468

(EDIT 3/29/20): We still don’t know this doctor’s identity, but we have received a link to his original post for attribution.


This is an open letter to the ER Doctor in New Orleans whose message below came to me on an email thread:

Thank you for granting permission to post this message, especially since I do not know who you are. I hope this blog post will help your email find its way to clinicians who need this information. If you contact me and are willing to be identified by name, I would feel much relieved. God protect your health, and thank you for leading by example.


Caroline E. Fife, MD

(There are many abbreviations below which physicians reading will understand. This blog is meant to be distributed to clinicians who can use this information in the care of patients.)


I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

 Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have covid-19 and do not need a nasal swab to tell you that.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all COVID-19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation. Luckily we are part of a larger hospital group. Our main teaching hospital re-purposed space to open 50 new COVID-19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the “lockdown”, our AI models are expecting a 200-400% increase in COVID-19 patients by 4/4/2020.

Clinical Course

Clinical course is predictable.

  • 81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.
  • 2-11 days after exposure (day 5 on average) flu-like symptoms start. Common are fever, headache, dry cough, myalgias (back pain), nausea without vomiting, abdominal discomfort with some diarrhea, loss of smell, anorexia, fatigue.
  • Day 5 of symptoms – increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.
  • Day 10 – Cytokine storm leading to acute ARDS and multi-organ failure. You can literally watch it happen in a matter of hours.

Patient Presentation

Patient presentation is varied.

  • Patients are coming in hypoxic (even 75%) without dyspnea.
  • I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA.
  • I have seen the bilateral interstitial pneumonia on the x-ray of the asymptomatic shoulder dislocation or on the CT’s of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it.
  • Seen three positive flu swabs in 2 weeks and all three had COVID-19 as well. Somehow this ***** has told all other disease processes to get out of town.
  • China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected COVID-19 patient. Even our non-COVID-19 STEMIs at all of our facilities are getting TPA in the ED and rescue PCI at 60 minutes only if TPA fails.
  • Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox. The hypoxia does not correlate with the CXR findings

Diagnostic

Basically, if you have a bilateral pneumonia with normal to low WBC, lymphopenia, normal procalcitonin, elevated CRP and ferritin- you have COVID-19 and do not need a nasal swab to tell you that.

  • CXR – bilateral interstitial pneumonia (anecdotally starts most often in the RLL so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings.
  • Labs – WBC low, Lymphocytes low, platelets lower than their normal, Procalcitonin normal in 95%
  • CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
  • Notice D-Dimer – I would be very careful about CT PE these patients for their hypoxia. The patients receiving IV contrast are going into renal failure and on the vent sooner.
  • A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.
  • An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes.
  • Other factors that appear to be predictive of poor outcomes
    • Thrombocytopenia
    • LFTs 5x upper limit of normal.

Disposition

  • I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen.
  • Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula.
  • We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won’t make it back.
  • We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all COVID-19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Supportive

  • Worldwide 86% of COVID-19 patients that go on a vent die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated.
  • Extubation happens on day 10 per the Chinese and day 11 per Seattle.
  • Plaquenil which has weak ACE2 blockade doesn’t appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell. With Plaquenil’s potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.
  • We are also using Azithromycin, but are intermittently running out of IV.
  • Do not give these patient’s standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA and renal failure dehydration, leave them dry.
  • Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings

  • Usual ARDS stuff, low volume, permissive hypercapnia, etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.
  • Do not use Bipap- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.
  • The same goes for nebulizer treatments. Use MDI. you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn’t often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.
  • Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis.

We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

Personal Protection

  • One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI is out with the symptoms and an SaO2 of 92%. She will be the first of many.
  • I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift.
  • I undress in the garage and go straight to the shower.

My wife and kids fled to her parents outside [city redacted]. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on.

Good luck to us all.

[Dr. identity not known]


Dr. Fife sees patients at the CHI St. Luke's Hospital Wound Clinic in The Woodlands, Texas. For an appointment call (936) 266-2150.



%d bloggers like this: