Earthquake Thread ~ Always Updated

Big prayers needed here!

Docs are saying that my papa (grandfather) has this damn virus! He has NOT been tested though.

He started getting symptoms Monday morning and things have continued to get worse for him since then. My nanny called his doctor today to report his symptoms and the nurse said they would have to call my grandparents back. They got the call back from the doctor who said that my papa didn't even have to come in for a test. That he has every symptom, therefore diagnosing by phone. I find that very odd, but that isn't the concern right now. Papa's doctor believes that Papa has it based on symptoms and has ordered him to self quarantine for 14 days. Said to go to the ER if symptoms get worse.



God be with him please!

Big prayers needed here!

Docs are saying that my papa (grandfather) has this damn virus! He has NOT been tested though.

He started getting symptoms Monday morning and things have continued to get worse for him since then. My nanny called his doctor today to report his symptoms and the nurse said they would have to call my grandparents back. They got the call back from the doctor who said that my papa didn't even have to come in for a test. That he has every symptom, therefore diagnosing by phone. I find that very odd, but that isn't the concern right now. Papa's doctor believes that Papa has it based on symptoms and has ordered him to self quarantine for 14 days. Said to go to the ER if symptoms get worse.



God be with him please!

Yes but, why not test? Not right!!!?

Well, will try again - my computer just keeps going nuts and cutting off what I'm doing!

Ethan and his girlfriend were in a wreck in his truck last Saturday. Girlfriend was driving and they were arguing. She lost control, rolled the truck and went into a business parking lot. Luckily both were ok and not hurt, although Ethan was thrown around in the truck. Not sure if his insurance is going to cover the truck or the damages to the business' signs. I may be liable for a lot of expenses! But I'm just grateful they were both ok!

She is from Oklahoma. I insisted she go home, so Monday hubby and I drove her half way and met her mom. It was so weird on the drive - it was beautifully green and lush and we drove through a part of Texas I'd never been to before. And I got so depressed thinking that I'd maybe never get a chance to take another road trip again! I got really depressed.

Yesterday, I got up to a beautiful day. And I decided that no matter what happens, I'm, going to live each day as though I have a great future to look forward to. So, I did the one thing that to me is the epitome of believing in the future - I planted my garden! And it was wonderful. Feeling and smelling the warm earth, planting seeds and starter tomato plants. Connecting with life again. It was a calming and renewing day.

Then today, I find out that we have 4 confirmed cases in my town. And that the first case, only confirmed last week, died this past Monday. And the newest case is a female in her 20's. And heard a rumor from someone I know that by Friday we will be on lockdown. We've been mostly staying home anyway (except for the trip to return girlfriend, and the only time we got out was to gas up & hubby used Clorox wipes on the gas pump handle & touchscreen), but when we got out and went through a drive-thru at the bank, it's been obvious that LOTS of people are going about like nothing is going on. So, a lockdown is probably warranted, unfortunately. I'll keep you posted!

Hoping & praying that all of you stay distanced and safe! This whole thing is more like a bad movie every day. I will be taking care of chickens and planting my garden. And praying this all gets better!!!

Love all of you!

Good morning! Got some much needed sleep last night and am enjoying my day off before returning to the ER tomorrow.

I'm a member of several nurse groups and thought y'all would enjoy reading this that was written by an ER doc in New Orleans. Very interesting read:

"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."

Boss just told me not to come back next week we will all be on furlough Xx