Here is a third Covid-19 AMA thread (see details)
Hidey ho,
I’ve done two other threads, and I figured I’d do one every week or so until people are sick of it or I get modded. My area of expertise is relatively narrow—hospital and ICU medicine. I don’t have any epidemiological experience so I really can’t answer those questions. And honestly, nothing really has changed in treatment since last week. But questions keep trickling in so I’ll bump it to the top.
However, I do request that before you ask a question, please take 15 minutes and read this infographic comic collaboration by SMBC and Fivethirtyeight.com It will answer questions about modeling.
https://fivethirtyeight.com/features/a-comic-strip-tour-of-the-wild-world-of-pandemic-modeling/
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96 Answers
Thank you, I appreciate your patience.
One take that I get is that we are no where near the peak of this thing, and ole orange hair still wants to flip the closed sign to open in may1 , if he does that will this thing (covid19) really balloon and wipe out a lot of innocent people?
And when do we know it’s safe to get back to work? I take it when there is no new cases for a set amount of time?
What is that set amount? a week? a month? longer?
@SQUEEKY2 Did you look at the link I asked everybody to look at? It answers your questions.
@Tropical_Willie Fine so far, thanks. But I don’t live in New York City. Those people are heroes.
@Caravanfan Nurses from our area sent another group this week to help up there. Sounds like a scary situation.
Just as a note of positivism, a patient three weeks ago I thought was going to die from COVID is going home today.
@Caravanfan, that “prone positioning” strategy makes so much sense to me. In the 1970s I had two severe bouts of bronchial asthma, each lasting four months, and I could not bear any pressure on my back, however slight. It impaired breathing and caused devastating coughing spells that lasted for hours. Even a gentle touch set me off.
I taught myself to sleep sitting up and straddling a chair, with my chin on a cushion on the chair back. I couldn’t really do the stomach thing (then or now) because of chronic neck and shoulder pain.
I have a horror of being incapacitated and left flat on my back in a hospital. I can’t sleep on my back even when well; I feel like I can’t breathe. I’d rather give out at home than be trapped in a suffocating position by well-meaning caregivers who don’t know my history.
And yes, I’ve written this down.
Hidey ho neighbor.
What do people mean when they say a virus is airborne? I have always assumed that meant it literally floated through the air and could float through duct work. If that is the case, social distancing is worthless.
But now I’m reading that it just means it’s only “airborne” when a person sneezes, and only for as long as it takes for the mucus carrying the virus to fall, or land on something.
Can you clear this up for me Dear Abby? What do they mean when they say a virus is “air borne”?
@Dutchess_III That’s exactly right. Airborne means it’s carried through the air. We think it’s droplet but for health care professionals taking care of patients we are assuming airborne. Sneezing is droplet.
But it doesn’t stay suspended in the air right?
Some buildings vent systems can keep smaller droplets suspended longer but not indefinietly right?
What is with reports of empty hospitals and Seattle removing treatment tents? Is is letting up or ? Conspiracy theorists are increasing.
@KNOWITALL I can’t speak for Seattle. In our case our tents are up and we are being vigilant. Social distancing is working in California.
Does simple breathing unloading the virus?
Well, on another post a jelly was worried about a person breathing in her car. The person was unloading her groceries. Can you spread the virus simply by breathing?
(Fluther is getting wonky. I tried to correct my q above you but the edit button disappeared too fast.)
@Dutchess_III Probably, yes. Which is why people are being asked to mask.
@Caravanfan What do you think about the information coming out about the virus causing blood clots? Is that something you have seen being discussed in depth in the literature you read about the virus? That is terrifying to me since I have a genetic predisposition to clotting and other cardiac risks. I feel like I want to start popping more aspirin, even better get some heparin.
I read that hospitals were seeing increases in strokes and clotting in during kidney dialysis, I assume they mean even before we knew COVID19 was really here, and that there is a theory that some of the lung problems might be lack of oxygen (blood) flowing freely throughout the lungs because of the clotting.
@JLeslie Yep, that’s a thing that is out there in the news now, but there is no good data to support it. It’s just anecdotes. It’s really important in medicine to keep our eye on the ball practice good evidenced based medicine. So it’s something that is interesting and we are aware of it but we absolutely must wait until better data is out there. We do not want to give people therapy (such as full dose heparin) without good reason as there can be increased complications from that.
What you absolutely should NOT do is start popping more aspirin or somehow illegally get heparin because you read a news report about it.
@Caravanfan Not to worry, I wasn’t planning on self medicating. I don’t have C19 to begin with.
Can they test clotting factor or blood running time or thickness? If it’s on my health information if I’m predisposed to clotting if I became ill? This is a concern of mine not only related to C19. Lying in a hospital bed isn’t good for clotting either.
@gorillapaws My phone is completely updated, but hospital doctor after hospital doctor says they don’t look at it, which I find annoying. I have it set to see without password.
I’m going to print my info and wear it around my neck. I’m only half joking. I’m actually concerned about a few things regarding my health, some of which I know doctors won’t address nor take seriously enough most likely. PLUS, we don’t have loved ones with us or friends to emphasize how important some things are.
@JLeslie “Can they test clotting factor or blood running time or thickness?”
Yes. But just because you can test for something does not mean that it is clinically relevant. When people are lying in hospital beds it is standard practice to give prophylactic heparin or enoxparin to prevent clotting.
@Caravanfan Oh interesting. I have never had it given to me when I was hospitalized so I didn’t know that. I was once flat on my back for 2 days, maybe that wasn’t long enough. I’m surprised people have blood clots when they are receiving heparin. I don’t know enough about the process or the drugs. I have only been on heparin twice, but I was giving it to myself. You made me feel better about it anyway.
@Caravanfan
Onset of symptoms can occur anytime between 2 to 14 days after exposure to the virus. Is there any data ranking when symptom onset occurs? I’m wondering if maybe 25% show symptoms after day 4, and half show symptoms after day 10.
Are researchers looking into the commonalities among people who have had mild or undetectable cases? I’m wondering not only if there’s a genetic factor in there somewhere but whether, as seems even likelier to me, they’re already taking some med that acts as a shield.
My husband and I are old guys with a lot of risk factors, a lot of exposure, and also a lot of ongoing treatments. What if, say, the Lipitor or allergy or asthma med we’ve been taking for ages were also coincidentally some kind of virus protection?
What if the allergy itself were having that effect? Weirder things have happened.
Not asking if it is the case. Asking if someone’s examining this thing from that angle.
@JLeslie Those appear to be no different than just a regular BiPAP machine, and no, we are not using them much because they leak too much and spew out contaminated air and risk staff.
@Hawaii_Jake I’m sure there is data, but I don’t have any more information than you do. I do know that people can spread it before they are symptomatic
https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html
@Jeruba I’m sure the epidemiologists are researching all sorts of risk factors and genetics. But it’s not clinically relevant at this time. It’s really hard at this time to say what medications affect what.
Is anyone showing up in the ER having ingested or injected disinfectants?
Yeah I would like to know that as well^^^^.
Ha, no. Even Trumpists aren’t that stupid.
We hope Doc, some of them are scared and desperate !! They feel cornered !
A friend is an RN in Westchester and she said the local poison hotline had over 100 calls asking about ingesting disinfectants.
@jca2 Amazing how stupid people are.
Heck I have a bottle of hundred proof moon shine probably safer than disinfect and a lot more fun.
@Caravanfan My Governor did a press conference today with Tampa General Hospital, and a doctor from the hospital talked about quelling inflammation as part of the treatment that was successful for them (or seemingly so, it wasn’t a study) and I was wondering how do they evaluate when to give that type of suppressive therapy? Is it actual observation of the lungs? Or, bloodwork? Is there any specific drugs they are using for that now that they have learned is working well? You don’t have to name the drugs, I’m just wondering how much is being learned that is becoming more of a standard for treatment.
I heard now Pepsid looks promising for some reason. Of course I’m allergic to that. I felt like my chest was going to explode out when I was prescribed it for an allergic reaction to a medication. Oh, I just realized as I write this maybe that’s why Pepsid helps? Blocks certain immunoresponses? Too bad it would probably kill me. Lol. Yes, it’s on my allergy list.
1) Re: immunosuppressive therapy. Absolutely no data to support this. But the drugs that people are talking about are steroids and a monoclonal antibody treatment
2) Pepcid: Absolutely no data to support this, and the run on pepcid is ridiculous.
Lol. I really think it’s people trying to spark the stock market and day trade on those pharmaceutical companies. I see mal intent when they release some of these theories regarding various drug treatments. Call me a conspiracy theorist.
@JLeslie Well, maybe. The steroids and monoclonal antibody treatment actually do have some clinical relevance and science behind them. The problem is that there is not outcome data.
The Pepcid thing is just baffling to me.
@Caravanfan When I was in the ER for an allergic reaction to a medication they dumped a large dose of steroids into my IV and gave me Benadryl (which I hated, my first time ever in Benadryl, it made me so drowsy) and prescribed me prednisone (to come down off the high dose) and Pepsid. The doctor even commented it might seem odd to take stomach medication, but it will help.
From what I understand Pepsid can reduce inflammation. It’s an H2 blocker, so a type of antihistamine. I’m not sure the specifics of H2, I think of H1 blockers as being the typical antihistamine we take for allergies.
Like I said above, I found out I can’t take Pepsid. In for an allergy, and then I had an allergy to one of the things given to me to treat the original allergy.
It doesn’t reduce inflammation. It’s just a type of histamine blocker. Used for reflux. It can be used as an adjunct to H1 blockers for allergic reactions.
@Caravanfan By adjunct do you mean it would only be effective in conjunction with the Benadryl (or another H1 blocker)?
If so that would be another instance where a doctor didn’t explain well enough the various medications prescribed. The only reason I knew how important it was I take the prednisone after being discharged was because my sister told me. I could have easily not filled the script. The doctor didn’t warn me it would be very dangerous.
@JLeslie It’s off topic for this thread, but I’ll answer this one since it’s in social. H1 blockers are most effective for allergy and are the primary treatments. H2 blockers are also sometimes given for severe allergy.
Testing sites are slowly opening up in Kansas. Do the tests just tell you if you’re currently infected (or not) or does it also test for the antibodies that would tell you if you had it and recovered?
@Dutchess_III As far as I understand, they tell you if you are current infected. Antibodies will tell you if you have been infected at some point in the past.
Thanks.
Do you see any value in testing for the antibodies?
@Dutchess_lll Possibly, especially if it means that someone who is antibody positive is immune. There is some early data to suggest that they are, but it’s by no means conclusive
I just don’t see the point of testing to determine if you are currently infected. All these people wasting all of these tests, to be told they aren’t infected at that moment…..but 10 minutes later they could be infected.
Should only receive a test if:
1 ) elevated temp over 101.5* F
2 ) negative for Flu
3 ) difficulty breathing
I agree Willy. Which I had all of the above in February. Except I don’t know about negative for the flu. They didn’t test any thing.
How effective are standard masks (surgical or homemade) at reducing the transmission of aerosolized COVID particles? I understand they are effective at preventing droplets and will not protect the wearer from becoming infected herself, but if an infected, asymptomatic person is in a closed room with you (while maintaining 6ft. separation) for a period of time while wearing a mask, how high is the risk of becoming infected yourself?
@gorillapaws No data on a specific number. But the 6 feet is actually a made up number. If you’re in a room with an infected patient who is wearing a mask guaranteed your risk of catching it is higher. It’s the reason why we medical professionals put positive patients in negative pressure rooms and we wear N95 masks that have been fitted to our face. The regular masks will stop droplets, but they still leak out around the side and masks get saturated after awhile.
The cloth mask thing is really for going out to a store or something. And they don’t protect you from others. They protect others from you. The idea is that if everybody is doing it then everybody is protecting everybody from themselves.
@Caravanfan Just to clarify, do aerosolized particles pass right through surgical/cloth masks being worn by an infected person as if nothing were there? Or do they mitigate aerosols from an infected patient?
@gorillapaws Regular surgical masks do not have protection against aerosolized particles.
@Caravanfan Is it safe to take ibuprofen for fever of COVID19? I know it was debated, but I can’t exactly remember the outcome of the debate.
@Caravanfan Are they seeing blood clots and strokes increase while being treated for covid? Or, are patients coming into ER’s with problem?
I partly ask because my family believes my dad’s DVT years ago was partly brought on because he had been prescribed a short term Rx of prednisone at the time he developed the DVT. He was high risk anyway, but we believe the prednisone was the straw to break the camel’s back so to speak. I was thinking how you mentioned steroid drugs sometimes being used to fight the immune response with covid.
@Hawaii_Jake Nobody really knows, but it’s probably okay.
@JLeslie You raised several questions.
1) Blood clots and strokes. Unclear. Blood clots are always more common in sick hospitalized patients.
2) Your father’s DVT—not going to comment on that.
3) Steroids being used as immunosupressives for COVID. No data to support its use.
^^So, it’s not that there is a rise in strokes coming into the ER’s is that right?
I wasn’t expecting you to comment on my father. A lot of doctors say it wasn’t related some say maybe it was. No way to know. We just know we think maybe it possibly aggravated his risks already present.
@JLeslie The data are not clear yet on this. It is hypothesized that there is a in increase in clotting and strokes. It has not yet been shown conclusively from an epidemiologic point of view.
Oh, ffs. What next? I have no idea if it’s for real or not.
@Caravanfan I bought a pulse oximeter and am taking readings daily. They’ve been varying from 98 to 89. Would the variation in rate of oxygen saturation occur because of congestion due to allergies or other factors? In other words, when should I worry?
On a scale from 1 – 10, how optimistic are you about Moderna’s early-stage phase-1 vaccine trial results?
I just checked the CDC’s website and it appears they still don’t know if it’s possible to become reinfected. I don’t understand how they can’t do a simple data analysis to query for people being diagnosed with COVID twice with a gap of x weeks in-between. All it would take would be a few cases and some follow-up interviews to confirm it was possible. Obviously the upper-bounds of the durability of any immunity can’t be established yet, but surely there are enough cases to confirm a lower-bound?
I realize epidemiology is not your expertise, but this is basic logic isn’t it? or am I missing something (quite possible)?
“All it would take would be a few cases ” that’s not how statistics works.
They need larger numbers then “a few”. Maybe several hundred cases.
@gorillapaws What I have read is that no one has been infected or sick twice so far. The problem is the virus has not been around long, so they don’t know if immunity will wane quickly if indeed we are getting immunity from having the virus.
They also question if people who were asymptomatic or very mild symptoms possibly don’t create strong antibodies. I personally think this would not be the case, but I am not a medical expert on infection, I am sure they have reason to think this might be a possibility. The scientist I saw discussing it did say that there is good reason to believe that someone who had a mild or no illness one, would have the same easy time of it a second time, if indeed they are susceptible to catching it twice.
In the vaccine trials they obviously are testing for antibodies, so I am not sure how the tests can be only 50% effective and do vaccine studies. Seems to me we won’t really know efficacy until people are exposed after being vaccinated I guess. I seem to remember pertussis titer also isn’t very accurate, because I once mentioned getting it done to my mom and she said don’t bother, but I do get a tetanus titer every few years. Some doctors rely on rubella titers for fertility patients so I guess they are accurate too.
Oops, my apologies, I thought this was my recent Q about antibody testing.
How risky would you think going on a road trip in the same car with a friend is in states that are stable?
@Caravanfan What is your opinion about face shields? Better than masks, worse than masks, equal. I realize wearing both is probably ideal, but I am specifically interested in one vs the other.
Have there been any meaningful updates on the science behind this virus? Do they have a better understanding of the risks of aerosolized particles vs. droplet transmission yet? Do you think it’s mostly being spread by droplets? or by aerosols at this point?
How’s your ER these days? Is it getting bad again? Do you feel everyone is better prepared (supplies, PPE, ICU/ventilator availability) for another round if things get bad again?
@gorillapaws Things are getting busier. 2 months ago we had 1–2 patients in the hospital. Now we have 9–11. We are as prepared as we can get.
The whole idea of aerosolized vs droplet is still in the air (see what I did there?). It’s always been a hybridized approach. We all wear regular masks in the hospital at all times. In a COVID patient room we go to N95 and assume it’s aerosol.
In terms of supplies, yes, we’re better prepared. We have all the things we need at this point.
@raum UCSF group is great. I haven’t seen that particular one, but I follow their grand rounds from time to time.
@Caravanfan I asked above but not sure if you saw it or didn’t have an answer. What precautions would you take if going on a road trip with a friend who is not in your household.
@Caravanfan What other sources do you follow for SARS-CoV-2 and C19?
Has your approach to treatment changed in any meaningful ways? Would you say that the medical community is better able to manage the care of COVID-19 patients now than they were months ago?
@gorillapaws Fantastic question. There are no treatments that have been proven to work. We give remdesivir, even though I don’t believe it’s really that helpful, and we give steroids based upon a recent study of dexamethasone. Mostly it’s just maintaining supportive care. These patients are sick a LONG time—we recently had someone on a ventilator for a month before she was able to come off. One thing we have learned is that we don’t need to put a tracheostomy in these patients after 2 weeks like we once thought.
@Caravanfan I heard during one interview a doctor say they know better know what settings to use on the ventilators for covid patients. Is that something that has been shared as a standard of care recommendation? Or, might be particular to this doctor’s ICU group?
How vulnerable is the patient regarding which hospital they wind up in?
Are ICU’s dealing with a lot of covid going to give a patient a better chance, because of their experience?
The hospitals nearest to me around known to be great hospitals in general. The stats (prior) to covid) are hard to decipher since we have such an elderly population here.
Question 1: Standard of care.
Question 2: Most hospitals have very strict protocols
Question 3: Not necessarily. Everybody has experience with it now
Have you heard of AeroNabs? It’s from UCSF, but it’s tripping all of my “overhyped prototype” alarms. Is this promising? over-hyped and insufficiently tested but a potential solution? complete snake oil? something else?
@gorillapaws Never heard of it. Seems really fishy to me, and if it weren’t UCSF I’d completely discount it.
What’s up with this convalescent plasma talk I’ve been reading about? Is it a treatment you’ve used with your patients? or intend to now that the FDA issued an emergency use authorization? or is this just hype with political motives behind it? or something else?
If you have used it are you seeing benefits?
@gorillapaws it has been used for 70,000 to 75,000 patients and someone that is behind in the Presidential polls (just before the RNC) is claiming it was his idea to use bleach . . . . . cleaning solutions . . . . . hydroxychloroquine . . . . . Ultraviolet . . . . . . . . PLASMA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . But NO MASKS
@gorillapaws Yeah, convalescent plasma is a treatment that has been around for a hundred years. The idea is you take plasma from patients who recovered from C-19 and then inject them into another patient, and the antibodies attack the virus.
A lot of places have participated in the Mayo clinic trial, including us, but the preliminary data is really not good data. There is absolutely nothing political about the convalescent plasma decision and FDA and the NIH are right not to approve it as an accepted treatment for C-19 as the data on it are unclear. This does not mean that a patient can not get it. It just means that in order for a patient to get it we have to fill out paperwork.
So yes, we have used it several times. Have we seen benefit? I have absolutely no idea as we do this on top of a crapton of other stuff that we do. It’s like throwing in the kitchen sink.
The thing is that NO therapy is really any good. Remdesivir is meh, dexamethasone is meh, and nobody knows if plasma works because there hasn’t been a placebo controlled trial.
What we know does work is active management of critical illness and prevention of injury. We are seeing prolongation of critical illness like we’ve never seen before and Covid-19 is breaking all the rules. I just came off a week in the ICU and we have one patient who has been intubated literally for a month. Stunningly, today she started turning a corner and I was able to get her oxygenation down to the lowest it’s ever been. Was it the remdesivir, the dexamethasone, or the plasma (for which she got two doses)? Doubtful, as those were well over 2 weeks ago. But who knows? It’s probably just time and good critical care. And tomorrow she may be worse again.
I, for one, would like up dates on that patient.
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