Get this to every Doctor you know: Direct from an ER MD

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"I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.


Clinical course is predictable.
2-11 days after exposure (day 5 on average) flu like symptoms start. Common are fever, headache, dry cough, myalgias(back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT's of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.

Other factors that appear to be predictive of poor outcomes are thrombocytopenia and LFTs 5x upper limit of normal.

Disposition
I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the "lockdown", our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment
Supportive

Worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil's potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin, but are intermittently running out of IV.

Do not give these patient's standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn't often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all."

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  • This commment is unpublished.
    Gregg Walker · 14 days ago
    Okay. I know some have discussed this here before. Today, I was speaking with my 87-year old mother by phone. She is not an overly religious person but believes in God and reads from the Bible. She told me, “I think this might be from God.” (The virus)

    Before the virus she used to say, “God has got to be pretty mad at this world”. She was so shocked by all the horrible crimes, murders, etc.
    Maybe she’s on to something...
    • This commment is unpublished.
      Ellen Kurek · 14 days ago
      I don't think God has anything to do with this. The devil and his Barbie doll spawn, maybe, but not God. God weeps.
  • This commment is unpublished.
    Christine Livengood · 14 days ago
    Hal, Metropolol is an ACE-inhibitor, info in an article on either or both www.pandemic.news and www.naturalnews.com states this med enhances ease of attachment by Corvid virus!
    • This commment is unpublished.
      Ellen Kurek · 14 days ago
      Metoprolol is a beta blocker, you silly goose! Yes, I can see how ACE-inhibitors, or angiotensin-converting-enzyme inhibitors, could enhance SARS-CoV-2's ease of attachment to human cells. On the other hand, it stands to reason that angiotensin inhibitor blockers (ARBs) would help block it. So I've stated taking a dose of the ARB losartan in the morning as well as bedtime. If you've saved up your ARBs blood-pressure pills, you may want to try to up your dosage -- as long as you don't go too low. Be sure to check your BP regularly if you try this.
      • This commment is unpublished.
        Ellen Kurek · 14 days ago
        Sorry -- I meant to type "Angiotensin Receptor Blockers" or ARBs.
    • This commment is unpublished.
      Gregg Walker · 14 days ago
      Of course it does. Tons of people take it.
  • This commment is unpublished.
    Deborah Cresswell · 14 days ago
    What about this??? I don't see any mention of this doctor using: Hydroxy Chloroquine.

    Also I've read that China and Italy have had great success with high doses of Vitamin C, taken intravenously.

    ----------

    A NY Doctor shared with Hannity his Hydroxy Chloroquine/Azithromycin results.

    200mg 2x daily Hydroxy Chloroquine

    500mg 1x daily Azithromycin

    220mg 1x daily Zinc sulfate 350 patients

    • Breathing restored 3-4 hours

    • Zero deaths

    • Zero hospitalizations

    • Zero intubations
    • This commment is unpublished.
      JuliaXYZ · 14 days ago
      For how many days? A week?
    • This commment is unpublished.
      Stephanie Salazar · 14 days ago
      Plaquenil is Brand name for hydroxychloroquine
      • This commment is unpublished.
        Gregg Walker · 14 days ago
        Yes. That is correct.
  • This commment is unpublished.
    Judith Rollings · 14 days ago
    Probably one of the best and most helpful posts - thanks!
  • This commment is unpublished.
    D Gardina · 14 days ago
    To "ER MD in New Orleans. Class of 98" thank you for putting this information out to us, something that would not normally be available unless you were directly in the medical field.
    K - thank you for putting out the information on the abbreviations. I used to know the terms years ago but have not had to use them for a long time. I was looking to pull out my Merck Medical Dictionary to check them out. I will still look for it, but here is a good link for those that would like to check these medical terms out themselves:

    https://www.merckmanuals.com/home/resourcespages/medical-terms

    Keep up the good Intel!
  • This commment is unpublished.
    Donald Foreman · 14 days ago
    From another Medical family in Kansas as follows: Background: My entire immediate family work in the medical field with four adults and one infant living in the same household. I (64) work as a paramedic in the hospital setting, my wife (58) is an ED manager, my DIL (22) is an ER nurse and my son (25) is a Trauma specialist (ER Nurse that works trauma). My son and DIL work at one major trauma center (hospital) in town, my wife and I at the other major trauma center. We reside in a moderate sized metropolitan area, one that can support two level one trauma centers, in south central Kansas. If you have a map, you can figure it out without me having to give you the exact location here on the the internet.

    March 13: My DIL worked an evening shift when a patient arrived complaining of chest pain. That was the patients primary complaint. No cough, cold symptoms, flu symptoms (other than low grade fever discovered later during evaluation and treatment), or anything else that would indicate a viral infection. It wasn't until later, when the patient was moved upstairs, that further lab work indicated that the patient was a candidate for Covid-19 testing. The patient, three days later, was diagnosed with Covid-19.

    I suspect that my DIL's possible exposure was community acquired as opposed to hospital acquired due to the long incubation time, but there is no way to prove that theory one way or the other.

    March 21: DIL developed a sore throat and 'cold like' symptoms.

    March 22: DIL developed a fever and has maintained a temperature between 99.1 and 101.6 for the past two days. Has displayed nocturnal dyspnea (more trouble breathing at night) and has had to utilize her asthma inhaler a few times. 02 saturation dropped to as low as 91 during these events (multiple times over two nights).

    March 24: Went to her MD and was tested for influenza A & B, Strep, and other viral infections (ones that could be ran in a rapid setting). All tests came back negative. She then was swabbed for Covid-19. KDHE (Kansas department of health & environment) will do the testing and results will be available in 4 to 5 days. She is now a Person Under Investigation.

    For the last five days, all of us in the household have been 'exposed'. My grand-daughter has ran a low grade fever for the past couple of days, but other than the elevated temperature, no other signs or symptoms of flu like illness are present. She doesn't 'act' sick and appears 'normal'.

    I've moved the fifth wheel up near the house to be used as a 'quarantine' abode, but at this point, it is probably a futile effort. We'll see. If my DIL symptoms worsen (which indicates an increased viral load), then I'll move my wife (who has CLL-Chronic Lymphocytic Leukemia) out there to reside. Our house (two story farm type on acreage) is large enough to provide a degree of social distancing, but like everything else, it's a crap shoot on how much is enough.

    Just remember, we ALL work where folks with Covid-19 tend to congregate when sick so social distancing is a mute point if viewed from that angle.

    No one else in the house has displayed any symptoms as of the time of this writing.
    • This commment is unpublished.
      Gregg Walker · 14 days ago
      My God. You are all heroes on the front lines! Thank you all for what you do. I pray God will protect each one of you.
  • This commment is unpublished.
    jw williams · 14 days ago
    Hal can you give your commentary on this..
    This is alot of medical terms that some of us arent familiar with.
    • This commment is unpublished.
      K · 14 days ago
      There are sometimes multiple options for medical abbreviations. I will provide the ones most commonly assigned to an acronym; however, cannot ensure that the expanded version below is what the doctor intended:

      ARDS: acute respiratory distress syndrome
      BiPAP: bilevel positive airway pressure
      BMI: body mass index
      CHF: congestive heart failure
      CRP: C-reactive protein (an inflammatory marker)
      CXR: chest x-ray
      DKA: diabetic ketoacidosis
      ER: emergency room
      LFTs: liver function tests
      MDI: metered-dose inhaler
      PEEP: positive end-expiratory pressure
      PCI: percutaneous coronary intervention
      PPE: personal protection equipment
      RLL: right lower lobe
      SOB: shortness of breath
      STEMI: ST-segment elevation myocardial infarction
      TPA (sometimes written as t-PA): t-plasminogen activator (protein involved in the breakdown of blood clots)
      URI: upper respiratory infection
      WBC: white blood count

      But, IMO, basically the doc is saying major heart issues, lung issues, and otherwise whole-body inflammation with a cytokine storm are the main problems in dealing with COVID-19, and everybody he is seeing, even those coming in with different issues other than COVID, has COVID-19.
      • This commment is unpublished.
        Anne1776 · 13 days ago
        ty so much K, that's terrifically helpful!
  • This commment is unpublished.
    Anne1776 · 14 days ago
    God bless our Doctors and Medical staff and their families!

    My takeaway is: If you have been sick with flu symptoms for five days, and it seems like covid19, do not drop the ball! This is when the riskiest time starts. Watch yourself, rest, vigilantly do all your healthcare for another five days - call it two weeks for good measure. If you're out of the woods by then, maybe you are out.

    I don't understand all the technical info, but I really appreciate it is here and others hopefully will help translate.