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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    Common things being common, viral illnesses over this past holiday season (weird thinking and saying that now, seem so long ago and far away) were predominately influenza, and we saw some sick ones this past winter.

    As for immunity after COVID infection - the answer is we don't know. We hope so in that convalescent serum from those recovered seems to contain neutralizing antibodies. However, there is really no way to know for sure because having neutralizing antibodies is only one step of many in developing "long term memories" in your immune system to remember it the next time around. The molecular immunology is very complicated, but it comes down to developing the right type of neutralizing antibody that your body has the ability to "remember" for next time around. Not all neutralizing antibodies do that. In fact, most don't. And we couple with that with anecdotal reports that people are getting repeat symptoms and testing positive again after they had recovered and tested negative. So, the answer is, we don't know.

    As for testing to see if you were infected in the past. Yes, IgG antibody testing is being developed, alongside vaccines. IgG is the "long term" antibody after an infection. Keep in mind I'm using the words "long term" very generally in laypeople's terms. "Long term" antibodies (IgG's) does not mean they are the correct antibody that will be remembered/ramped up and protect you next time around. A prime example is Hepatitis C antibody - the antibody your body naturally develops against hepatitis C hangs around just about forever, but offers absolutely no protection against re-infection for those who clear it naturally the first time around (about 1/3 of them do).
     
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  2. steveksux

    steveksux Massive Member

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    I was thinking the S Korea plan, testing, contact tracing and quarantine rather than wholesale lockdowns of population works great IF you start early enough so that you have low enough numbers and sufficient testing kits.

    Too late for much of the US, too many cases outstripping our ability to trace and test in major cities already hard hit.

    But every other area that has only seen the beginning stages I would think are ripe for that changed strategy, could use that strategy effectively and prevent mass outbreaks more effectively than we’ve done so far.

    Only problem is test kits, assuming we’d have to lockdown to keep numbers down in areas not hard hit so far until we can get sufficient test kits to be able to implement it.

    If we open up too early, places with few cases now that look like they could be open relatively safely will see the same exponential growth and we end up with another wave.

    Am I simply deluding myself, any merit to this idea?

    I keep thinking that it’s not too late for many states/cities to avoid major infections as well as lengthy shutdowns, even though we waited for too long in other states/cities to avoid major pains, both medical and financial.

    But the size spread out nature of the country gives us second and third chances to avoid the early mistakes that allowed this to get out of hand in many areas for a large portion of the country due to the geographically isolated layout of population density between population centers. As long as we don’t keep making the same mistakes and keep downplaying the potential severity of this. Some states have yet to lock down. With no testing and transmission without symptoms, waiting until you start seeing an increase in cases means you’re already too late.

    Randy


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  3. PicardMD

    PicardMD Make It So!!

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    South Korea is a relatively small country both geographically and population-wise compared with the US. And the Asian culture of respecting authority makes it easier to promote and enforce whatever cooperation that is needed from the population at large.

    Problem we have is, our population is very mobile, and short of completely closing each state's borders (and in larger states, even sectioning off states into smaller pieces), we will not able to achieve enough small, stable cohorts to manage contact tracing and quarantine.

    However, social distancing on a state/local level is working. We are seeing places that started social distancing early with flatter curves, even within individual states.

    And, btw, second wave/surge is very common in epidemics/pandemics. So I fully expect to see a second wave/surge once we open up the country. Hopefully, by then, there will be enough herd immunity (assuming catching and recovering from the infection make you immune to future infections - that is a big unknown at this time), and some combination treatment strategies to tame down the second wave.
     
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  4. PicardMD

    PicardMD Make It So!!

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    Also, we had a round table discussion among physicians, researchers, and clinical pharmacist locally looking at Ivermectin.

    Unfortunately, the drug concentration researchers had to use to stop COVID in cell cultures is at least several thousand times (if not tens of thousands times) more than what is realistically achievable in humans. So, it looks like this is another example of very few promising cell culture studies end up being realistic treatment options in actual human beings....
     
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  5. steveksux

    steveksux Massive Member

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    Isn’t that something of a catch 22? The more successful of a lockdown we have the worse the second wave will be?

    Seems like treatments are going to be paramount to prevent subsequent waves from getting bad enough to require subsequent lockdowns?

    Any rough estimates relating what % herd immunity would mute infection rates the second time around?

    What % might we expect to have been infected after first wave is contained? Seems like it’s still small % of population getting it, even with all the hype.

    Seems like 70% is the number bandied about to make it manageable and stable long term

    Randy


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    Last edited: Apr 7, 2020
  6. seanmac45

    seanmac45 CLM

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    Posting this with the hope Picard can read and provide feedback;

    Covid-19 had us all fooled, but now we might have finally found its secret.
    [​IMG]
    libertymavenstock

    Apr 5 · 8 min read
    In the last 3–5 days, a mountain of anecdotal evidence has come out of NYC, Italy, Spain, etc. about COVID-19 and characteristics of patients who get seriously ill. It’s not only piling up but now leading to a general field-level consensus backed up by a few previously little-known studies that we’ve had it all wrong the whole time. Well, a few had some things eerily correct (cough Trump cough), especially with Hydroxychloroquine with Azithromicin, but we’ll get to that in a minute.

    There is no ‘pneumonia’ nor ARDS. At least not the ARDS with established treatment protocols and procedures we’re familiar with. Ventilators are not only the wrong solution, but high pressure intubation can actually wind up causing more damage than without, not to mention complications from tracheal scarring and ulcers given the duration of intubation often required… They may still have a use in the immediate future for patients too far to bring back with this newfound knowledge, but moving forward a new treatment protocol needs to be established so we stop treating patients for the wrong disease.

    The past 48 hours or so have seen a huge revelation: COVID-19 causes prolonged and progressive hypoxia (starving your body of oxygen) by binding to the heme groups in hemoglobin in your red blood cells. People are simply desaturating (losing o2 in their blood), and that’s what eventually leads to organ failures that kill them, not any form of ARDS or pneumonia. All the damage to the lungs you see in CT scans are from the release of oxidative iron from the hemes, this overwhelms the natural defenses against pulmonary oxidative stress and causes that nice, always-bilateral ground glass opacity in the lungs. Patients returning for re-hospitalization days or weeks after recovery suffering from apparent delayed post-hypoxic leukoencephalopathy strengthen the notion COVID-19 patients are suffering from hypoxia despite no signs of respiratory ‘tire out’ or fatigue.

    Here’s the breakdown of the whole process, including some ELI5-level cliff notes. Much has been simplified just to keep it digestible and layman-friendly.

    Your red blood cells carry oxygen from your lungs to all your organs and the rest of your body. Red blood cells can do this thanks to hemoglobin, which is a protein consisting of four “hemes”. Hemes have a special kind of iron ion, which is normally quite toxic in its free form, locked away in its center with a porphyrin acting as it’s ‘container’. In this way, the iron ion can be ‘caged’ and carried around safely by the hemoglobin, but used to bind to oxygen when it gets to your lungs.

    When the red blood cell gets to the alveoli, or the little sacs in your lungs where all the gas exchange happens, that special little iron ion can flip between FE2+ and FE3+ states with electron exchange and bond to some oxygen, then it goes off on its little merry way to deliver o2 elsewhere.

    Here’s where COVID-19 comes in. Its glycoproteins bond to the heme, and in doing so that special and toxic oxidative iron ion is “disassociated” (released). It’s basically let out of the cage and now freely roaming around on its own. This is bad for two reasons:

    1) Without the iron ion, hemoglobin can no longer bind to oxygen. Once all the hemoglobin is impaired, the red blood cell is essentially turned into a Freightliner truck cab with no trailer and no ability to store its cargo.. it is useless and just running around with COVID-19 virus attached to its porphyrin. All these useless trucks running around not delivering oxygen is what starts to lead to desaturation, or watching the patient’s spo2 levels drop. It is INCORRECT to assume traditional ARDS and in doing so, you’re treating the WRONG DISEASE. Think of it a lot like carbon monoxide poisoning, in which CO is bound to the hemoglobin, making it unable to carry oxygen. In those cases, ventilators aren’t treating the root cause; the patient’s lungs aren’t ‘tiring out’, they’re pumping just fine. The red blood cells just can’t carry o2, end of story. Only in this case, unlike CO poisoning in which eventually the CO can break off, the affected hemoglobin is permanently stripped of its ability to carry o2 because it has lost its iron ion. The body compensates for this lack of o2 carrying capacity and deliveries by having your kidneys release hormones like erythropoietin, which tell your bone marrow factories to ramp up production on new red blood cells with freshly made and fully functioning hemoglobin. This is the reason you find elevated hemoglobin and decreased blood oxygen saturation as one of the 3 primary indicators of whether the **** is about to hit the fan for a particular patient or not.

    2) That little iron ion, along with millions of its friends released from other hemes, are now floating through your blood freely. As I mentioned before, this type of iron ion is highly reactive and causes oxidative damage. It turns out that this happens to a limited extent naturally in our bodies and we have cleanup & defense mechanisms to keep the balance. The lungs, in particular, have 3 primary defenses to maintain “iron homeostasis”, 2 of which are in the alveoli, those little sacs in your lungs we talked about earlier. The first of the two are little macrophages that roam around and scavenge up any free radicals like this oxidative iron. The second is a lining on the walls (called the epithelial surface) which has a thin layer of fluid packed with high levels of antioxidant molecules.. things like abscorbic acid (AKA Vitamin C) among others. Well, this is usually good enough for naturally occurring rogue iron ions but with COVID-19 running rampant your body is now basically like a progressive state letting out all the prisoners out of the prisons… it’s just too much iron and it begins to overwhelm your lungs’ countermeasures, and thus begins the process of pulmonary oxidative stress. This leads to damage and inflammation, which leads to all that nasty stuff and damage you see in CT scans of COVID-19 patient lungs. Ever noticed how it’s always bilateral? (both lungs at the same time) Pneumonia rarely ever does that, but COVID-19 does… EVERY. SINGLE. TIME.
     
  7. steveksux

    steveksux Massive Member

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    I saw that, was wondering if there was anything to that... fingers crossed.

    Randy
     
  8. collim1

    collim1

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    I somewhat understand all that.......

    So then, now that we maybe understand what happening, what is the new treatment protocol?
     
  9. PicardMD

    PicardMD Make It So!!

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    Interesting concept, but poorly sourced and poorly reasoned out by a non-physician... and widely cited on the internet as gospel without any real scientific fact checks.

    1) The source of this blog (by a non-physician as the blogger admitted himself) is a lab bench study published by Chinese researchers in an obscure non-clinical journal. The Chinese researchers laid out a theoretical pathway on how COVID 19 may attack hemoglobin. As far as I can search, these theoretical pathways have not been independently confirmed by others.

    2) There are several problems with this bloggers reasonings -
    • If the primary pathology is really the viral attack on hemoglobin, we ought to see hemolysis (breaking up of red blood cells) in COVID patients. Most other forms of hemoglobinopathy (disease of hemoglobin) causes some degrees of hemolytic anemia (anemia caused by hemolysis). This is readily detectable by routine blood work, and has not been reported as a common finding.
    • He cited elevated hemoglobin level as evidence that hemoglobin is being attacked. He further claims that hemoglobin level is elevated due to kidneys producing the hormone erythropoietin that asks your body to make more hemoglobin. Well, that process is true for hypoxia of any cause, not just defective hemoglobin. COPD patients have elevated hemoglobin level through the exact same pathway.
    • He states that bilateral lung involvements are rare in pneumonia, further suggest that pneumonia (or direct viral attack on lung tissues) is not the problem. Well, bless his heart, he ain't a doctor that's for sure. Any second year medical student can tell you that viral pneumonias are typically bilateral "ground glass infiltrates," exactly what COVID 19 patients x-rays and CT's look like.
    • He also states "high pressures" from intubation and ventilators cause further lung damages. Our field experience is, COVID patients tend not to have stiff lungs. In fact, their lungs are quite compliant. He also says "high PEEP is not good" - without getting too much into details, high PEEP is what gets more oxygen into the lungs/blood. COVID patients actually tolerates high PEEP VERY WELL.
    • In his full blog, he suggests blood transfusion as the way to save COVID patients - umm... ARDS patients don't do well when they are "wet." We are trying to keep them as dry as possible. Adding intravascular volume when blood pressure is not low is probably not a good idea. And too high of hemoglobin level can actually cause heart attacks, strokes, kidney failures... etc due to stasis.
    • Bless his heart that he threw in Vitamin C for good measure.
    3) I'm not saying that the Chinese researchers bench findings should be ignored. Far from it. I think they deserve to be further properly vetted by animal studies and then human studies. While their findings may be a piece of a much larger puzzle, it doesn't mean our current understanding of the viral pathology is wrong. And this blogger basically took a poorly vetted bench study, added his own half-baked embellishments that real physicians reading this will scratch our heads and say Huh? While there may be some truth to his postings, the overall reasoning doesn't make too much sense.

    4) Funny in his original blog, he ranted about not trusting the Chinese or anything coming out of China... but he relied his entire blog on a study coming from China, a study that has not been vetted by other researchers...
     
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  10. seanmac45

    seanmac45 CLM

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    Can't thank you enough, once again. He sounded as though he knew what he was talking about.

    That's why I wanted to run it past someone who really DOES.
     
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  11. steveksux

    steveksux Massive Member

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    So I guess I’m not going to post the 25 min video from a guy that claims to be a doctor saying quinine and zinc is a miracle cure, and good as a preventative measure...

    And by the way, if you can’t find quinine, drink Schweppes and zinc, it’s loaded with quinine...

    It was on Facebook, and I know they’re really fact checking stuff rigorously there!

    Randy


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  12. steveksux

    steveksux Massive Member

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    So just saw something about huge coronavirus outbreak in Chicago jail, Cook County.

    Combine that with some jurisdictions saying release prisoners to prevent them from becoming infected.

    Without testing or quarantining them for 14 day’s first, aren’t we risking sending out a bunch of asymptomatic covid infected people out into the world?

    Randy


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  13. PicardMD

    PicardMD Make It So!!

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    Yes, depending on the actual situation on the ground, you may be sending infectious asymptomatic folks into the community. The actual impact of this is complicated, and depending on the totality of circumstances in that community.
     
  14. ateamer

    ateamer NRA4EVR

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    And not just that, but they’re people who don’t care about their own health, nor anyone else’s, and they are unable to follow rules. Releasing infected prisoners will amount to a death sentence for some people in the community, a sentence imposed on them by the politicians and/or incompetent sheriffs who gave the release orders.
     
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  15. Mayhem like Me

    Mayhem like Me Semper Paratus

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    so are we good taking zinc, vitamin D, and sodium Bi carb ? The science on these 3 seem as good as anything.
     
  16. collim1

    collim1

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    They can say whatever they want as to the reason why........but it is one reason and one reason only.

    The logistics and expense of their obligation for them to provide adequate medical care to people in their custody.

    Release them and it becomes somebody elses’ problem. Period.
     
  17. Tvov

    Tvov

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    So I'm curious about how you think the US health care system is handling this. Are hospitals being overrun? Are healthcare workers running out of PPE and having to wear home made masks? Have hospitals run out of ventilators?

    Just wanted to add... in my little town, the police, ambulance, and fire department all have enough PPE for this.... so far. Everyone keeps saying there is a "shortage", but all departments have extra in storage. The thing is, departments are looking at worst case scenarios, which is why everyone is asking for more equipment and PPE. Also, in a "worst case scenario", no one anywhere would have enough PPE anyways (!).

    We have not run out of PPE, and have been getting more on a regular basis.
     
  18. TeaDub

    TeaDub

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    A question for @PicardMD . Early on, I read an article that referenced a study about warm weather and lowering the R0 value. It was a China based study so a big grain of salt. It did show what they thought was a lowering of between .5 and 1 to the rating.

    My question is, have y'all seen any additional emerging data on this virus losing a bit of steam as we heat up?
     
  19. steveksux

    steveksux Massive Member

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    One thing that made me suspect “quack” about the Hydroxychloroquine and z pak theory is that z-pak is an antibiotic which has no effect on viruses.

    Is there any theory behind why that was added to the mix, any reason to suspect it would help? Some side effect rather than it’s antibiotic properties?

    Randy


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  20. DocCasualty

    DocCasualty Wolverine

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    I’ve read that the French used Zithromax to treat possible secondary bacterial infection in their limited study, and I’ve also read there is some theoretical activity against viral activity, though no in vitro studies demonstrate that. Good overview here: https://www.contagionlive.com/news/...tion-therapy-measure-up-for-covid19-treatment

    My hospital/ health system recognizes the off-label use of CQ/HQC in CoViD19 in select hospitalized patients and considers the concurrent of Zithromax contraindicated due to QT prolongation concerns, which @PicardMD has already discussed.