Walter Reed
- 2 incidents of drop in O2, last to 93%. This alone is not that worrisome
- First dose of dexamethasone. This is the only treatment shown to improve survival, but only in those who have needed oxygen (and these oxygen levels are higher than most given steroids)
Radiology findings of changes due to COVID are quite common. Without specifics, could certainly have findings without these being signs of severe disease.
O2 drop was yesterday morning. Press conference yesterday would have been at about the same time, apparently
None of these reported oxygen levels are worrisome but it's still early in the course, and early days are usually mild, though the start date of symptoms has not been fully clarified. The findings relative to the day of symptoms help determine severity of course.
COVID takes a while to get over. Of those hospitalized most are not back to their baseline a month later.
In general, steroids should be withheld if a patient is not needing oxygen as benefit has not been shown in these cases. Steroids can have many downsides - lowered immune response, weight gain, hypertension, elevated sugars, muscle weakness, mood changes etc
Again, just boring the public with facts would be the best approach. Lung fundings on imaging would only be expected. Evasive responses make a very common finding sound more ominous.
Will need to see over the next few days how the course changes. Without knowing which day of illness this is, it is hard to chart the course accurately.
Again, just boring the public with facts would be the best approach. Lung fundings on imaging would only be expected. Evasive responses make a very common finding sound more ominous.
Also, a doctor knows whether or not their patient is on oxygen. Being on oxygen briefly is not the end of the world. Again, best to bore with facts.
The discharge plan - an intern would be told they needed to rethink the idea of discharging a patient on an IV medication, who just started steroids.
Remdesivir and Dexamethasone courses, though, are often stopped early in patients who do well and are being discharged.
The dexamethasone - certainly could be a sign that the patient had more severe disease and oxygen needs than described and met criteria for treatment. It could also be VIP medicine where the slightest drop in oxygen results in treatment, which carries side effects and risks.
Also note, fever isn't a good predictor of severe disease in COVID. They can be uncomfortable but they aren't the mediator, or a big predictor, of badness. Temperatures also aren't that reliable on steroids as steroids suppress temperatures.
It should also be noted although evasiveness has been an issue throughout the medical press briefings, there's also an element of VIP medicine. VIP Patients often receive treatments they shouldn't which carry risks. Most with COVID who do not need O2 are not even admitted.
A patient's VIP status plus a slight change in clinical status can make level headed attending doctors seem more like jittery interns, wanting to provide any treatment, right now, when sometimes just watchful waiting is the best course.
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Infection Prevention and Control 101. 1. Do not rely on one tool. Do not build a Maginot Line 2. Work from broadest communal protection down to personal protection. Reduce entry, design environments with reduced contacts, ensure rules allow for compliance.
3. The slices of Swiss cheese, each line of defense, have to line up for the pathogen to pass through the holes. Line up so many slices that probability makes this an impossibility. 4. Don't allow for work arounds and honor codes. We're all in denial about having an infection.
5. Design is a tool for health. Layout can permit communication (or observation) without contact/exposure. Flows of traffic can be designed to reduce mixing. Natural ventilation and outdoor spaces can be maximized.
Nurses of Filipino descent comprise just 4% of the US workforce, but nearly a third of registered nurse deaths due to COVID-19, according to National Nurses United union businessinsider.com/filipinos-make…
Nurses of Filipino descent make up of the staff in many hospitals hit hard by COVID.
There are about 150,000 Filipino nurses working in the United States — and 20% of the nursing force in California. usatoday.com/story/opinion/…
Vulnerability to infectious diseases though is not always due to increased exposure. There may be increased genetic vulnerabilities as well, as we have seen certain immune differences that can be genetic, such as seen with Interferon genes. genengnews.com/news/severe-co…
Dr Conley, White House doctor: "we are trying to maximize everything that we could do for him and we debated whether we'd even start it - the dexamethasone, and we decided that, in this case, the potential benefits early on the course, probably outweighed any risks at this time."
Two things 1. Maximizing everything we do is not the goal. Less is often more. 2. If indeed has not had persistent low oxygen levels, the concern is this drug, whose side effects are well known, could cause more harm than good, especially 'early on the course'
VIP medicine is more prone trying to do everything. Patients often want to do everything. Everything is not always best. In this case, the med can affect the patient's ability to do his job, which the patient may not have fully understood.
If a patient becomes severely ill with COVID, the course is long and the outcome uncertain for weeks. COVID is cruel. We have no crystal ball for a patient with early signs of severe COVID where they will be come November. They may be intubated. They may be fine. They may not be.
Care progresses from needing oxygen to high flow oxygen to non-invasive ventilation to intubation/mechanical ventilation to sometimes ECMO.
Many patients do quite well with oxygen alone. Those who need intubation do much more poorly.
Progression through the stages of oxygen support can be slow and steady. Some patients though can change quickly. They may look quite well medically, until they don't, and rapidly decline. Outcomes though are usually not quickly determined.
Back in February, a Champions League football match between teams from Valencia and Lombardy appeared to act as a super-spreading event, seeding COVID in Europe, with spread soon to NYC.
There's no reason to repeat any of this. cbssports.com/soccer/news/co…
Atalanta, the football team from Lombardy, Italy, in this apparent superspreading event earned 50 million euros in prize money from this ill-fated match news.fenomeno.app/2020/03/how-at…football-italia.net/151062/atalant…€50m?fbclid=IwAR317iExsxwmLpolizaPMMbJtdn2WTFP36OhatWBbW0yyD-jQAFiATwuK00
It takes tremendous political will to stand in front of the power of football, but it's crucial that the love of the game - and the prize money waiting - do not let us backtrack into seeing more COVID cases.
What is happening in Aruba?
Around 1 in 1500 diagnosed a day for over a month. Population 115K but this is a persistently high outbreak.
Confirmed cases per 1 million sxmgovernment.com/2020/09/10/aru…
Aruba's experience may also be a reminder why tourism cannot be business as usual. Aruba kept borders open to travelers, remaining one of 8 countries that would allow US visitors tripadvisor.com/Articles-l2006…
In absolute numbers this means Aruba is seeing about 100 new cases a day, but for a country with a population of 112k this is a tremendous number.
Per report, today: 96 new cases of COVID-19 reported and 91 recoveries. Active cases increase to 1434. visitaruba.com/news/general/c…