New Orleans is becoming the next COVID19 hot spot, most likely due to Mardi Gras and the crowds that it brought. This is what I am hearing from ER doctors who are seeing many cases of COVID19 in their busy Emergency Departments in New Orleans, that I thought I would pass along. My one recommendation is to purchase a home pulse oximeter, which can be purchased on Amazon. Please read below.
ER Physician, New Orleans: "I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred COVID19 patients and this is what I think I know.
The 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 (decreased appetite), and fatigue.
Day 5 of symptoms - increased shortness of breath, and bilateral viral pneumonia from direct viral damage to lung parenchyma (tissue).
Day 10 - cytokine storm leading to acute ARDS (acute respiratory distress syndrome) 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 (low oxygen level), even 75% (should be 100%) without dyspnea (shortness of breath). I have seen COVID19 patients present with encephalopathy, renal failure from dehydration and 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 asymptomatic polytrauma patient. Essentially if they are in my ER, they have it (COVID19). Seen three positive flu swabs in 2 weeks and all three had COVID19 as well. Somehow this ******bleep***** disease has told all other disease processes to get out of town.
China reported 15% cardiac involvement. I have seen COVID19 patients present with myocarditis, pericarditis, new onset CHF (congestive heart failure) and new onset atrial fibrillation."
"Chest XRay - bilateral interstitial pneumonia (anecdotally starts most often in the right lower lobe so bilateral on chest xray is not required). The hypoxia (low oxygen level) does not correlate with the chest xray findings. Their lungs do not sound bad. Keep your stethoscope in your pocket and evaluate with your eyes and pulse oximeter."
This physician goes on to describe certain lab tests that they see with COVID19. I won't list the specific lab tests here, but I have a lab slip ready to go to test for these lab values. This physician goes on to say
"I would be very careful about Chest CT for these patients. The patients receiving IV contrast are going into renal failure and on the ventilator sooner.
Basically, if you have a bilateral pneumonia with normal to low WBC (white blood cells), normal procalcitonin, elevated CRP and ferritin - you have COVID19 and do not need a nasal swab to tell you that.
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 supplemental 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 (oxygen level). We know many of these patients will bounce back (return to the ER) but if it saves a bed for a day we have accomplished something. Obviously we are fearful some won't make it back.
Treatment
Supportive
Plaquenil (hydroxychloroquine) 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 (affects heart rhythm) and liver toxic effects (both particularly problematic in COVID19 patients), I am no longer selectively prescribing this medication as I stated on a previous post.
We are also using azithromycin, but are intermittently running out of IV.
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."
This physician shared a lot more information for physicians, but I thought this was the most relevant to share. The one recommendation I have is for you to go ahead and purchase a home pulse oximeter. They are available on Amazon, but shipping is delayed, and quantities are limited.
Please continue to maintain 6 feet of distance from others, and consider wearing gloves when you go to the grocery store and pumping gas.
Stay safe and be well.
Michelle Parsons
