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Covid 19 - Are you ready to raise sail outa here...?

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19 hours ago, bigal.nz said:

I don't think this is correct: Corona is a "single strand" virus. This means it is made up of a single strand of genetic material. Seasonal flu is different - multi strand DNA. The combination of the strands in different ways is how it mutates.

Corona should not be able to easily escape a vaccine, since being single strand it can't mutate (very easily).

My missing post was in reply to this comment from Bigalnz.
It won't be the same as I wrote last time. Please realise that I am no Microbiologist. I don't have a vocabulary of the Words that such People would use. So my explanations may not be accurate in the sense of using the correct terminology.

Firstly, in reply to Bigal, no the "Flu" is not double strand. Double strand are a completely different Virus altogether. Rotovirus is of the Double strand RNA type. There is also a DNA type Virus as well. The Covid19 or Corona Virus is very much the "Flu". There are several different forms of Flu. The two main categories are Upper Respiratory and Lower Respiratory infections.

A Virus is not "Alive" as such. It is either active or non active. It has no intelligence. It cannot move of it's own accord. It simply operates by chance. By chance, it may land against a Host Cell.
A Virus is like any other cell. It has a protein Cell wall and some even have a Lipid envelope around the the Protein. Inside there is the RNA and an Enzyme. The Virus breaks through the Host Cells wall and the Enzyme is what causes the Virus to replicate. The RNA is the Blue print for which copies of the Virus are made from. This "Blue Print" can sometimes be altered and this is one of the paths of Mutation. There are different ways a Virus can mutate and the different ways result in very different changes in Characteristic of the Virus.

Here is an interesting thing, Even a Virus can get a Virus.
There are Millions of them in our World. Any living thing, from Animal to Plant can catch a Virus. Each Virus has found a different means of transport, by the Air, Water, Animals and Insects or multiples of the above.
The Covid 10 Virus has been studied to find out where it came from. There are many Social media stories about this that have lots of facts wrong. For instance, It did not come from someone eating a Bat. However, this particular virus does thrive among a species of Bat found in a Cave in the Wuhan province. The Bat itself is not affected by the Virus. Somehow, the Virus has made a jump to a Civet Cat. Perhaps a Civet Cat may have eaten a Bat or something like that, but just how exactly the virus was picked up by the Cat is not known.
What is known is the very first transmission to Human happened in a small Market in a Town in the Wuhan province. How the Virus from Cat to Human took place, no one knows either. A total of 27 People walking through that Market were infected and away it went.
 

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From my reading any chance of a vaccine being rolled out is at least 18 months away. Im thinking we will have to get used to switching between L4 and L3 and letting the virus slowly make its way through the herd. 

Can you go sailing under L3?

 

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The frontliners in the US:

"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."
📷
Health care professionals have my utmost respect. NOT following recommended public anti transmission protocols is disrespect.

Highlighting is mine.

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33 minutes ago, wheels said:

My missing post was in reply to this comment from Bigalnz.
It won't be the same as I wrote last time. Please realise that I am no Microbiologist. I don't have a vocabulary of the Words that such People would use. So my explanations may not be accurate in the sense of using the correct terminology.

Firstly, in reply to Bigal, no the "Flu" is not double strand. Double strand are a completely different Virus altogether. Rotovirus is of the Double strand RNA type. There is also a DNA type Virus as well. The Covid19 or Corona Virus is very much the "Flu". There are several different forms of Flu. The two main categories are Upper Respiratory and Lower Respiratory infections.

 

Yeah my terminology might not be entirely accurate either. Nevertheless I have seen enough articles from different reputable sources that Covid doesnt mutate quickly:

https://www.washingtonpost.com/health/the-coronavirus-isnt-mutating-quickly-suggesting-a-vaccine-would-offer-lasting-protection/2020/03/24/406522d6-6dfd-11ea-b148-e4ce3fbd85b5_story.html

 

Re the flu, perhaps the terminology was wrong, not multi stranded, but genome segments (Flu has 8 of them):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074182/

Coivd has 1 https://www.sciencedirect.com/topics/medicine-and-dentistry/coronaviridae

The photocopier analogy in the twitter link is pretty good one for us lay people.

 

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Regarding the articles in Stuff and Te Harald, they quote "Izzy Fordham".  Sadly for the people that elected her to be their representative, she seems hysterical and uninformed.  Someone anchored in a boat presents 0% risk to those around them.

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And from Stuff:

"Police have become involved in a stand-off between irate residents on Great Barrier Island/Aotea and boaties anchored up in their waters for the lockdown."

Someone with a calm and reassuring tone should remind all involved that they are not "their" waters.

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Interesting. I can understand that buying stuff from the local supermarket may not be the best look but not unlawful. The message i read from government was stay were you happen to be on wednesday night. If the boats were there wednesday then stay put surely?

unfortunately those elected into power are not always the best suited to the role. The “ownership” thing comes up quite often with people feeling they own the road outside their house, the beach, the view etc. ahh the joys if folk.

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