COVID-19 Update

[SigmundChurchill]

12 hours ago, Euripidespants said:

Sigmund. I’m curious if and how your institution is using ECMO to treat your patients. This past weekend I’ve seen our main hospital use it on several patients. Several of these have advanced disease on imaging, and several were not intubated (I am a radiologist). I didn’t get a chance to speak with one of the pulmonary/critical care docs directly this past weekend, but my understanding is they are seeing some success with the very sick patients. 

Thanks

Well, it’s kind of like trying to use Bentleys to fix a public transportation problem.  They are not the most practical solution for the pandemic, but for the right patient, it can be the difference between life and death.  There are far too few ECMO machines and they are really, really expensive to run.  We have used it on a select few patients with good results.  Life saving results.  The patients are chosen carefully, because the expense is so high, and if you have one success and one failure, then you just doubled the expense for that one success.  So, we aren’t putting any 80 year old patients with a history of CHF, on ECMO.  We use it for the people like the 39 year old who walked into our ER with an oxygen saturation of 35%.

[CaptainQuintero]

11 minutes ago, SigmundChurchill said:

Well, it’s kind of like trying to use Bentleys to fix a public transportation problem.  They are not the most practical solution for the pandemic, but for the right patient, it can be the difference between life and death.  There are far too few ECMO machines and they are really, really expensive to run.  We have used it on a select few patients with good results.  Life saving results.  The patients are chosen carefully, because the expense is so high, and if you have one success and one failure, then you just doubled the expense for that one success.  So, we aren’t putting any 80 year old patients with a history of CHF, on ECMO.  We use it for the people like the 39 year old who walked into our ER with an oxygen saturation of 35%.

 Sig just wondering what the population health is of the hospital you're at?

  My wife's hospital is surrounded by historic mining towns that closed down in the 80's and the vast majority of their COVID19 inpatients are 65+ male who worked in that industry for decades prior to health and safety legislation so have significant respiratory health issues

  Is what you're seeing representative of your national picture or does it look like it's heavily influenced by local public health issues?

[SigmundChurchill]

11 hours ago, tigger said:

Thank you. Interesting read!

Yes, it is.  The first 2 or 3 paragraphs are a little technical, but after that, it gets a lot easier to read.  If there is anything you dont understand, just ask.  I didn’t realize that TNF was so critical to the cytokine cascade, which is probably why it works so well on autoimmune diseases.  

I am a little more comfortable with immune modulators rather than immunosuppressive drugs though.  I have to say that the potential negative effects of suppressing the immune system are a little worrisome.  And I do mean “a little” in the literal sense.  Patients on a lot of these immunosuppressants are usually only around 5% more susceptible to pathogens than people not taking them.  And the article did address the concerns about the possibility of bacterial and fungal superinfections.  Clinical trials showed no increased risk for that.

It definitely shows promise, and I would probably not have even considered it until you pointed it out to me.  So thank you for that.

 

Also, I am happy to say that it looks like we are on the downslope at my hospital.  I dont want to jump the gun, but I only did 4 intubations in the last 12 hours vs the usual 10-15 that I was doing.  And the people on the intubation teams over the weekend are reporting the same.

[tigger]

29 minutes ago, SigmundChurchill said:

Yes, it is.  The first 2 or 3 paragraphs are a little technical, but after that, it gets a lot easier to read.  If there is anything you dont understand, just ask.  I didn’t realize that TNF was so critical to the cytokine cascade, which is probably why it works so well on autoimmune diseases.  

I am a little more comfortable with immune modulators rather than immunosuppressive drugs though.  I have to say that the potential negative effects of suppressing the immune system are a little worrisome.  And I do mean “a little” in the literal sense.  Patients on a lot of these immunosuppressants are usually only around 5% more susceptible to pathogens than people not taking them.  And the article did address the concerns about the possibility of bacterial and fungal superinfections.  Clinical trials showed no increased risk for that.

It definitely shows promise, and I would probably not have even considered it until you pointed it out to me.  So thank you for that.

 

Also, I am happy to say that it looks like we are on the downslope at my hospital.  I dont want to jump the gun, but I only did 4 intubations in the last 12 hours vs the usual 10-15 that I was doing.  And the people on the intubation teams over the weekend are reporting the same.

That's great news! Here's hoping it's a trend!

Thanks again for your thoughts. I got the gist of the technical jargon in the article.

I'l be interested in seeing if there are studies down the road about TNF inhibitors and ARDS.   
 

[SigmundChurchill]

3 minutes ago, CaptainQuintero said:

 Sig just wondering what the population health is of the hospital you're at?

  My wife's hospital is surrounded by historic mining towns that closed down in the 80's and the vast majority of their COVID19 inpatients are 65+ male who worked in that industry for decades prior to health and safety legislation so have significant respiratory health issues

  Is what you're seeing representative of your national picture or does it look like it's heavily influenced by local public health issues?

My hospital is on the border of two of the wealthiest towns in NJ, so the health of the general population is excellent.  They typically go to the gym, buy organic foods, and see their doctors regularly.  That said, this being NJ, we are only a few miles away from some of the poorest cities in NJ, and even though these cities have many hospitals, some of that population travels to my hospital for better care.  And who could blame them?  It is the smart move.  I would do the same in their position.

So the population is mixed.  The patients on ventilators are highly over-represented by the patients from the poorer areas, for a number of reasons.  Diabetes being the main one, but also heart disease, obesity, cigarette smoking/COPD, kidney disease, and hypertension, which are all seen at much higher rates in the poor communities.

We are losing all types of patients though.  This disease is taking it’s share of healthy, young people as well, but at a much lower rate than the elderly or unhealthy population.  

I put people into two categories. 

1.  Diabetes and obesity seem to have a link to a worse presentation of the disease.  These people tend to last a little longer than the second category, and they eventually die from multiorgan failure rather than respiratory failure

2.  Elderly, previous lung disease (your local population), and heart disease.  They tend to die more quickly, and it is usually directly related to the respiratory failure.  Very old people often die so quickly they never even make it to the hospital, and I dont even think they make it to the ARDS stage.  It’s just that the mucus is so thick, that they dont have the strength to breath through it.  If younger, healthy people who have recovered, having never even been hospitalized, say that they they had nights where they could barely breath, you can just imagine what that would do to an old, frail person at home in their bed.  The work of breathing would be so much, they would eventually just give up.  This is the same for people who may not be as old and frail in general, but already have weakened lungs from pre-existing lung disease.  Only they may be otherwise strong enough to get to the hospital and be placed on a ventilator, giving them more time to get to the ARDS stage, which is even more deadly when combined with other lung diseases.  That is, if their heart was strong enough to withstand the work for long enough for them to even get to that point.  Which brings me to people with pre-existing heart disease.  Even if relatively young, if you have a history of heart damage, from a previous heart attack, now you have a person with a heart that already does not pump well, getting greatly decreased oxygen from the lungs, so it beats faster and harder to try to compensate, putting such a strain on an already damaged heart, that it eventually leads to a fatal arrhythmia and stops beating.

[CaptainQuintero]

4 minutes ago, SigmundChurchill said:

My hospital is on the border of two of the wealthiest towns in NJ, so the health of the general population is excellent.  They typically go to the gym, buy organic foods, and see their doctors regularly.  That said, this being NJ, we are only a few miles away from some of the poorest cities in NJ, and even though these cities have many hospitals, some of that population travels to my hospital for better care.  And who could blame them?  It is the smart move.  I would do the same in their position.

So the population is mixed.  The patients on ventilators are highly over-represented by the patients from the poorer areas, for a number of reasons.  Diabetes being the main one, but also heart disease, obesity, cigarette smoking/COPD, kidney disease, and hypertension, which are all seen at much higher rates in the poor communities.

We are losing all types of patients though.  This disease is taking it’s share of healthy, young people as well, but at a much lower rate than the elderly or unhealthy population.  

I put people into two categories. 

1.  Diabetes and obesity seem to have a link to a worse presentation of the disease.  These people tend to last a little longer than the second category, and they eventually die from multiorgan failure rather than respiratory failure

2.  Elderly, previous lung disease (your local population), and heart disease.  They tend to die more quickly, and it is usually directly related to the respiratory failure.  Very old people often die so quickly they never even make it to the hospital, and I dont even think they make it to the ARDS stage.  It’s just that the mucus is so thick, that they dont have the strength to breath through it.  If younger, healthy people who have recovered, having never even been hospitalized, say that they they had nights where they could barely breath, you can just imagine what that would do to an old, frail person at home in their bed.  The work of breathing would be so much, they would eventually just give up.  This is the same for people who may not be as old and frail in general, but already have weakened lungs from pre-existing lung disease.  Only they may be otherwise strong enough to get to the hospital and be placed on a ventilator, giving them more time to get to the ARDS stage, which is even more deadly when combined with other lung diseases.  That is, if their heart was strong enough to withstand the work for long enough for them to even get to that point.  Which brings me to people with pre-existing heart disease.  Even if relatively young, if you have a history of heart damage, from a previous heart attack, now you have a person with a heart that already does not pump well, getting greatly decreased oxygen from the lungs, so it beats faster and harder to try to compensate, putting such a strain on an already damaged heart, that it eventually leads to a fatal arrhythmia and stops beating.

 I think you highlighted exactly the experiences they are having. Like you say, they are still having young patients although again it's pre-existing conditions like asthma that are the majority, the exceptions are worrying though.

  Normally she estimates 7/10 patients she sees in her ED are that older mining population that usually have at least 2 or 3 of heart disease, diabetes (with limb losses), kidney failure of some degree, work related respiratory diseases, obesity, cancers. The ratio seems the same but it's only a tiny minority of these that leave resus and go to ICU. Ironically it looks like it's these pre-existing conditions of the patients that is keeping their ICU from being overwhelmed. If their patients were coming in a lot healthier then they would be is a lot worse situation. I'm wondering if this might be something that we see start to play out in poorer nations where the population health is already so low that what limited ICU driven care they have, isn't needed in such high quantities in the end

  Dementia is an interesting one, usually there is a continuous stream but it's almost non existent, part of me is taking that to be down to them deteriorating so fast it doesn't get to ED; ambulance crews are operating under a very strict policy; eg Wife mentioned that crews are only attempting one round of resuscitation if responding to patients with certain health issues or age. DNR forms have been sent out en mass to care homes and those with certain underlying health conditions.

  One which is keeping staff a little amused at least is that norovirus, both on wards and admissions are essentially nill; people are actually washing their hands like they always should have been

[SigmundChurchill]

4 hours ago, CaptainQuintero said:

 I think you highlighted exactly the experiences they are having. Like you say, they are still having young patients although again it's pre-existing conditions like asthma that are the majority, the exceptions are worrying though.

  Normally she estimates 7/10 patients she sees in her ED are that older mining population that usually have at least 2 or 3 of heart disease, diabetes (with limb losses), kidney failure of some degree, work related respiratory diseases, obesity, cancers. The ratio seems the same but it's only a tiny minority of these that leave resus and go to ICU. Ironically it looks like it's these pre-existing conditions of the patients that is keeping their ICU from being overwhelmed. If their patients were coming in a lot healthier then they would be is a lot worse situation. I'm wondering if this might be something that we see start to play out in poorer nations where the population health is already so low that what limited ICU driven care they have, isn't needed in such high quantities in the end

  Dementia is an interesting one, usually there is a continuous stream but it's almost non existent, part of me is taking that to be down to them deteriorating so fast it doesn't get to ED; ambulance crews are operating under a very strict policy; eg Wife mentioned that crews are only attempting one round of resuscitation if responding to patients with certain health issues or age. DNR forms have been sent out en mass to care homes and those with certain underlying health conditions.

  One which is keeping staff a little amused at least is that norovirus, both on wards and admissions are essentially nill; people are actually washing their hands like they always should have been

With a bit of irony, we may actually see lower death rates in many countries where McDonalds and frozen pizzas are not a dietary option for poor people, who instead, just get by on eating less.  Our diet and lifestyle are the cause of many of our country’s health issues.

But yes, the lack of proper health care may even things out.