

justhookit 4177

Posted
Posted
8 minutes ago, landman said:

Exactly.  And to say it's a 3% mortality rate is wrong as well, yet we've about collapsed the economy and have everyone in a panic. 

But the data suggests it will be more flu like levels. Not everyone gets tested for the flu, so they estimate how many get it. This thing has been here for weeks, not days. And thousands are estimated to have already had it and recovered. 

 

Good grief. We don’t have any data suggesting this is flu like levels. There are adults talking numbers in this thread. Maybe sit this one out?

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MNLonghornFUKM

MNLonghornFUKM 8799

Posted
Posted
As a CDL holder, I can say the hours of service limits for truckers are rather cautious. States relax them on occasion for "crises" like propane shortages and such. (It's somewhat political.) In this case I think it's premature to do so, but still.

The risk of overtaxed truckers getting in accidents is much smaller than all the other things going on right now. Let's not worry about this.


We just had a dot audit last week. He looked at logs but didn’t really ask about the 10 hr driving shit
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Somnio

Somnio 751

Posted
Posted

Let's pretend there are 1,000,000 infected currently in the US.

At a doubling rate of every three days that means 6 days ago there only would have been 250,000 cases.

6 days before that less than 65,000 cases.

So in that hypothetical situation in the last 12 days the cases grew by 935,000.

Or another way to put it, 94% of those infected in the US have had the virus for less than two weeks.

That is why the sickness and death is not in your face yet.

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Surly Bevo

Surly Bevo 24695

Posted
Posted

If you start with US case one on first reported date of 1/20 and double every three days and run the 51 known deaths (not counting the ship) against that yields you around 262K infected and then you could use CFR at various times to run course, obviously telling the story that it's pretty raggedy still given some have supposedly taken 14 days to show symptoms much less be all the way through 

14 days to fully run course .62%

21 days to fully run course 2.4%

also would mean a lot of cases that have come online in the last week (230K in the last 9 days) 

 

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atomheartbevo

atomheartbevo 89408

Posted
Posted
2 hours ago, Dr. Beeper said:

To clarify you also insist SHE not go. 

My wife is livid with me I’m being so controlling not letting her take my kiddos to see her parents or my parents. All in their 70s. I said I’m sorry but this will be one time I put my foot down. We’re not getting near olds. We are staying at home. She is pissed. Don’t give a fuck. 

My wife chewed out a friend of hers who’ had this attitude.  She told her “if you or your kids catch it, and pass it on to your mom or your grandma, how are you going to explain to your daughters that you put grandma or grandmama in the hospital, or even killed them?”

Said friend was still being a whiny shit about it - she’s here in Austin, her mom and grandma are in Dallas.  This wasn’t  some cross-country trip that happens once a year, she usually visits them once a month with the girls.   

This is exposing some really selfish types.   

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atomheartbevo

atomheartbevo 89408

Posted
Posted
2 minutes ago, Surly Bevo said:

If you start with US case one on first reported date of 1/20 and double every three days and run the 51 known deaths (not counting the ship) against that yields you around 262K infected and then you could use CFR at various times to run course, obviously telling the story that it's pretty raggedy still given some have supposedly taken 14 days to show symptoms much less be all the way through 

14 days to fully run course .62%

21 days to fully run course 2.4%

also would mean a lot of cases that have come online in the last week (230K in the last 9 days) 

 

Don’t forget, the assisted care facility had 10-11 deaths in the 2-3 weeks prior to the testing, when they normally have 5-7 a month.    And it’s probably not easy to test deceased folks who meet the criteria after the fact.  

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closetojumping

closetojumping 62215

Posted
Posted
18 minutes ago, Enchubben said:

At least you have Hummel’s down by Pirate’s cove. You could not drag me into the Kroger near 61st.

Yeah, not going into town. Brought a ton of provisions down and then just went through the Seven Seas grocery. They were stocked with everything ... except toilet paper. They said they ran out Thursday with people buying 15-20 packs of it each. That is so fucking weird. 

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Goredho

Goredho 17345

Posted
Posted
56 minutes ago, ChiTownDoc said:

I believe there are different more virulent strains.  That’s just conjecture.  Far from scientific fact.  But it’s Novel to us all.  
I am drinking so I don’t have the time to explain it all.  
 

Wasn’t there some evidence of two strains of different virulence in China?

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atomheartbevo

atomheartbevo 89408

Posted
Posted
1 minute ago, CleverNickname said:

I thought the doubling rate was more like 4 to 6 days.

1,000 or so cases on the 10th.  2,300 or so yesterday.   So it’s hanging with those numbers.   But, we are still bottlenecked, just like China and South Korea were early on.  

We are hitting 400 new cases that we know about today, taking us to 2,7000 or so overall, and there will be more announced later, plus it’s Saturday, so not all results will be announced.   I expect we hit 3,000 cases tomorrow morning, and are close to our first 1,000:case day.  

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Armybrat

Armybrat 40725

Posted
Posted

European threat levels by country:

The English are feeling the pinch in relation to recent virus threat and have therefore raised their threat level from “Miffed” to “Peeved.” Soon, though, level may be raised yet again to “Irritated” or even “A Bit Cross.”
The English have not been “A Bit Cross” since the blitz in 1940 when tea supplies nearly ran out.
The virus has been re-categorized from “Tiresome” to “A Bloody Nuisance.” The last time the British issued a “Bloody Nuisance” warning level was in 1588, when threatened by the Spanish Armada.
The Scots have raised their threat level from “Pissed Off” to “Let's Get the Bastard.” They don't have any other levels. This is the reason they have been used on the front line of the British army for the last 300 years.
The French government announced yesterday that it has raised its alert level from “Run” to “Hide.” The only two higher levels in France are “Collaborate” and “Surrender.” The rise was precipitated by a recent fire that destroyed France's white flag factory, effectively paralyzing the country's military capability.
Italy has increased the alert level from “Shout Loudly and Excitedly” to “Elaborate Military Posturing.” Two more levels remain: “Ineffective Combat Operations” and “Change Sides.”
The Germans have increased their alert state from “Disdainful Arrogance” to “Dress in Uniform and Sing Marching Songs.” They also have two higher levels: “Invade a Neighbour” and “Lose.”
Belgians, on the other hand, are all on holiday as usual; the only threat they are worried about is NATO pulling out of Brussels.
The Spanish are all excited to see their new submarines ready to deploy. These beautifully designed subs have glass bottoms so the new Spanish navy can get a really good look at the old Spanish navy.
Australia, meanwhile, has raised its alert level from “No worries” to “She'll be alright, Mate.” Two more escalation levels remain: “Crikey! I think we'll need to cancel the barbie this weekend!” and “The barbie is cancelled.” So far, no situation has ever warranted use of the final escalation level.
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Stunns38

Stunns38 3357

Posted
Posted

On the way from Dallas to Mansfield earlier, I drove past multiple chuckie cheeses, A main event, Dave and busters, tons of chain sit down restaurants, box stores that aren’t grocery stores, and a couple movie theaters. Parking lots were all full. This may end badly because half of us DGAF. Plus traffic on both 20 and 360 was relatively heavy. PGBT wasn’t very empty either.

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Anastasis

Anastasis 23393

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Posted
2 minutes ago, Stunns38 said:

On the way from Dallas to Mansfield earlier, I drove past multiple chuckie cheeses, A main event, Dave and busters, tons of chain sit down restaurants, box stores that aren’t grocery stores, and a couple movie theaters. Parking lots were all full. This may end badly because half of us DGAF. Plus traffic on both 20 and 360 was relatively heavy. PGBT wasn’t very empty either.

We need a virus that selectively targets stupid people. 

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GreenspointTexas

GreenspointTexas 9559

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This is from a front-line ICU physician in a Seattle hospital 

This is his personal account:

* 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.

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Thetexashammer

Thetexashammer 1062

Posted
Posted

Iran building mass graves. https://edition.cnn.com/2020/03/13/middleeast/iran-coronavirus-mass-graves-intl/index.html

France and Spain are joining Italy on complete lockdown. https://www.bbc.com/news/world-europe-51892477

Lockdown sucks. It really sucks. It can't last more than a month to six weeks I don't think.

 

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Somnio

Somnio 751

Posted
Posted
1 minute ago, Stunns38 said:

On the way from Dallas to Mansfield earlier, I drove past multiple chuckie cheeses, A main event, Dave and busters, tons of chain sit down restaurants, box stores that aren’t grocery stores, and a couple movie theaters. Parking lots were all full. This may end badly because half of us DGAF. Plus traffic on both 20 and 360 was relatively heavy. PGBT wasn’t very empty either.

Until it impacts them directly, or they are forced, the vast majority will not change their behavior.

I'm guilty of it myself.  I mean life does have to go on, but it is definitely going to fuck us very, very soon.

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Aqua Buddha

Aqua Buddha 14501

Posted
Posted
4 hours ago, Trey3216 said:

First part of the sentence being the operative.   @Aqua Buddha has been telling us this for 2 weeks 

 

4 hours ago, Pato del Muerto said:

They say they have plenty, just need time to distribute to stores and stock shelves. 

 

Last few days have been what I suspected would happen but it’s still a surreal sight along with the actual numbers.  Complete panic buying a national scale but without the panic.  Been in lots of stores lately and it’s fascinating.  People shopping at a normal pace but you can tell they’re thinking about what they might have to cook 10 days from now.  LOTS of paper.  Holy fuck lots of paper.  The shopping baskets are all crammed full of product.    

Hand sanitizer is basically depleted in the industry.  Paper is close.  One very large consumer goods company has shipped it’s last case of paper from what I understand.  They’re making more, mind you, but they can’t make it fast enough to meet demand.

With everything else, it just depends on the category, really.  Hand sanitizer, cleaning products, and paper were the first wave of products but food was the second wave.  Big Retail start putting in massive orders about two weeks ago, only to order more and more since then.  The thing is, they’re selling it all.  Big Food’s safety stock is essentially gone and with the huge spike we’ve seen the past 4 days, Big Food can only fill about 80% of the orders coming in, particularly in the canned and frozen food categories.  (That number is usually over 98%.)  There’s enough food in the network right now to cover for the next week.  (By network, I mean in the stores, retail warehouses, and in transit.)  After that, we’ll see periodic shortages and big suppliers will have to start allocating customers.  ALDI is essentially empty from what I understand as they don't use the big brands.  I'm curious as to what Trader Joe's looks like as well.  EBT cards load tonight in a lot of the country.  There might not be much food left by then.

What I’ve seen the last 4 days is something I never thought I’d see and I hope I never see again.  The consumer supply chain is extremely strained from the manufacturing plants, the trucking lines, DC’s, and stores.  It simply can’t handle the volume.  HEB and Publix are both reducing hours in order to restock the stores overnight.

Just surreal.  It's like a movie but it's not a movie.

 

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Anastasis

Anastasis 23393

Posted
Posted
9 minutes ago, GreenspointTexas said:

This is from a front-line ICU physician in a Seattle hospital 

This is his personal account:

* 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.

Well this sounds fucking rosey.

 

Seriously, thanks for sharing this. 

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