COVID 19 - Thoughts from a frontline doc

Discussion in 'Cop Talk' started by PicardMD, Mar 28, 2020.

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  1. PicardMD

    PicardMD Make It So!!

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    As an LEO-Physician who is now knee deep in COVID 19 frontline, I thought I'd share some current information and field experiences with ya'll, with a spin on more first responder relevant viewpoint, and answer some questions I've seen from first responders.

    1) Yes, as test becomes more widely available, the overall mortality rate will go down. Vast majority of those infected have very mild to no symptoms. However, "low overall mortality rate" is only half of the story. Unlike the flu, the COVID virus survives much longer outside of the body and asymptomatic patients can spread the virus.

    2) Our current tests are molecular based. They have excellent specificity (meaning, very, very, very low false positives). However, their real world sensitivity (meaning ability to catch cases) is reportedly at around 75% - this means, one out of 4 people with COVID may test false negative.

    3) While the overall mortality rate is low, a larger percentage of COVID patients need hospital-level care compared with the flu. Therefore, a region's hospital level care capacity will influence that region's mortality - in other words, really sick but survivable cases that cannot get hospital care will die, and increase mortality for that region.

    4) A much larger percentage of those who need hospitalization need ICU-level care. They are also needing much longer ICU care compared with the flu. This is why we are running out of ventilators. Worldwide experience is, 86% of those COVID patients needing ventilators die after a prolonged ICU course. In the US, the Seattle experience is 70% death rate for those needing a ventilator. These numbers are much higher than the flu.

    5) Social distancing is very important. We need to flatten the curve - meaning, slow down the spread of infection in the community so that we don't get a large influx of patients needing hospital care all at once - this is how we run out of hospital beds. And maxing out hospital capacity itself will accelerate disease spread because you will have sick patients in the community who need close contact personal care by their friends and family members, putting them at risk... and you can do the math.

    5) While the general statement is true that older people with pre-existing conditions are more at risk for being severely sick, we are seeing more younger and healthy people getting really sick from COVID 19. We don't fully understand this heterogeneity of severe cases. We suspect a combination of lack of herd immunity and some yet undiscovered genetic susceptibility are the reasons. Point is, younger and healthier people are getting sick and needing hospitalization.

    6) Workforce protection - if you are sick, stay home. I cannot stress this enough. In New York City, young and healthy healthcare workers (ie interns, residents, young nurses) who were minimally symptomatic took out entire teams of healthcare workers early on in the outbreak, crippling their workforce just when the **** hit the fan. And unlike the flu, COVID patients are infectious to others for much longer period of time, so infected healthcare workers are out of commission for much longer periods of time, further crippling the workforce. Don't let that happen to your department.

    7) Vaccine - good news is, this virus has a fairly stable genome. This means, we are likely to have effective vaccines in the near future. This will probably not help us right now. The projection is, this may help with "COVID 20" and beyond.

    8) Treatments - lots of clinical trials in progress. No magic bullet in the near future, though there are some attractive candidates. The malarial medication Plaquenil is a double-edge sword due to its toxicity, and probably not a magic bullet by any means. The HIV drug that had some hopes early on turned out to be a dud.

    Please feel free to post questions. I'll try to answer them the best I can as time permits.

    This generous offer and free sharing of hard-earned experience is NOT an invitation to be an ass. Conspiracy theorists, rude people and general problems will be disappeared from the thread faster than you can dry cough. Thanks in advance. /s/Your mods.
     
    Last edited by a moderator: Mar 29, 2020
  2. coma1924

    coma1924

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    Thank you for all that you have done and will do.
     

  3. Keith E.

    Keith E.

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    @PicardMD,

    Many, many thanks for what you and your people are doing.

    Are there or will there be tests for people, who earlier, had symptoms that mirror the COVID 19 symptoms? Obviously this is not a high-priority topic at this point in the fight.

    Thanks,
    Keith
     
  4. Valmet

    Valmet M62/76 Silver Member

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    Picard- thanks for the work you do and the real world info!
     
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  5. pblanc

    pblanc

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    Thank you very much for the information and your intelligent comments.

    I am retired from medicine now and have been out of the loop for some time, but your experience mirrors that of health care delivery personnel I have communicated with who are operating in various "hot spots".

    It is very clear to most anyone that has any real knowledge of either infectious disease or health care delivery that this particular virus has the potential to do enormous damage. Hopefully, it will not live up to its full potential.
     
  6. Tvov

    Tvov

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    Thanks for that post.
     
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  7. pblanc

    pblanc

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    Serological tests to detect circulating antibodies to the covid-19 virus are being developed. They will allow identification of immunocompetent individuals who have been exposed to the virus, but no longer harbor transmissible virus in their systems.
     
  8. PicardMD

    PicardMD Make It So!!

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    Short answer is yes, eventually there will likely be tests for those who were previously infected.

    The tests we have now for active infections look for the actual virus in various ways.

    To test those who were infected, cleared the virus, and have recovered, we will need to look for antibodies in our serum. Specifically, we need to look for COVID-19 specific IgG. This will likely be developed as a part of vaccine development because that's how we track vaccine's response - look for antibodies after your are vaccinated.

    One major question we have now is, whether or not infection itself confers immunity. That is a very complex molecular immunology question. In order to be immune from future infection, the type of antibody our body naturally develops to fight against COVID 19 must be the right type against the right viral antigen (parts of the virus that elicits antibody response) that our body can "remember" for next time around. We are not sure that's the case right now because there are anecdotal reports of re-infections with COVID 19. Vaccine development essentially focuses on finding the right viral antigen for our body to produce the right type of antibody that we will "remember" for the next round.
     
  9. wapiti22

    wapiti22

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    Thank you for the info and Thank You for your service!!!!!
     
  10. PicardMD

    PicardMD Make It So!!

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    Time to reactivate your license and join the fight... ;)

    ACGME (governing body for residency trainings for those who are not used to medical jargon) has come out with a position statement that if an institution declares pandemic crisis, it can suspend most residency training rules to maximize the usage of residents/interns workforce.

    Colleagues from NYC are saying most of them are functioning at least 1 level above their trainings - interns functioning as residents, residents functioning as fellows, and fellows functioning as attendings. And they are giving "just in time" (crash course) training for various specialists to function as inpatient hospital medicine doctors... and most hospitalists are functioning exclusively as intensivists (which thankfully for most is not a stretch).

    We are also worried about running out of nurses in general and ICU capable nurses in particular. We are proning a whole lot of COVID 19 patients on vents now. That's very nursing labor intensive.
     
    Last edited: Mar 28, 2020
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  11. PicardMD

    PicardMD Make It So!!

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    I am confident that this will pass and we will come out stronger as a nation and humanity will shine through this.

    In the US, politics aside, I am grateful that we took action early on to flatten the curve. Yes, we have hotspots and the worse may be yet to come, but we took affirmative actions to slow down the spread early on, so many of us on the frontline have some breathing room for now...

    More importantly, I am VERY grateful that our communities have, for the most part, come together and people are watching out for one another. We've sent our medical students and nursing students home to keep them safe... but guess what? They stepped up and have been volunteering (as in not asking to get paid) childcare to doctors, nurses, hospital workers, first responders...etc so that we can keep working. Several of our tired nurses and doctors have reported that when they go get take out foods from various mom-and-pop restaurants (like my favorite local Chinese take out place), these places are giving healthcare workers deep discounts or flat out refusing to take our money and giving us plenty of food... all the while when they themselves are struggling financially to keep their restaurants afloat.... like I said, I am confident that humanity will shine through this... and this challenge will pass.
     
  12. OttoLoader

    OttoLoader

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    Picard
    What is the latest understanding any updates?

    COVID-19 causing virus incubation period.

    Once infected what is the virus sheding period duration.

    Virus activity duration on
    Hard surface such as metal
    Plastic
    Clothing soft upholstery.
     
  13. alnicoG22

    alnicoG22

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    Thanks for the info! I have no symptoms and will continue to perform my LEO and pharmacist duties in Arkansas.
     
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  14. okiegtrider

    okiegtrider

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    Thanks for posting this Picard. Stay strong, stay well.
     
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  15. PicardMD

    PicardMD Make It So!!

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    Our understanding is evolving.

    The good news is, majority of those infected are having very mild to no symptoms.
    Bad news is, they are still infectious to other people.

    Our best current understanding is, infected people will test positive for COVID 19 for 14 to 30 days. We believe they are infectious to others for the majority of this timeframe.

    Our best current understanding is, unlike the flu virus, COVID 19 survives considerably longer outside of human bodies. It can be infectious on hard surfaces for many, many days, and on soft surfaces for many hours, if not days. So environmental decontamination is important.
     
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  16. cowboy1964

    cowboy1964

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    It's my understanding that in the short term toxicity/side effects really aren't a big problem. There are a lot of people using it long term for other reasons. If I have COVID-19 I'd be happy to try Plaquenil.
     
  17. PicardMD

    PicardMD Make It So!!

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    Problem is, many of the Plaquenil acute toxicities hit the same organs that COVID 19 hits.

    Many of the sickest COVID 19 patients have acute liver failure, which can be greatly exacerbated by Plaquenil toxicity.

    We are also seeing more acute myocarditis (heart muscle inflammation) from COVID 19 than previously thought, which makes Plaquenil's QT prolongation property worrisome, as it can send these patients into fatal V-tach (a fatal heart rhythm). Many of other supportive care meds (such as anti-vomiting meds, Zithromax to prevent secondary bacterial infections... etc) also prolong QT, making their concomitant use with Plaquenil problematic.

    We are also finding that acute renal failure is not uncommon in hospitalized COVID 19 patients. Plaquenil is problematic in acute renal failure.

    Plaquenil's therapeutic effect on COVID 19 is convoluted and theoretical, as is with many of the existing meds in clinical trial as potential COVID 19 treatments (such as losartan, and even Viagra). We will see how this bears out... but I am very cautious with Plaquenil and currently NOT in favor of widespread use against COVID 19. Obviously, my view on this may change as we have more data.
     
    Last edited: Mar 28, 2020
  18. thewitt

    thewitt

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    Just a note on statistics for the layman.

    If something has a 75% chance of being right, that means every time it's used, there is a 75% change of being right.

    It's not self-correcting.

    This does not mean 1 in 4 will be a failed test, it means every time the test is used there is a 75% chance it is correct...

    This is known as a binomial distribution, where there are no connected data points between events. Each event has the exact same chance of producing the result as the prior event did.

    In order for a binomial distribution to look like a normal distribution, a very large number of events must be considered, often in the hundreds of thousands, or even in the millions.

    So in the case of testing for the CONIV-19 virus, every patient tested has exactly the same chances of being one of the test failures. There is no relationship to the tests that were done before.
     
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  19. papershoot

    papershoot

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    Could treatment with other antimalarial drugs such as Quinine/Qualaquin be of some benefit? Thanks
     
  20. pblanc

    pblanc

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    I'm not entirely sure that is correct in this instance. The current RT-PCR (reverse transcriptase/polymerase chain reaction) test that detects the RNA of the covid-19 virus might require a certain viral load to test positive. It may be that some individuals harbor low levels of virus that might not be detected. That would be a possible explanation for the anecdotal reports of individuals who became "reinfected" but were thought to have recovered. If so, such individuals would be much more likely to test negative a second time but potentially remain infectious and susceptible to relapse.

    One of the problems that occurred when treatments were being developed and evaluated for the acquired immune deficiency syndrome caused by AIDS was that the virus proved to be able to survive within the host at levels that were virtually undetectable. These individuals were thought to have been "cured" by treatment but relapsed when the treatment was discontinued.

    When it comes to diagnostic tests, the odds of a false negative or false positive result do not conform to the same rules that would govern the results of a coin toss or dice roll, where the result of a subsequent iteration is completely independent of prior results. Take mammographic screening for example. Some malignant lesions are either too small, or do not manifest any of the characteristic radiographic features of breast malignancy. In such a case, a repeat mammogram done a short time later would likely also yield a false negative result.
     
    Last edited: Mar 28, 2020