***NON-POLITICAL COVID-19 Discussion Thread***

[JakeF]

A couple of reminders...

Originally Posted by Bwana

Once again, don't come in this thread with some kind of political agenda, or you will be shown the door. If you want to go that route, there is a thread about this in DC.

Originally Posted by Dartgod

People, there is a lot of good information in this thread, let's try to keep the petty bickering to a minimum.

We all have varying opinions about the impact of this, the numbers, etc. We will all never agree with each other. But we can all keep it civil.

Thanks!

Click here for the original OP:

Spoiler!

Apparently the CoronaVirus can survive on a inanimate objects, such as door knobs, for 9 days.

California coronavirus case could be first spread within U.S. community, CDC says
By SOUMYA KARLAMANGLA, JACLYN COSGROVE
FEB. 26, 2020 8:04 PM

The Centers for Disease Control and Prevention is investigating what could be the first case of novel coronavirus in the United States involving a patient in California who neither recently traveled out of the country nor was in contact with someone who did.

“At this time, the patient’s exposure is unknown. It’s possible this could be an instance of community spread of COVID-19, which would be the first time this has happened in the United States,” the CDC said in a statement. “Community spread means spread of an illness for which the source of infection is unknown. It’s also possible, however, that the patient may have been exposed to a returned traveler who was infected.”

The individual is a resident of Solano County and is receiving medical care in Sacramento County, according to the state Department of Public Health.

The CDC said the “case was detected through the U.S. public health system — picked up by astute clinicians.”

Officials at UC Davis Medical Center expanded on what the federal agency might have meant by that in an email sent Wednesday, as reported by the Davis Enterprise newspaper.

The patient arrived at UC Davis Medical Center from another hospital Feb. 19 and “had already been intubated, was on a ventilator, and given droplet protection orders because of an undiagnosed and suspected viral condition,” according to an email sent by UC Davis officials that was obtained by the Davis Enterprise.

The staff at UC Davis requested COVID-19 testing by the CDC, but because the patient didn’t fit the CDC’s existing criteria for the virus, a test wasn’t immediately administered, according to the email. The CDC then ordered the test Sunday, and results were announced Wednesday. Hospital administrators reportedly said in the email that despite these issues, there has been minimal exposure at the hospital because of safety protocols they have in place.

A UC Davis Health spokesperson declined Wednesday evening to share the email with The Times.

Since Feb. 2, more than 8,400 returning travelers from China have entered California, according to the state health department. They have been advised to self-quarantine for 14 days and limit interactions with others as much as possible, officials said.

“This is a new virus, and while we are still learning about it, there is a lot we already know,” Dr. Sonia Angell, director of the California Department of Public Health, said in a statement. “We have been anticipating the potential for such a case in the U.S., and given our close familial, social and business relationships with China, it is not unexpected that the first case in the U.S. would be in California.”

It is not clear how the person became infected, but public health workers could not identify any contacts with people who had traveled to China or other areas where the virus is widespread. That raises concern that the virus is spreading in the United States, creating a challenge for public health officials, experts say.

“It’s the first signal that we could be having silent transmission in the community,” said Lawrence Gostin, director of the World Health Organization Collaborating Center on National and Global Health Law. “It probably means there are many more cases out there, and it probably means this individual has infected others, and now it’s a race to try to find out who that person has infected.”

On Tuesday, the CDC offered its most serious warning to date that the United States should expect and prepare for the coronavirus to become a more widespread health issue.

“Ultimately, we expect we will see coronavirus spread in this country,” said Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases. “It’s not so much a question of if, but a question of when.”

According to the CDC’s latest count Wednesday morning, 59 U.S. residents have tested positive for the new strain of coronavirus — 42 of whom are repatriated citizens from a Diamond Princess cruise. That number has grown by two since Messonnier’s last count Tuesday, although the CDC was not immediately available to offer details on the additional cases.

More than 82,000 cases of coronavirus have been reported globally, and more than 2,700 people have died, with the majority in mainland China, the epicenter of the outbreak.

But public health leaders have repeatedly reminded residents that the health risk from the novel coronavirus to the general public remains low.

“While COVID-19 has a high transmission rate, it has a low mortality rate,” the state Department of Public Health said in a statement Wednesday. “From the international data we have, of those who have tested positive for COVID-19, approximately 80% do not exhibit symptoms that would require hospitalization. There have been no confirmed deaths related to COVID-19 in the United States to date.”

CDC officials have also warned that although the virus is likely to spread in U.S. communities, the flu still poses a greater risk.

Gostin said the news of potential silent transmission does not eliminate the possibility of containing the virus in the U.S. and preventing an outbreak.

“There are few enough cases that we should at least try,” he said. “Most of us are not optimistic that that will be successful, but we’re still in the position to try.”

[cdcox]

Originally Posted by Donger

Ah, I see. But it still had an R0 of 2 to 3.

R0 refers to a person roaming around in the general population with no controls in place. Social distancing is thought to be able to reduce an R0 from 2 to below 1. If you throw an active SARS patient in a quarantine situation with all of the medical personnel in moon suits, R0 goes to zero.

[O.city]

I've read some stuff on this one that R0 might be in the 4 range, which isn't ideal.

[Donger]

Originally Posted by cdcox

R0 refers to a person roaming around in the general population with no controls in place. Social distancing is thought to be able to reduce an R0 from 2 to below 1. If you throw an active SARS patient in a quarantine situation with all of the medical personnel in moon suits, R0 goes to zero.

I know. Just stunning that it had that R0 figure and a CFR of 10. No thank you.

[TLO]

Cases in Missouri: 838

Total Deaths: 10

Patients tested in Missouri (by all labs): approximately 12,385

This was updated a little bit ago.. Good to see Missouri is rolling out the testing now.

[cdcox]

Originally Posted by O.city

Viruses never mutate to more virulent forms. It would be to their detriment.

Minor technical correction. Mutations are random, so of course it could mutate to a more virulent form. But natural selection would not allow it to be as "successful" hence it would not replace a less virulent form as the major population in the wild.

[O.city]

Originally Posted by cdcox

Minor technical correction. Mutations are random, so of course it could mutate to a more virulent form. But natural selection would not allow it to be as "successful" hence it would not replace a less virulent form as the major population in the wild.

Yeah, that.

[Titty Meat]

Any word on OTW?

[dirk digler]

Took 2 1/2 days to go from 1000 deaths to 2000. We are going to see close to 6 figures deaths or higher if we don’t tighten up our restrictions.

[O.city]

Originally Posted by dirk digler

Took 2 1/2 days to go from 1000 deaths to 2000. We are going to see close to 6 figures deaths or higher if we don’t tighten up our restrictions.

We've been chasing this thing since the beginning. Some places like SF have gotten ahead of it a bit.

The longer you wait, the worse. I don't know why all these other places are reluctant to lock it down. The sooner you lock it down the sooner you can open back up.

[Tnerped]

Originally Posted by philfree

I've been out of the house about once a day it seems like. I travel in a small area and constantly disinfect and wash my hands and then I do it again. The wife hadn't been out of the house for 3 weeks but today she wanted sushi so we did curb side pickup. It made me nervous but I didn't want to tell her no since she was so excited. Then we've both done lots of online shopping. I try to spray down the boxes with disinfectant and then there's a constant flow of mail. I feel like my every move is a roll of the dice and If the wife gets it I don't think she'll make it.

Wouldn't worry about your mail too much. We're dealing with thousands of packages and letters a day and we're still not sick. I think you'd really only need to worry if you were in an area where there are a lot of sick people already. We keep the office relatively sanitized and all of our employees are practicing social distancing. We had one guy go to Florida and he's now in quarantine in his home for another week.

Luckily only one case in the county I work in and I go straight home after work.

[BWillie]

Originally Posted by dirk digler

Took 2 1/2 days to go from 1000 deaths to 2000. We are going to see close to 6 figures deaths or higher if we don’t tighten up our restrictions.

I've been trying to tell ppl the deaths are coming. Simple to see. We were simply lagging behind most of the most infected Euro nations by a couple of weeks because most of our cases are newer.

[cdcox]

Originally Posted by Donger

No. There's no evidence that SARS-CoV-2 is airborne.

I agree that the airborne route is lower risk of exposure, but the risk is greater than zero:

Airborne transmission through small particles (< 5 microns), which may stay airborne for hours and can be transported long distances. These are also generated by coughing and sneezing and talking. Small particles (droplet nuclei or residue) form from droplets which evaporate (usually within milliseconds) and desiccate. The size of a coronavirus particle is 80-160 nanometre2 and it remains active at common indoor conditions up to 3 hours in indoor air and 2-3 days on room surfaces (unless there is specific leaning). Such small virus particles stay airborne and can travel long distances carried by airflows in the rooms or in the extract air ducts of ventilation systems. Airborne transmission has caused infections of SARS-CoV-1 in the past; currently there is no reported evidence yet specifically for Corona disease (COVID-19) infection via this route. There is also no reported data or studies to rule out the possibility of the airborne-particle route. One indication for this: Corona virus SARS-CoV-2 has been isolated from swabs taken from exhaust vents in rooms occupied by infected patients. This mechanism implies that keeping 1-2 m distance from infected persons might not be enough and increasing the ventilation is useful because of removal of more particles.

https://www.rehva.eu/fileadmin/user_...-17_final2.pdf

[oaklandhater]

it took Italy 4 days to go from 1,000 to 2,000 deaths, whereas the U.S. just did it in 3 days.

The coronavirus death toll in the U.S. has surpassed 2,000. More than 120,000 confirmed cases https://t.co/47MXF0XUJ0

— BNO Newsroom (@BNODesk) March 28, 2020

still waiting for that shutdown...

[oaklandhater]

based on the current rate We are now in a trajectory of 3-4K deaths/day by next Saturday.

[BigRedChief]

Originally Posted by KS Smitty

There is a lot of detailed info in this post, some of which I don't understand since I'm not a medical professional. It's quite long too.

Spoiler!

From the front lines in New Orleans, -
This is the kind of information sharing that’s going to help us get through this mess. We are learning on the fly, TOGETHER!
Copied from another group with permission. Hope this helps!
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."”

short answer is that they went into ARDS. ARDS creates a cascading chain of events in the body. All bad. Once you have it, even previously healthy Patients who go into ARDS have a chance of dying.

COPD which is huge underlying condition, to say the least, die “in normal times” at a rate of about 40% when they go into ARDS.

86% of coronavirus patients dying that go into ARDS? I’ve never heard of anything causing that much of a death rate. That’s so much out of whack, this may be anecdotal information and not what coronavirus does to patients who go into ARDS. Why is this virus different and sending so many more patients into ARDS? People die from the flu a lot. They don’t go into ARDS at this rate.

Average patient, in normal times, stays on a vent for 2-5 days. Reports are that coronavirus patients are staying on vents for 21-28 days.