Advanced Mediterranean Diet

She may have the right idea

Infectious Disease Professor Kim Woo-joo from Korea University Guro Hospital has no doubt that the common use of face masks by the public in Korea and other Asian countries helps to reduce the spread of coronavirus and COVID-19. His pertinent comments start at 15:50 or so. If you’re fairly knowledgeable  about this pandemic, you can skip everything up until then.

He thinks the World Health Organization and DCD pooh-pooh face masks for the general public so that healthcare workers have enough.

Did you know you can increase the playback speed? I listened at speed 1.5 and had no trouble. Most of the video has subtitles in English.

Dr Woo-too stresses the importance of frequent hand-washing.

Also discussed is that the common street mask in Korea is the KF94, which I’d never heard of. Dr W says they’re nearly as good as the N95.

Dr W implies that smoking by itself is a risk factor for contracting COVID-19, regardless of any underlying diagnosis of emphysema or COPD.

Not this hospital

The problem is two-fold. If a hospital is overwhelmed with critically ill patients, there won’t be enough equipment or staff to go around. So you’re forced to ration resources—there’s no alternative unless you can transfer the patient to another facility. The other issue is that it may be futile to do cardiopulmonary resuscitation on a certain subset of patients, because they all die anyway. Use your limited resources on patients who have a fair chance of eventually walking out of the hospital.

From The Washington Post:

Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.

Wyese, the Michigan ICU nurse, said his own hospital has been thinking about these issues for years but still is unprepared.

“They made us do all kinds of mandatory education and fittings and made it sound like they are prepared,” he said. “But when it hits the fan, they don’t have the supplies so the plans they had in place aren’t working.

”Over the weekend, Wyese said, a suspected covid-19 patient was rushed in and put into a negative pressure room to prevent the virus spread. In normal times, a nurse in full hazmat-type gear would sit with the patient to care for him, but there was little equipment to spare. So Wyese had to monitor him from the outside. Before he walked inside, he said, he would have to put on a face shield, N95 mask, and other equipment and slather antibacterial foam on his bald head as the hospital did not have any more head coverings. Only one powered air-purifying respirator or PAPR was available for the room and others nearby that could be used when performing an invasive procedure — but it was 150 feet away.

While he said his hospital’s policy still called for a full response to patients whose heart or breathing stopped, he worried any efforts would be challenging, if not futile.

“By the time you get all gowned up and double-gloved the patient is going to be dead,” he said. “We are going to be coding dead people. It is a nightmare.”

Source: Doctors consider universal do-not-resuscitate orders for coronavirus patients – The Washington Post

I hadn’t thought about it before, but that last sentence has some truth to it. If someone is circling the drain toward cardiac or pulmonary arrest, it’s best to do it before they actually “code.”

Steve Parker, M.D.

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Post-viral apocalypse? Raccoon City?

Wise words from economist Brian Wesbury:

The government-mandated shutdown of business, and the massive drop in economic activity it is causing, may actually do more harm to the United States than the coronavirus itself.  Early estimates suggest the U.S. economy will contract at a staggering 20% annualized rate in the second quarter, and the number may move even higher.  Despite multiple recessions, global wars, the avian flu, SARS, 9/11, and natural disasters, the U.S. hasn’t experienced a quarterly drop in activity like this since the Great Depression.

The unemployment rate is likely to double from 3.5% to 7% in the coming months, representing a loss of more than 5 million jobs.  And the longer the shutdown lasts, the further that number is likely to rise.  Few businesses have cash hoards that can tide them over for this drastic a decline in activity.  People are coming up with creative solutions, stopping rent and loan payments, but there isn’t enough money in most business coffers to survive a trillion-dollar drop in economic production.  The greater the number of businesses that don’t survive, the slower the path to recovery when this global tragedy passes.

Tax payments to federal, state and local governments will fall precipitously, and many government entities will face serious financial challenges (if they didn’t already).  Illinois, for example, still has billions of dollars of unpaid bills, not to mention a severely underfunded pension system.  A 10%-to-20% drop in tax revenue makes these problems that much worse.  And every extra day the shutdown continues, the deeper the hole is dug.

Source: Cut the Politicians’ Pay

RTWT for Wesbury’s proposed solution.

Are you tired of this pic yet?

Physicians in New York City, Los Angeles, and Seattle may soon need to answer the question, if they haven’t already.

From a Perspective article in the New England Journal of Medicine:

But though approaches vary even within a single hospital, I sensed that age was often given the most weight. I heard one story, for instance, about an 80-year-old who was “perfect physically” until he developed Covid-19–related respiratory failure. He died because mechanical ventilation could not be offered. Though Lombardy’s richly resourced health care system has expanded critical care capacity as much as possible, there simply were not enough ventilators for all patients who needed them. “There is no way to find an exception,” Dr. L. told me. “We have to decide who must die and whom we shall keep alive.”

Contributing to the resource scarcity is the prolonged intubation many of these patients require as they recover from pneumonia — often 15 to 20 days of mechanical ventilation, with several hours spent in the prone position and then, typically, a very slow weaning. In the midst of the outbreak’s peak in northern Italy, as physicians struggled to wean patients off ventilators while others developed severe respiratory decompensation, hospitals had to lower the age cutoff — from 80 to 75 at one hospital, for instance. Though the physicians I spoke with were clearly not responsible for the crisis in capacity, all seemed exquisitely uncomfortable when asked to describe how these rationing decisions were being made. My questions were met with silence — or the exhortation to focus solely on the need for prevention and social distancing. When I pressed Dr. S., for instance, about whether age-based cutoffs were being used to allocate ventilators, he eventually admitted how ashamed he was to talk about it. “This is not a nice thing to say,” he told me. “You will just scare a lot of people.”

Dr. S. was hardly alone. The agony of these decisions prompted several of the region’s physicians to seek ethical counsel. In response, the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) issued recommendations under the direction of Marco Vergano, an anesthesiologist and chair of the SIAARTI’s Ethics Section.2 Vergano, who worked on the recommendations between caring for critically ill patients in the ICU, said that the committee urged “clinical reasonableness” as well as what he called a “soft utilitarian” approach in the face of resource scarcity. Though the guidelines did not suggest that age should be the only factor determining resource allocation, the committee acknowledged that an age limit for ICU admission may ultimately need to be set.

It would be easier to make this life-and-death decision if the experienced Italian physicians would share their ventilator survival rates—i.e., how many and what kind of patients were successfully weaned off the ventilator and walked out of the hospital—and who were the patients in which ventilator care was futile. As far as I know, 97% of ventilator patients in China died.

Source: Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line | NEJM

Steve Parker, M.D.

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

Deliberate sabotage of Trump’s presidency?

From ABC3340:

WASHINGTON (SBG) – As the coronavirus spread to all fifty states over the last two months, the Trump administration faced mounting criticism for the lack of reliable, widely accessible test kits. Now, a former senior federal health official nominated to his post by President Trump, alleges that the delays in testing occurred because leaders at the Centers for Disease Control “lied” to the president, and to Health and Human Services Secretary Alex Azar, about the center’s ability to produce the kits.

Source: EXCLUSIVE: Former HHS official claims CDC leaders “lied” to Trump over coronavirus testing | WBMA

Who knows?!

Artist’s rendition of coronavirus

The U.S. CDC has published some preliminary data on 4226 U.S. citizens diagnosed with COVID-19 between mid-Feb and mid-March, 2020. Twelve percent of those were hospitalized. The CDC confirms that those over 60–65 years old are at greatest risk of serious illness or death; nothing new there.

The startling info for me was that adults of all age groups were prone to being admitted to a hospital with the infection. For instance, the rate of hospitalization for those aged 45–64 was 25%. The hospitalization rate for those 20–44 was not fare behind at 20%.

Early on during this epidemic, we thought young adults overall didn’t get terribly sick with this illness. A 20% hospitalization rate sounds pretty sick to me. We’re still in the early phase, so the statistics will change over time. As medical resources are under increasing pressure, admission criteria will tighten up, and you may have to be sicker than these 4226 to get admitted.

Of the 4226 patients, 121 were admitted to the ICU. Twelve percent of those were aged 20–44, compared with 36% being 45–64 years old.

Fortunately, it also appears that those under 19 years old are very unlikely to require hospitalization or ICU admission.

The report doesn’t mention how many of those admitted to the ICU were on mechanical ventilation, nor how many made it out of the hospital alive.

To quote the report:

As of March 16, a total of 4,226 COVID-19 cases had been reported in the United States, with reports increasing to 500 or more cases per day beginning March 14 (Figure 1). Among 2,449 patients with known age, 6% were aged ≥85, 25% were aged 65–84 years, 18% each were aged 55–64 years and 45–54 years, and 29% were aged 20–44 years (Figure 2). Only 5% of cases occurred in persons aged 0–19 years.

Among 508 (12%) patients known to have been hospitalized, 9% were aged ≥85 years, 36% were aged 65–84 years, 17% were aged 55–64 years, 18% were 45–54 years, and 20% were aged 20–44 years. Less than 1% of hospitalizations were among persons aged ≤19 years (Figure 2). The percentage of persons hospitalized increased with age, from 2%–3% among persons aged ≤19 years, to ≥31% among adults aged ≥85 years. (Table).

Among 121 patients known to have been admitted to an ICU, 7% of cases were reported among adults ≥85 years, 46% among adults aged 65–84 years, 36% among adults aged 45–64 years, and 12% among adults aged 20–44 years (Figure 2). No ICU admissions were reported among persons aged ≤19 years. Percentages of ICU admissions were lowest among adults aged 20–44 years (2%–4%) and highest among adults aged 75–84 years (11%–31%) (Table).

Source: Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020 | MMWR

Steve Parker, M.D.

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

Artist’s rendition of Coronavirus

Previously I shared with you some data from two hospitals in Wuhan, China, regarding their experience with COVID-19 as of Jan 31, 2020.

Something led me back to that study and on closer review I found shocking numbers. The report outlines their experience with 191 hospitalized patients. 137 were eventually discharged. 54 died.

Here’s the shocker: Of the 54 who died, 32 required mechanical ventilation. Of those 32, 31 died. That’s a 97% mortality rate if you end up on a ventilator in China.

I readily admit I know nothing about the quality of medical care anywhere in China. Nor do I know if we can trust the data coming out of China.

If a therapeutic modality has a 97% failure rate, that’s awfully close to being futile. Physicians have no obligation to offer futile “therapy” to patients. Before the U.S. ramps up production of an extra several hundred thousand ventilators,  maybe we need to re-think that. What I don’t know offhand is, what is the Italian experience with COVID-19 patients on ventilators. If it’s just as poor as China’s, should we even be offering ventilators to patients? Don’t forget, every ventilator patient takes up an ICU bed and ventilator that might be needed for a patient—maybe you or someone you love—with a much higher survival rate.

I’ve heard anecdotal reports of U.S. COVID-19 patients getting off ventilators alive and walking out of the hospital. But anecdotes are not hard data. Italy has a lot of experience with this issue. What are their survival rates after intubation and mechanical ventilation? Or ECMO? I’ll let you know when I find out. If you know now, please leave a comment below.

The time may come in the very near future that physicians have to tell 80-year-old patients with heart failure and COPD (chronic obstructive pulmonary disease) and now COVID-19 that we won’t put them on a mechanical ventilator because their chance of survival is zero, or no ventilator is available. Sad.

Anxiously awaiting more data.

Steve Parker, M.D.

PS: Of the three Chinese patients given ECMO, all died.

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Artist’s rendition of Coronavirus

In a word: No.

Scientists and physicians are furiously looking for existing drugs that fight coronavirus (COVID-19). The combo of hydroxychloroquine and azithromycin showed promise in a French population.

These are my personal notes after reading the article below. They will bore you, so move along.

These researchers say hydroxychloroquine is generally safer and less toxic than chloroquine, a similar drug that had been used as a COVID-19 treatment in China (IIRC, 500 mg by mouth twice daily).

Contraindications to use of hydyroxychloroquine include G6PD deficiency (more common in Mediterranean populations that in the U.S.) , retinopathy, QT prolongation. Azithromycin and can also prolong QT interval, so  daily EKGs were done on these patients.

In lab studies, azithromycin seems to inhibit Zika and Ebola viruses. And it tends to prevent bacterial infections (pneumonia, sinusitis, pharyngitis?) that sometimes soon follow a virus infection.

Study Population

Twenty adult patients who were hospitalized, six of whom had no symptoms. (So why were they hospitalized? Authors don’t say.) Most of the patients with symptoms had upper respiratory tract symptoms (sore throat, runny nose, sinus congestion, or isolated low-grade fever and myalgias). The others had lower respiratory tract symptoms (symptoms of pneumonia or bronchitis, which will always include cough). The latter all had CT-confirmed pneumonia.

Hydroxychloroquine dose was 200 mg three times daily for 10 days. Twenty-six patients (average age 52) received the drug; six were deleted from analysis because they quit the drug. Of the 20 remaining, six received Z-pak to prevent super-infection (a bacterial infection along with the virus). How they chose who  got azith was not specified. The control patients (16) were others in various other hospitals (or clinics?).

Three of the 36 original enrollees were “lost to follow-up” because they were transferred to the ICU.

Results

Patients receiving the combo of hydroxychloroquine and azithromycin demonstrated greater rates of negative viral testing (via PCR) in nasopharyngeal swabs, in only three to six days in most patients. Note: averaged duration of viral shedding  in China was 20 days.

I saw no mention in the text about other real-world clinical outcomes such as death rates, decreased hospitalization length of stay, number of days before becoming symptom-free, etc.

My Assessment

This was a tiny pilot study that shows promise. Results my not be reproducible. Of course, we need a much larger study. If the drugs are widely available, I’d consider the combo as a treatment, particularly for the elderly or others at high risk of serious illness from COVID-19. This combo certainly CANNOT be considered the standard of care for this illness at this time. I’m surprised the authors are recommending it now, in the absence of any other proven effective anti-viral drugs.

Steve Parker, M.D.

Update on March 23, 2020: Dr David Gorski did a much more extensive and erudite fisking of the article. I highly recommend it to you if you have a medical or scientific background. I think he’d agree with my assessment. After reading his, I’m even less likely to prescribe the combo. He also discusses chloroquine, a relative of hydroxychloroquine.

Reference: Gautret et al (2020). Hydroxychloroquine and azithromycin as treatment for COVID-19: results of an open-label non-randomized trial. International Journal of Antimicrobial Agents – in press March 17, 2020 – DOI 10.1016/jinjantimicag.2020.105949

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An oxygen saturation monitor. Top number is O2 sat, bottom number is heart rate.

On Feb 26, 2020, I published and article on how to prepare your household for Coronavirus (COVID-19). I have a few more thoughts. How about an oxygen saturation monitor (aka pulse oximeter) and supplemental oxygen?

Most of the victims of this pandemic will be treating themselves at home. Just like most flu sufferers are treated at home, not the hospital, and do well. However, COVID-19 seems to be more serious if not lethal, particularly for those with particular pre-existing conditions.

A Little Cardiopulmonary Physiology

Your heart pumps blood to your lungs to blow off carbon dioxide and pick up oxygen for delivery to your tissues, to keep them alive and functioning well. Your arterial blood typically carries a lot of oxygen, but there’s a limit to how much it can hold. With a healthy cardiopulmonary system, your blood carries 94–99% of all the oxygen your blood could hold. That number is called your “oxygen saturation” or, among medical workers, “O2 sat.” Diseases in either the heart or lungs can impair your blood’s ability to carry oxygen, so your oxygen saturation may go down.

How Does COVID-19 Kill?

All the tissues in your body—some tissues more than others—need a steady supply of oxygen. Without oxygen, they die. Viral-induced inflammation in the lungs impairs oxygen delivery to your tissues. It’s not always that simple, but that’s all you need to know for now.

The earliest warnings of possible life-threatening coronavirus infection typically are shortness-of-breath and increased respiratory rate. Heart rate is usually higher, too. These are indicators that your body is working harder to get enough oxygen. That’s because the virus-induced lung inflammation partially blocks the transfer of oxygen from the atmosphere to the bloodstream.

Respiratory rate is your number of breaths per minute. A normal respiratory rate for an adult at rest is between 12 and 20. One breath is one inspiration and one expiration. Click to see a nurse teaching how to measure respiratory rate.

Artist’s rendition of coronavirus

How Do You Know If You Might Be Getting Into Serious Trouble With Coronavirus Or Any Other Lung Infection?

Your respiratory rate will be significantly elevated, approaching or above 30/minute, and/or your oxygen saturation will be under 92–93%. Your heart rate may be over 110 beats per minute, too. If you go to a hospital emergency department with breathing trouble, they will always check your oxygen saturation. If it’s under 92%, you’ll get supplemental oxygen to get you back up to at least 92%. And there’s a good chance you’ll be admitted to the hospital partly because it’s usually impossible to get oxygen delivered to the home in a timely fashion. If you have your own oxygen saturation monitor at home, you may be able to avoid an emergency department or urgent care visit if your O2 sat is over 92%.

What I’m reading online from other physicians is that COVID-19 patients tend to have lower O2 sats than they expected just from eyeballing the patient and looking at heart and respiratory rates.

If you have signs and symptoms of COVID-19 plus a respiratory rate 30 or higher, or oxygen saturation under 92-93%, seek medical attention immediately,

Emergency Departments and urgent care centers may soon be overwhelmed with coronavirus patients. Some will need to be admitted (assuming a bed is even available) and others can safely be sent home. In addition to vital signs and the overall appearance of the patient, a deciding factor for admission will often be oxygen saturation level. If too many patients that don’t need a hospital  level of care clog up the system, then other seriously ill folks will get delayed medical care, or none at all. 

That being said, if you think you need to go the emergency department or urgent care center, then go. Or talk to your personal physician first. I’m not your physician and don’t know the details of your case. I don’t want to be responsible for someone dying because they delayed or didn’t seek care because of what they read here.

What Can the Hospital Do For You If You Have COVID-19 Infection?

At first, it’s just going to be supplemental oxygen. That’s about it. We have no effective anti-viral drugs yet. Chloroquine, remdesivir, or other drugs might eventually pan out, but we don’t know as of March 20 2020. If things go south after admission, you’ll be put into a medically-induced coma and placed on a mechanical ventilator (if one’s even available), or get ECMO. Odds of death at this point are 50% or higher. If you go into shock (low blood pressure), drugs to raise blood pressure will be given, usually in the ICU (intensive care  unit), assuming a bed is available. Some COVID-19 patients will develop a bacterial infection on top of the virus, in which case antibiotics will be given.

So Is There Any Other Equipment I Need to Consider Acquiring In View of the Coronavirus Pandemic?

Yes….especially if you have risk factors for serious illness from COVID-19:

1. A pulse oximeter. I mentioned this to my wife about six days ago, so she went online, checked reviews, and chose the Onyx Vantage model 9590 finger pulse oximeter by Nonin, in the photo above. This is not my personal endorsement. She got a great deal on ours, $30 or less, perhaps because I’m a medical professional. Not sure of her source (McKesson?). I just check the price at Amazon and was shocked to see it priced at $139. I know several hospital nurses that purchased their own oximeters at local pharmacies for $40 or less (before onset of the pandemic).
2. A home oxygen supply. I know of only two options, One is an oxygen tank with nasal cannula tubing. Cost is unknown to me. I don’t know if you can get this without a doctor’s prescription. It’s dangerous if you don’t get instructions; you can blow yourself up or cause a fire. Oxygen is highly flammable. See the Apollo 1 conflagration of 1967. Option #2 is an oxygen concentrator device. The atmosphere is 21% oxygen; most of the rest is nitrogen. This device somehow concentrates oxygen and delivers it via nasal cannula at a concentration greater than 21%. I don’t know how much they cost, but I’m guessing several hundred or a thousand dollars. I don’t know if you can get one without a doctor’s prescription. Like oxygen from a tank, it can be dangerous if you don’t have instructions.

Stay tuned to various medical sources because the coronavirus situation changes on a daily basis.

May God bless us all, even if we don’t deserve it (and we don’t).

Steve Parker, M.D.

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

Elderly couple hoping to avoid inhalation of coronavirus

This is a reproduction of a post I made on one of my other blogs on Feb 26, 2020. If you have failed to prepare, it’s probably too late by now. I’m trying to consolidate all my coronavirus (COVID-19) posting here.

What I would add now is that you consider acquiring a pulse oximeter (aka oxygen saturation monitor) and a home oxygen supply (see a future post).

*  *  *

I hadn’t been too concerned about coronavirus (COVID-19), but then I read about quarantined towns in northern Italy. I’m still not terribly worried for my own health, even if I end up treating cases at the hospital. I’m 65—a risk factor for viral death—but otherwise healthy, thank God! There’s still a good chance this will blow over and not affect the U.S. in a major way. [That horse is already out of the barn!]

BUT…

If coronavirus becomes an epidemic in the U.S., you will want to be prepared. You’ll want to avoid unnecessary contact with others, especially if you’re over 65 or have significant chronic medical conditions like heart disease, COPD, asthma, active cancer, impaired liver or kidney function, or a poor immune system (e.g, cancer chemotherapy).

If your city or neighborhood is quarantined, will supply trucks be allowed through the checkpoints? Will drivers be willing to enter the quarantine zone? I’ve started to call Wal-Mart, “China-Mart.” Because is it seems like at least half the goods there are made in China. China’s industrial output has already been reduced by the coronavirus epidemic there. A significant number of prescription drugs in the U.S. depend on a healthy China.

A severe coronavirus outbreak in the U.S. might mean you need to hunker down at home, or close to it, for one or two months. So consider stocking up on the following items to last for 4–6 weeks. The good new is, you’ll eventually use most of this anyway.

• various foods with a long shelf-life
• face masks (you’re too late; this ship has already sailed)
• toilet paper
• paper towels
• over-the-counter cold and flu remedies
• acetaminophen
• ibuprofen
• throat lozenges
• antiseptic wipes
• toothpaste
• a multivitamin
• hand sanitizer
• facial tissues
• important prescription medicines (you may need to call your doctor for a three-month supply)
• body soap
• dishwashing and clothing detergents
• feminine hygeine products
• household cleaning products

Have I missed anything?

Steve Parker, M.D.

Update on March 3, 2020: hand sanitizer (60+% alcohol)