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Sumdumguy
Posts: 14
Incept: 2020-03-14

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BTW, the NYC map of the virus spread looks basically like a subway map.
https://www.timeout.com/newyork/news/nyc....
And despite all this public BS claims about shutdown in NY, the subway is still running. My personal pet hypothesis is that it is all of the above (including hospitals and restaurants with poor hygiene) but first and foremost public transport.
I do expect the measures in NYC to work but very slowly and painfully compared to what would happen if they actually did shut it down for real.

And speaking of Petri dish in London, have a look at what they are doing with Javitz center in NYC.
https://abcnews.go.com/Politics/army-hel....
There is no way I can see to make that into a negative pressure facility. I do trust the Army Core of Engineers but I have my doubts about this one.
Tickerguy
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If everyone in the place is positive it doesn't matter if it's negative pressure.

The problem is that there's not a snowball's chance in Hell you're going to get handwashing protocol there. Anyone working there has to be seroconverted or they WILL wind up taking the love out of there and spreading it all over the city.

If you're seroconverted (and thus immune) you can decontam at the end of your shift before leaving the building and, if handled properly, that can work. But otherwise all this is going to do is spread the damn thing to everyone in the city at an accelerated rate.

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Orionrising
Posts: 145
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read an interesting thread elsewhere. lots of ambulance services around the country are actually cutting hours because their call volume has dropped so much because the frequent fliers no longer want a free trip to the er half a dozen times a day.

also on the Italian case rate, has anyone seen exactly how they are enforcing their age caps?
are they just not putting you in the ICU for covid if your over 60 or whatever or are they just not treating you for ANYTHING if your older? that would certainly explain things.
Tickerguy
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@Orionrising -- They're out of beds so if you have a heart attack you're ****ed.

Note that contrary to all the bull**** thrown around Italy typically runs very, very close to zero excess capacity during flu season when it comes to ICU and bed counts, especially in the northern part of the country. They literally had no excess capacity to absorb anything.

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Asimov
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Pharmadude: No offense, but we've been talking about fecal/oral and handwashing being key since... late january? Definitely early feb.

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Smacktle
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Why does anybody argue with Karl? They never win.


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Jwm_in_sb
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Doesn't Italy also have the highest concentration of Chinese nationals in Europe there in the clothing manufacturers?
Tickerguy
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Yep. And what is (well, was up until this) essentially a "greyhound bus" style air schedule between Wuhan and northern Italy.

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Debtfree2200
Posts: 491
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@Jwm_in_sb - When I was there maybe 15 years ago, Rome was full of Chinese storefronts and immigrants. I thought I was in NYC when I walked into a few mini-marts when I was there. No difference.
Jesjohn94
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Im amazed the world has been shutdown to save the number of lives likely between the delta of doing this and something still major but less dramatic to the global economy. India shutdown with 4 hours notice for 3 weeks and wont even let people shop. That is 1.3 billion people. South Africa has banned buying booze, tobacco and walking dogs. Anyone holding stocks except speculative ones that have already been hammered are idiots. If this goes on much longer we wont see DOW 30,000 for 10 years.
Asimov
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jesjohn: My. Aren't you optimistic. You think it's only going to take a decade to recover from this?


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Smooth
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From an MD only web site an ER doctor in New Orleans posted the following -- they are now sending people home with supplemental oxygen. Good move.

"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."
Mabman
Posts: 220
Incept: 2009-11-08

toronto
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I recall seeing evidence of fecal transmission of covid19 in recent studies. My recollection is the studies took place in Japan (maybe also Hong Kong).

www.ncbi.nlm.nih.gov ...
by KS Yuen - ‎2020 - ‎Cited by 1
Mar 16, 2020 - Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory ... A pioneering study conducted in the city of Shenzhen near Hong Kong by a ... involvement in SARS-CoV-2 infection and fecaloral transmission.



Coronavirus can be transmitted through faeces, Chinese ...

www.scmp.com News Hong Kong Health & Environment

Mar 17, 2020 - Some respiratory system specimens tested negative for Covid-19 but coronavirus was detected in faecal samples from all ... of Hong Kong experts say, after their study confirmed Covid-19 can be transmitted through faeces.



Fecal transmission may be responsible for ... - Fortune

fortune.com 2020/02/20 coronavirus-fecal-transmission

Feb 19, 2020 - Scientists suspect a fecal-oral route for coronavirus that's infected tens of thousands worldwide. ... The coronaviruses that cause Covid-19 and SARS, or severe acute ... a clinical professor of pathology at the University of Hong Kong. ... virus transmission, said Nicholls, who was part of the research team that ...



COVID-19 Transmission 'Plausible' on Surfaces, in the Air ...

www.medpagetoday.com infectiousdisease covid19

Mar 17, 2020 - Research about COVID-19 transmission via surfaces has been conflicting, with reports from Hong Kong and Singapore showing varied results.



Coronavirus study implicates fecal transmission | The Japan ...

www.japantimes.co.jp news asia-pacific science-health-asia-pacific

Feb 8, 2020 - Fecal transmission of SARS was implicated in sickening hundreds in Hong Kong's Amoy Gardens housing estate in 2003. A rising plume of ...
M1919a2
Posts: 862
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@Ticker Guy
From Brietbart

Trump has declared GUNS essential in this emergency. All Manufacturers and Dealers are essential businesses.

https://www.breitbart.com/politics/2020/....
Tickerguy
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@Smooth -- Well that's good that they're getting the PX out of there -- but very, very bad that their people are getting infected.

They've become the vector; this one is going to home to an empty house, but how's that house getting resupplied?

The biological markers are very good considering that they can run those faster than they can get a "test" back.

O2 and monitoring SpO2 is IMHO the right path, but it's concerning they're getting no results out of the French protocol. Ain't liking that.

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Jesjohn94
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@Asimov. Im just floating 10 years right now. Thats a complete guess. The longer this goes on who knows what the impacts will be. We didnt have the ability to model the financial impact of the great recession in 2009 with subprime loans. If anyone thinks we have a clue about this they are crazy.
Bagbalm
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They are cancelling the International Auto Show in downtown Detroit so the venue can be converted into a temporary hospital. They asked a 6 month lease.
Tickerguy
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Still called Cobo Hall?

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Rickylc
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TCF Center, renamed in 2019 for TCF Financial. (Chemical - TCF)

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M1919a2
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@Ticker Guy
India has approved the anti-malaria drug for home use.

https://www.precisionvaccinations.com/hy....
Drifter
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I am looking, but cannot find any data: do we have any idea what % of cases is F/Oral and what % was contracted by aerosol? Maybe we can't know...

Just a question: is it possible that we have two different viral phenotypes that differ in severity and method of transmission? Thinking bubonic/pneumonic plague-- a bacterium in that case, of course.
Tickerguy
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@Drifter - No, and there's no good way to be sure. But what we DO know is that the "lockdowns", even just whacking essentially ALL social interaction on an ordinary, routine basis has done almost NOTHING to the transmission rate.

Therefore that's not how it's spreading. It's simple -- if you think a fire is fed by "X" for its fuel source, you remove the source and the fire continues to burn YOU GOT IT WRONG *******!

As for serotypes there are some 100 strains identified so far. But the serotype is quite stable on a comparative basis so far.

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M1919a2
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@Ticker Guy
With no operatives, the organ cease to function ...

So goes the pension seeking LEOs, would they have been Peace Officers of the Old West...

https://www.breitbart.com/news/officers-....
Marc2mrkt
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Interesting to note on Smooth's post (and noted by KD)
Quote:
Plaquenil which has weak ACE2 blockade doesn't appear to be a savior of any kind in our patient population.


Karl, I get the hospital spread issue - in fact when I was in the hospital for an operation a year ago, the doctors and nurses were all insistent that I only spend 1 day recovering and leave asap due to potential bug issues.

One issue that is hard to explain is that most of the new cases in Taiwan are from people who have recently traveled. It would seem they would likely infect many others on the flight if they were contagious, but the numbers are only like +9 or +16 new cases here a day, some which are from their family members. It seems like the new cases should be much more.

FYI: 283 cases in TW, 55 in Guam
Tickerguy
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@Marc2mrkt -- Yep. That's more evidence that it's just not easy to transmit when asymptomatic via air.

I'm sure it's POSSIBLE, but not easy.

But fecal/oral is ridiculously easy any time there is surface/surface contact with someone's body. Remember polio had an R0 of 5! That sounds INSANE but it did, and it was almost-exclusively fecal/oral transmission. In fact of all the "nasties" I believe only chicken pox and measles score materially higher.

A large percentage of the cases of polio (nearly all in fact!) were either asymptomatic or very mild flu-like -- and that conferred immunity. Sound familiar?

But the few that weren't got into the nervous system and ****ed you HARD, and just like this bitch the older you were the more-likely you were to get ****ed too.

Interestingly enough part of why polio got to be so ugly in the US is that with greatly improved plumbing and water systems little kids didn't get a dose of it when they were very young, where the risk was almost zero of it getting them the bad way. But they'd eventually get exposed. So, rather amusingly, "white man sanitation" as it rolled through the nation ****ed people with polio as instead of being exposed to it by the time they were toddlers they got hit by it as older children or adults.

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