Category Archives: Coronavirus

Mitchell Feierstein on Wall Street and #COVID19 and #Coronavirus

Are you tired of this pic yet?

This writer sounds like Michael Krieger.

From Mitchell Feierstein writing at RT.com:

Banks, politicians and governments will scapegoat Covid-19 to shift the blame for over 30 years of fiscal profligacy, loose monetary policies, fraud, and the lack of any proper regulatory enforcement away from themselves and onto anything or anyone else. Eventually, taxes will skyrocket to pay for these opaque bailouts, reckless spending policies, and record low interest rates during the past three decades.

Covid-19 presents an easy way to assign blame while forcing through “emergency legislation” allowing big government to implement 1984-style draconian social controls that will impinge and dismantle personal freedoms, liberties and democratic principles as they fleece taxpayers – again. If you think the 2008 recession and bailouts were bad, wait until you see how the greatest economic depression in history plays out.

This bubble has only begun to pop, and there are many more shoes to drop from this centipede before prices hit bottom. The downside will be significantly worse than the upside. Until leverage, valuations and corporate debt return to reasonable levels, stay clear. When these events do happen, we will see once-in-a-lifetime opportunities to create wealth.

The two most important lessons I learned from my 40 years in international financial markets, lessons that can also be applied to politics and to life in general, are to never make any decision based on emotion or ideology and to never, ever trust the news. Today’s media are exponentially worse than they were in the 1980s and 1990s. They no longer provide news. What they provide are stories that are around 80 percent ideology and opinion, 10 percent lies and spin, and 10 percent fact. You need to divorce yourself from emotion and ideology.

You need to base decision-making on statistical probability utilizing raw economic data, rational reason, logic and facts. Fasten your seat belts tightly; severe turbulence is coming, and the ride will be bumpy.

Source: For 40 years I watched ‘rampant fraud’ on Wall Street destroy capitalism, Covid-19 nailed its coffin shut — RT Op-ed

Steve Parker, M. D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

ZDoggMD Interviews Intensivist Dr Herbert Patrick on #COVID19 Critical Care #Coronavirus

The tube in the mouth goes down into the lungs. The actual ventilator machine is out of the picture. You have to be heavily sedated to tolerate this 

I am not an intensivist, a physician that works full-time in critical care units, aka ICUs. Although I’m a hospitalist, I don’t do much work at all in the ICU. Intensivists are usually pulmonologists although I think more recently there are fellowship programs that bypass typical pulmonology training and go straight to critical care.

Anyway, if this Coronavirus pandemic really takes off in my area, I may have to start impersonating an intensivist because there may not be enough to go around.

Local TV news last night mentioned that the Feds are re-opening a hospital in Phoenix that closed down last fall—Phoenix St Luke’s—to provide 340 ICU beds. I swear that’s what I heard—340 ICU beds. Where will they get the staff: intensivists, respiratory therapists, ICU nurses??? My hospital has 8–10 ICU beds. Sometimes a bed is available, but no nurse to staff it. So the bed is useless. Be aware that ICU nursing is a specialty; you can’t just take any nurse and throw him in there.

The video below will be unintelligible to you unless you are a hospital-based physician, respiratory therapist, or nurse. So move along. Dr Z interviews Philadelphia intensivist Dr Herbert Patrick, who’s had experience with critically ill COVID-19 patients.

A few of my personal notes, “just in case.” These may not be accurate because Dr Patrick’s voice recording was sub-optimal.

  • his ICU patient are in “airborne isolation” negative pressure rooms
  • since Dr Patrick didn’t want to shave his beard, he uses a PAPR (powered air-purifying respirator)
  • some physicians are buying their own PAPRs for $1500-3000 (they are in short supply
  • providers not using PAPRs are covering the N95 masks with a “paper mask” (a surgical mask, I assume)
  • he advocates everyone in the hospital wear a surgical mask all the time (?)
  • don’t assume shock is always due to virus; search for bacteria and you will find
  • most COVID-19 ICU admits get an arterial line and central venous catheter, certainly if going on a vent
  • proning (prone body position)  is helpful: 4 hours prone, 4 hours on back or side, alternating every 4 hours
  • Ventilators: Start with PEEP of 8. 100% O2 at first, as usual. Tidal volume depends on plateau pressures during inhalation (keep under 30 cm H2O). A “weanable” patient should have FIO2 down to 50% and PEEP around 8.
  • permissive hypercapnia OK if needed; prevent or treat the associated acidosis with enteral bicitra via ore-gastric tube
  • don’t use so much PEEP that you interfere with cardiac output
  • if central venous O2 saturation is under 60-70, your PEEP may be impairing cardiac output, try to back off PEEP
  • he mentions external cardiac output measurement devices, which I’m not familiar with
  • the Impella device may help support cardiac output in selected cases; sounds like he prefers it over IAPB when available

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

 

Still Need to Know the Survival Rate of U.S. #COVID19 Patients on Mechanical Ventilation #Coronavirus

I paid istockphoto for these pics, so I’m gonna use ’em

If a COVID-19 patient ends up on a ventilator, what are the odds of survival? I haven’t found good data from non-China countries. I found one Chinese study of ~200 patients and it was quite discouraging. Only one of the 32 patients on a ventilator in the ICU survived.

I’ve been reading Karl Denninger’s blog and, if memory serves, he says that once you’re put on mechanical ventilation in a hospital, your odds of surviving that hospital stay are only 50:50. And a year later, of all ventilator patients, only three in 10 are still alive.

I ran across a 2015 article on long-term survival of critically ill patients treated with prolonged mechanical ventilation. “Prolonged” meaning over 14 days in this instance. I’ve only read the abstract. It’s a multi-country meta-analysis involving both acute and post-acute hospitals. Here are a few factoids:

  • overall mortality at one year was ~60% (only 4 in 10 still alive)
  • U.S. post-acute care hospital mortality one year out was 70%, worse than pooled non-US countries (so only 1 in 3 still alive, as Denninger says)

BTW, in the U.S. if you’re on mechanical ventilation for 12-14 days and your physicians figure you’ll need prolonged ventilation, you’ll get a tracheostomy.

COVID-19 patients on ventilators seem to need it for about 10 days. So the study at hand has little to do with them, in general. On the other hand, if a COVID-19 patient also has COPD, emphysema, or moderate-to-severe asthma, prolonged ventilation may well be in their future.

I’ve taken care of these prolonged ventilator patients in what we in the U.S. call long-term acute care hospitals (LTACHs). Many of these patients have Foley indwelling catheters which predispose them to urinary tract infections. They’re also prone to pressure sores, pneumonia, deep vein thrombosis, and life-threatening blood clots in the lungs. They need so much blood work done, they start to feel like a pin cushion. It’s a tough life, for sure. Not to mention the cost, which runs into the millions.

If you have data on the survival rates of U.S. COVID-19 patients on mechanical  ventilation, please leave a comment below or email me at stevepakermd AT gmail DOT com. The medical literature should have published date in a month or so, in an ideal world.

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

From the New Orleans War Zone: Clinical Pearls on #Covid19 for ER Practitioners and Others #Coronavirus

Not in New Orleans

I read an anonymous post a few day ago at TexAgs.com, which I assume is a forum for graduates of Texas A&M University. You will find it interesting and useful if you are a physician, respiratory therapist, or nurse that will be treating COVID-19.

The writer says he (she?) works at a small community hospital in New Orleans that has 22 ICU beds. I’m guessing total bed total is 300-350. The entire article seems legitmate, but you never know. The only slightly fishy item was a mention of checking interleukin-6 (IL-6) levels, which I never see ordered in my hospital. I always figured it was just a research tool. He implies it’s a marker of imminent clinical deterioration.

I am an ER [emergency room] 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 [On March 25, 2020].

Clinical course is predictable.

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 multiorgan failure. You can literally watch it happen in a matter of hours. 81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

The writer has not seen any great improvement with hydroxychloroquine.

He posits that worldwide 85% of COVID-19 patients that go on a ventilator die. I’ve never seen that figure before, and question it. I think we just don’t know yet. Wouldn’t surprise me if true.

The actual ventilator is out of the picture. This is the tubing. 

I’m sure the author would advise all practitioners to stay alert for new and optimal treatment modalities. We’re still learning the best way to treat this thing.

Source: Clinical Pearls Covid 19 for ER practitioners | TexAgs

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

 

Outcomes and Characteristics of 21 Critically Ill Patients With #COVID19 in Washington State #Coronavirus

 

For a COVID-19 patient, she’d be wearing more personal protective equipment (PPE)

JAMA Network has a descriptive account of 21 patients with COVID-19 admitted to the ICU at Evergreen Hospital in Kirkland, WA. Most cases were related to the nursing home outbreak and were admitted late Feb-early March, 2020. Average age was 70.

I’ve been wondering how many COVID-19 patients survive their period of intubation in the U.S. I still don’t know. That survival rate was abysmal in the one Chinese study I saw.

15 of these 21 patients required intubation and mechanical ventilation. As of March 17, the mortality rate was 67%, and 9.6% were discharged from the ICU. Current survivors are not out of the woods yet, so the mortality rate could trend upwards.

An abnormal chest radiograph was observed in 20 patients (95%) at admission. The most common findings on initial radiograph were bilateral reticular nodular opacities (11 patients [52%]) and ground-glass opacities (10 [48%]). By 72 hours, 18 patients (86%) had bilateral reticular nodular opacities and 14 (67%) had evidence of ground-glass opacities. The mean white blood cell count was 9365 μL at admission and 14 patients (67%) had a white blood cell count in the normal range. Fourteen patients (67%) had an absolute lymphocyte count of less than 1000 cells/μL. Liver function tests were abnormal in 8 patients (38%) at admission (Table 1).

Mechanical ventilation was initiated in 15 patients (71%) (Table 2). Acute respiratory distress syndrome (ARDS) was observed in 15 of 15 patients (100%) requiring mechanical ventilation and 8 of 15 (53%) developed severe ARDS by 72 hours. Although most patients did not present with evidence of shock, vasopressors were used for 14 patients (67%) during the illness. Cardiomyopathy developed in 7 patients (33%).

Source: Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State | Cardiology | JAMA | JAMA Network

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

U.S. Office of Civil Rights Issues Bulletin on Civil Rights Laws That Apply During the #COVID19 Pandemic #Coronavirus

Tube’s about to go in

When two people need a ventilator and only one vent is available, a physician will have to keep civil rights in mind, as always. You or one of your loved ones may be in line for that vent.

Today, the Office for Civil Rights (OCR) at the U.S Department of Health and Human Services (HHS) is issuing a bulletin to ensure that entities covered by civil rights authorities keep in mind their obligations under laws and regulations that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and exercise of conscience and religion in HHS-funded programs, including in the provision of health care services during COVID-19.

OCR is particularly focused on ensuring that covered entities do not unlawfully discriminate against people with disabilities when making decisions about their treatment during the COVID-19 health care emergency.

OCR enforces the Americans with Disabilities Act, Section 504 of the Rehabilitation Act, the Age Discrimination Act, and Section 1557 of the Affordable Care Act which prohibits discrimination in HHS funded health programs or activities. These laws, like other civil rights statutes OCR enforces, remain in effect. As such, persons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative “worth” based on the presence or absence of disabilities or age. Decisions by covered entities concerning whether an individual is a candidate for treatment should be based on an individualized assessment of the patient and his or her circumstances, based on the best available objective medical evidence.

“Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism,” said Roger Severino, OCR Director. “HHS is committed to leaving no one behind during an emergency, and helping health care providers meet that goal.” “Persons with disabilities, with limited English skills, and older persons should not be put at the end of the line for health care during emergencies.” Severino added.

I don’t know the amount of fines or length of prison terms if these civil rights laws are violated.

Source: OCR Issues Bulletin on Civil Rights Laws and HIPAA Flexibilities That Apply During the COVID-19 Emergency | HHS.gov

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.

FDA authorizes use of anti-malaria drugs #hydroxychloroquine and #chloroquine for #coronavirus care #COVID19

“Give it to me, doc!”

Right on the heels of my last post, which wasn’t optimistic for hydroxychloroquine….

From Politico:

The Food and Drug Administration on Sunday issued an emergency use authorization for hydroxychloroquine and chloroquine, decades-old malaria drugs championed by President Donald Trump for coronavirus treatment despite scant evidence.

The agency allowed for the drugs to be “donated to the Strategic National Stockpile to be distributed and prescribed by doctors to hospitalized teen and adult patients with COVID-19, as appropriate, when a clinical trial is not available or feasible,” HHS said in a statement, announcing that Sandoz donated 30 million doses of hydroxychloroquine to the stockpile and Bayer donated 1 million doses of chloroquine.

Source: FDA issues emergency authorization of anti-malaria drug for coronavirus care – POLITICO

French researcher Didier Raoult​ M.D./Ph.D. and associates recently published their results of an 80-patient study using hydroxychloroquine and azithromycin in COVID-19 patients. From the abstract:

This [treatment] allowed patients to rapidly [be] [discharged] from highly contagious wards with a mean length of stay of five days. We believe other teams should urgently evaluate this cost-effective therapeutic strategy, to both avoid the spread of the disease and treat patients as soon as possible before severe respiratory irreversible complications take hold.

So their focus seems to be on reducing viral shedding from infected patients, rather than on overall clinical outcomes, e.g., reduction of death, reduced admissions to hospital and ICU. Click for an explanatory article at TechStartUps.

Dr David Gorski has already done a thorough fisking of the study, so I won’t bother. For example:

I was scratching my head as I read this. By this description, these patients mostly had mild disease. Only 15% had fever? Fever is a prominent feature of symptomatic adults with COVID-19. Only 53% had lower respiratory tract infection symptoms? Four of the patients (5%) were asymptomatic? 92% had low COVID-19 severity scores as measured by the National Early Warning Score (NEWS)? Why were they even admitted in the first place, rather than instructed to isolate themselves in their homes? That’s what’s generally done; asymptomatic SARS-CoV-2-positive patients and patients with mild COVID-19 symptoms are generally just told to stay home for at least two weeks and call if their symptoms worsen. Later in the paper, we learn that only 15% of these patients required oxygen, while only three required ICU admission, with one death.

***

Basically, this is a nothingburger of a paper. It studied patients with low severity or even asymptomatic COVID-19 disease, the vast majority of whom would likely have cleared the virus just as fast without the medications. Again, this is such a useless paper, even as an observational paper, that it tells us, in essence, nothing new.

Helpfully, Dr Gorski also commented on New York’s 15-minutes-of-fame Dr   Vladimir Zelenko. Dr G is not a fan, calling some of his actions and words irresponsible and unethical. Not having a large legal defense fund, I’m not often as outspoken as Dr Gorski. Yes, the truth is defense against libel, but how much truth can I afford? Not much.

A final thought from Dr Gorski:

I fear that, when all is said and done, the COVID-19 pandemic will be the single greatest opportunity for grifters and snake oil salesmen. Until a vaccine and/or effective treatment is developed, the grift will continue.

Steve Parker, M.D.

Steve Parker MD, Advanced Mediterranean Diet

Click the pic to purchase at Amazon.com. E-book versions also available at Smashwords. com.