Ditch the fear and panic and tune in to some rational discussion on the current state of our understanding of the coronavirus pandemic.

Check out EMCrit’s great overview here, it’s a great resource. Podcast links to this show are here.

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– Hey guys, it’s Dr. Z. Alright it’s time for our Covid update, which could not be more timely. It’s March 16th, 2020 and the ish is hitting the fan. And when I say that, I mean it both medically, which is one piece of this. And also psychologically, socially, economically. The much like the disease itself, Covid-19 disease, much of the damage that we’re seeing may come from the body’s response, rather than the disease itself. And what we’re seeing now is fear, panic, hysteria, as city after city goes under a lockdown to try to mitigate the spread of the virus. So what I wanna do today as a physician, as someone who’s connected to a lot of the people working on this stuff, who’s been following carefully, and who has a lot of skin in this game. I’m in the Bay Area of California. This is one of the epicenters. People at Stanford are seeing lots of cases, my wife who is a chest radiologist, specializes in diseases and infections of the chest is reading out these cases and we’re seeing a lot of it.

So we’re starting to see an increase again in the number of cases. Now, what’s happening though nationally is people are loosing their minds. They’re panicking. So what I wanna do is first of all talk about updates as we know ’em. Overall course of the disease from a medical standpoint and I’ll use some medical terminology. But it’ll also be accessible to people who are patients and are interested. Alright so let’s do this. Because we really have, the only way you fight anxiety, panic and hysteria is through knowledge, understanding, preparation and a rational look at the situation. And looking at the situation rationally, I could tell you that we’re gonna get through this. We’ll get through it.

We’ll manage it if we prepare and we don’t we don’t respond in a way that actually makes things worse. Because that’s what I’m seeing happening in many cases. Runs on the grocery stores. Today I went to just go get some milk. They just announced the Bay Area’s gonna go on lockdown starting tonight. People are losing their minds. And yet, I’m seeing kindness. I’m seeing courtesy. I’m seeing a degree of solidarity that only Americans can pull off. And I’m proud to be a part of it. So we wanna encourage more of that. Okay so here’s the update. Covid-19, which is the name, not of the virus but of the disease but I will use them interchangeably. The virus is the SARS-2 Corona Virus. Is now at a point where we’re past the initial phase where we were hoping to actually contain it. And there’s a lot of theories as to why this is what happened, what ball was dropped, et cetera.

And at this point, it’s less important to try to start pointing fingers and blaming. Although, there will be plenty of that. It’s more important to kinda see what’s happened so that we can understand where we might be now and where the puck’s gonna be. Okay and skate to that. So when the first cases started getting reported in China, it had probably been circulating for a little bit. Not a long time. But then you’re starting to see sort of a lot of very sick people coming to the hospital. Round about then, there was probably travel. And the first cases were peculating, maybe Washington State, et cetera. Now because this is such an interesting disease, medically, it’s pretty clear now that Covid-19 disease caused by this corona virus does not necessarily have to show really exuberant symptoms. So I think many people, especially young people, maybe children can be infected, can have virus replicating in their body and can spread the disease without actually showing a whole bunch of symptoms or signs.

Which makes it very difficult. Maybe you won’t have a fever, maybe any of the typical signs are fever, dry cough, some people get headaches, muscle aches and then that can progress to shortness of breath. The medical term being, dyspnea. So, there’s other symptoms though. 10% of people can have these gastrointestinal symptoms, where they get stomach pain or nausea vomiting as their first symptom. And there’s a reason for that because the way this virus actually works is it enters the body and has these proteins on it’s surface that give it its name, the corona, the crown. This sort of, you know if you think about the corona of the sun or a crown on a king. It’s these little things that come off. Those bind to receptors on specific cells. Those receptors are called Angiotensin-converting enzyme 2 receptors, ACE2. Turns out their present in pneumonocytes, which are cells of the lung, as well as intestinal cells, heart cells, et cetera. Now why does this become important.

People seem to have gastrointestinal symptoms, and pulmonary symptoms. That’s where the virus may first bind, enter the cell, replicate and cause cellular damage. And as a result, you see these initial phase of symptoms. Now again, it’s pretty non-specific in the early phase. So you can imagine that people are running around the community. Spreading this person to person and it turns out that the reproductive number, in other words, the number of people that get infected from a single person who’s already infected, seems to be between two to four for this disease. And that’s pretty exuberant. You know some influenzas, two to three. By comparison, something like measles is like 12. So one person infects 12 people, highly contagious. And the ideas is that it’s spreading around the community. Now that infectivity, the ease with which this virus spreads, is actually a crucial component because it tells you how rapidly through a population you’re gonna get the spread. Now since this thing is pretty infective and very important point, that infectivity is not necessarily a pure property of the virus, it contributes. It’s also a property of how the people deal with the virus when they’re infected. So here’s a good example. Out in the wild, the reproductive number may be three, so three people get infected for every person that’s infected. On the cruise ship, the Diamond Princess, that reproductive number was 15. One person infected 15 people. Why? Because it’s closed loop ventilation. People are in closed quarters. There weren’t good isolation techniques.

And how does this virus spread in the first place. So let’s review that. The virus spreads through a couple of means. Alright. One is droplets. And technically these are large respiratory droplets. So I cough or I sneeze, it aerosolizes these droplets and they’re pretty big. So they fall to earth in about a six feet radius or so, plus or minus. And if those end up going into people’s eyes or mouths, you can get infected but another way that it’s gonna happen is that they spray this area and then people touch objects on which the virus is sitting through their droplet spray or through an infected person rubbing themselves and touching stuff. And as a result, it turns out that this virus can live, it appears, anywhere between two hours and 24 plus hours on different surfaces. So wood is different than plastic is different than paper, but it can live on all of those things. So why is this important? Well, this is a bit of foreshadowing.

Because in the hospital, it’s crucially important then to clean surfaces with a bleach solution or an alcohol solution or however you’re disinfecting that’s approved and that takes time. So you’re already starting to see a challenge with preventing, what they call nosocomial infection, in other words infections in the hospital. Because each room has to be clean and that means environmental services needs to be staffed up. It means there’s time involved. It means if you do a CT scan, it can take 40 minutes to clean the scanner, to disinfect it so that you can see other patients in it that aren’t Covid patients. You would need like a dedicated scanner. So for all these reasons, this particular mode of transmission can be highly problematic. And this is why people are telling you, don’t touch your hands. Don’t touch your nose. Don’t touch your eyes. Don’t touch, if you touch stuff wash your hands for the duration of a couple happy birthdays using soap and water. It doesn’t have to be antimicrobial soap. Just plain old soap and water. And you know, these hand sanitizers can help but their not as effective. So they can help, they’re not as effective as hand washing. So the idea then that this stuff is in the environment.

It can live for hours to longer. And then you’re touching yourself. That’s one mechanism of transmission. And so as a result, we’re seeing that. Now, what about aerosol or airborne transmission. People talk about this, airborne transmission. Measles is airborne. That’s why it can infect 12 people from a single person because it actually travels on the currents of air, long distances. It’s one of the most infectious viral diseases we know. And in this case, with Covid, it seems to be becoming increasingly clear from our experience with it in hospitals that generally, it’s droplet spread and then people touching and so on. So the kind of precautions that a healthcare worker might use or someone out in the field, or in the community, would be hand washing, a healthcare worker with a known exposure, or a known patient with Covid would wear, a standard surgical mask, eye face gear to protect eyes in case there are droplets.

Contact gown, right. Gloves. Maybe a hair net thing. So that kinda thing, you would do kind of at baseline. But if it were airborne, aerosolized, it’s different. You need a different type of mask, the N95 mask. Which is much tighter and sealed against air currents and things like that. And what we’re seeing is maybe that this virus becomes aerosolized in healthcare settings when you’re doing stuff to people. So you’re doing a bronchoscopy or you’re intubating somebody who’s sick, that can cause aerosolization. The other concern is that if you ventilate somebody without using a closed loop ventilator, something along those lines and stuff is escaping, that can aerosolize the virus. And this is a particular important for my healthcare colleagues because you wanna make sure you have the best protection that you can. And so it depends on what you’re doing to that patient, which means you wanna do as little as possible, if it’s not necessary. And you wanna be safe and be cognizant of this. Now the key thing for my healthcare colleagues that we’re seeing is and this was in Ebola as well and other sort of outbreaks. If you don’t know how to put the personal protective equipment on, and more important, take it off right. You’re gonna put yourself and others at risk. And that means like, there are different and again, this stuff is online. I can include some links. How do you pull the gown over. How do you take the mask off and the gloves off without touching virus that could be on those surfaces and then later touching your eyes.

And there’s a process for that, that you go through and if you do it correctly and you wash your hands afterwards and you follow a protocol, you’re gonna minimize your risk. We need all hands on deck because there’s two things we have to think about here. The first is number of infections are going up because what I’ve been talking about. It’s been circulating in the community. Many infections are silent. And we’re only seeing the sickest ones, right. So when you look at Italy, they’re talking about these huge numbers of very sick people. They have a very old population, a lot of rural medicine issues, and there’s probably a lot more circulating in the community and so they’re not able to calculate mortality numbers that are like less than 5% because they’re only seeing the sickest people and they don’t know actually, it’s out of how many. They don’t really know. Where as in South Korea, a lot of younger people, much more aggressive testing.

And so because of that great testing, you can actually calculate more accurate mortality numbers. They’re looking at maybe half of 1%. That’s a vastly different number, isn’t it? So again, how you get these numbers really matters. Now one thing we should talk about, how is it that the horse got out of the barn in the US? Well part of the problem was we weren’t screening and testing early. There were problems with the tests. Labs couldn’t get access to the virus. The CDC and the government and FDA have these, FDA mostly, have these arcane rules about how you can test in outbreaks because they wanna make sure like with Ebola and things like that that the tests are accurate. But in this rapidly moving situation, it became very difficult for outside labs to be able to generate tests. Then the CDC zone tests had a flawed component which delayed everything.

And by now we’ve already, it’s a series of events. Now each government agency has good people and they’re trying to do the right thing but they’re not communicating well. They’re not coordinating well. And so that was another potential problem. And then getting access to the virus itself was a problem. Because the Chinese have a policy of not necessarily sharing the virus itself. And so, getting the virus was a problem. So for all these reasons, we’re now way behind. And so, the idea now is things are gonna start to really potentially take off and that could overwhelm the healthcare system. So we have the healthcare system side of it, which are my colleagues who are now, we’re seeing real, real, real numbers, you guys. Like this is not a made up thing. This is a real thing. Now does that mean that people in this side, the community should panic. Absolutely not. The panic is what’s driving a lot of problems on the healthcare side. Should people showing up to clinics with coughs and runny noses and sore throats saying do I have Covid and freaking out and demanding testing and all that and the truth is, that’s gonna be very counter productive. Because we’re already out of the phase where containment would’ve helped.

At this point, if you have symptoms, call your doctor. Connect with your team and they will tell you what the next step is. Alright. But showing up to your doctor’s office, I’ve already done a video on this. So I would watch that. How to prevent Covid from getting worse. So that being said, now, we’re in a situation where you have the healthcare system that could get overwhelmed because the need in sick patients for ventilators will outstrip very rapidly our infrastructure to do this. And we’re starting to see that this is a danger. It happened in Italy. It’s gonna happen in Spain, and they’re on national lock downs now. So that’s why you’re seeing this very exuberant response by government officials, a little late. ‘Cause if you’d done this earlier, and actually tested effectively like what the South Koreans did, you would’ve had a much lower slower slope of infection and you wouldn’t have necessarily overwhelmed the system. So now we’re in the situation where we have to be more reactive than proactive. Typical American healthcare. So all that being said, in patients themselves, there seem to be two phases of the infection itself. There’s the first phase where again, the virus enters the body, binds to these Angiotensin receptors in the lung or in the gut, however, because the thing can also be transmitted through feces. That’s another way of getting it. Again wash your hands. Wash your hands. Cover your cough. Right. Keep a distance from people. This is what we’ve been telling everybody. And once it enters it start replicating.

And it seems like this is the first phase, viral replication. In the majority of people, 80% plus, the immune system of the host, keeps that viral replication in check. Has a proper response, you get symptoms at that point but they’re not severe. And you get better over some time, one to two weeks. In patients for whom, this doesn’t happen and they tend, not exclusively, but they tend to be older, have some cardiovascular disease, in fact more so than lung disease. So there seems to be a trend reported that it’s people with cardiovascular disease, hypertension, other kinds of heart disease, on cardiac medications, that sort of thing, and that seems to put them at higher risk for going into this next phase, which is this adaptive immunity phase. So several days later, people might be feeling okay and then all of a sudden they get potentially worse.

This is when the body’s immune system really kicks in and viral replication might go down a little. But at this point, you have this immune response. Now that can lead to damage to lung cells. Now it seems to be there’s some debate. Is the virus itself damaging these lung cells, which would explain why older people tend to get it worse because they have weaker immune systems and can’t mount this exuberant response in the beginning and young people are able to fight it off. But the virus itself is what they call cytotoxic, in other words it’s actually damaging pneumonocytes, lung cells, kidney cells, heart cells that it can bind to. And in that way is actually causing the damage that then the immune system compounds by piling on with cells and debris. What we’re seeing clinically and pathologically, seems to maybe support some of that. In at least some patients. So what happens is people are doing better and then all of a sudden they start to get a little more short of breath.

And now remember this, there are some patients, particularly elderly patients who will not manifest symptoms of shortness of breath. But if you put an oxygen probe on them, their oxygen is low. So called silent hypoxia. So those older patients, you really have to be more careful. Those are the ones that end up hospitalized. You wanna monitor them more, whereas younger, healthier people, it seems to be less of an issue. Again, there’s always outliers. But it’s less of an issue. So in these patients then, you might develop some shortness of breath and then it’s a rapid deal. So then they fall into a couple buckets. The kind that do okay with oxygen by mask or by nasal canula. Trying to avoid these high flow oxygens where you’re actually blowing virus around and that kind of thing. So that’s another thing you have to think about. Alright. And when you intubate, there’s a series of procedures you wanna think about. There’s online researches that I might link to that show good sequences of how to intubate safely. Because when you’re putting a breathing tube in to someone that needs help, that’s when you can aerosolize virus and put everybody in the room at risk, alright. So something that again, very important for healthcare colleagues.

So in patients who are just on the nasal canula, some of them do okay and they get better. But the other parts, they start needing more and more support very rapidly. If turns out you’re thinking about using BiPap, one of those face masks with the BiPap, the sources online are really saying, at that point, just intubate them. Just go mechanical ventilation because they’re gonna need it. It’s just pretty much assured at that point. Because at that point, there’s an exuberant reaction called ARDS, Acute Respiratory Distress Syndrome. And what they are seeing pathologically is diffuse alveolar damage. So, the little alveolar sacs become sledged up with material and gunk and it impedes the ability to exchange gas from the blood and the air through the lung and that’s why people have big trouble. What they’re finding is when you, and again, it’s more it seems, they’re starting to think maybe there’s a direct viral cytotoxic effect. And so, it seems that they’re requiring the kind of ventilation that you would require for ARDS, with one exception. It seems there’s less of the very stiff lung that we sometimes see, stiff noncompliant lung, like a very stiff balloon. We’re not seeing as much of that. We’re seeing more the sort of need to prone ventilate, so put the patient prone because there may be changes in VQ mismatch. There may be changes in secretion management and congestion in those alveoli that may be benefited by the prone positioning. So it’s pretty clear that from the Italian experience in others that prone ventilation seems to work. ARDS protocols, sort of Permissive hypercapnia, for people who are speaking my language here. Those kind of things that would manage a typical viral influenza, pneumonia with in an elderly patient or another patient.

There’s nothing particularly exceptional about Covid-19, so we would treat it very similarly. Right with some caveats. So it seems that that kind of ventilator management, which means we gotta support our respiratory therapist, our ICU docs or ICU nurses ’cause they’re gonna be running and managing those ventilators and there’s gonna be a lot of patients who need this assistance. A lot meaning if there’s a ton of infections, the small percentage that need those are gonna represent a lot of people. That’s another reason we don’t wanna overwhelm the healthcare system. So this being said, now you have, people who are requiring ventilation. So what happens in those patients. Okay. What would you end up doing there. And by the way, given that there’s two phases of this infection that means maybe there’s two different approaches in the different phases. In the first phase, there’s some speculation that antivirals like the experimental, remdesivir and chloroquine and these kinda things, the people are talking about could they be helpful? Kaletra, which a HIV antiretroviral. Could those be useful in the first phase, early rather than later, when virus is replicating. And it’s not so much as an immune response compounding it. And then later, it’s less helpful but maybe later what may be more helpful is immune modulation. Now it seems clear from data that steroids are associated with worse outcomes. And so the idea of putting people on steroids is not, it’s not a comfortable thing right now. Because we may be making things worse and again, is it because we’re allowing viral replication to occur and it’s cytotoxic. Or is there some other reason. Are we allowing, the higher likelihood of secondary bacterial infections associated with ventilators and other things like that. Or is there some other reason we’re promoting cardiomyopathy or other things that can happen with steroids, we don’t know. But we know that the association is bad. But there’s some theorizing that maybe steroids earlier sorry, steroids later in the disease might be more effective if there’s an immune component that we’re trying to suppress.

So we don’t know yet, but the current teaching is don’t steroids if you can avoid them unless somebody’s needs them for other reasons, bad COPD et cetera. So at this point, you have these ventilated patients. Now what happens to the ventilated patients. Some of them get better with conservative management. Now what you have to watch for are a couple of things. What their seeing is that this Covid-19 disease, and again I apologize because I’m doing this out of my brain. I don’t have notes or anything. I have a laptop but I can’t keep track of any notes. So I apologize if it’s a little desequenced but I do it as I do it. In the beginning of the infections, you can look at certain laboratory parameters. Now one of those laboratory parameters, it’s really interesting is that your white blood cell count is typically normal or low. It’s very rarely high. So if you see a high white count, you may wanna think there’s a second co-infection, whether it’s bacterial or something else. You just wanna think about that. The second thing to think about is procalcitonin. Procalcitonin is often used in IC settings to look for infections, so bacterial infections, things like that can raise your procalcitonin level and give you a sense that there’s an infection going on, particularly in patients who are septic. In Covid-19 disease, procalcitonin without other complications is often normal. So it’s a good thing to follow a procalcitonin because if it becomes abnormal, that may be a sign that you’ve got a secondary infection, at which point, something like an antibiotic or other cultures, or even rarely bronchoalveolar lavage through bronchoscopy may be necessary. In general, you wanna avoid that because it’s a great way to get your healthcare professionals infected. And it’s not really helpful in standard Covid disease.

But if you’re looking for secondary infection, that can be helpful so procalcitonin. The other things that you see that are abnormal are liver function tests. Now this becomes important because, there’s been some people out of Washington, I see docs that have been writing in saying, you know remdesivir, this compassionate use protocol for this experimental drug developed by Gilead for Ebola, there’s been problems getting patients approved because you have to have LFTs that are too liver function tests that aren’t too abnormal. And the problem with this particular disease is the liver function tests are often abnormal, and we don’t know if that’s a direct effect or some secondary effect of the virus. So something you can watch are again liver function test. Kidney function does tend to take a hit. Although not often sever initially. So creatinine’s still less than two. Creatinine clearance still greater than 30. In a lot of the experience that people have had, now remember, people who are older have a lot of comorbidities.

All bets can be off because they can have problems with all kinds of things, including something called cytokine storm. So cytokine storm is where the immune system just goes totally belligerent, and you get shock, a picture of sepsis, multi organ failure and potentially death. So again, in that case, all bets are off. But otherwise you’re looking at kidneys, liver, slight abnormalities. We talked about procalcitonin, the complete blood cell count, and then this is something I should mention. Well, let me keep with these particular labs, alright. What they found is that because these patients aren’t necessarily super dehydrated or shocky, pouring these fluids in is a terrible idea. So you wanna be very conservative with the fluids in these patients. It’s not like your standard sepsis where you still have to be careful but in this case, it’s particularly salient that you don’t wanna flood with fluids. So you wanna keep an eye, maybe don’t do maintenance fluids if you don’t have to, that sort of thing because it can be counterproductive, especially when we talk about what seems to be killing some of these patients, which is acute asystole or other cardiac arrest. So this is an interesting thing. People start to get better sometimes. They even maybe come off the vent, and then they have cardiac arrest. And all of a sudden someone who had a normal ejection fraction, normal heart, has an EF of 10. They’re running a code, it’s often asystole or V-fib. And there done. That’s it. And the thought is there’s a myositis going on. Myositis is inflammation or damage to the myocardial cells. The cells of the heart. Well, it turns out we don’t know if that’s due to a direct viral effect.

‘Cause we know that ACE receptors. We don’t know if it’s due to some of the medication or treatment or stress of being ICU, especially why, remember we talked about it’s people with cardiac disease that seem to have the highest problems with this. Could there be pre-existing stuff? Or is it secondary to the cytokine storm itself, which can cause a myopathy. Or is it a direct viral myocarditis. We don’t really know yet. There’s some speculation but we don’t know yet. The bottom line is you have to watch very carefully for this dreaded complication. The questions about early pacing, careful cardiac monitoring, that kind of thing, those things arise, making sure electrolytes are good. But again, until we know exactly kind of the etiology of it, it’s hard to have a good course of action for how to manage the myocardial stuff. Now this is why people have talked about ACE inhibitors. By giving an ACE inhibitor, could you prevent viral binding and this kind of thing but what the data seems to preliminary show is that people on ACE inhibitor seem to do worse. Again this is associational data. So they’re already on ACE inhibitors, which means, they already have a cardiac issue, hypertension, heart failure, diabetes, that is requiring an ACE so it’s an associational thing.

So it’s hard to tease out, right. The reason, by the way, people are talking about Advil and nonsteroidal anti inflammatories early in the disease, the French health minister says don’t use these, right. It’s based on the idea that it may be slightly immunosuppressive in the early replicative phase of the disease where virus is replicating, where you want the immune system to tamp it down. Now again, there’s not really good evidence for this. It may be associational so, making a blanket statement like that may not be a good idea. But think of it this way. If you’re gonna end up developing some renal insufficiency, kidney problems, stress ulcers from being ICU-bound NSAIDs are not a good idea to begin with. So Tylenol or Paracetamol if you’re nasty, is a better idea in that case anyways. So you wanna think about that. All right so, at this point, now let’s back up for a second. Remember I said I’m disjointed because I don’t really go by notes. I’m trying to synthesize what we’ve been learning over the course of the last few weeks. From colleagues, from data online, from a lot of stuff. Why, okay. What would we want, first of all, in our testing when we’re screening patients for this thing, for this type of disease to contain it. We would want a test that is rapid, that is available at the point of care, and that has very few false negatives. What is a false negative? A false negative means you do the test and it falsely tells you that it’s negative. So in other words someone with Covid-19 disease is told they’re okay. They go out in the community, the infect a ton of people. Well it turns out, false positives are less problematic. In other words, the test tells you you’re infected. ‘Cause what happens to that person? They go into quarantine. So at least, it’s damaging to them. Right, psychologically but it’s not damaging to society as much.

A false negative is damaging to the fight against this thing. So what we find with this particular test, the PCR, at least early on. It’s got a pretty poor sensitivity. Meaning there a lot of false negatives. Maybe it’s 60% sensitive. So that means you’re sending home a lot of people that may still be positive. So what the Chinese were doing to overcome that was CT scans. They were screening with CT. Because it’s more sensitive, when you have a high clinical suspicion. And in this country, we’re not gonna really do that. Alright and part of the problem is disinfecting those scanners takes 40 minutes. It’s not a very good way. You can look at patients clinically and do the rapid test and put two and two together, hopefully. So you want a test that’s got good sensitivity and you combine it with other things. So chest Xray, not very sensitive, 50, 60%. But you see findings. So my wife showed me quite a few and it’s quite, look if you don’t read Xrays a lot, you’re gonna miss ’em. But to somebody who reads a lot of Xrays, it’s pretty clear. You see these sort of patchy, often peripheral opacities. We’re not seeing a lot of pleural effusions, pleural thickenings, things like that. It’s kind of atypical. So if you see that, you may wanna think about coinfection or a complication. The CT shows ground glass opacitites, often peripherally in the lung and basilar and often bilaterally. And they can be confluent in severe disease. So it does kinda correlate a little bit to severity. You’re not seeing a lot of lymphadenopathy, big lymph nodes. You’re not seeing pleural effusions. So those are interesting findings. And so, our screening tests are kinda still pretty crappy. So we have to go a little bit on clinical clinical intuition and that’s another reason that again, the Koreans did it very quickly. But now we’re already late. So at this point, we wanna do a lot of telemedicine. We wanna kinda screen people over phone and video. Asking good questions, risk stratifying them. What’s your age, your comorbidities, that kind of thing. Now the other twist in this is there’s some speculation that since this virus replicates, as it replicates it mutates.

We’re seeing maybe changes in patterns. So early on mortality was very high. Later on, we’re seeing mortality rates maybe dropping and is that because there are now two strains of virus. One that has a higher mortality, in other words, it’s more virulent. And the other that has a lesser mortality and how are these changing over time? We don’t entirely know. We also don’t know how temperature is gonna effect this thing long term. Is the summer gonna give us a relief. Like it does for influenza. Perhaps the virus doesn’t live on surfaces as long when it’s hot. Perhaps there’s less people packed together. People are outdoors more. We don’t know so these are things that are still unknown. So looking at again, so we talked about radiology, what you see on CT, what you see on Xray. You can also do pulmonary ultrasound. There’s some resource online. EMCrit is a great resource for all this stuff. E-M-C-R-I-T .org. My friend, Scott Weingart runs that site and it’s got a great set of resources for all these things for managing these patients. Highly, highly recommend it. I’ll link to it in the notes. So, you have ultrasound, chest Xray, CT scan. You have the lab testing that we talked about. The other thing we notice is coagulation parameters, D-dimer can sometimes be elevated. Over time you can develop disseminated intravascular coagulation and so you wanna monitor coags fairly regularly and that may be just part of this inflammatory cascade. C-reactive protein is another test that has shown some interesting correlations to disease severity so, people who are very sick have higher inflammatory markers like C-reactive protein, CRP. And so there may be some utility to checking it just to understand the potential for severity. And where the patient is but again, you can also do that clinically and without doing a bunch of blood. I’m trying to think if there’s other major testing on this, I am not recalling anything off the top of that. Those are the main things that stick with me when I think about this. So, you know again, for these patients now, they’re gonna require ventilators.

They’re gonna require safe intubation, safe for the staff. They’re gonna require environmental services to turn over rooms, which means we have to be staffed. They’re gonna require respiratory therapists to help manage the vents. They’re gonna require ICU level beds, and cardiac monitoring. They’re gonna require looking at new therapies like remdesivir and I hope I’m even saying that right because I’ve never had to say that word. Thankfully. Kaltera, chloroquine. It doesn’t look like ACE inhibitors are a thing. And other sort of speculation around steroids and those kind of things. So we’re in a state now where we’re on the healthcare side of this equation, people are going to get extremely busy. They’re gonna be very stressed. They’re gonna need all our support. That’s what keeps me up at night. Alright, the community side of it, I’m gonna be totally honest with you, does not keep me up at night because you are more likely to die from flu because you’re more likely to get flu because it’s much more widespread. Even with a lower mortality. Flu kills, listen, let’s just be very clear here. We’re scared of this virus because it’s an unknown. Because it spreads rapidly and it does have a mortality rate that’s higher than flu. However, this 10 times higher thing is a panic number. You need to look at absolute risk, not relative risk. What’s your absolute risk of getting and dying of this? It’s so low. It’s higher in elderly people, people with comorbidities. But they can take precautions.

Staying home, isolating, et cetera. But what we’ve had to do now is put a draconian hammer on everything. It’s already out of the barn. Draconian hammer on everything. Which is gonna harm our poorest people, middle class business owners, our economy. It’s gonna harm people long term, because we’re wrecking their livelihoods. This is something we really have to think about, guys. Now we’re in this position because the ball was dropped early on on containment. And now we’re here having this discussion so the community, I don’t worry about that. I know the community’s panicked. I’ll tell what I worry about, fear and stupidity. And the idea that people are capitalizing on this to really blow it up for the average Joe and make it such that they’re panicking and running to the doctor. Who I worry about are my colleagues in medicine because they’re gonna deal with this whether it’s a lighter epidemic or a serious one. They’re going to be slammed. And we need to help them.

And that means, if they’re telling you work from home, if they’re telling you keep away from other people, if they’re telling you don’t have big gatherings, if they’re telling you wash your damn hands, if they’re telling you those things, just do it. Alright. Let’s do it with a smile and understand that we come together in these situations to help our most vulnerable. That’s what it is. And that’s this group of people. The caregivers and the sickest patients that are gonna suffer through this. Now bottom line is we’re gonna get through it, period. It is going to be a tough few weeks, maybe months, but we’re gonna get through it. And it means that we have to be rational. It means that we cannot let fear drive us. And you know, one thing I’ll say is I have been trying really hard every morning to get up very early and do at least 30 minutes of meditation and that keeps me centered. Because even I can get very phased if I sit and watch the news. You start second guessing and going wait, what about this, what about. The truth is, this is something that is explainable, there’s some unknowns.

But we know what we need to do now, which is slow the rate of new infections. Help learn and understand how to manage the infections we have. Support our healthcare professionals. Support each other. And then work hard on vaccines and future prevention and future coordination. That’s the key thing. There’s a lot of politicization. There’s a lot of blame. Non of that is gonna be helpful right now. What’s gonna be helpful is the task at hand. Then we can throw the feces later, okay. Hopefully, Covid negative feces. So do me a favor, I hope this was helpful. Again I do this kind of the top of my head and sometimes that’s good and sometimes that’s bad. But I just hate that rehearsed like reading off notes thing. It makes me wanna stab myself in the eye. I would rather get Covid than have to watch a lecture like that. But for some people, that’s better. There’s plenty of resources online for that. I’m gonna put links in the thing. But I’d love it is if you share this, if you leave a comment, if you hit like. If you really want to support what we do, becoming a supporter, our supporter tribe has a private discussion group. It’s about I don’t know, a few thousand people now. And we have discussions in under closed doors. That you can’t have that are very helpful. We support each other and share data and then spread it out to the world. So the supporter tribe on Facebook. You can support us on YouTube by becoming a member. Patreon is another way. Alright guys. Do me a favor. Chill. To everybody on the front lines, we’re thinking about you supporting you. We’re gonna try to continue to educate with these updates. And stay safe out there. We are out, peace.

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