Recruiting Forum Football Talk II

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#119,928
#119,928
delfonic said:
Ever had a job were it was so urgent to get it done, you didn't necessarily care about efficiency? I have.
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Yes, efficiency isn't everything.

Also depends on the type of govt. Ours is actually set up to move slower because we have all those silly checks and balances and processes and audits and votes, etc.
 
#119,929
#119,929
This was posted by our resident doctor on 247.

These are not my words but are very informative from an ER physician in New Orleans. One of my ENT friends graduated with him from Medical school. A lot of this information is counterintuitive on how we usually treat respiratory failure and pneumonia. Thought you guys might enjoy it.

(Copy and pasted from a private group)this is a really interesting read and breakdown of covid for this U.S. facility.

"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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#119,934
#119,934
scvolfan7 said:
Stolen from reddit
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It starts "not my words". He was just passing it along from a fellow doctor. I'm sure it has made rounds on medical forums or subreddits. Private groups among doctors and healthcare workers has been a big source of gathering and passing along info, what works, what doesnt, etc.
 
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#119,935
#119,935
Devo182 said:
Though I would also caution against trying it anytime soon, until volatility comes down. Traders seem to inherently enjoy volatility, because they think of opportunity...but research has shown times of high volatility produce the worst results for them. A lot of traders get slaughtered in times like these.
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Thanks for the info. I really do appreciate the thought you put into your responses. I haven't even thought about trying out a trading plan to see how well it works before actually trading with real money. I was listening to a finance podcast earlier today and on that episode they talked about day trading and how they typically don't like it as for most people it's far better to just put the money into a retirement fund.
 
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#119,936
#119,936
sutro said:
Wow. Fabulous summary. Thank you for posting. Any idea how to track back to the source discussion? Lots of hard-won pearls of wisdom in there, and I expect that there will be more to come.
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Looks like the author also posted it on TexAgs and made its rounds. Seems to be a well known doctor on their board. Sounds like doctors from all over are trying to contact him. Fwiw their board has a "Verified Doctor" tag, once the person has been vetted as a doctor. That board is yuge. Their COVID subforum alone has posts every minute and lots of doctors, nurses, etc posting. Interesting stuff.

He is answering further questions on there (user NawlinsAg):
Clinical Pearls Covid 19 for ER practitioners | TexAgs

Screenshot_20200327-164442.jpg
 
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#119,939
#119,939
Pepe_Silvia said:
So was efficacy disregarded as well? Because the government is also inept at making things work effectively as well.
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We are well past the point of government bad, business good. Continuing to treat this like a normal problem that doesn't require the full brunt of our ability to organize be brought to bear will result in many deaths. I am not willing to pay that cost hypothetically or practically. There is no institution on Earth with a greater ability to organize or mobilize at a large scale than the federal government of the United States of America. It's time to do so and pull out all the stops. We can worry about what comes next when we get there.
 
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#119,944
#119,944
delfonic said:
We are well past the point of government bad, business good. Continuing to treat this like a normal problem that doesn't require the full brunt of our ability to organize be brought to bear will result in many deaths. I am not willing to pay that cost hypothetically or practically. There is no institution on Earth with a greater ability to organize or mobilize at a large scale than the federal government of the United States of America. It's time to do so and pull out all the stops. We can worry about what comes next when we get there.
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Well this part is definitely true because unfortunately the government is a totally unrestrained monopoly on power. I'm more concerned about the increased authority being handed to the government and the constitutional overreach being tolerated by the populace.
 
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#119,945
#119,945
InVOLuntary said:
@Devo182 I'm going to share this in the pub and PF forums unless you object.
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Not at all, it isn't mine. Just thought it was interesting, albeit 90% of it was gibberish to me. It has clearly meant something to experts that have read it. For once it felt like someone was understanding how this thing operates and had some options for what works and what does not.
 
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