COVID-19 from the ER

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11:44p, 3/21/20
You guys are the greatest of humans....;I don't think the information about everybody should be tested is coming from the government. They have been pretty clear across all branches of the administration that you don't.
The media is another matter. Some clearly understand. Others pretend there is some confusion about this. Some ( having been in news of one sort or another for 50 years) some are just dumb as stumps.
But I think much of this is self generated by the public it's self. Fear and self interest always gives rise to this pressure. Just ask all my neighbors who dug bomb shelters in the back yards during the 1950 and 60's. All the while knowing it wouldn't do a bit of good.
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Infection_Ag11
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In reply to Doug Ross • 11:44p, 3/21/20
AG
Doug Ross said:
PikesPeakAg said:
Doug,

Your fear is understandable. You are one of the few on here who is on the front lines. The ICU/pulmonary guys are a distant second as they don't triage the larger number of patient's in the ER like you guys do. As frightening as it seems, several things offer hope. The recently approved POC testing with 45 minute turn around time and the most recent info on therapeutics, particularly the plaquenil stuff. The idea that this can be identified quickly and may be treatable with existing generic drugs makes this more managable in my mind.

Some of us will turn positive. It's inevitable. Rest assured that the majority of our colleagues will go all in and treat us with the promising treatments if we develop respiratory progression at the minimum. You never know what's real but someone on this board was the comment that Italy did not treat early with meds as the W.H.O. had not "approved" certain treatments. Their system is so overwhelmed, who knows what reality is. To be sure most of US critical care docs aren't waiting for the RCT trials to go for it. Time is critical as this point. (We can always have an open label trial and place the guys that want to wait for RCT's in the control arm of 14 days of isolation + vents if needed.)

Good Luck. Stay Healthy!

Thanks for kind words.

The POC will be interesting. A quick turn around could drastically change management. Use of nebulized medicine and BiPAP/CPAP, puts healthcare workers at risk so we are trying to avoid use when possible. A quick POC could allow us to be confident in treating a patient as CHF rather than COVID.

There also have been some scary EKGs floating around on twitter. Patient's presenting with chest pain, with an ischemic EKG, only to have a negative cath and positive covid later. Instead found diffuse myocardial ischemia....myocarditis vs takostubo...that pathophys is very interesting and more will be uncovered soon. However, itwill be very easy to miss a COVID patient who presents as classic chest pain and vise versa.

The plaquenil/azithro evidence is interesting. ICU docs in DFW are treating this way....like you said, without a RCT... what do we have to lose when a patient is critical? Plaquenill/azithro vs having to put a 45 yo on ECMO? I'll take the former anytime.


Plaquenil/Azithro makes me very nervous given what we're finding out about the viruses propensity to cause viral myocarditis late in the disease course. That combo is a perfect set up for torsades in any patient who has or develops ventricular dysfunction.

That combined with less than quality evidence for the efficacy and I'm not in love with it to say the least.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Orlando Ayala Cant Read
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11:45p, 3/21/20
AG
Fauci already on record saying the only thing that'll almost certainly bring this thing under control is several more weeks of isolation except when absolutely needed to go out. Knowing what we know that's what makes sense. Not just a few more days.
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Doug Ross
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In reply to DallasAg 94 • 11:50p, 3/21/20
AG
DallasAg 94 said:
Interested to hear your perspective on the numbers.

I'm less concerned about the number infected.

You seem to imply several admits to the hospital each day and the daily addition of ventilators.

This site implies 64 "Serious or Critical." Statistically that's is 1 in the State of Texas. Maybe 2. To me, "Serious or Critical" implies admitted to the hospital... and/or ICU/Ventilator treatment.

The second number on the site is the Daily Deaths.

It would appear:

57 on March 19.
49 Yesterday
46 Today

The numbers are trending down. It also implies 1 death per state. With 60% of confirmed cases in NY, NJ, Wa, and Cal... How do those numbers correlate with what you are seeing.

You make it seem like you are getting over 2-3 patients daily who need ventilator.
I use the same website for my statistical data and I have asked myself the exact same question. I personally have heard of >6 pts intubated for covid/suspected covid in the DFW area. Those "critical" numbers do not add up to what I am seeing. I am unclear of the worldometer definition of critical, but I can promise you there are more than 64 people in the US intubated or in the ICU due to COVID. The only possible explanation I can come up with is that is the number of patients on ECMO.
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Infection_Ag11
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In reply to Doug Ross • 11:57p, 3/21/20
AG
Doug Ross said:
DallasAg 94 said:
Interested to hear your perspective on the numbers.

I'm less concerned about the number infected.

You seem to imply several admits to the hospital each day and the daily addition of ventilators.

This site implies 64 "Serious or Critical." Statistically that's is 1 in the State of Texas. Maybe 2. To me, "Serious or Critical" implies admitted to the hospital... and/or ICU/Ventilator treatment.

The second number on the site is the Daily Deaths.

It would appear:

57 on March 19.
49 Yesterday
46 Today

The numbers are trending down. It also implies 1 death per state. With 60% of confirmed cases in NY, NJ, Wa, and Cal... How do those numbers correlate with what you are seeing.

You make it seem like you are getting over 2-3 patients daily who need ventilator.
I use the same website for more statistical data and I have asked myself the exact same question. I personally have heard of >6 pts intubated for covid/suspected covid in the DFW area. Those "critical" numbers do not add up to what I am seeing. I am unclear of the worldometer definition of critical, but I can promise you there are more than 64 people in the US intubated or in the ICU due to COVID. The only possible explanation I can come up with is that is the number of patients on ECMO.


From a tertiary referral center in Dallas, I can say with first hand certainty the number of cases reported (overall and severe) locally is laughably low.

The presentation is fairly unique once you have all the imaging and lab data it becomes fairly easy to confidently say who has it before the test comes back. I fully expect our confirmed in house cases to more than double in the next 48 hours.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
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Doug Ross
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In reply to Infection_Ag11 • 11:58p, 3/21/20
AG
Infection_Ag11 said:
Doug Ross said:
PikesPeakAg said:
Doug,

Your fear is understandable. You are one of the few on here who is on the front lines. The ICU/pulmonary guys are a distant second as they don't triage the larger number of patient's in the ER like you guys do. As frightening as it seems, several things offer hope. The recently approved POC testing with 45 minute turn around time and the most recent info on therapeutics, particularly the plaquenil stuff. The idea that this can be identified quickly and may be treatable with existing generic drugs makes this more managable in my mind.

Some of us will turn positive. It's inevitable. Rest assured that the majority of our colleagues will go all in and treat us with the promising treatments if we develop respiratory progression at the minimum. You never know what's real but someone on this board was the comment that Italy did not treat early with meds as the W.H.O. had not "approved" certain treatments. Their system is so overwhelmed, who knows what reality is. To be sure most of US critical care docs aren't waiting for the RCT trials to go for it. Time is critical as this point. (We can always have an open label trial and place the guys that want to wait for RCT's in the control arm of 14 days of isolation + vents if needed.)

Good Luck. Stay Healthy!

Thanks for kind words.

The POC will be interesting. A quick turn around could drastically change management. Use of nebulized medicine and BiPAP/CPAP, puts healthcare workers at risk so we are trying to avoid use when possible. A quick POC could allow us to be confident in treating a patient as CHF rather than COVID.

There also have been some scary EKGs floating around on twitter. Patient's presenting with chest pain, with an ischemic EKG, only to have a negative cath and positive covid later. Instead found diffuse myocardial ischemia....myocarditis vs takostubo...that pathophys is very interesting and more will be uncovered soon. However, itwill be very easy to miss a COVID patient who presents as classic chest pain and vise versa.

The plaquenil/azithro evidence is interesting. ICU docs in DFW are treating this way....like you said, without a RCT... what do we have to lose when a patient is critical? Plaquenill/azithro vs having to put a 45 yo on ECMO? I'll take the former anytime.


Plaquenil/Azithro makes me very nervous given what we're finding out about the viruses propensity to cause viral myocarditis late in the disease course. That combo is a perfect set up for torsades in any patient who has or develops ventricular dysfunction.

That combined with less than quality evidence for the efficacy and I'm not in love with it to say the least.
Agree 100%. I need to read more about the QT prolongation aspect of all of it. My only argument would be, if you have an otherwise healthy 35 yo M, no PMH, intubated....crashing, what do we have to lose. In a critical patient that otherwise needs to be on ECMO, then I would treat.
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Doug Ross
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In reply to Infection_Ag11 • 12:00a, 3/22/20
AG
Infection_Ag11 said:
Doug Ross said:
DallasAg 94 said:
Interested to hear your perspective on the numbers.

I'm less concerned about the number infected.

You seem to imply several admits to the hospital each day and the daily addition of ventilators.

This site implies 64 "Serious or Critical." Statistically that's is 1 in the State of Texas. Maybe 2. To me, "Serious or Critical" implies admitted to the hospital... and/or ICU/Ventilator treatment.

The second number on the site is the Daily Deaths.

It would appear:

57 on March 19.
49 Yesterday
46 Today

The numbers are trending down. It also implies 1 death per state. With 60% of confirmed cases in NY, NJ, Wa, and Cal... How do those numbers correlate with what you are seeing.

You make it seem like you are getting over 2-3 patients daily who need ventilator.
I use the same website for more statistical data and I have asked myself the exact same question. I personally have heard of >6 pts intubated for covid/suspected covid in the DFW area. Those "critical" numbers do not add up to what I am seeing. I am unclear of the worldometer definition of critical, but I can promise you there are more than 64 people in the US intubated or in the ICU due to COVID. The only possible explanation I can come up with is that is the number of patients on ECMO.


From a tertiary referral center in Dallas, I can say with first hand certainty the number of cases reported (overall and severe) locally is laughably low.

The presentation is fairly unique once you have all the imaging and lab data it becomes fairly easy to confidently say who has it before the test comes back. I fully expect our confirmed in house cases to more than double in the next 48 hours.
We may have already talked on the phone this week

Agree, our testing in Dallas has taken 6-10 days to come back.....so once tests comes back, the number of reported cases will skyrocket (despite them being tested a week ago). Gives a false sense of reality.
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Infection_Ag11
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In reply to Doug Ross • 12:03a, 3/22/20
AG
Doug Ross said:
Infection_Ag11 said:
Doug Ross said:
PikesPeakAg said:
Doug,

Your fear is understandable. You are one of the few on here who is on the front lines. The ICU/pulmonary guys are a distant second as they don't triage the larger number of patient's in the ER like you guys do. As frightening as it seems, several things offer hope. The recently approved POC testing with 45 minute turn around time and the most recent info on therapeutics, particularly the plaquenil stuff. The idea that this can be identified quickly and may be treatable with existing generic drugs makes this more managable in my mind.

Some of us will turn positive. It's inevitable. Rest assured that the majority of our colleagues will go all in and treat us with the promising treatments if we develop respiratory progression at the minimum. You never know what's real but someone on this board was the comment that Italy did not treat early with meds as the W.H.O. had not "approved" certain treatments. Their system is so overwhelmed, who knows what reality is. To be sure most of US critical care docs aren't waiting for the RCT trials to go for it. Time is critical as this point. (We can always have an open label trial and place the guys that want to wait for RCT's in the control arm of 14 days of isolation + vents if needed.)

Good Luck. Stay Healthy!

Thanks for kind words.

The POC will be interesting. A quick turn around could drastically change management. Use of nebulized medicine and BiPAP/CPAP, puts healthcare workers at risk so we are trying to avoid use when possible. A quick POC could allow us to be confident in treating a patient as CHF rather than COVID.

There also have been some scary EKGs floating around on twitter. Patient's presenting with chest pain, with an ischemic EKG, only to have a negative cath and positive covid later. Instead found diffuse myocardial ischemia....myocarditis vs takostubo...that pathophys is very interesting and more will be uncovered soon. However, itwill be very easy to miss a COVID patient who presents as classic chest pain and vise versa.

The plaquenil/azithro evidence is interesting. ICU docs in DFW are treating this way....like you said, without a RCT... what do we have to lose when a patient is critical? Plaquenill/azithro vs having to put a 45 yo on ECMO? I'll take the former anytime.


Plaquenil/Azithro makes me very nervous given what we're finding out about the viruses propensity to cause viral myocarditis late in the disease course. That combo is a perfect set up for torsades in any patient who has or develops ventricular dysfunction.

That combined with less than quality evidence for the efficacy and I'm not in love with it to say the least.
Agree 100%. I need to read more about the QT prolongation aspect of all of it. My only argument would be, if you have an otherwise healthy 35 yo M, no PMH, intubated....crashing, what do we have to lose. In a critical patient that otherwise needs to be on ECMO, then I would treat.


I really hope we're able to amp up production and distribution of remdesivir for our critically ill ones, I like the data and proposed mechanism a bit better. And I've seen it have good anecdotal success on two people already, but again it's purely anecdotal.

The IL-6 inhibitors are also intriguing. We're involved in a trial right now using sarilumab.
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PikesPeakAg
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12:05a, 3/22/20
AG
After posting a sense of perspective came to mind. I had seemingly forgotten what seems like a lifetime ago. Many years ago I was an intern and resident in large county hospital. In those days we had AIDS wards. It was sad, truly sad. A disease with no cure that essentially wasted the patient way. Our terminal patients seemed to weigh 100 lbs or less easily.

I don't remember the statistics but it was universally fatal to my recollection. We took care of those patients until their last day. I remember placing central lines in incredibly sick people that were essentially skin and bones. That was scary. One needle stick or blood exposure and you could see the likely outcome in front of you. I never really appreciated how risky that was back then. Crazy at is seems, I actually think COVID is significantly better as the mortality rate is much better especially with observation and isolation actually being an option.

If we could develop treatment for the untreatable back then, rest assured COVID will be managed as well.

Hopefully you have a few days off!!



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Infection_Ag11
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In reply to Doug Ross • 12:11a, 3/22/20
AG
Doug Ross said:
Infection_Ag11 said:
Doug Ross said:
DallasAg 94 said:
Interested to hear your perspective on the numbers.

I'm less concerned about the number infected.

You seem to imply several admits to the hospital each day and the daily addition of ventilators.

This site implies 64 "Serious or Critical." Statistically that's is 1 in the State of Texas. Maybe 2. To me, "Serious or Critical" implies admitted to the hospital... and/or ICU/Ventilator treatment.

The second number on the site is the Daily Deaths.

It would appear:

57 on March 19.
49 Yesterday
46 Today

The numbers are trending down. It also implies 1 death per state. With 60% of confirmed cases in NY, NJ, Wa, and Cal... How do those numbers correlate with what you are seeing.

You make it seem like you are getting over 2-3 patients daily who need ventilator.
I use the same website for more statistical data and I have asked myself the exact same question. I personally have heard of >6 pts intubated for covid/suspected covid in the DFW area. Those "critical" numbers do not add up to what I am seeing. I am unclear of the worldometer definition of critical, but I can promise you there are more than 64 people in the US intubated or in the ICU due to COVID. The only possible explanation I can come up with is that is the number of patients on ECMO.


From a tertiary referral center in Dallas, I can say with first hand certainty the number of cases reported (overall and severe) locally is laughably low.

The presentation is fairly unique once you have all the imaging and lab data it becomes fairly easy to confidently say who has it before the test comes back. I fully expect our confirmed in house cases to more than double in the next 48 hours.
We may have already talked on the phone this week

Agree, our testing in Dallas has taken 6-10 days to come back.....so once tests comes back, the number of reported cases will skyrocket (despite them being tested a week ago). Gives a false sense of reality.


I'm hopeful that all the major DFW centers will have in house testing within a week or two. One already has it and two more are supposed to be on line this week.

Ideally the PCR turnaround should be 24 hours so we can get it back within the earliest proposed incubation period (48-72 hours or so).
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The Ragonk Strikes Back
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In reply to saltyoldguy • 12:52a, 3/22/20
saltgap said:
Thank you for the info sir. God bless you and your coworkers.
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White Liberals=The Worst
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In reply to Orlando Ayala Cant Read • 1:02a, 3/22/20
Orlando Ayala Cant Read said:
Fauci already on record saying the only thing that'll almost certainly bring this thing under control is several more weeks of isolation except when absolutely needed to go out. Knowing what we know that's what makes sense. Not just a few more days.


The economic impact of something like this should scare the hell out of everyone. Just hope everyone understands how bad "just a few more weeks" of this will be.
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YellowPot_97
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2:19a, 3/22/20
AG
Good luck and stay safe Doc.
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Dr. Not Yet Dr. Ag
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3:02a, 3/22/20
Its crazy to think that many of us will have colleagues that will likely die from this. It's a tough thing to do to put on your scrubs and go to work with that knowledge. It's even tougher after you've intubated a healthy individual that is barely older than yourself. It's perfectly understandable to be scared, but you are stepping up to the plate when people need you. Dr. Doug Ross was a fictional doctor who did heroic things. You're a ****ing real life superhero. Remember that what you do matters.
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Badace52
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3:41a, 3/22/20
AG
Our Covid swabs are also taking 6-10 days to come back. I have a Friend in New York whose wife works as a hospitalist in a major center in New York. He told me today they have 424 Covid confirmed patients in their hospital currently and around 20% of them are in the ICU currently.
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jagvocate
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4:34a, 3/22/20
AG
This is war

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dermdoc
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In reply to Doug Ross • 8:30a, 3/22/20
AG
As a Derm all I can say is how much I admire the work you and your colleagues are doing. Prayers for you and your family.

God bless you doc!
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Hodor
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11:00a, 3/22/20
AG
Appreciate what you front line docs are doing!

Our CMO emailed this article to my radiology group today, and thought I'd share it:
http://www.newyorker.com/news/news-desk/keeping-the-coronavirus-from-infecting-health-care-workers

Hopefully the link works, as the New Yorker is a sub site, but I read it without one.
Good info, and reassuring in regards to risk of transmission with good precautions.
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flakrat
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11:03a, 3/22/20
TRADUCTOR
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11:06a, 3/22/20
If not answering a question; give a doctor a break when they appear aloof when you talk...they have no say in the matter that most of their patients are idiots, plus every Idiot has google. No doctor going to invest time into focused listening after being burned and burned again for wasting that time.
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wbr_iii
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11:22a, 3/22/20
AG
Thanks Dr. You are truly doing God's work.

Staff this should be pinned at the top. This message needs to get out more. Maybe even pasted to home page.
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PikesPeakAg
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11:34a, 3/22/20
AG
Infection Ag. If Azithromycin turn as out to be part of a standardized regimen to treat the sickest I don't think I would let the risk of prolonged QT dissuade you much. It's a relative risk thing at that point. If the the drug has therapeutic benefit and can save a life and the risk of death is high without it that would be preferable to having prolonged QT. Not every prolonged QT leads to Torsades. Most I would argue do not. In fact the drug we stop the most leading to prolonged Qt is amiodarone which everyone uses for VT. The half life of amiodarone is so long and we are still successfully able to mange those patients. The heart scares everyone but that is the world I live in every day. We are to help our colleagues in all of this.

Gig'em and good luck!
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spud1910
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In reply to Doug Ross • 12:43p, 3/22/20
AG
Thank you for all you are doing.
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DTP02
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In reply to Doug Ross • 12:53p, 3/22/20
AG
Quote:
I strongly believe this lack of testing is at the best interest of our health care providers and community as a whole.


Thank you for saying this and doing what I also believe is the right thing.

It's been clear for 1-2 weeks that the media emphasis on tests and getting everyone tested was going to be counter-productive.

I don't know that we ever would have had a chance in the US to strangle this thing with testing and tracing, but if we did ever have the chance we missed it 4-6 weeks ago.

Once we deal with this initial wave then we can use testing and tracing going forward, but it's not the answer right now.
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Proposition Joe
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In reply to DTP02 • 1:00p, 3/22/20
Yeah, I think the media like everyone else (government included) seems to be 2 weeks behind where we needed to be.
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Pelayo
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In reply to Dr. Not Yet Dr. Ag • 1:03p, 3/22/20
AG
Dr. Not Yet Dr. Ag said:
Its crazy to think that many of us will have colleagues that will likely die from this. It's a tough thing to do to put on your scrubs and go to work with that knowledge. It's even tougher after you've intubated a healthy individual that is barely older than yourself. It's perfectly understandable to be scared, but you are stepping up to the plate when people need you. Dr. Doug Ross was a fictional doctor who did heroic things. You're a ****ing real life superhero. Remember that what you do matters.
Thank you Mel Herbert
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Dr. Not Yet Dr. Ag
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In reply to Pelayo • 2:09p, 3/22/20
The ****ing super hero part is Mel Herbert, too. From his 2018 ACEP speech. Love listening to that guy talk.
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Pelayo
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In reply to Dr. Not Yet Dr. Ag • 3:04p, 3/22/20
AG
Dr. Not Yet Dr. Ag said:
The ****ing super hero part is Mel Herbert, too. From his 2018 ACEP speech. Love listening to that guy talk.
I used to get cassette tapes for EMA as early as 1997 when it was just Rick & Jerry.

In one of my summer of '99 EMA package was the first EM:RAP done 100% by Mel, sort of as a trial. He talked about acute MI management and I believe had an entirely separate segment on aspirin. I listened to it on my sony walkman when I would jog back in residency.

Been a subscriber ever since.
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