Covid19 - clinical / epidemiological thread

[deleted171991]

I mean, we know the R0 of COVID19, we know its doubling time, and we have an idea of the number of cases (which is likely underestimated). Given these numbers, the number of cases to come in the following weeks/months can be estimated. And even the most conservative numbers are not something our system/resources can come close to handling.

The only way we will be able to handle this tsunami is if we self-isolate NOW, so that many people won't get sick AT THE SAME TIME, like in Italy or China.

But that would require some serious IQ in the executive national healthcare leadership, which I am very afraid is missing in this administration, which is more concerned with its public image in an electoral year than with the health of the American people.

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[GravelRider]

I'm in the Seattle area and can tell you there's only one hospital I know of canceling elective procedures. Regardless, patients are starting to cancel their own elective procedures. Testing is a HUGE issue. Not sure what the deal is (limited kits, expensive, etc) but it's fairly hard to get someone to test you in Seattle area. Bill and Melinda Gates Foundation is working on testing kits that can get sent to your home and Univ of WA has developed their own test and is ramping up. My understanding is UW is testing their own symptomatic employees in a well ventilated parking lot - people get an appointment online, drive by at the appropriate time, stay in their cars while doing their swab. Pretty smart to limit exposure.

‘It’s Just Everywhere Already’: How Delays in Testing Set Back the U.S. Coronavirus Response (Published 2020)

A series of missed chances by the federal government to ensure more widespread testing came during the early days of the outbreak, when containment would have been easier.

www.nytimes.com

It was a issue of awaiting federal approval for the tests and patient privacy issues. The bottom line is we were not prepared for this.

What gets me is we have no problem gathering data on the type of porn you like or what will get you to buy something, but our ability to collect the necessary data in a developing pandemic was kind of a joke.

 

[propadope]

Coronavirus: COVID-19 Is Now Officially A Pandemic, WHO Says

It's the first time the WHO has called an outbreak a pandemic since the H1N1 "swine flu" in 2009.

www.npr.org

 

[GravelRider]

The only way we will be able to handle this tsunami is if we self-isolate NOW, so that many people won't get sick AT THE SAME TIME, like in Italy or China.

But that would require some serious IQ in the executive national healthcare leadership, which I am very afraid is missing in this administration, which is more concerned with its public image in an electoral year than with the health of the American people.

What’s even worse is you now have low IQ sycophants on social media saying this is a liberal scam created to hurt the economy and Trump’s re-election chances.

 

[Ezekiel2517]

I assume this is the post you're talking about:

What do I need to know about coronavirus?

I run a dedicated COVID19 Screening Clinic, because our hospital's ED and UCC was just getting hammered by masses of 'worried well' people presenting with just a simple cold/flu, who do not even fit the suspected case definition to warrant testing. I have had no positives for COVID19 at our...

forums.studentdoctor.net

Yah, that’s the one

 

[marr65]

What’s even worse is you now have low IQ sycophants on social media saying this is a liberal scam created to hurt the economy and Trump’s re-election chances.

Well, to be fair you have high IQ people spreading the same false news. Some of them are physicians too and some are posting on this board.

I hope it’s not too late to contain this but it’s getting dimmer by the day.

 

[deleted171991]

Well, to be fair you have high IQ people spreading the same false news. Some of them are physicians too and some are posting on this board.

I hope it’s not too late to contain this but it’s getting dimmer by the day.

American physicians are usually NOT truly high IQ (i.e. top 2.5-5%), just higher than average (which is really not that hard/rare/smart).

High IQ tends to be associated with decreased social skills (it takes a lot of stomach to listen to much dumber people all day long, like Doc Martin), which are essential in American healthcare, especially with all the snowflakes (slowly turning into a blizzard nationwide). That's why we don't have paternalistic medicine or truly physician-directed healthcare anymore. As a side effect, I would bet we also have fewer highly intelligent people in medicine than decades ago.

I can probably count on my fingers (and maybe toes) the number of highly intelligent individuals I have ever met. They also tend to be math, physics and science wizards (a la Good Will Hunting or Stephen Hawking or billionaire quants), not doctors. High IQ people tend to have an innate talent at exact (i.e. logical) sciences, especially advanced mathematics, which many (most?) doctors hate. But they are the cold robot-like superintelligent people we need for national security issues (e.g. an epidemic) - think Fiona Hill. The public usually doesn't hear about them, but I hope they still exist behind the scenes, even in this medieval administration.

 

[deleted171991]

When a danger is growing exponentially, everything looks fine until it doesn’t

 

[Spikebd]

Italian death rate appears to be 6.6%. Can we trust the Chinese data?

 

[deleted171991]

Italian death rate appears to be 6.6%. Can we trust the Chinese data?

6.6% among hospitalized..., or total confirmed patients? The former would not be that bad (given the estimate that only 20% of the patients end up in the hospital, hence 20% of 6.6% would be 1.32% of the total), and the latter cannot really be trusted, given the lack of a cheap, widespread and reliable test for Covid-19 (think saliva-based HIV test, or pregnancy test).

There a ton of undiagnosed, mild or asymptomatic, cases in the population (that's why it spreads so easily). By the time the first US case was confirmed, the virus had been spreading for weeks in a stealth manner.

 

[nimbus]

Italian death rate appears to be 6.6%. Can we trust the Chinese data?

Korea and Italy have similar number of cases but fatality rate in Italy is 10x Korea. I think Italy is undercounting their total number of cases so their denominator is way too low which makes their case fatality rate much higher.

 

[Tramadeezy]

South Korea so far has over 7 thousand cases and 60 deaths. Any reason to think when its all said and done the overall mortality will be similar? Is their population different than the rest of the world? Those seem like good numbers...

 

[AMEHigh]

South Korea so far has over 7 thousand cases and 60 deaths. Any reason to think when its all said and done the overall mortality will be similar? Is their population different than the rest of the world? Those seem like good numbers...

I don't think the population is different per say (Italy does have a lot of older people), but how Korea handled it is VASTLY different than how we're handling it here.
I have an acquaintance that lives there now that has been keeping us updated.
They pretty much essentially went on immediate quarantine. She and her kids will have been out of school/work for 1 month.
You can get tested by drive-thru so you don't have to risk infecting anyone. They have tested A LOT of people since the government set it up. So their denominator is a lot higher.
They've suspended reporting any illegal immigrants so no one is afraid to get tested or treated.
They've extended all visas so people don't have to go stand in line at immigration to get renewals.
They also have a database of tracking people so people could understand who was directly affected (which has actually caused drama in regards to people finding out their partner was cheating on them for example).
They've put other social programs in support.
So none of that is going to happen here because of our culture and our government, nor did it happen in Italy until very recently.
So we'll see what the consequences of that are.

 

[Leinie]

Actually, if you head over to the ER forum and browse their COVID19 thread, one post shares a very detailed report from one of the intensivists from the physician group that managed many of these patients recently in WA.

Thanks, I followed FFPs link. That is concerning.

 

[marr65]

South Korea so far has over 7 thousand cases and 60 deaths. Any reason to think when its all said and done the overall mortality will be similar? Is their population different than the rest of the world? Those seem like good numbers...

One main point is that they are overwhelmed as well. I also think that the city overall has a younger Demographic compared to the Italians.

 

[Tramadeezy]

I don't think the population is different per say (Italy does have a lot of older people), but how Korea handled it is VASTLY different than how we're handling it here.
I have an acquaintance that lives there now that has been keeping us updated.
They pretty much essentially went on immediate quarantine. She and her kids will have been out of school/work for 1 month.
You can get tested by drive-thru so you don't have to risk infecting anyone. They have tested A LOT of people since the government set it up. So their denominator is a lot higher.
They've suspended reporting any illegal immigrants so no one is afraid to get tested or treated.
They've extended all visas so people don't have to go stand in line at immigration to get renewals.
They also have a database of tracking people so people could understand who was directly affected (which has actually caused drama in regards to people finding out their partner was cheating on them for example).
They've put other social programs in support.
So none of that is going to happen here because of our culture and our government, nor did it happen in Italy until very recently.
So we'll see what the consequences of that are.

Right but they still had a mortality rate of 0.6% with a lot of confirmed cases. Once the numbers start rolling in, and the world gets an idea of the overall denominator, there is a good chance that overall mortality will be very low. I dont think this virus is uniquely more dangerous than the common flu or any other respiratory viruses.

 

[Lawpy]

Useful thread, and i'll be following this and the EM version closely. Also i found a cool math video explaining more on how projections work

 

[Spikebd]

I don't think the population is different per say (Italy does have a lot of older people), but how Korea handled it is VASTLY different than how we're handling it here.
I have an acquaintance that lives there now that has been keeping us updated.
They pretty much essentially went on immediate quarantine. She and her kids will have been out of school/work for 1 month.
You can get tested by drive-thru so you don't have to risk infecting anyone. They have tested A LOT of people since the government set it up. So their denominator is a lot higher.
They've suspended reporting any illegal immigrants so no one is afraid to get tested or treated.
They've extended all visas so people don't have to go stand in line at immigration to get renewals.
They also have a database of tracking people so people could understand who was directly affected (which has actually caused drama in regards to people finding out their partner was cheating on them for example).
They've put other social programs in support.
So none of that is going to happen here because of our culture and our government, nor did it happen in Italy until very recently.
So we'll see what the consequences of that are.

If that’s the way they’re handling it and they’re being truthful about their data that should be the model on how to handle the outbreak.

 

[deleted171991]

If that’s the way they’re handling it and they’re being truthful about their data that should be the model on how to handle the outbreak.

You mean like this?

Fact check: A list of 28 ways Trump and his team have been dishonest about the coronavirus

President Donald Trump has been comprehensively misinforming the public about the coronavirus.

www.cnn.com

The Liar And The Sycophants, episode 1147. Don't miss it on Fox!

 

[marr65]

Right but they still had a mortality rate of 0.6% with a lot of confirmed cases. Once the numbers start rolling in, and the world gets an idea of the overall denominator, there is a good chance that overall mortality will be very low. I dont think this virus is uniquely more dangerous than the common flu or any other respiratory viruses.

You are looking at the data from the wrong side. Covid 19 is not just like any other respiratory diseases. Hospitalization rate even for H1N1 pandemic in 2009 was Roughly 1.3%, Covid 19 is roughly 10-15%. You have already seen that even a prepared country like the Koreans are having their hospitals overwhelmed. In Italy, they aren’t even treating traumas or strokes at the moment.

 

[deleted171991]

Italian death rate appears to be 6.6%. Can we trust the Chinese data?

I'm looking at the Johns Hopkins database, and they indicate 12462 confirmed cases and 827 deaths. So the 6.6% is among the confirmed cases.

What may have happened there is that they got a tsunami of new cases and got overwhelmed. Btw, that is EXACTLY what will happen in the US. Hospitals will be like war zones. We only have 46,500 ICU beds in the country. I doubt we can get more than double that number on mechanical ventilation at the same time.

Waiting till the death rate picks up, like in Italy, is a *****'S errand. We should have closed down the entire non-essential economy and quarantined the whole country the day we had the first case. This impotent federal government is literally killing tens to hundreds of thousands of Americans by sitting on their hands and waiting for miracles. They are simply mathematically-challenged; this is an infection that spreads exponentially. If only I had as many dollars as the number of Americans who may end up infected.

It also seems that the Italians didn't waste resources on the patients over 65, who tend to die at a rate of 20-30% even with care.

 

[MoMoGesiologist]

I'm looking at the Johns Hopkins database, and they indicate 12462 confirmed cases and 827 deaths. So the 6.6% is among the confirmed cases.

What may have happened there is that they got a tsunami of new cases and got overwhelmed. Btw, that is EXACTLY what will happen in the US. Hospitals will be like war zones.

It also seems that the Italians didn't waste resources on the patients over 65, who tend to die at a rate of 20-30% even with care.

You mean no ECMO for demented grannie from the nursing home that no one visited until she got sick? Thats just plain un-American!

 

[deleted171991]

You mean no ECMO for demented grannie from the nursing home that no one visited until she got sick? Thats just plain un-American!

Dude, nobody will do ECMO even for the 20 year-old. We simply won't have enough resources to waste that much on one person.

All people will get will be O2 by NC (no NIPPV), mechanical ventilation +/- proning, pressors (rarely needed), antibiotics/antivirals (still not proven effective). That's it. This is an epidemic, meaning that every intensivist will probably cover a ton of sick patients. This is the textbook example that ICU care is mostly supportive care; only Nature can cure the patient. The best we can do is avoid making things worse (e.g. these patients don't need fluids or steroids).

 

[nimbus]

Italian death rate appears to be 6.6%. Can we trust the Chinese data?

Well there’s the Twitter thread that says they don’t have enough ventilators for everyone who needs one, and ortho and path are manning ICUs in Italy because they are so overwhelmed.

 

[Spikebd]

Well there’s the Twitter thread that says they don’t have enough ventilators for everyone who needs one, and ortho and path are manning ICUs in Italy because they are so overwhelmed.

Even having general anesthesiologists manning ICU vents would be a seismic shift. Let’s hope we never need to ask an orthopod or pathologist to stand by these patients in the USA

 

[nimbus]

Inside a Seattle-area hospital on the front lines of the nation’s first major coronavirus outbreak

In the days since the outbreak, staffers have refashioned their hospital to treat the critical patients at the center of the outbreak -- and would see 15 die. Most of the afflicted were associated with assisted-living facility Life Care Center...

www.google.com

 

[Hoya11]

Right but they still had a mortality rate of 0.6% with a lot of confirmed cases. Once the numbers start rolling in, and the world gets an idea of the overall denominator, there is a good chance that overall mortality will be very low. I dont think this virus is uniquely more dangerous than the common flu or any other respiratory viruses.

We have no way of knowing what the true death rate will be, we dont have enough information to establish a denominator...

We have all seen healthy 30 year olds die from the flu for whatever reasons, I dont think we have enough evidence to make assumptions that this will be any different than the flu

I would think that most of the people who will benefit the most from containment measures (like canceling school/work/elective surgeries) will be the sickest, most at-risk people, who will inevitably die soon anyways from another cause..

 

[VA Hopeful Dr]

Even having general anesthesiologists manning ICU vents would be a seismic shift. Let’s hope we never need to ask an orthopod or pathologist to stand by these patients in the USA

You'd be better off sending my FP-who-hasn't-set-foot-in-an-ICU-since-residency ass in there than those 2 groups.

 

[AMEHigh]

Right but they still had a mortality rate of 0.6% with a lot of confirmed cases. Once the numbers start rolling in, and the world gets an idea of the overall denominator, there is a good chance that overall mortality will be very low. I dont think this virus is uniquely more dangerous than the common flu or any other respiratory viruses.

Well all the data seems to be pointing towards it being different.
I just heard a doctor and epidemiologist say on NPR that if he hears 1 more person compare it to the flu he's going to scream. It doesn't matter what you think, it matters what data and science is showing us.
It doesn't seem like we need to go scorched earth, but clearly it's a pandemic and there are a lot of unknowns. We don't want our medical system overrun. Our country already has SO MANY vulnerable people we should take small steps like social distancing that the experts are suggesting to limit the possible catastrophe. It seems like social distancing for 2-4 weeks would be helpful to spread things out so that systems don't get overrun and things don't linger even longer affecting our economy.

 

[anbuitachi]

The mortality rate will vary significantly from country to country as we enter the acute infection phases. Italy is getting crushed right now and are rationing care, contributing to their high mortality rates.

Many Asian countries don't have as many problem as US or similar types bc their system is very efficient. Minimal HIPAA type rules, regulations , insurance BS, etc. Literally their focus is just clinical care and thus can handle such a huge surge of patients. Kind of like how China built a hospital in 10 days. No way Italy or USA doing that. We had weeks to prepare and US still are very unprepared.

 

[Mman]

Kind of like how China built a hospital in 10 days. No way Italy or USA doing that. We had weeks to prepare and US still are very unprepared.

To be fair China also had people quarantined in a hotel that collapsed. Perhaps building something in 10 days does not lead to the highest quality construction (insert made in China joke here).

 

[anbuitachi]

Italians smoke like


To be fair China also had people quarantined in a hotel that collapsed. Perhaps building something in 10 days does not lead to the highest quality construction (insert made in China joke here).

Yup . The building was built in 2013 and was being renovated. Unclear to me if something happened during renovation or initial construction sucked.

 

[dchz]

" - multiple pts here have had nl EF on formal Echo or POCUS at time of admit (or in a couple of cases EF 40ish, chronically). Also nl Tpn from ED. Then they get the horrible resp failure, sans sepsis or shock. Then they turn the corner, off Flolan, supined, vent weaning, looking good, never any pressor requirement. Then over 12hrs, newly cold, clamped, multiple-pressor shock that looks cardiogenic, EF 10% or less, then either VT->VF-> dead or PEA-> asystole in less than a day. Needless to say this is awful for families who had started to have hope. - We have actually had more asystole than VT, other facilities report more VT/VF, but same time course, a few days or a week after admit, around the time they're turning the corner. This occurs on med-surg pts too; one today who is elderly and chronically ill but baseline EF preserved, newly hypoTN overnight, EF<10. Already no escalation, has since passed, So presumably there is a viral CM aspect, which presents later in the course of dz. - of note, no WMAs on Echo, RV preserved, Tpns don't bump. Could be unrelated, but I've never seen anything like it before, esp in a pt who had been HD stable without sepsis."

This is from the other thread from the EM forum.

This feels weird to me, is the virus blocking calcium channels or potassium channels or something?

 

[deleted171991]

" - multiple pts here have had nl EF on formal Echo or POCUS at time of admit (or in a couple of cases EF 40ish, chronically). Also nl Tpn from ED. Then they get the horrible resp failure, sans sepsis or shock. Then they turn the corner, off Flolan, supined, vent weaning, looking good, never any pressor requirement. Then over 12hrs, newly cold, clamped, multiple-pressor shock that looks cardiogenic, EF 10% or less, then either VT->VF-> dead or PEA-> asystole in less than a day. Needless to say this is awful for families who had started to have hope. - We have actually had more asystole than VT, other facilities report more VT/VF, but same time course, a few days or a week after admit, around the time they're turning the corner. This occurs on med-surg pts too; one today who is elderly and chronically ill but baseline EF preserved, newly hypoTN overnight, EF<10. Already no escalation, has since passed, So presumably there is a viral CM aspect, which presents later in the course of dz. - of note, no WMAs on Echo, RV preserved, Tpns don't bump. Could be unrelated, but I've never seen anything like it before, esp in a pt who had been HD stable without sepsis."

This is from the other thread from the EM forum.

This feels weird to me, is the virus blocking calcium channels or potassium channels or something?

Viral cardiomyopathy. Like septic cardiomyopathy (which happens frequently - if you look for it), just worse by degrees of magnitude.

 

[dchz]

Viral cardiomyopathy. Like septic cardiomyopathy (which happens frequently - if you look for it), just worse by degrees of magnitude.

Call it what you want, but what's the mechanism or pathophys?

 

[deleted171991]

Call it what you want, but what's the mechanism or pathophys?

Inflammation.

 

[dchz]

Inflammation.

source?

 

[deleted171991]

source?

Personal brain and experience. They used to think septic cardiomyopathy was on-demand ischemia, but it's way more than that.

Here's some evidence: A review of sepsis-induced cardiomyopathy .

 

[dchz]

Personal brain and experience.

So no source then

 

[deleted171991]

This feels weird to me, is the virus blocking calcium channels or potassium channels or something?

It's more than that, for the simple reason that inotropes don't improve survival.

 

[Mman]

I guess the question is why would cardiomyopathy be presenting so relatively late in the course of illness after having no impact earlier in the disease course.

 

[deleted171991]

So no source then

No indexed source. I must have read it somewhere.

I think in mental models. My mental model for infectious cardiomyopathy is inflammation/cytokines/NO.

 

[deleted171991]

I guess the question is why would cardiomyopathy be presenting so relatively late in the course of illness after having no impact earlier in the disease course.

Why does the Earth go round the Sun, instead of the other way round?

This virus affects much more than the lungs. It's know to induce MODS/MOSF.

If other viruses can induce severe myocarditis, why isn't Covid allowed to, especially given the sh-tfest it produces in the lungs and the lymphopenia?

 

[Mman]

Why does the Earth go round the Sun, instead of the other way round?

This virus affects much more than the lungs. It's know to induce MODS/MOSF.

If other viruses can induce severe myocarditis, why isn't Covid allowed to, especially given the sh-tfest it produces in the lungs?

not disagreeing, but why would the pulmonary effects be so pronounced and then almost completely resolved before any hint of cardiac abnormality? With a virus those sort of effects are usually simultaneous.

 

[dchz]

Personal brain and experience. They used to think septic cardiomyopathy was on-demand ischemia, but it's way more than that.

Here's some evidence: A review of sepsis-induced cardiomyopathy .

I guess the question is why would cardiomyopathy be presenting so relatively late in the course of illness after having no impact earlier in the disease course.

skimmed the link, remember reading it a few years back when FFP and I had this discussion about whether or not sepsis induced cardiomyopathy is real.

I am personally still skeptical and I think the ICU docs just want to rename something when it's a clearly defined previously known pathophysiology (combo of hypocalcemia, catecholamine depletion, and demand ischemia). Regardless of naming rights, it seems that down regulation of adrenergic receptors and calcium insensitivity are culprits.

Just spit-balling on how I would treat this pt if was the ICU doc:

TTE (or TEE) to really show reduced LVEF -> start calcium supplementation IV (fairly low downside) and inotropes (Dobutamine vs Epi vs milirinone) -> treat the resultant hypotention from dobutamine and milrinone with vasopressin (for god's sake, titrate vasopressin to effect plz).

What yall think?

Why does the Earth go round the Sun, instead of the other way round?

:troll:

 

[deleted171991]

TTE (or TEE) to really show reduced LVEF -> start calcium supplementation IV (fairly low downside) and inotropes (Dobutamine vs Epi vs milirinone) -> treat the resultant hypotention from dobutamine and milrinone with vasopressin (for god's sake, titrate vasopressin to effect plz).

What yall think?



:troll:

Inotropes have been proven not to improve survival, unlike what Manny Rivers wanted us to believe.

Go do a CCM fellowship, now that you are a cardiac hip-shooter.

 

[dchz]

If other viruses can induce severe myocarditis, why isn't Covid allowed to, especially given the sh-tfest it produces in the lungs and the lymphopenia?

Absolutely SARS-COV-2 can, but that's nothing new and nothing we can't treat. How do you treat myocarditis? you support contractility with meds (or ECMO) and let the patient recovery. But i bet you there is a lot of hesitation on initiating the treatment for myocarditis!! Most ICU docs aren't great t initiating inotropic support/steroids because of the current trend in literature. If you look at the evidence behind those literature, it's expert consensus, but people take it as absolute truth and refuse to treat the pathology they see in front of them.

 

[deleted171991]

Absolutely it can, but that's nothing new and nothing we can't treat. But i bet you there is a lot of hesitation on initiating the treatment for myocarditis? Most ICU docs aren't great t initiating inotropic support/steroids because of the current trend in literature.

Repeat after me: nor-epi-neph-rine.

And gods forbid you give steroids to a coronavirus patient, including his own inhaled CS for COPD.

 

[dchz]

Inotropes have been proven not to improve survival, unlike what Manny Rivers wanted us to believe.

Go do a CCM fellowship, now that you are a cardiac hip-shooter.

Inotropes have not been shown to improve survival in septic patients. I don't need to do an awesome suck up to midlevels fellowship to know that this patient pop with ARDS and LV failure is very distinctively different from the sepsis patient population. I'm just a simple country doc.

Repeat after me: nor-epi-neph-rine.

Repeat after me: different patient population. Different pathology, different etiology. This cardiomyopathy and ARDS is not caused by low SVR states. Don't try to make everything into a nail because you only have a hammer.

The patient has low CO (sudden EF drop), low contractility. You know their coronaries are in the same state they came in, and in the young no comorbidity patient population, the coronaries are most likely not diseased. You have a low CO problem, not the high CO low SVR problem in sepsis. Treat the patient's problem, don't try to make this patient into a sepsis patient.

 

[MoMoGesiologist]

It's more than that, for the simple reason that inotropes don't improve survival.

Would you not start an inotrope then? Most trials show no change in mortality but we do it anyways. Just curious how u would manage.