Covid19 - clinical / epidemiological thread

[deleted59964]

I haven’t had any clinical experience with this yet, hope it stays that way - but I doubt it.



The numbers of this thing are concerning.

so this Harvard epidemiologist

Cooperating to Combat Coronavirus

is saying 20 - 60 % of the worlds population will get covid 19.

lets say he’s wrong. Let’s say it’s only 5%.
lets say 80% of the time it’s just like a cold

lets say 20% of the time it’s severe
lets say a third of severe cases need a ventilator (I’ve heard it’s half)

so in a city of 1 million
1,000,000 x 5/100 = 50,000 cases

20/100 x 50,000 = 10,000 severe cases
10,000 x 1/3 = 3333 patients requiring ventilation

not sure how many ventilated beds you have per 1,000,000 people ... in Australia it’s around 100

if that epidemiologist is right, hell even if he’s way pessimistic ... it’s gonna be bad - am I missing something here, is he on crack?

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[facted]

I haven’t had any clinical experience with this yet, hope it stays that way - but I doubt it.



The numbers of this thing are concerning.

so this Harvard epidemiologist

Cooperating to Combat Coronavirus

is saying 20 - 60 % of the worlds population will get covid 19.

lets say he’s wrong. Let’s say it’s only 5%.
lets say 80% of the time it’s just like a cold

lets say 20% of the time it’s severe
lets say a third of severe cases need a ventilator (I’ve heard it’s half)

so in a city of 1 million
1,000,000 x 5/100 = 50,000 cases

20/100 x 50,000 = 10,000 severe cases
10,000 x 1/3 = 3333 patients requiring ventilation

not sure how many ventilated beds you have per 1,000,000 people ... in Australia it’s around 100

if that epidemiologist is right, hell even if he’s way pessimistic ... it’s gonna be bad - am I missing something here, is he on crack?

It's going to be bad. You're not missing anything. Just look at what's going on in northern Italy at the moment.

A thread from the frontlines:

 

[dhb]

The numbers are not as scary as what that tweet suggests:

How does the new coronavirus compare with the flu?

Research so far indicates that COVID-19 spreads more easily and has a higher death rate than the flu.

www.livescience.com

 

[facted]

The numbers are not as scary as what that tweet suggests:

How does the new coronavirus compare with the flu?

Research so far indicates that COVID-19 spreads more easily and has a higher death rate than the flu.

www.livescience.com

This infographic shows the Italy numbers pretty well (though in Italian).

Don't know about you, but a 4.3% mortality is pretty scary to me.

Granted, I think this a systems overwhelmed number (true mortality with full medical care is probably closer to the S Korea or china ex-Wuhan number of .7-1%).

But then again, that's why pandemics are so destructive. They swamp resources and that's a huge part of the problem.

 

[caligas]

 

[facted]

Oh wow! Dr Drew, a trained addiction specialist telling me that CDC/WHO, the govts of Italy, China, Israel, S Korea, etc are full of ****!

Now I'm comforted.

 

[dannyboy1]

So if they close the ORs to everything guess I’ll be going home early. With that and the nice rate on my refinance this is turning out ok....

 

[deleted126335]

So if they close the ORs to everything guess I’ll be going home early. With that and the nice rate on my refinance this is turning out ok....

Or maybe you be will working your ass off as ORs and PACUs are turned into ICUs and patients put on Anesthesia ventilators to keep them alive due to the massive shortage of the usual ICU ventilators

 

[dannyboy1]

Or maybe you be will working your ass off as ORs and PACUs are turned into ICUs and patients put on Anesthesia ventilators to keep them alive due to the massive shortage of the usual ICU ventilators

Not sure how that would work. I’m not an intensivist. I am not credentialed to provide prolonged ICU care. Would we all sit on the stool 24/7 until for as long as a patient is attached to a ventilator ? Would ED and ICU nurses staff their patients in the OR? Who would be the attending making medical decisions? Also I am hired by the AMC which I work for to do cases/generate billing, not to do unreimbured labor for the hospital.

 

[Drwine]

COVID-19

Information for Health Care Professionals curated by the ASA Committee on Occupational Health

www.asahq.org

 

[deleted126335]

Not sure how that would work. I’m not an intensivist. I am not credentialed to provide prolonged ICU care. Would we all sit on the stool 24/7 until for as long as a patient is attached to a ventilator ? Would ED and ICU nurses staff their patients in the OR? Who would be the attending making medical decisions? Also I am hired by the AMC which I work for to do cases/generate billing, not to do unreimbured labor for the hospital.

I really don't know either. But if there was an ongoing disaster and a desperate call for personnel with our skill set, I couldn't see staying home and hiding.

 

[dhb]

This infographic shows the Italy numbers pretty well (though in Italian).

Don't know about you, but a 4.3% mortality is pretty scary to me.

Granted, I think this a systems overwhelmed number (true mortality with full medical care is probably closer to the S Korea or china ex-Wuhan number of .7-1%).

But then again, that's why pandemics are so destructive. They swamp resources and that's a huge part of the problem.

Ok but >80% of mild disease is not very scary. Mortality, unlike an influenza pandemic, is concentrated in the very old or already sick patients.

 

[Iso4ane]

I really don't know either. But if there was an ongoing disaster and a desperate call for personnel with our skill set, I couldn't see staying home and hiding.

I agree, overseas it seems to a all hands on deck scenario. And honestly, if it was your family member on the other side of the country, where an intensivist is unavailable, who do you want taking care of them, ortho?

 

[nimbus]

Ok but >80% of mild disease is not very scary. Mortality, unlike an influenza pandemic, is concentrated in the very old or already sick patients.

Even if that is the case, it is concerning that a couple dozen Chinese physicians in their 30s-50s have succumbed. They had access to advanced care.

 

[surgndoc]

I had a friend in town for a wedding Valentine’s Day weekend and remember discussing how the quarantine measures we were seeing in China and massive construction of hospitals, fever checks, etc. would be completely unfeasible in a country like the US. And that if it initially broke out in the US we would be in big, big trouble. And here we are now

Last week I saw one or two people out and about wearing masks. Over the weekend I’ve seen people sanitizing carts at the grocery store, using their sleeves to open doors, and numerous people all wearing masks throughout the hospital.

My hospital already has several positive cases and I know of staff out on forced quarantine. Didn’t think it would hit this close to home this soon. news from Italy, especially the series of tweets from the italian ICU MD are quite concerning. Not so much the numbers because I think what we will end up seeing will be easily enough to overwhelm the system.

Major Cities will go on some type of quarantine and we will see a drastic reduction of scheduled OR cases if not shutting them down entirely except emergencies. It’s hard to predict exactly how bad this will get but to me, and perhaps I’ve been consuming too much media, this seems to be the tip of the iceberg.

 

[pgg]

I agree, overseas it seems to a all hands on deck scenario. And honestly, if it was your family member on the other side of the country, where an intensivist is unavailable, who do you want taking care of them, ortho?

Funny you should say that. See post #2 in this thread. Can't figure out how to embed the whole thread without copying each and every tweet, but here's the first:



In particular #6

"My friends call me in tears because they see people dying in front of them and they con only offer some oxygen. Ortho and pathologists are being given a leaflet and sent to see patients on NIV. PLEASE STOP, READ THIS AGAIN AND THINK."

This is in Italy, not China or some sketchy backwater.

In the good ol' sue-happy US of A though, I figure ortho and path won't be helping out with the vents.

 

[Ezekiel2517]

Ok but >80% of mild disease is not very scary. Mortality, unlike an influenza pandemic, is concentrated in the very old or already sick patients.

In WA state, intensivists have reported they were managing healthy, fit patients in their 20’s who were critically ill and vented.

 

[nimbus]

 

[dannyboy1]

I cant imagine my greedy community hospital shutting down the ORs for anything. They will have RT hand bagging people in the bathroom before shutting down the moneymaker....

 

[10KHertz]

In WA state, intensivists have reported they were managing healthy, fit patients in their 20’s who were critically ill and vented.

But what’s the true story? Are these young bucks using flavored inhalation vaping as well, or inhalation medical MJ, are their lungs uniquely different than ours?? Possible CF? Would be a good case report to discuss ...

 

[nimbus]

One report I’ve read says severe cases typically have biphasic course. Respiratory failure will respond to maximal intervention (vent/prone/flolan) and look like they are turning the corner from a pulmonary standpoint and not requiring any pressors. Then they go on to develop florid cardiomyopathy. Patients are going from a normal ventricle to 10% EF to 0% EF in a matter of hours.

 

[10KHertz]

One report I’ve read says severe cases typically have biphasic course. Respiratory failure will respond to maximal intervention (vent/prone/flolan) and look like they are turning the corner. from a pulmonary standpoint and not requiring any pressors. Then they go on to develop florid cardiomyopathy. Patients are going from a normal ventricle to 10% EF to 0% EF in a matter of hours.

This coupled with extreme HTN(afterload), per recent reports come from the ‘field’ specialists. Sounds like HTN control is critical as well.

 

[Gasper]

Coronavirus in Italy: ICU video shows patients struggling to survive

At an intensive care unit in Cremona, Italy, coronavirus patients are being treated by medical staff in protective suits. This rare look inside an ICU shows patients on ventilators lying face-down …

nypost.com

 

[nimbus]

Doctors give emotional warnings from Italy's Coronavirus outbreak | World Economic Forum

 

[dhb]

From the title of the thread i was hoping for a scientific discussion not hearsay...
Anyway from the CDC:
"Among more than 44,000 confirmed cases of COVID-19 in China as of Feb 11, 2020, most occurred among patients aged 30–69 years (77.8%), and approximately 19% were severely or critically ill [9]. Case-fatality proportion among cases aged ≥60 years was: 60-69 years: 3.6%; 70-79 years: 8%; ≥80 years: 14.8%. Patients who reported no underlying medical conditions had an overall case fatality of 0.9%, but case fatality was higher for patients with comorbidities: 10.5% for those with cardiovascular disease, 7% for diabetes, and 6% each for chronic respiratory disease, hypertension, and cancer. Case fatality for patients who developed respiratory failure, septic shock, or multiple organ dysfunction was 49%. [9]"

 

[dchz]

Even if that is the case, it is concerning that a couple dozen Chinese physicians in their 30s-50s have succumbed. They had access to advanced care.

I am from China, my parents were physicians in China. I lived inside the Court yard of a hospital until I was 11. Nothing over there is "advanced care". LOL

Wuhan, hubei isn't a very affluent province either. Wonder what the mortality rate is in Beijing or Shanghai? Their equipment/setup is more comparable to the US.

Patients are going from a normal ventricle to 10% EF to 0% EF in a matter of hours.

This part is scary.

 

[deleted59964]

From the title of the thread i was hoping for a scientific discussion not hearsay...

i‘m with you on that.
It may seem like I’m chicken little, since the start of this it has however been underestimated and played down.
I’m all for sharing and discussing the best evidence.

 

[Iso4ane]

I am from China, my parents were physicians in China. I lived inside the Court yard of a hospital until I was 11. Nothing over there is "advanced care". LOL

Wuhan, hubei isn't a very affluent province either. Wonder what the mortality rate is in Beijing or Shanghai? Their equipment/setup is more comparable to the US.

This part is scary.

Parts of China may not be advanced; but what about Italy, at the moment it looks like they got the crap kicked out of them.

 

[Ezekiel2517]

Per CDC and JAMA:

Teens with flu: 5 out of 100,000 die. Teens with COVID19: 200 out of 100,000.

In ppl aged 50-69: 57 deaths per 100,000 with the flu. 2,360 deaths per 100,000 with COVID19.

~1.6% of people w flu are hospitalized.
But ~2/3 of those people are > 65.

~14% of COVID-19 cases were "severe"
~5% led to respiratory failure, septic shock or multiple organ failure.

~2/3 of COVID-19 patients are < 60.

 

[marr65]

Per CDC and JAMA:

Teens with flu: 5 out of 100,000 die. Teens with COVID19: 200 out of 100,000.

In ppl aged 50-69: 57 deaths per 100,000 with the flu. 2,360 deaths per 100,000 with COVID19.

~1.6% of people w flu are hospitalized.
But ~2/3 of those people are > 65.

~14% of COVID-19 cases were "severe"
~5% led to respiratory failure, septic shock or multiple organ failure.

~2/3 of COVID-19 patients are < 60.

Wow! I’m praying like hell that we aren’t heading toward a catastrophe like the Italians.

 

[radsisrad]

Wow! I’m praying like hell that we aren’t heading toward a catastrophe like the Italians.

Given the apparent attitude of residents in one of the country's largest cities, there's little reason for optimism.

 

[Mman]

from an anesthesia/OR point of view, my biggest question is if hospitals will start cancelling elective cases going out over a month or two time frame to free up hospital beds/resources or if they will wait til it hits in their area. And then if an area starts getting overwhelmed, will they actually need to use anesthesia machines as ventilators? If so will they physically use patients in the OR? Will they drag those machines to say step down/intermediate beds that get turned into make shift ICUs?

You start getting into uncharted territory really quickly and also hitting bottom lines extremely hard when those elective cases go bye for a while.

 

[GravelRider]

from an anesthesia/OR point of view, my biggest question is if hospitals will start cancelling elective cases going out over a month or two time frame to free up hospital beds/resources or if they will wait til it hits in their area. And then if an area starts getting overwhelmed, will they actually need to use anesthesia machines as ventilators? If so will they physically use patients in the OR? Will they drag those machines to say step down/intermediate beds that get turned into make shift ICUs?

You start getting into uncharted territory really quickly and also hitting bottom lines extremely hard when those elective cases go bye for a while.

It has already hit in WA, CA, NY, and FL. What have hospitals in those areas done? I don’t know. I’m not aware of hospitals cancelling elective surgeries yet, but I could be wrong.

The biggest problem I see is we really fumbled the start of this by not testing people more broadly. It’s difficult to respond to a pandemic when you don’t have the data.

 

[kmurp]

I know one of our larger local hospitals has discussed shutting down the OR for electives if it becomes necessary. For our group, any prolonged 3-4 week shutdown will cause us to be unable to meet payroll as we tend to not have much extra cash on hand this early in the year.

 

[GravelRider]

I know one of our larger local hospitals has discussed shutting down the OR for electives if it becomes necessary. For our group, any prolonged 3-4 week shutdown will cause us to be unable to meet payroll as we tend to not have much extra cash on hand this early in the year.

The one thing we do know is that extreme “social distancing” is the best way to stop a communicable disease. What will the downstream costs be if we wait too long to enact measures to actually enforce “social distancing?” China was able to slow the spread because they are an authoritarian government with a docile populace. What’s going to happen in a capitalist society where businesses run on tight margins and always have their eye on the bottom line? The lack of data about the disease early in its course is going to have exponential negative downstream effects because of a delayed response.

A week ago I was firmly in the camp of “ah this will blow over.” Now, I’m not so sure.

 

[Iso4ane]

A week ago I was firmly in the camp of “ah this will blow over.” Now, I’m not so sure.

Same here, but I think it’s the anesthesiologist in us. It is like the BP is trending down and you’re not sure if it’s just the anesthetic or if the patient is going septic. I feel like the medical community is gearing up; but no one else is yet.

 

[cowbydoc]

Anyone here debating what to do if you have a vacation coming up? We leave for Florida in about ten days and depending on the moment you talk to me I will tell you I’m going or not going. Pretty sure we could get through everything unscathed with our precheck and direct flight be I also don’t want to be stupid with my family’s health.

 

[Leinie]

In WA state, intensivists have reported they were managing healthy, fit patients in their 20’s who were critically ill and vented.

Do you have a source for this?

 

[SingfrAbsoltion]

It has already hit in WA, CA, NY, and FL. What have hospitals in those areas done? I don’t know. I’m not aware of hospitals cancelling elective surgeries yet, but I could be wrong.

I heard Sinai canceled elective cases today? Anyone know if it’s true?

 

[deleted162650]

Anyone here debating what to do if you have a vacation coming up? We leave for Florida in about ten days and depending on the moment you talk to me I will tell you I’m going or not going. Pretty sure we could get through everything unscathed with our precheck and direct flight be I also don’t want to be stupid with my family’s health.

Ya, planning for HI in August. I would go without hesitation, but my youngest will be 9mo old at the time, and not sure I want to put her on a plane right now. Otherwise I would go without hesitation.

 

[AMEHigh]

Anyone here debating what to do if you have a vacation coming up? We leave for Florida in about ten days and depending on the moment you talk to me I will tell you I’m going or not going. Pretty sure we could get through everything unscathed with our precheck and direct flight be I also don’t want to be stupid with my family’s health.

I do think social distancing as a mitigation strategy is going to become more and more important. There’s a reason that other countries have essentially shut down nonessential travel. The majority of us whom are young and healthy will be ok but is there a way to help mitigate the spread? Yes absolutely, by not travelling via plane and cruise ship for example.

Clearly there are a lot of unknowns, will our health system struggle with resources? Who knows. But I think laying low for the next 2-4 weeks is likely a good idea and what I plan to do. Already had 2 conferences cancelled & 1 personal trip. This will all unfortunately have (and already is) widespread financial consequences for many.

 

[nimbus]

Ya, planning for HI in August. I would go without hesitation, but my youngest will be 9mo old at the time, and not sure I want to put her on a plane right now. Otherwise I would go without hesitation.

I wouldn’t expose a baby either but they tend to have mild illness from COVID with no reported fatalities to date. China reported no fatalities in anybody under 9 years old.

 

[deleted162650]

I wouldn’t expose a baby either but they tend to have mild illness from COVID with no reported fatalities to date. China reported no fatalities in anybody under 9 years old.

Ya I know. Would rather not be the first case report though.

It’s uncanny how strong of a preference this virus shows for the aged (particularly those with comorbidities) where as most other illnesses tend to hit the very young as well as the old. It’s almost as if the Chinese cooked this up in a lab in an effort to reduce their “less productive” segment of the population.

 

[agammaglobulin]

It has already hit in WA, CA, NY, and FL. What have hospitals in those areas done? I don’t know. I’m not aware of hospitals cancelling elective surgeries yet, but I could be wrong.

The biggest problem I see is we really fumbled the start of this by not testing people more broadly. It’s difficult to respond to a pandemic when you don’t have the data.

I'm in the Seattle area and can tell you there's only one hospital I know of canceling elective procedures. Regardless, patients are starting to cancel their own elective procedures. Testing is a HUGE issue. Not sure what the deal is (limited kits, expensive, etc) but it's fairly hard to get someone to test you in Seattle area. Bill and Melinda Gates Foundation is working on testing kits that can get sent to your home and Univ of WA has developed their own test and is ramping up. My understanding is UW is testing their own symptomatic employees in a well ventilated parking lot - people get an appointment online, drive by at the appropriate time, stay in their cars while doing their swab. Pretty smart to limit exposure.

 

[Shimmy8]

Belize in 5 weeks with a big group of mid 30s couples. We’re going unless travel isn’t allowed. I’d be very hesitant with kids/grandparents though.

 

[deleted171991]

Belize in 5 weeks with a big group of mid 30s couples. We’re going unless travel isn’t allowed. I’d be very hesitant with kids/grandparents though.

I would be very hesitant to go anywhere in an almost pandemic, especially to a non-developed country.

I would say the kids are the only ones who are close to 100% safe.

 

[Ezekiel2517]

Do you have a source for this?

Actually, if you head over to the ER forum and browse their COVID19 thread, one post shares a very detailed report from one of the intensivists from the physician group that managed many of these patients recently in WA.

 

[Ezekiel2517]

A week ago I was firmly in the camp of “ah this will blow over.” Now, I’m not so sure.

I mean, we know the R0 of COVID19, we know its doubling time, and we have an idea of the number of cases (which is likely underestimated). Given these numbers, the number of cases to come in the following weeks/months can be estimated. And even the most conservative numbers are not something our system/resources can come close to handling.

 

[deleted171991]

This is a very good presentation (as most from Maryland CC are) about Covid vs Flu. One number that should jump out to everybody is 46,500 (the total number of ICU beds in the US). It's very easy to imagine ICUs being overwhelmed in a major epidemic.

Deming & Williams – Influenza vs. Coronavirus: Just another cold? | University of Maryland

maryland.ccproject.com

 

[deleted171991]

Actually, if you head over to the ER forum and browse their COVID19 thread, one post shares a very detailed report from one of the intensivists from the physician group that managed many of these patients recently in WA.

I assume this is the post you're talking about:

What do I need to know about coronavirus?

I run a dedicated COVID19 Screening Clinic, because our hospital's ED and UCC was just getting hammered by masses of 'worried well' people presenting with just a simple cold/flu, who do not even fit the suspected case definition to warrant testing. I have had no positives for COVID19 at our...

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