COVID-19 coronavirus medical center experiences

Please visit the main COVID-19 coronavirus and cancer page here.
==Canada==
*"Here in Vancouver I’ve seen 5 COVID19 cases; 2 are nurses without travel history or sick contacts. We have only had to intubate 1 patient in the whole province. Already extubated." (Twitter @jeremyfaust 3/14/2020)
==Italy==
===Week of 3/8/2020===
*"The current situation is difficult to imagine and numbers do not explain things at all. Our hospitals are overwhelmed by Covid-19, they are running 200% capacity" (Twitter @jasonvanschoor, 3/9/2020)
*"Cases are multiplying, we arrive at a rate of 15-20 admissions per day all for the same reason. The results of the swabs now come one after the other: positive, positive, positive. Suddenly the E.R. is collapsing." - ICU physician in Bergamo, Dr. Daniele Macchini. (Twitter @silviast9 3/9/2020 interpreted translation from original document, Con le nostre azioni influenziamo la vita e la morte di molte persone)
*"Very aggressive disease, many young and fit people severely ill, some colleagues too. We're turning ORs into ICUs to increase positive pressure beds with respirators" (Twitter @EvaristoCroce, 3/9/2020)
*"Today, some hospitals are so overwhelmed that they simply cannot treat every patient. They are starting to do wartime triage." (Twitter @Yascha_Mounk, 3/11/2020 interpreted translation from original document, RACCOMANDAZIONI DI ETICA CLINICA PER L’AMMISSIONE A TRATTAMENTI INTENSIVI E PER LA LORO SOSPENSIONE)
*"We stop intubating people over 60. We leave them die. 30 per cent of patient are 30-60 years old. We have no more ventilators for all patients. 600 intubated in milan.... We are ready to sacrifice our lives to stop it.... There are no more surgeons or dermatologist--only doctors--all together to stop it." (Twitter @Strosterud 3/12/2020)
*"He had to let 3 people die that day, nurses crying because they see people dying in front of them and can't do anything aside from offering some oxygen." (Reddit u/goddessofthebitches 3/12/2020)
*Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy - Early Experience and Forecast During an Emergency Response, Giacomo Grasselli, MD; Antonio Pesenti, MD; Maurizio Cecconi, MD3, JAMA 3/13/2020 -- Companion 3/13/2020 JAMA Youtube video interview with Maurizio Cecconi MD "If you don't take down the transmission of the virus, then the capacity of your system will be overwhelmed." - 29:27
*“Single isolation was only for our detection period. As soon as a #COVID19 test is positive, transfer the patient to cohort isolation. At some point your negative pressure rooms are full – and you cannot isolate anyone else" “We are in a war zone here. In our 1000 bed hospital we closed up wards & programs, all outpatient clinics & built up cohort areas. Now, we have 400 #COVID19 patients. 56 intubated, 2 ECMO, 2 ECCOR, 12 on NIV, 80 CPAP on wards” (Twitter @PedsIntensiva 3/14/2020)
===Week of 3/15/2020===
*"Day 27 of #covid19italy surge. Still on the peak, more than 70 COVID pts in 24 hs. Currently, in our ER there are: 3 intubated patients, 13 on CPAP/NIV, and 55 patients on O2 1 Prepare your ER (enormous lung unit on 3 acuity levels) 2 Pre-empy your hospital 3 check O2 supply" (Twitter @rob_cosentini 3/16/2020)
*The Treatment of Patients With Cancer and Containment of COVID-19: Experiences From Italy ASCO Daily News, 3/17/2020
===Week of 3/22/2020===
*"As many as 5 to 10 percent of the severe cases and of deaths are actually among the healthcare personnel.... We forget to eat, we forget to drink, and we keep on working.... The worse is somebody dying in the isolated ward asking for the wife, the husband, for the last hours of their life and having no chance to have anybody around and dying on their own." Italian doctors interviewed by New York Times (Youtube 3/23/2020)
*
==South Korea==
*"Emphasis was placed on transparency, rapidly available and accurate information. Transparency is essential to ensure active participation from citizens." (Twitter @HannahNamMD, 3/11/2020), English Youtube video of South Korea 3/9/2020 briefing about COVID-19)
==Spain==
*"Spreading there very fast with young people in ICUs now and doctors getting infected" (Twitter @david raben 3/14/2020)
*Difficult decisions made to transition care to younger patients, in Spanish (Twitter @WellingMichael 3/21/2020)
==United Kingdom==
====Week of 3/8/2020====
*"Today in our trust we are closing CCU to modify it to have ventilators for COVID patients. 7 extra ITU beds at Western Sussex NHS." (Twitter @kristelly79 3/13/2020)
====Week of 3/29/2020====
*"Is it normal to keep bursting into tears? Driving home last night, I welled up. At work, several of us were crying. I am not as resilient as some of my tweets make me out, or as hard." (Twitter @EmergMedDr 3/30/2020)
==United States==
===Boston===
====Week of 3/16/2020====
*"We are rapidly shutting down routine care. We have canceled all planned follow-ups with patients with diabetes and heart failure at this point because we have to preserve that personal protective equipment." (Dr. Daniel Horn with Franklin Foer, The Atlantic 3/16/2020)
====Week of 3/29/2020====
*"11 patients placed on ventilators in one day shift. There’s still one hour left. Unprecedented. The curve is not flat. Please stay home, Boston." (Twitter @AlisterFMartin 3/31/2020)
*"1. Staff morale is high 2. Real sick patients: 18/18 patients intubated, 11 prone 3. Age range: 30s to 80s 4. ICU nurses are heroes: watching them prone a patient in < 3 min is humbling 5. Proning works 6. No families around is sad." (Twitter @hayfarani 4/2/2020)
===New York===
====Week of 3/15/2020====
*"We already have #COVID19 cases. The # increases EVERY day. If they keep going at this rate, our system will be overwhelmed. We won’t have the space, personnel or supplies to provide the best care to our #coronavirus AND our regular patients." (Twitter @Craig_A_Spencer 3/15/2020)
*"8 COVID patients with ARDS in ICU and half were severe. My team proned 3 of the severe ARDS with good response to PEEP and proning." (Twitter @MichelleNgGong 3/15/2020)
*"We are seeing sudden deterioration with arrhythmias and cardiac arrest. Can't tell yet if it is viral myocarditis and still not enough sample size for me to call it an association but it is notable to me." (Twitter @MichelleNgGong 3/15/2020)
*"They’re dangerously short on supplies. Her entire floor, roughly 30 people, was given two boxes of masks for a total of 100. The hospital has told them they need to make them last for at least two weeks. That’s roughly 3.33 masks per health worker" (Twitter @evansiegfried 3/18/2020)
*"Just saw ~50 COVID patients (presumed) and took lab report on 10 positives sent last week - all in one 8 hour shift. Ladies and gentlemen, we are effed!" (Twitter @ManiniAlex 3/18/2020)
*"Our most senior clinicians are saying what is obvious to anyone on the front lines right now: COVID-19 is unprecedented and dire." (Facebook Colleen Farrell, MD 3/20/2020)
*"Spoke to physician friends in NYC. Situation quickly deteriorating... multiple hospital floors designated as COVID, ICU quickly filling, Jacobs Javits Center converted to 1000 bed COVID hospital, military deployed, Navy Hospital Ship to NYC Harbor" (Twitter @BioBreakout 3/21/2020)
====Week of 3/22/2020====
*"The difference in the ER from last week to this week is stark. Last Sunday: a few #COVIDー19 + patients mixed w/ the chest pains, abdominal pains, etc. Today: overwhelming majority are #COVIDー19 suspected/confirmed. Very little of anything else." (Twitter @Craig_A_Spencer 3/22/2020)
*"Finally home after 13 hours in the ER. Today >90% of my patients were confirmed or likely #COVID19. Many really sick, some in their 30s like me. The sirens on otherwise empty NYC streets are unending & haunting." (Twitter @Craig_A_Spencer 3/22/2020)
*"The stress is being felt across entire hospitals and health systems. Many people are working longer hours, people are working extra shifts, and people are being asked to step out of their normal roles and contribute in other ways." (Dr. Caldwell at NYU via Twitter @evankirstel 3/22/2020)
*"Spoke to an NYC ER doctor colleague today who said their ER is intubating 1-2 patients *per hour*. That’s a 12 to 24 new ICU admissions requiring ventilators per day. NYC hospitals about to hit max capacity." (Twitter @kit_delgadoMD 3/23/2020)
*"ICU started calling families of pts who have low quality of live to extubate them so they can save younger or healither (sic) people. Things are progressing badly" (Twitter @chadinabhan 3/24/2020)
*"I just pronounced a couple #COVID19 patients. We're out of vents, ICU beds, calling codes earlier than we're used to." "ICU & CCU full, difficult to wean off vents, very sensitive to PEEP, no extubations yet" (Twitter @DrMichelleLin 3/24/2020)
*"For the rest of your shift, nearly every hour, you get paged: Stat notification: Very sick patient, short of breath, fever. Oxygen 88%. Stat notification: Low blood pressure, short of breath, low oxygen. Stat notification: Low oxygen, can't breath. Fever. All day..." (Twitter @Craig_A_Spencer 3/24/2020)
*"230 admitted covids, 70 boarding in the ED. Vent allocation beginning soon." (Twitter @ManiniAlex 3/24/2020)
====Week of 3/29/2020====
*"In my 7 days on one of our (now 12!) non ICU #COVID19 units, I admitted 58 patients for COVID rule out, of whom 50 tested positive. Two died (DNR), 2 went to hospice, and 5 went to the ICU." (Twitter @leorahorwitzmd 3/30/2020)
Dr. Horwitz's 3/30/2020 observations (expand for more information)
*1st, I was shocked by the persistence of fevers. My patients had fevers every day, often all day, often >39, for days on end, not especially Tylenol responsive. And they had all had several days fevers before admission.
*2nd, the fevers did not seem particularly related to outcome. In fact most of my ICU transfers did not have persistent fever. They did, however, make patients miserable.
*3rd, this is not your usual sepsis picture. NONE of my patients, even the deaths/ICUs, developed meaningful AKI or liver failure (most had trivial transaminitis). There is no multiorgan failure. Just respiratory failure (I know reported later cardiac; I didn’t see those).
*4th I did have a bunch of mild troponin elevations, but mostly demand ischemia. No EKGs c/w myocarditis. Suspect too late a complication for me to see.
*5rd, as noted by others, just about all of my patients had had symptoms for 7-10 days before needing admit for O2. This posed a conundrum for the few who were admitted with less than 5d sx (all on RA) – keep to await nadir? Can’t afford the beds. Had to discharge with warning.
*6th, I found CRP and ferritin often to move in opposite directions (usually CRP ↘️while ferritin still ↗️; CRP leading indicator?). This was confusing. Moreover, I had patients with ferritin >3,000 who did well and others with less than 800 who struggled. So, not universally helpful.
*7th, as noted by others, these patients deteriorate fast. Really fast. I started calling ICU for any patient who went from RA to 6L in <24 hours; nearly all wound up at least on 100% NRB or high flow if not intubation.
*8th I kept underestimating their exertional hypoxia. Learned my lesson when I transferred one pt to lower acuity floor and he had a syncopal event getting from wheelchair to new bed. Walked all patients with pulse ox prior to d/c.
*9th On the topic of syncope, I admitted 3-4 COVID+ patients with presenting complaint of syncope (2 with head lacs), all early in course, with orthostatic hypotension without significant antecedent fevers. Could COVID be having some effect on autonomic system?
*10th Our standard protocol right now is azithro/hydroxychloroquine/zinc but I have little faith in efficacy. For the patients I really worried about (fast O2 requirement rise, high inflammatory markers) I gave tocilizumab off label. Clinical trial of sarilumab starting this week.
*11th Proning is now standard in our ICU and I tried hard to get my sicker patients to do it too to head off intubation. This is much harder than it sounds. Most patients couldn’t get into position on their own, found it uncomfortable (back pain), refused.
*12th Most of my patients didn’t eat anything. Partly lack of taste/smell, partly misery with fever, partly hypoxia with exertion, partly lack of visitors/staff in room to encourage and help. Several asked me for soft diet to reduce effort of chewing. Must attend to nutrition.
*13th Lastly, one of the biggest concerns for non-critically ill patients was persistent painful cough. Most had paroxysmal dry, wheezy coughing spasms, often precipitating desaturations. Tried cough syrup, albuterol MDI with spacer (avoiding nebs), codeine, with little effect.
*"I don’t think lay folks get the gravity of the situation in NYC. Literally every patient that walks into my urgent care has COVID 19. I know this not because I’ve tested them, but because they all have the *same* story, regardless of age, race or gender.... So, if you are in NYC. Assume *everyone* has COVID19... Fever, headache, dry cough, muscle aches, fatigue, some with loss of smell and taste and diarrhea. Fluctuating course. By day 5, shortness of breath & chest tightness. Shortness of breath worsens around day 8-10. Many hypoxic in low 90s with bilateral infiltrated in chest X-ray." (Twitter @uche_blackstock 3/31/2020)
*"Masks are rationed. Can’t speak up. Not good for ‘hospital optics’. OUR FRONLTINE PROVIDERS WILL DIE. WE NEED PPE!" (Twitter @Craig_A_Spencer 4/1/2020)
*"26 yo resident died from covid in our cardiac ICU.... They are not protecting us, we are not safe, it's horrible" (Twitter @tsaiduck77 4/2/2020)
*"It’s physically exhausting, it’s mentally mentally exhausting, but it’s something that we all love to do and we’re gonna keep doing it everyday as long as we need to." (Twitter @Craig_A_Spencer 4/2/2020)
*"There's really no way to describe what we're seeing. Our new reality is unreal. The people and places we've known so long & so well have been transformed. Our ERs are ICUs. Everything looks, sounds and feels different. Just one week and it's a whole different world. There are tents outside our hospitals. Every time I see them, I stop, startled. Their drab and dirty flaps seem so out of place against the grand facades of world-class hospitals. Desperate times, desperate measures. The last time I worked in a tent was West Africa." (Twitter Dr. Craig Spencer with @TheView 4/2/2020)
Dr. Spencer's 4/2/2020 observations (expand for more information)
There's really no way to describe what we're seeing.
Our new reality is unreal.
The people and places we've known so long & so well have been transformed.
Our ERs are ICUs.
Everything looks, sounds and feels different.
Just one week and it's a whole different world.
There are tents outside our hospitals. Every time I see them, I stop, startled. Their drab and dirty flaps seem so out of place against the grand facades of world-class hospitals.
Desperate times, desperate measures.
The last time I worked in a tent was West Africa.
In those same tents, I saw too much pain, loneliness, and death. People dying alone. I never thought I'd have to see or experience that ever again. I never wanted to. Once was painful enough.
We have no other option now.
Our ICUs are filling fast.
Our ERs are ICUs.
The patients I normally see are nowhere to be found. Every single person I see has #COVID19. Every single patient.
Working in the ER means walking through a corridor of coughing. All a slightly different pitch & different frequency, but all caused by the exact same thing.
It's not just the volume of patients that's hitting us. It's the severity.
Respiratory arrest.
Respiratory arrest.
Respiratory arrest.
Each takes 6-8 professionals. Nurses, respiratory techs, ER docs, anesthesiologists. Each takes an hour or more.
Back to back. All shift.
And it's not just the severity, back to back.
We're all being asked to do things we've never done before.
Run a code as your goggles fog & you can't decipher the vital signs on the monitor.
Try to predict which COVID patient will crash if you send them home. And which won't.
Talk to palliative care. Talk to family members. Long discussions about likely outcomes. Listen as family members sob. They aren't here to say goodbye when they ask to withdraw care. We FaceTime so they can say goodbye.
We stop the drips.
Turn off the ventilator.
And wait.
Your hands upon theirs.
You think of their family. At home. Sobbing.
Someone starts saying a prayer.
You can't help but cry.
This isn't what we do.
You stand by. You wait.
This isn't what we do.
You stand by. You wait.
Time of death: 7:19pm
In West Africa, I saw too many people die. Have a long talk with them in the morning. Go have lunch. Come back and they're dead.
But this is different.
This isn't what we do.
But then again, none of this is.
I see it on my colleagues' face. We are tired. We are physically exhausted.
Hours in goggles, gowns and masks feel like days.
But we are only at the beginning.
The mental exhaustion is only starting to set in. The things we do, the things we see. This isn't what we do.
I worry about my colleagues. Every day someone calls me crying. How long will they hold? How long will I hold?
I remember how this anxiety gnawed at me every day in Guinea in 2014. Was today the day I got infected? Won't know for a week. The days add up. The worry adds up.
I've never seen my colleagues so afraid, so unsettled.
But I've also never seen them all work so well together. I've never seen us more unified, more focused, more sincere.
Yes, we worry about PPE.
Yes, we worry about lack of medications.
Yes, we worry about each other.
But I've never seen so much sense of purpose. So much honor to do this job.
I think of this when I finally get home. Clothes in a bag. Hot shower. Look in the mirror. Indentations of the goggles still deep on my face. Bllisters on the bridge of my nose.
How long will we hold?
*"A frontline doctor at a major NYC hospital told me he lost his first patient this morning to rationing of care — not enough ventilators to go around. The lack of supplies and testing is real — and costing lives" (Twitter @danielsgoldman 4/2/2020)
====Week of 4/5/2020====
*"Unfortunately, the majority of the COVID patients follow a somewhat predictable albeit miserable track.... When I see them, I wonder how long they have left before they start declining. It’s not a matter of if, but when. I start them on the “treatment” hydroxychloroquine and azithromycin, which at this point I’m not really convinced makes any difference at all. They all follow seem to follow the same track with few exceptions. At some point after the patient is admitted and comes to the floor, I’ll get the first of many calls that they’re desaturating.... Sprinkled between the pages are the overhead codes going off at least hourly." (Reddit madresident 4/5/2020)
===San Francisco===
====Week of 3/8/2020====
*"We continue to face inadequate COVID-19 testing capacity. This is a national crisis.... At SF General Hospital, we’ve created and operationalized a quick low radiation dose chest CT that takes very little time, and has been very useful in helping us evaluate and risk stratify patients." (Twitter @VivekJainMD 3/12/2020)
====Week of 3/15/2020====
*"Shortages real: have enough PPE now but may run out soon. Testing: doing ~100/d now, but big shortage of reagent & swabs may force cuts. Beds, ICUs, vents OK for now but seeking more if we need, including at other SF hospitals. Blood shortage looming" (Twitter @Bob_Wachter 3/18/2020)
*"Very mild uptick in volume today: 8 patients in hospital with confirmed #COVID19 (2 in ICU), 18 w/ tests pending. Other COVID+ patients doing OK as outpatients.... PPE shortage dire–limiting MDs seeing pts to one (& subbing inpt televisits), no pt visitors, reusing PPE if safe. A tension all over: areas in which evidence-based guidelines say surgical mask/eye protect good enough, but some feel more secure w/ N95." (Twitter @Bob_Wachter 3/19/2020)
*"Shortages: still big problems w/ swabs, gowns, masks. Many(!) offers of donations–we're organizing to manage. Testing growing; amazing that swabs will be hurdle c) Rule changes: interstate #Telehealth visits now OK; MDs/RNs can work if back from Level 3 country & no sxs" (Twitter @Bob_Wachter 3/20/2020)
====Week of 3/22/2020====
*"Still not seeing NY-like surge: such sad stories there, system nearly overwhelmed. Our PPE stable, though tenuous; grateful for donations. Some hope on swab front." (Twitter @Bob_Wachter 3/22/2020)
*Interview with Dr. Bob Wachter with Dr. Armond Esmaili, Medical Director of COVID isolation floor at UCSF (Youtube 3/23/2020)
*"Still just 10 Covid pts @ucsfhospitals...Testing @ucsf now ramped up to ~400/day. Limiting factor was the special swabs... We just received ~4000 of them from federal emergency stockpile, which relieves that bottleneck, at least for now. We’re still triaging testing; not testing asymptomatic people for now. With each day w/o big surge, we struggle re: elective surgeries/transfers. Currently doing ~none, but ? when are we safe to open up? One 1 hand, major need/backlog. On other, must save capacity, esp. after hearing how fast @nyphospital was overrun w/ Covid pts." (Twitter @Bob_Wachter 3/23/2020)
*"stable # of Covid+ pts (n=9) tho ICU up (6). SF cases up (178, vs 40 8d ago), but not NY-like, where its awful. Still slower growth curve in CA...w/ stability, may open up for some surgeries next wk. Complex calculus: saving space/PPE for ? Covid surge while caring for pts that really need our services." (Twitter @Bob_Wachter 3/25/2020)
===California===
*"Tough week in hospital: More COVID-19 cases including my hospitalized colleague; a sick pregnant mom induced bc of COVID-19; all the usual death and badness from cancer, sepsis and CV disease. COVID-19 a marathon. Made the mistake of thinking a sprint." (Twitter @Shepinions 3/23/2020)
===Seattle===
====Week of 3/8/2020====
*"We are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen.... Currently, all of ICU is for critically ill COVIDs, all of floor medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New resp-sx pts in Pulmonary Clinic as offshoot" (Twitter @Chenbariatrics1 3/13/2020)
Seattle, WA 3/10/2020 (expand for more information)
*March 10,2020 “This is from a front-line ICU physician in a Seattle hospital This is his personal account:
*we have 21 pts and 11 deaths since 2/28.
*we are seeing pts who are young (20s), fit, no comorbidities, critically ill. It does happen.
*US has been past containment since January
*Currently, all of ICU is for critically ill COVIDs, all of floor medsurg for stable COVIDs and EOL care, half of PCU, half of ER. New resp-sx pts in Pulmonary Clinic as offshoot
*CDC is no longer imposing home quarantine on providers who were wearing only droplet iso PPE when intubating, suctioning, bronching, and in one case doing neurosurgery. Expect when it comes to your place you may initially have staff home-quarantined.
*Plan for this NOW. Consider wearing airborne iso PPE for aerosol-generating procedures in ANY pt in whom you suspect COVID, just to prevent the mass quarantines.
*we ran out of N95s (please stop hoarding!) and are bleaching and re-using PAPRs, which is not the manufacturer's recommendation. Not surprised on N95s as we use mostly CAPRs anyway, but still.
*terminal cleans (inc UV light) for ER COVID rooms are taking forever Enviro Services is overwhelmed. Bad as pts are stuck coughing in the waiting room. Rec planning now for Enviro upstaffing, or having a plan for sick pts to wait in their cars (that is not legal here, sadly)
*CLINICAL INFO based on our cases and info from CDC conf call today with other COVID providers in US:
*the Chinese data on 80% mildly ill, 14% hospital-ill, 6-8% critically ill are generally on the mark.
*Data very skewed by late and very limited testing, and the number of our elderly pts going to comfort care.
*being young & healthy (zero medical problems) does not rule out becoming vented or dead
*prob the time course to developing significant lower resp sx is a Wk longer which also fits with timing of sick cases we started seeing here, after we all assumed it was endemic as of late Jan/early Feb).
*based on our hospitalized cases (including the not formally diagnosed ones who are obviously COVID it is quite clinically unique) about 1/3 have mild lower resp sx, need 1-5L NC. 1/3 are sicker, FM or NRB. 1/3 tubed with ARDS.
*Thus far, everyone is seeing: nl WBC. Almost always lymphopenic, occasionally poly-predominant but with nl total WBC. Doesn't change, even 10days in. BAL lymphocytic despite blood lymphopenic (try not to bronch these pts; this data is from pre-testing time when several idiopathic ARDS cases) fevers, often high, poss intermittent; persistently febrile, often for >10d. It isn't the dexmed, it's the SARS2. low ProCalc; may be useful to check initially for later trend if concern for VAP etc. up AST/ALT, sometimes alk phos. 70-100 range. No fulminant hepatitis. Notably, in our small sample, higher transaminitis at admit (150-200) correlates with clinical deterioration and progression to ARDS. LFTs typically begin to bump in 2nd week of clinical course. mild AKI (Cr <2). Uncertain if direct viral effect, but notably SARS2 RNA fragments have been identified in liver, kidneys, heart, and blood.
*characteristic CXR always bilateral patchy or reticular infiltrates, sometimes perihilar despite nl EF and volume down at presentation. At time of presentation may be subtle, but always present, even in our pts on chronic high dose steroids. NO effusions.
*CT is as expected, rarely mild mediastinal LAD, occ small effusions late in course which might be related to volume status/cap leak. Not more helpful than CXR.
*when resp failure occurs, it is RAPID (likely 7-10d out from sx onset, but rapid progression from hospital admit). Common scenario for our pts is, admit 1L NC. Next 12hrs -> NPPV. Next 12-24hrs -> vent/proned/Flolan 18/ interestingly, despite some needing Flolan, the hypoxia is not as refractory as with H1N1. Quite different, and quite unique. Odd enough that you'd notice and say hmmm.
*thus far many are dying of cardiac arrest rather than inability to ventilate/oxygenate given the inevitable rapid progression to ETT once resp decompensation begins, we and other hosps, including Wuhan, are doing early intubation. Facemask is fine, but if needing HFNC or NPPV just tube them. will need a tube anyway, & no point risking the aerosols. no MOSF.
*cardiomyopathy. 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.
*Treatment - *Remdesivir might work, some hosps have seen improvement with it quite rapidly, marked improvement in 1-3 days. ARDS trajectory is impressive with it, pts improve much more rapidly than expected in usual ARDS. Recommended course is 10d, but due to scarcity all hosps have stopped it when pt clinically out of the woods - none have cont >5d. May cause LFT bump, but interestingly (200s-ish) for a day or 2 then rapidly back to normal suggests not a primary toxic hepatitis.
*unfortunately, the Gilead compassionate use and trial programs require AST/ALT less than 5x normal, which is pretty much almost no actual COVID pts. Also CrCl>30, which is fine. CDC is working with Gilead to get LFT reqs changed now that we know this is a mild viral hepatitis. currently the Gilead trial is wrapping up, NIH trial still enrolling, some new trial soon to begin can't remember where.
*steroids are up in the air. In China usual clinical practice for all ARDS is high dose methylpred. Thus, ALL of their pts have had high dose methylpred. Some question whether this practice increases mortality.
*it is likely that it increases seconday VAP/HAP. China had a high rate of drug resistant GNR HAP/VAP and fungal pna in these pts, with resulting increases mortality. We have seen none, even in the earlier pts who were vented for >10d before being bronched (don’t do now) 29/ - unclear whether VAP-prevention strategies are also different, but wouldn't think so? Hong Kong is currently running an uncontrolled trial of HC 100IV Q8. general consensus here (in US among docs who have cared for COVID pts) is that steroids will do more harm than good, unless needed for other indications. - many of our pts have COPD on ICS. After some observation & some clinical judgment, is to stop ICS if able, based on known data with other viral pneumonias and increased susceptibility to HAP. Thus far pts are tolerating that, no major issues with ventilating them that can't be managed with vent changes. We also have quite a few on AE-COPD/asthma doses of methylpred, so will be interesting to see how they do.
====Week of 3/15/2020====
*"With the time and resources needed to go into the room of a patient getting ruled out for #COVID19, we try to think carefully and plan ahead before entering the room because we can’t go back and forth so easily." (Twitter @KiraNewmanMDPhD, 3/15/2020)
*(This report was retracted 3/15/2020 by @scott_mintzer "because of concerns about both the amount of attention is was getting and the accuracy of some of the information." A copy of the original account can be found here (Reddit).) "None are sleeping more than a couple hrs a night. Everyone is utterly exhausted. My colleague has seen so many people die as to have become totally numb.... there were no IV pumps available. So the nurse had given some of it, left the syringe attached, and planned to come by to give more a little later, and then finish it.... In short, this is a nightmare, teetering on the precipice of even worse destruction. The goal of every American city should be to avoid becoming the next Seattle." (Twitter @scott_mintzer, 3/15/2020)
*"Things are tough, he says, but not apocalyptic.... Radiology volumes are down because of cancellation of elective stuff. Radiology has capacity" (Twitter @RogueRad, 3/16/2020)
*"One of our UW Medicine hospitals just closed the OR to convert to ICU to manage COVID-19 cases." (Twitter @gorejohn 3/16/2020)
*"I’ve been surprised by the amount of fear not just from the public but also from other healthcare workers. I am becoming accustomed to caring for people with #COVID19, yet many are still not. It manifests as friction and pushback when calling a consult." (Twitter @KiraNewmanMDPhD 3/21/2020)
===Michigan===
*"6 out of my 18 patients all should have been tested for the coronavirus, and I could only test one of them.... Cannot test the patients I need to test" (Twitter @DrRobDavidson 3/18/2020)
===New Jersey===
====Week of 3/8/2020====
*"So far I've treated 5 confirmed COVID-19 patients reqiring hospitalization, and currently have 14 suspected cases... and I can tell you that in 18 years of medical practice I've never seen anything like this" "It's a severe viral pneumonia. The problem is there is a flood of COVID-19 suspected cases coming to the ER, and we are quickly filling the hospital with them" (Twitter @BioBreakout, 3/14/2020)
*"NJ ER/ICU doc here. We are already overrun. And without appropriate cleaning/protective equipment." (Twitter @CHRISTO37877949, 3/14/2020)
*"What we’ve seen in the patients who ultimately are positive is that things can turn very rapidly. We had a patient that we were thinking about releasing — he seemingly was recovering — and then, two days later, he was put in the ICU. The flu isn’t like that.... Holy Name’s 11 positives are all males — and all between the ages of 28 and 48." (roi-nj, Life at the epicenter of N.J.’s coronavirus outbreak by Tom Bergeron 3/14/2020)
====Week of 3/15/2020====
*"their hospitals are saying doctors & nurses will be *disciplined* for wearing protective gear, including masks." (Twitter @wendellpotter 3/21/2020)
====Week of 3/22/2020====
*"I worked 12hrs in the ER today.We intubated 5patients.4 people died.Seasoned nurses were found hiding&crying in storage rooms.I'm literally in a war zone & the battle has only just begun.The front line is failing, you guys are on your own now" (Twitter @gaeliclass149 3/25/2020)
*"We completely reorganized the structure of our critical care units today... medical, surgical, neuro, cardiac, trauma, cardiothoracic units relocated to different parts of hospital to make rooms available for COVID-19 ICU patients requiring mechanic ventilation" (Twitter @BioBreakout 3/25/2020)
*"Most baffling & bewildering aspect of treating COVID-19 patients, both young & old, is the rapid unexpected respiratory deterioration... dyspneia, tachypnea, severe hypoxia resulting in intubation mechanical ventilation and transfer to ICU. Multiple cases today" (Twitter @BioBreakout 3/25/2020)
*"Having collected, run, reported, analyzed, re-collected, re-run, and re-analyzed tests for quite a few #COVID19 patients, I am now quite confident in saying that there are no symptoms that are reliably present or absent in those who are infected." (Twitter @Rick_Pescatore 3/26/2020)
*"I intubated my colleague today, a young, healthy ER doc like me." (Twitter @DavidZodda 3/27/2020)
====Week of 4/5/2020====
* "Today I witnessed the pain and disappointment that false hope can bring. When politicians push messages of miracle cures they reach into the hearts and minds of vulnerable families and they poison the sacred relationship between patients and doctors. It is cruelty." (Twitter @Rick_Pescatore 4/10/2020)
===Indiana===
====Week of 3/15/2020====
*"We're seeing some patients present to the ED with diarrhea, #COVID19 unsuspected but later confirmed" (Twitter @suzchongmd, 3/15/2020)
===Ohio===
====Week of 3/29/2020====
*"Today given one N95 to reuse for the ‘foreseeable future’. One surgical mask a shift. Can only wear masks for confirmed #coronavirus patients." (Twitter @Craig_A_Spencer 4/1/2020)
===South Carolina===
====Week of 3/29/2020====
*"Here in SC (where it is just starting to ramp up), we're being given 1 mask per shift and only 1 N95 if we have confirmed COVID patent. They are also starting to "sterilize & recycle" N95s. Staff scrambling to find their own PPE. Staff also being inexplicably furloughed." (Twitter @The_Debeers 4/2/2020)
===Tennessee===
====Week of 3/29/2020====
*"An RN friend in TN has been banned from wearing PPE and was admonished, in print, by her supervisor to alert said supervisor of any MD's wearing PPE as well so she can tell them to stop. This is blowing my mind." (Twitter @NBL2006 4/2/2020)
===Texas===
====Week of 3/29/2020====
*"I’m a full-time ER doc getting ready to work a 24 hour shift in the emergency department. I am genuinely more concerned about going to work tomorrow morning than I was the day I launched on the space shuttle. 1.5% shuttle mortality vs 9-12% if I get COVID-19.... Some of your comments question the wisdom of what I am doing. I have been practicing emergency medicine for 45 years. I like it, it’s interesting, and I have lots of experience. To abandon ship during the greatest public health crisis of our lifetimes is inconceivable to me. A ship is safe in harbor, but that’s not what ships are for." (Twitter @DrBillFisher 4/1/2020)
===Misc===
====Week of 3/15/2020====
*"I am dead center in one of the hotspots. PPE is a HUGE problem.... I was offered one N95. Just one. No face shields... and those that have them are being told to wash them. No bunny suits.. just those flimsy yellow fabric gowns.... we will start dropping like flies very soon without proper safeguards in place" (Twitter @drjohnm 3/18/2020)
*"She has been seeing many patients & developed a cough. No fever. She asked if she should be tested. She was told no, more than once. She kept working, seeing patients, while using PPE. Now, she’s #COVID19 +" (Twitter @AshleySumrallMD 3/18/2020)
Category:General reference pages