Clinical Pearls Covid 19 for ER practitioners

331,847 Views | 254 Replies | Last: 2 yr ago by plain_o_llama
Mordred
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TelcoAg said:

Hello facebook and Reddit people. Please take the time to participate in our welcome center forum: https://texags.com/forums/16
Well that's a good way to decrease the exponential growth here.
Rmueller77
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Thank you for your hard and effective work.
Do you have any ability to use ozone in the blood? See "A Plausible "Penny" Costing Effective Treatment for Corona Virus - Ozone Therapy" in Journal of Infectious Diseases and Epidemiology Volume 6 | Issue 2. They used direct injection of a 95% oxygen - 5% ozone to cure Ebola in 5 of 5 patients treated. My wife had shingles and instead of direct injection, had 200 ml of blood drawn, the O2/O3 mix added to the blood bag, and then had the blood returned to her body. She needed three such treatments in four days (we were heading to Antarctica with the Traveling Aggies the following weekend - highly recommend it!), and the shingles were gone after the third treatment. Her pain went from an 8/10 to 2/10 during the first treatment. Ozone has great power to supercharge the immune system. I have tried to get someone interested in working with it in order to get FDA approval, but of course FDA is heavily influenced by drug companies, which would not profit from ozone treatments. Would love to hear if you are able to try it and see that it works. From our experience, I am confident it would save lives. Not many MDs know of ozone's usefulness; I doubt it is in the PDR. Had to go to a homeopathic doc for wife's treatments; my MD brother recommended it but he was out of state.
ThatOneGuy
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This has already been posted to EM Docs on Facebook multiple times today. You are an EM celebrity.
BuffsAg47
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Good luck, Doc and stay safe.
aggieann
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Also on several conservative-leaning blogs! Stay safe, Doc!
Infection_Ag11
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Just heard from a buddy who is at Mt. Sinai in NY that they just adopted a mandatory DNR policy for COVID patients if via 2 physician consent it is determined a patient is unlikely to survive no matter what is done.

Wow
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HotardAg07
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TelcoAg
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How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.
Ag In Ok
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Contingency plan or immediately implemented?
AgLiving06
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TelcoAg said:

How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.

I believe Cuomo also said they have ICU beds available and 1-2k ventilators that have yet to be used.
TelcoAg
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Negative. Brix said that, but that is what they're shipping from FEMA. Pence said another 2,000 tomorrow. They are out (or out in some facilities that can't magically resupply from the stockpile whenever needed) and Cuomo approved splitting ventillators.
Infection_Ag11
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TelcoAg said:

How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.


I know first hand much of what the administration is stating in these pressers is false, because I see things to the contrary at my own facilities. I voted for Trump but it's extremely frustrating listening to him and those around him telling the American people things that just aren't true.

Most major medical centers already have or are drafting plans with their legal departments for this scenario. It's going to be implemented at more than a few before this is done. There are even medical and ICU directors at major institutions ON THE RECORD stating as much. Anything said to the contrary is, at best, misleading.
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KidDoc
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Infection_Ag11 said:

TelcoAg said:

How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.


I know first hand much of what the administration is stating in these pressers is false, because I see things to the contrary at my own facilities. I voted for Trump but it's extremely frustrating listening to him and those around him telling the American people things that just aren't true.

Most major medical centers already have or are drafting plans with their legal departments for this scenario. It's going to be implemented at more than a few before this is done. There are even medical and ICU directors at major institutions ON THE RECORD stating as much. Anything said to the contrary is, at best, misleading.
Today is yet another day I am glad I picked Pediatrics:

but anyway I agree with your political sentiments 100%. Very frustrating.

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Infection_Ag11
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KidDoc said:

Infection_Ag11 said:

TelcoAg said:

How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.


I know first hand much of what the administration is stating in these pressers is false, because I see things to the contrary at my own facilities. I voted for Trump but it's extremely frustrating listening to him and those around him telling the American people things that just aren't true.

Most major medical centers already have or are drafting plans with their legal departments for this scenario. It's going to be implemented at more than a few before this is done. There are even medical and ICU directors at major institutions ON THE RECORD stating as much. Anything said to the contrary is, at best, misleading.
Today is yet another day I am glad I picked Pediatrics:

but anyway I agree with your political sentiments 100%. Very frustrating.




It's a really bad look when you say there's nothing to that "rumor" the same day the as the ICU directors of multiple elite institutions are going on the record about the reality of that situation.
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BigHead 04
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Was reading this from a pulm/cc colleague, who got it from the Covid-19 physician group on FB (20,000+ people).

Of course it's from TexAgs. Hang in there Nawlins. Many prayers coming your way!
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Mordred
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Infection_Ag11 said:

KidDoc said:

Infection_Ag11 said:

TelcoAg said:

How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.


I know first hand much of what the administration is stating in these pressers is false, because I see things to the contrary at my own facilities. I voted for Trump but it's extremely frustrating listening to him and those around him telling the American people things that just aren't true.

Most major medical centers already have or are drafting plans with their legal departments for this scenario. It's going to be implemented at more than a few before this is done. There are even medical and ICU directors at major institutions ON THE RECORD stating as much. Anything said to the contrary is, at best, misleading.
Today is yet another day I am glad I picked Pediatrics:

but anyway I agree with your political sentiments 100%. Very frustrating.




It's a really bad look when you say there's nothing to that "rumor" the same day the as the ICU directors of multiple elite institutions are going on the record about the reality of that situation.
Not doubting you at all, but could you provide links or sources for these statements by ICU directors? Even just names of hospitals so I can look them up. Thanks.
TelcoAg
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I hear you, and I believe you. Was just asking if you think this is solid because there's a whole lot of folks reading this stuff and, if it's slightly less than solid, it's worth providing caveats as necessary.

Let me ask you this as plainly as I can - is it MFBarnes, hardest working man in healthcare?

But for real, while I expect Trump to bull****, I was hopeful it wasn't coming from the doctors on stage
Infection_Ag11
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Mordred said:

Infection_Ag11 said:

KidDoc said:

Infection_Ag11 said:

TelcoAg said:

How good is this buddy? I ask because Dr. Brix stood up at the podium today and said that the DNR stuff is fake news. I'd like to believe you but hell of a statement from her in the White House today if it's legit. Just might want to think through the source on that before posting here as a confirmed thing, is all I'm saying.


I know first hand much of what the administration is stating in these pressers is false, because I see things to the contrary at my own facilities. I voted for Trump but it's extremely frustrating listening to him and those around him telling the American people things that just aren't true.

Most major medical centers already have or are drafting plans with their legal departments for this scenario. It's going to be implemented at more than a few before this is done. There are even medical and ICU directors at major institutions ON THE RECORD stating as much. Anything said to the contrary is, at best, misleading.
Today is yet another day I am glad I picked Pediatrics:

but anyway I agree with your political sentiments 100%. Very frustrating.




It's a really bad look when you say there's nothing to that "rumor" the same day the as the ICU directors of multiple elite institutions are going on the record about the reality of that situation.
Not doubting you at all, but could you provide links or sources for these statements by ICU directors? Even just names of hospitals so I can look them up. Thanks.


Richard Wunderink at Northwestern

Lewis Kaplan at Penn (and head of the CCM society)

Various sources from Wisconsin, UCLA, NYU, George Washington and Washington have also publicly said these policies are already primed and ready or in the works at their institutions.
No material on this site is intended to be a substitute for professional medical advice, diagnosis or treatment. See full Medical Disclaimer.
Infection_Ag11
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TelcoAg said:

I hear you, and I believe you. Was just asking if you think this is solid because there's a whole lot of folks reading this stuff and, if it's slightly less than solid, it's worth providing caveats as necessary.

Let me ask you this as plainly as I can - is it MFBarnes, hardest working man in healthcare?

But for real, while I expect Trump to bull****, I was hopeful it wasn't coming from the doctors on stage


The caveat is that it's physician discretion (and I said as much in the initial post), not a blanket ruling. They've given physicians the power to restrict resources on the basis of prognosis out of necessity.
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BigHead 04
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Infection_Ag11 said:

TelcoAg said:

I hear you, and I believe you. Was just asking if you think this is solid because there's a whole lot of folks reading this stuff and, if it's slightly less than solid, it's worth providing caveats as necessary.

Let me ask you this as plainly as I can - is it MFBarnes, hardest working man in healthcare?

But for real, while I expect Trump to bull****, I was hopeful it wasn't coming from the doctors on stage


The caveat is that it's physician discretion (and I said as much in the initial post), not a blanket ruling. They've given physicians the power to restrict resources on the basis of prognosis out of necessity.


Read "they've found a way to dump the blame on physicians when someone eventually sues"

Sorry to go there. But that's their typical stance.
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TelcoAg
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I'll stop, I'm not trying to put you under oath. I absolutely know as fact it's under consideration and being planned for in many many places, but I was specifically asking about it being implemented at Mt. Sinai. About how sure you are that that source is accurate.

You don't need to answer if you don't want, man. Just wanted to know how sure sure was on that.
Infection_Ag11
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BigHead 04 said:

Infection_Ag11 said:

TelcoAg said:

I hear you, and I believe you. Was just asking if you think this is solid because there's a whole lot of folks reading this stuff and, if it's slightly less than solid, it's worth providing caveats as necessary.

Let me ask you this as plainly as I can - is it MFBarnes, hardest working man in healthcare?

But for real, while I expect Trump to bull****, I was hopeful it wasn't coming from the doctors on stage


The caveat is that it's physician discretion (and I said as much in the initial post), not a blanket ruling. They've given physicians the power to restrict resources on the basis of prognosis out of necessity.


Read "they've found a way to dump the blame on physicians when someone eventually sues"

Sorry to go there. But that's their typical stance.


An institution isn't going to implement that without legal being on board. It has to be air tight.
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Infection_Ag11
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TelcoAg said:

I'll stop, I'm not trying to put you under oath. I absolutely know as fact it's under consideration and being planned for in many many places, but I was specifically asking about it being implemented at Mt. Sinai. About how sure you are that that source is accurate.

You don't need to answer if you don't want, man. Just wanted to know how sure sure was on that.


He's someone I know from medical school and have no reason to doubt it. It's a group chat with six of us, all physicians at different institutions.

But I can report tomorrow if others are hearing the same because stuff like that immediately gets disseminated in the physician community. Everyone will be talking about it quickly if it's true.
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TelcoAg
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That's all I was asking about my man. Just know there are a lot of eyes on this thread from around the EM community.
Infection_Ag11
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Apparently the hospitals in NY are also starting run short on commonly used ICU meds, such as pressors and sedation.
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BigHead 04
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I certainly agree. Legal will be in charge. But when the SHTF they don't give a flying **** about you or me. They've made that abundantly clear through this whole process. It was plenty clear to me beforehand, for other reasons.
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Doug Ross
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nawlinsag said:

I just spent an hour typing a long post that erased when I went to change the title so I apologize to the grammar and spelling police. This one will not be proofread and much shorter.

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.









great ****ing post

I am ER, trained at the Lake in BR

We are doing plaq/azithro in the ICU....obviously we have the ability to keep them on the monitor if they go into Torsades. Agree, I am not testing anyone unless they are admitted. I am sorry, but I am not putting my nursing staff at risk for a mildly symptomatic patient to whom the treatment does not change,

Intubation wise, trying to minimize risk as best as possible. I have the vent set up before hand, minimize bagging, have them on 100% NRB until RSI. Then I am pushing paralytic before hand to minimize sedation time. Tube them w glidescope and immediately put them on vent to decrease open circuit time. Can do this <90 sec if prepared.

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Doug Ross
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i saw the writing on the wall so I have a $200 p100 at my disposable now when resources deplete
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Dr. Not Yet Dr. Ag
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Doug Ross said:

i saw the writing on the wall so I have a $200 p100 at my disposable now when resources deplete
Lol, you dumb***, you should've called me. I got mine for $50. People are price gouging like crazy on the filters too. How many filters did you get?
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Mordred
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Infection_Ag11 said:


Richard Wunderink at Northwestern

Lewis Kaplan at Penn (and head of the CCM society)

Various sources from Wisconsin, UCLA, NYU, George Washington and Washington have also publicly said these policies are already primed and ready or in the works at their institutions.

Gotcha, and thanks.

Depending on how you parse her statement she might not be lying. I took it as, as of this moment no one is being DNR'd for this because the situation doesn't warrant it yet, but that hospitals might be thinking and planning for that eventuality. If your friend at Sinai is saying this policy just went into effect, then maybe the situation has changed since Birx spoke.

I make no claims to the veracity of anything else that was said in the presser, but her statement on the surface doesn't strike me as false.
Bought In Ag 96
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SIAP, but what is the status of HCQ trials? This seems to have dropped out of the news the last 48 hours.

Any developments here?





AgDoc03
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Been seeing this circulated around Facebook by medical and non-medical friends. A TexAgs post going viral! Just another reason this site and its members are the best!
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hrompel
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Nawlinsag if you are the originator of this post (or whoever is the originator of this post) would you please email vluther@wakehealth.edu ?

I am a peds nurse who is reading Covid info and passing it along to a friend, Vera Luther, who is in infectious disease at Wake Forest Baptist Health in Winston-Salem, NC

I saw your post reposted on a healthcare workers FB and sent it to her and she is interested in your experience and specifically your experience with hydroxychloroquine.

Thanks so much for sharing info during this!!

McInnis 03
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hrompel said:

Nawlinsag if you are the originator of this post (or whoever is the originator of this post) would you please email vluther@wakehealth.edu ?

I am a peds nurse who is reading Covid info and passing it along to a friend, Vera Luther, who is in infectious disease at Wake Forest Baptist Health in Winston-Salem, NC

I saw your post reposted on a healthcare workers FB and sent it to her and she is interested in your experience and specifically your experience with hydroxychloroquine.

Thanks so much for sharing info during this!!


Nawlins is indeed the originator of the post, but don't be surprised if he's a bit bogged down atm. Welcome to our forum.
hrompel
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Yes Mcinnis, I am sure he is, it's a thorough explanation that folks are appreciating. Are you able to share his name or at least where I could find it so I can let my ID folks know?
 
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