COVID 19 - Thoughts from a frontline doc

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

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  1. Garweh

    Garweh CLM

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    Just sent in my privilege forms for NYC HHC credentials. Since our outpatient units are closed, I plan to go to NYC and help out in the ICUs. Intubations, vent management, critical care medicine; all are part of my everyday practice. PLEASE, wish me “bon chance.”
     
  2. DocCasualty

    DocCasualty Wolverine

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    Good luck, stay safe!
     
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  3. OttoLoader

    OttoLoader

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    PicardMD.

    You mentioned th use of COPD exasperation medicines for covid treatment.

    My understaing of some more populate use.

    COPD
    Prednisone taper concurrent with z pack and zinc.

    Compare that to the HCQ off label use.

    HCQ, z pack and zinc.

    Simple comparison is Prednisone is used in place of HCQ .
    I know Prednisone is an anti-inflammatory and slightly suppress the immunity system.
    HCQ also could be doing the same thing.
    Not necessarily true, just posed in this question.

    If so why is it not more discussed or news worthy that the copd exasperation regime early in the infection is a viable course of treatment.?

    HCQ attacks the malaria, Prednisone does not do that is a major difference.

    Any insight is appreciated.
     
  4. Garweh

    Garweh CLM

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    I expect my credentials for NYCHHC to come through in the next 24 hours; I have no idea where I will be assigned (I put “any” in my application for location). Have 24 hours in the ICU here in Central NY this Saturday (4/18), then off to NYC. Sounds like (to paraphrase “M*A*S*H”) it will be “meatball medicine!”

    FYI: One of my “normal” practice locations is in the “Baseball Hall of Fame” village, the others are in Utica NY. Sitrep here is: “watchful waiting.”
     
  5. PicardMD

    PicardMD Make It So!!

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    Prednisone and HCQ are two completely different drugs with completely different mechanisms of actions. It's like comparing an apple to a... pickled chicken foot.

    Our immune system is exceedingly complex. "Immunosuppressants" as a generic term actually means very, very little because they mean very, very different things in different parts of the immune system. You cannot simply "compare" two "immunosuppressants" without putting them in context of what part of immune system you are "suppressing" and for what disease process.

    While HCQ's efficacy in COVID is controversial and not well studied (hopefully this will change in the next few weeks), prednisone actually harms in COVID, at least early on in the disease process.

    And no, zinc is not a routine part of COPD exacerbation treatment.
     
  6. OttoLoader

    OttoLoader

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    For privacy concerns names are not provided.

    I was discussing with an MD as to what medicines could be used early in a possible covid infection for severe COPD patients. Really cannot risk any lung scaring.

    The Prednisone z-pack for exasperation and zinc lozenges were used for an elderly covid patient with severe COPD. That patient recovered.

    I mentioned that was similar to the combo used in the hcq saga per the media.

    The difference between the hcq combo was not discussed other than both hcq and Prednisone or other steroid would suppress the immune system. No more detail discussed though.

    That doctor used hcq through the years when in the South Pacific and Africa. So is familiar with it and contraindications.
    Note
    The zinc was used to help prevent secondary infections not actually the exasperation .

    Z-pack in the last few years is being used more frequently with COPD patients not just for exasperations but also preventative with early symptoms of possible upper respiratory infection.
    Primarily to prevent from developing pneumonia.

    The puzzle to me is what is the mechanism of the hcq such that it can also be used for arthritis. Yet compared to the mentioned COPD exasperation combo it is replaced with a steroid. That would indicate immunity suppression is important.
    Could the key actually be small immunity suppression is important to recovery?

    Also lupis patients are prescribed hcq for chronic long term preventative treatment.
    Description of purpose is to suppress immunity but not enough to increase likely hood of infection.

    I know it is speculation not definitive .

    Common thread is immunity suppressive property.
     
    Last edited: Apr 14, 2020
  7. PicardMD

    PicardMD Make It So!!

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    You are generalizing (and incorrectly so) some very complex molecular immunological processes and pathophysiology. Unfortunately, without teaching you years of molecular biology and immunology, I cannot explain it to you in this thread. Like I said, the general term of "immunosuppression" is meaningless unless you put them in molecular context to specify the exact part of the immune system and the disease process you are trying to modify. And again, without you having the molecular biology, immunology, and pathophysiology background, it is not possible to really explain them to you here.

    Zinc has no role in preventing secondary bacterial infection. It may prevent complete cell entry in various human coronaviruses (not talking about COVID 19), and is probably better than nothing in COVID.

    Use of Zithromax in COPD patients not in acute exacerbation is controversial. It is NOT used to prevent secondary bacterial infection in this context. It has to do with manipulating your bacterial flora in your lungs.

    HCQ's role in COVID is controversial, as I've explained in another thread. It's not a magic shield or magic bullet. And it has actual potential fatal side effects. Don't have time to rehash that thread here. Please feel free to search my posts. The mechanism, if you must know, has to with possibly modifying endosomal pH. If that doesn't mean a whole lot to you, then it is too complex to go into details.

    The short answer is no, you are mixing apples with pickled chicken feet. COPD exacerbation, COVID infection, RA, Lupus are four different disease processes that share very little in common (yes, we can argue RA and Lupus are both autoimmune diseases). While all 4 of them involves the immune system in some way, the involvements are not the same (again, way too complex to explain them to you in molecular details). So no, you cannot "transpose" treatment for one into another simply on the bases of "immune suppression."

    If you intent is to argue about HCQ because Trump and Hannity said its magic, please go to the other threads in the COVID-19 sub-forum. We can continue there after you've read the entire threads there. If that's not your intent, my apologies.
     
    Last edited: Apr 15, 2020
  8. OttoLoader

    OttoLoader

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    Last edited: Apr 15, 2020
  9. Zerodefect

    Zerodefect I feel pretty.

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    How many of the patients in the hospital have tried HCQ?

    Is this the same malaria drug I've had in the past?
     
  10. steveksux

    steveksux Massive Member

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    It is the same malarial drug, and it is being used sporadically off label for coronavirus in some cases in Detroit area at least. I believe more likely as you approach last resort scenarios, but not sure. Potentially fatal cardiac problems mean it’s not risk free and appropriate for wide scale usage.

    Randy


    Sent from my iPad using Tapatalk
     
  11. RussP

    RussP Super Moderator Staff Member Moderator

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    Closed for some chill time.png

    No matter our profession, we need to remember and practice good, positive bedside manners and customer relations when exchanging information with other members.

    Thank you.

    rp
     
    Last edited: Apr 15, 2020
  12. RussP

    RussP Super Moderator Staff Member Moderator

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    Thread is back open...
     
  13. steveksux

    steveksux Massive Member

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    Does the virus require oxygen to survive? Has anyone tried removing the oxygen from patients lungs?

    Has anyone looked at the reason kids seem to not be affected as much as adults? Maybe all those Tide Pods they were eating?


    View: https://youtu.be/QQzg1vpxnnY



    See if I can break the ice with a little humor to get this rolling again . I think it was greatly appreciated and very useful.

    Regarding Vegas, even if we assume for the sake of argument that they open up and acquire herd immunity, does that even matter? Locals become immune, but an area that depends on tourism is still going to have sick asymptomatic people come spreading it to other tourists. Vegas will be a macroscopic infected cell churning out infected people and spreading them around the country like virus particles.

    And who’s going to risk going through crowded airports to get on crowded planes to visit a crowded destination when the rest of the country is still at significant risk of infection? So what difference does it make opening up casinos that are going to be virtually empty except for locals?

    At some point there’ll be enough herd immunity to make that an acceptable risk for tourists, but we’re far from that point. Local immunity seems nearly irrelevant to their problem.

    Randy


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  14. PicardMD

    PicardMD Make It So!!

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    Here's a link to another thread I started in the COVID subforum:
    https://www.glocktalk.com/threads/m...rent-covid-treatment-clinical-trials.1824078/
    Lots of good discussions there about HCQ and other therapies. I do apologize in advance that there are a few arguments in that thread where I felt the need to spank a poster for being unreasonable and wanting to bring politics into the discussion.

    To briefly summarize -

    Yes, HCQ is a relatively safe drug that has been in existence for a long, long time and we have used it to treat rheumatoid arthritis and Lupus as a slow immunomodulating medication with success - in the outpatient setting with an otherwise healthy, ambulatory population who have been properly screened for risk factors for complications.

    The major risk factor for HCQ is fatal cardiac arrhythmia by causing "QT prolongation." Older people, people on other QT prolonging medications, people with pre-existing cardiac conditions or acute heart injuries are particularly at risk. COVID is known to cause acute (and sometimes silent) heart injury in a significant percentage of patients, making HCQ problematic without very close monitoring (meaning, 24/7 cardiac telemetry monitoring at the minimum.) COVID also causes sepsis in hospitalized patients. About 50% of patients with sepsis have measurable acute cardiac stress that meets a subtype of "acute MI" definition. In fact, before COVID, HCQ was one of the first meds we would STOP in ICU patients who had been taking it outpatient.

    Zithromax also prolongs QT. This side effect is additive with other QT prolonging meds, including HCQ.

    Early on, there have been several French and Chinese studies that show significant benefits of HCQ in treating COVID 19. Unfortunately, all of these studies are very poorly done with too many confounders - such as other medications being used, too few people in the study, or flat out data manipulation.

    There are also anecdotal stories from various doctors who have treated patients with HCQ with success. However, these are generally from outpatient doctors who are treating ambulatory COVID patients - these patients have nearly 100% survival rate to begin with, so these doctors could have been giving Skittles to these patients and claim the same survival benefit.

    A major concern for doctors at this point is, when we see ambulatory patients survive on HCQ, we give HCQ credit even though 99+% of these patients would have survived without HCQ. And when critically ill patients die on HCQ, we are blaming the deaths exclusively on COVID, when we know for a fact that HCQ kills critically ill patients. This is why we need controlled, randomized trials to truly understand the benefit AND THE HARM of HCQ.
     
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  15. PicardMD

    PicardMD Make It So!!

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    For what it's worth, here is a news report about FDA warning of using HCQ outside of hospital settings due to reports of cardiac rhythm problems and deaths:

    https://www.foxnews.com/health/hydroxychloroquine-avoided-outside-hospitals-fda-warns

    Despite what some posters may have thought of my "tone" in my post as against HCQ use, we actually have been using HCQ +/- Zithromax locally in hospitalized patients. Our experience is, it may have some benefits in some patients, but it's not a "game changer" as some media and politicians have claims.

    More importantly, we keep every patient on continuous telemetry heart monitor and watch their heart rhythms 24/7 while on HCQ, precisely due to the potential fatal arrhythmia concern. And we have stopped HCQ on patients "just in time." Imaging what would have happened to these patients without someone watching their heart monitor 24/7.
     
  16. doktor doom

    doktor doom

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    PicardMD- thank you for some of the most cogent and informative discourse on the subject of Covid-19 that I have seen ANYdamnWHERE since this Pandemic began.

    I went yesterday for the IgG antibody test, and expect results back early next week.
    I was in Barcelona, Spain the first week of March, and my wife and I came down with what we suspect were the milder expressions of this disease (I more mild than she).
    We had the textbook symptoms, though each with slight differences, and neither of us had any fever.
    We did have sore throat, fatigue, a runny nose, dry cough (hers was worse than mine), I had a 3 day mild headache, she had some leg pain/ muscle stiffness. It basically felt like a cold, with a little lower respiratory element.
    The duration of my feeling bad was also shorter than my wife's.
    Anecdotally, I have blood type O positive; my wife is unsure what hers is.

    We flew Barcelona to Charles DeGaulle to JFK to CLT on March 7, after a truly wonderful vacation.
    The plane from Paris to NYC had a whole rainbow of EU passports.
    Customs at JFK was a mess. Zero screening, not a digital thermometer in sight, everyone crowded together like a rock concert, touching the same passport photo kiosks, not a single question about "where were you travelling? Have you been in Northern Italy? How do you feel? Have you had a fever recently?" from Customs. The only thing an ICE agent said to me when he looked at my passport was "Huh, looks like you grew a beard." It was a S#!&show.

    When my wife presented with symptoms, probably March 9 or 10th, she called the NC Coronavirus hotline and was told "You don't have a fever, go to work." Understandable at the time, but positively awful in retrospect. We are learning as we go, as this is a NOVEL disease. We are still disappointed that there was no effort to ask her for her name or contact info so she could be retroactively traced/ tested should outlook/ understanding change.

    So my interest in getting the IgG antibody test is not to make me any more or less cautious than I have been for the entirety of April, but more out of interest in becoming one more data point for the public health authorities to hopefully learn from.
    Thank you for your continued efforts in fighting this disease.
     
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  17. PicardMD

    PicardMD Make It So!!

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    Glad to hear both of you are OK.

    Two things to keep in mind with the current IgG testing -

    1) We rushed these tests into market without the usual quality control process. We are seeing many false positives (more so than false negatives) with these tests as the antibody testing is not precise and cross reacts with other viruses.

    2) We are not certain recovery from infection actually confers long lasting immunity. It didn't in prior coronaviruses outbreaks such as SARS or MERS. It probably will confer some short term immunity, but we are not 100% sure.