COVID-19 - Coronavirus 2019-nCoV

[wily]

Thanks...I’ll check out those ace professionals

[snagged in outlet 3]

10 hours ago, wily said:

Thanks...I’ll check out those ace professionals

I've bought high end tools off of Craigslist.  I don't have Facebook but I think they have a for sale are too.  

[snagged in outlet 3]

https://www.msn.com/en-us/news/world/coronavirus-rule-breakers-draw-public-ire-online/ar-BB11PPgh?li=BBnb7Kz

[N9BOW]

13 hours ago, wily said:

I thought I got an email that harbor freight closed...I know they said they donated all their Ppe gear

i need a good homeowner tool set...got any recommendations?  Always wanted a craftsman but with sears in the tank...not sure what to get???

i went up town today too...Home Depot style...got some peat moss...and 13-13-13

I picked up a set of these...Love them. Have one for the Garage and Mancave.

you can get the larger tool set something like 300 Pieces from Tractor supply - no case

Crescent CTK170CMP2 Mechanics Tool Set, 170-Piece picked it up for 89.00 -

https://www.ebay.com/itm/Crescent-1-4-3-8-1-2-In-Drive-6-12-Point-SAE-Metric-Mechanics-Tool-170-Pc-Set-/223148601275?hash=item33f4b16fbb

[oneshot 1]

My Daughter and Daughter in Law are both working for Hospice.

Our Daughter is working from Home and a Hospital is wanting her to work there but she is refusing to.

oneshot

[N9BOW]

If you have family members who are Doctors this may be of some help.

I'm editing the medical terminology based on google searches so check back and look for green ("definitions")....Google it yourself to make sure I have it right

ER doctor offers lessons on treating Covid-19 patients… Cheat Sheet for Physicians (excellent read)…

Posted by Kane on March 29, 2020 1:50 am
Categories: Breaking

https://www.citizenfreepress.com/breaking/er-doctor-offers-lessons-on-treating-covid-19-patients-cheat-sheet-for-physicians-excellent-read/

 

“I am an Emergency Room MD in New Orleans, UNC class of ’98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know.

 

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 and taste, anorexia, fatigue.

Day 5 of symptoms- increased SOB (Shortness Of Breath), and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm (A potentially fatal hyperrelease of inflammatory mediators in response to stimulation of T cells and macrophages by pathogens and immune insults
Triggers Graft versus host disease, adult respiratory distress syndrome, sepsis, avian influenza, and systemic inflammatory response syndrome) leading to acute ARDS (Acute Respiory Distress Syndrom) and multiorgan failure. You can literally watch it happen in a matter of hours.

81% mild symptoms, 14% severe symptoms requiring hospitalization, 5% critical.

Patient presentation is varied. Patients are coming in hypoxic (diminished availability of oxygen to the body tissues) (even 75%) without dyspnea (Shortness of Breath). I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA (Diabetic ketoacidosis). I have seen the bilateral interstitial pneumonia on the xray of the asymptomatic shoulder dislocation or on the CT’s of the (respiratory) asymptomatic polytrauma patient. Essentially if they are in my ER, they have it. Seen three positive flu swabs in 2 weeks and all three had Covid 19 as well. Somehow this ***** has told all other disease processes to get out of town.

China reported 15% cardiac involvement. I have seen covid 19 patients present with myocarditis, pericarditis, new onset CHF (Congestive Heart Failure) and new onset atrial fibrillation. I still order a troponin, but no cardiologist will treat no matter what the number in a suspected Covid 19 patient. Even our non covid 19 STEMIs at all of our facilities are getting TPA (Tissue plasminogen activator?) in the ED and rescue PCI (Percutaneous coronary intervention) at 60 minutes only if TPA fails.

Diagnostic

CXR  (chest X-ray)- bilateral interstitial pneumonia (anecdotally starts most often in the RLL (right lower lobe) so bilateral on CXR is not required). The hypoxia does not correlate with the CXR findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse ox.

Labs- WBC (White Blood cells) low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP (C-reactive protein) and Ferritin (the complex of iron and apoferritin, a major form in which iron is stored in the body.)elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT (Computed tomography) PE (Pulmonary Embolism) these patients for their hypoxia (diminished availability of oxygen to the body tissues). The patients receiving IV contrast are going into renal failure and on the vent sooner.

Basically, if you have a bilateral pneumonia with normal to low WBC (White Blood cells), lymphopenia, normal procalcitonin, elevated CRP (C-reactive protein) and ferritin (the complex of iron and apoferritin, a major form in which iron is stored in the body.)- you have covid-19 and do not need a nasal swab to tell you that.

A ratio of absolute neutrophil count to absolute lymphocyte count greater than 3.5 may be the highest predictor of poor outcome. the UK is automatically intubating these patients for expected outcomes regardless of their clinical presentation.

An elevated Interleukin-6 (IL6) is an indicator of their cytokine storm. If this is elevated watch these patients closely with both eyes. Other factors that appear to be predictive of poor outcomes are thrombocytopenia (Thrombocytopenia is an abnormal drop in the number of blood cells involved in forming blood clots) and LFTs (Liver Function Test???) 5x upper limit of normal.

Disposition

I had never discharged multifocal pneumonia before. Now I personally do it 12-15 times a shift. 2 weeks ago we were admitting anyone who needed supplemental oxygen. Now we are discharging with oxygen if the patient is comfortable and oxygenating above 92% on nasal cannula. We have contracted with a company that sends a paramedic to their home twice daily to check on them and record a pulse ox. We know many of these patients will bounce back but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won’t make it back.

We are a small community hospital. Our 22 bed ICU and now a 4 bed Endoscopy suite are all Covid 19. All of these patients are intubated except one. 75% of our floor beds have been cohorted into covid 19 wards and are full. We are averaging 4 rescue intubations a day on the floor. We now have 9 vented patients in our ER transferred down from the floor after intubation.

Luckily we are part of a larger hospital group. Our main teaching hospital repurposed space to open 50 new Covid 19 ICU beds this past Sunday so these numbers are with significant decompression. Today those 50 beds are full. They are opening 30 more by Friday. But even with the “lockdown”, our AI models are expecting a 200-400% increase in covid 19 patients by 4/4/2020.

Treatment

Worldwide 86% of covid-19 patients that go on a ventilator die. Seattle reporting 70%. Our hospital has had 5 deaths and one patient who was extubated. Extubation happens on day 10 per the Chinese and day 11 per Seattle.

Plaquenil (hydroxy-chloroquine) which has weak ACE2 blockade doesn’t appear to be a savior of any kind in our patient population. Theoretically, it may have some prophylactic properties but so far it is difficult to see the benefit to our hospitalized patients, but we are using it and the studies will tell.

With Plaquenil’s potential QT prolongation and liver toxic effects (both particularly problematic in covid 19 patients), I am not longer selectively prescribing this medication as I stated on a previous post.

We are also using Azithromycin.

Do not give these patient’s standard sepsis fluid resuscitation. Be very judicious with the fluids as it hastens their respiratory decompensation. Outside the DKA (Diabetic ketoacidosis) and renal failure dehydration, leave them dry.

Proning vented patients significantly helps oxygenation. Even self proning the ones on nasal cannula helps.

Vent settings- Usual ARDS (Acute Respiory Distress Syndrom)  stuff, low volume, permissive hypercapnia (An abnormally high concentration of carbon dioxide in the blood, usually caused by acute respiratory failure from conditions such as asthma and obstructive pulmonary disease. It can lead to seizures and death if acute and untreated.), etc. Except for Peep of 5 will not do. Start at 14 and you may go up to 25 if needed.

Do not use Bipap (Bilevel positive airway pressure, commonly referred to by the trademarked names BiPAP and BIPAP, is a form of non-invasive mechanical pressure support ventilation that uses a time-cycled or flow-cycled change between two different applied levels of positive airway pressure)- it does not work well and is a significant exposure risk with high levels of aerosolized virus to you and your staff. Even after a cough or sneeze this virus can aerosolize up to 3 hours.

The same goes for nebulizer treatments. Use MDI (metered-dose inhaler). you can give 8-10 puffs at one time of an albuterol MDI. Use only if wheezing which isn’t often with covid 19. If you have to give a nebulizer must be in a negative pressure room; and if you can, instruct the patient on how to start it after you leave the room.

Do not use steroids, it makes this worse. Push out to your urgent cares to stop their usual practice of steroid shots for their URI/bronchitis (Upper respiratory infection,). We are currently out of Versed, Fentanyl, and intermittently Propofol. Get the dosing of Precedex and Nimbex back in your heads.

One of my colleagues who is a 31 yo old female who graduated residency last may with no health problems and normal BMI (Body Mass Index - She's not overweight) is out with the symptoms and an SaO2 of 92%. She will be the first of many.

I PPE best I have. I do wear a MaxAir PAPR the entire shift. I do not take it off to eat or drink during the shift. I undress in the garage and go straight to the shower. My wife and kids fled to her parents outside Hattiesburg. The stress and exposure at work coupled with the isolation at home is trying. But everyone is going through something right now. Everyone is scared; patients and employees. But we are the leaders of that emergency room. Be nice to your nurses and staff. Show by example how to tackle this crisis head on. Good luck to us all.”

[wily]

Scary stuff...thanks for the info...I don’t understand all of it but get the gist 

[N9BOW]

15 minutes ago, wily said:

Scary stuff...thanks for the info...I don’t understand all of it but get the gist 

I dont fully understand all of it either.. lots of those test are blood related tests and I'm sure it makes sense to those in the field. (I think white blood cell etc)

I think the best thing for a lay person is the noted time frames and symptoms..... and dont mess around as things can go south pretty quick if you are in the 19-20% of those that need hospitalization 

[MrGiggles]

16 hours ago, wily said:

I thought I got an email that harbor freight closed...I know they said they donated all their Ppe gear

i need a good homeowner tool set...got any recommendations?  Always wanted a craftsman but with sears in the tank...not sure what to get???

i went up town today too...Home Depot style...got some peat moss...and 13-13-13

That Crescent set is pretty good. It's a decent jack of all trades set. The wrenches are too short and fat for me, but they work.

Check out Tekton. Great stuff. 

Harbor Freight is good and bad. Most of the Pittsburg Pro tools are pretty good. I really like the new Icon stuff, but it's pretty spendy. I've been upgrading my Pittsburg stuff to Icon as they break, they'll let you exchange if you pay the difference.

Home Depot, Lowes, Pittsburg, and Craftsman are all pretty equal IMO. They're all imported, usually from Taiwan, although China is becoming more common.

What bugs me the worst about most entry-level sets is that they skip sizes. If you do any work on domestic vehicles, 15 and 18mm are essential and often skipped. Tekton is good in that regard, their sets don't skip.

I agree with Wrench, you'll get a lot better tools by buying them separately, without all the useless filler. 

[jdmidwest]

I like Harbor Freight, but you take it with a grain of salt.

I am not a professional tool guy.  My box of tools that I work with has Cresent Wrenchs, Snap On, and Craftsman.  I have Eastwing hammers, Gerber axes, and other high end stuff from yard sales and purchases.

But Harbor Freight has alot of stuff that works for low usage.  I keep a set of wrenches in the truck from them and they do the job when I am not home.  I picked up screwdrivers, cresent wrenches of 3 sizes, a pair of channel lock pliers, a pry bar, pliers, zip ties, a waterproof ammo box, cable protector, assorted waterproof wire connectors, and a small hand axe for the boat.

They have cheap stuff, but its handy to have if you need it a few times.