Coronavirus Sars-CoV-2/Covid-19 Megathread

[katmai]

Katmai just made it across the border in time.  The Federal Quarantine Act has just been amended to make quarantine mandatory for anyone entering the country.

Here's hoping they don't quarantine him when he crosses over into Alaska.

um I will have to go into quarantine at home for 14 days, or face fine up to $25,000

But still in Canada till Saturday.

[celedhring]

Now this is grim.

https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate/?utm_campaign=wp_main&utm_medium=social&utm_source=twitter

Hospitals consider universal do-not-resuscitate orders for coronavirus patients
Worry that 'all hands' responses may expose doctors and nurses to infection prompts debate about prioritizing the survival of the many over the one

By
Ariana Eunjung Cha

Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation few have encountered in their lifetimes — how to weigh the "save at all costs" approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.

The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient "codes," and their heart or breathing stops.

Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.

Richard Wunderink, one of Northwestern's intensive-care medical directors, said hospital administrators would have to ask Illinois Gov. J.B. Pritzker for help in clarifying state law and whether it permits the policy shift.

"It's a major concern for everyone," he said. "This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances."

Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country's major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

Several large hospital systems — Atrium Health in the Carolinas, Geisinger in Pennsylvania and regional Kaiser Permanente networks — are looking at guidelines that would allow doctors to override the wishes of the coronavirus patient or family members on a case-by-case basis due to the risk to doctors and nurses, or a shortage of protective equipment, say ethicists and doctors involved in those conversations. But they would stop short of imposing a do-not-resuscitate order on every coronavirus patient. The companies declined to comment.

Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

"We are now on crisis footing," he said. "What you take as first-come, first-served, no-holds-barred, everything-that-is-available-should-be-applied medicine is not where we are. We are now facing some difficult choices in how we apply medical resources — including staff."

The new protocols are part of a larger rationing of lifesaving procedures and equipment — including ventilators — that is quickly becoming a reality here as in other parts of the world battling the virus. The concerns are not just about health-care workers getting sick but also about them potentially carrying the virus to other patients in the hospital.

R. Alta Charo, a University of Wisconsin-Madison bioethicist, said that while the idea of withholding treatments may be unsettling, especially in a country as wealthy as ours, it is pragmatic. "It doesn't help anybody if our doctors and nurses are felled by this virus and not able to care for us," she said. "The code process is one that puts them at an enhanced risk."

Wunderink said all of the most critically ill patients in the 12 days since they had their first coronavirus case have experienced steady declines rather than a sudden crash. That allowed medical staff to talk with families about the risk to workers and how having to put on protective gear delays a response and decreases the chance of saving someone's life.

A consequence of those conversations, he said, is that many family members are making the difficult choice to sign do-not-resuscitate orders.


Code blue
Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient's life, absent an order, such as a DNR, to do otherwise. But as cases mount amid a national shortage of personal protective equipment, or PPE, hospitals are beginning to implement emergency measures that will either minimize, modify or completely stop the use of certain procedures on patients with covid-19.

Some of the most anxiety-provoking minutes in a health-care worker's day involve participating in procedures that send virus-laced droplets from a patient's airways all over the room.

These include endoscopies, bronchoscopies and other procedures in which tubes or cameras are sent down the throat and are routine in ICUs to look for bleeds or examine the inside of the lungs.

Changing or eliminating those protocols is likely to decrease some patients' chances for survival. But hospital administrators and doctors say the measures are necessary to save the most lives.

The most extreme of these situations is when a patient, in hospital lingo, "codes."

When a code blue alarm is activated, it signals that a patient has gone into cardiopulmonary arrest and typically all available personnel — usually somewhere around eight but sometimes as many as 30 people — rush into the room to begin live-saving procedures without which the person would almost certainly perish.


"It's extremely dangerous in terms of infection risk because it involves multiple bodily fluids," explained one ICU physician in the Midwest, who did not want her name used because she was not authorized to speak by her hospital.

Fred Wyese, an ICU nurse in Muskegon, Mich., describes it like a storm:

A team of nurses and doctors, trading off every two minutes, begin the chest compressions that are part of cardiopulmonary resuscitation or CPR. Someone punctures the neck and arms to access blood vessels to put in new intravenous lines. Someone else grabs a "crash cart" stocked with a variety of lifesaving medications and equipment ranging from epinephrine injectors to a defibrillator to restart the heart.

As soon as possible, a breathing tube will be placed down the throat and the person will be hooked up to a mechanical ventilator. Even in the best of times, a patient who is coding presents an ethical maze; there's often no clear cut answer for when there's still hope and when it's too late.

In the process, heaps of protective equipment is used — often many dozens of gloves, gowns, masks, and more.

Bruno Petinaux, chief medical officer at George Washington University Hospital, said the hospital has had a lot of discussion about how — and whether — to resuscitate covid-19 patients who are coding.

"From a safety perspective you can make the argument that the safest thing is to do nothing," he said. "I don't believe that is necessarily the right approach. So we have decided not to go in that direction. What we are doing is what can be done safely."

However, he said, the decision comes down to a hospital's resources and "every hospital has to assess and evaluate for themselves." It's still early in the outbreak in the Washington area, and GW still has sufficient equipment and manpower. Petinaux said he cannot rule out a change in protocol if things get worse.

GW's procedure for responding to coronavirus patients who are coding includes using a machine called a Lucas device, which looks like a bumper, to deliver chest compressions. But the hospital has only two. If the Lucas devices are not readily accessible, doctors and nurses have been told to drape plastic sheeting — the 7-mil kind available at Home Depot or Lowe's — over the patient's body to minimize the spread of droplets and then proceed with chest compressions. Because the patient would presumably be on a ventilator, there is no risk of suffocation.

In Washington state which had the nation's first covid-19 cases, UW Medicine's chief medical officer, Tim Dellit, said the decision to send in fewer doctors and nurses to help a coding patient is about "minimizing use of PPE as we go into the surge." He said the hospital is monitoring health-care workers' health closely. So far, the percentage of infections among those tested is less than in the general population, which, he hopes, means their precautions are working.

'It is a nightmare'
Bioethicist Scott Halpern at the University of Pennsylvania is the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a blanket stop to resuscitations for infected patients is too "draconian" and may end up sacrificing a young person who is otherwise in good health. However, health-care workers and limited protective equipment cannot be ignored.

"If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair," he said.

Halpern's document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.

Wyese, the Michigan ICU nurse, said his own hospital has been thinking about these issues for years but still is unprepared.

"They made us do all kinds of mandatory education and fittings and made it sound like they are prepared," he said. "But when it hits the fan, they don't have the supplies so the plans they had in place aren't working."

Over the weekend, Wyese said, a suspected covid-19 patient was rushed in and put into a negative pressure room to prevent the virus spread. In normal times, a nurse in full hazmat-type gear would sit with the patient to care for him, but there was little equipment to spare. So Wyese had to monitor him from the outside. Before he walked inside, he said, he would have to put on a face shield, N95 mask, and other equipment and slather antibacterial foam on his bald head as the hospital did not have any more head coverings. Only one powered air-purifying respirator or PAPR was available for the room and others nearby that could be used when performing an invasive procedure — but it was 150 feet away.

While he said his hospital's policy still called for a full response to patients whose heart or breathing stopped, he worried any efforts would be challenging, if not futile.

"By the time you get all gowned up and double-gloved the patient is going to be dead," he said. "We are going to be coding dead people. It is a nightmare."

Ben Guarino in New York and Desmond Butler contributed to this report.

[Sheilbh]

God, that is grim celed. There's been big issues here with PPE, which I think is getting easier, but especially in the absence of widespread staff testing it's a huge issue. Incidentally one of the fatalities yesterday was the first example (in the UK) of someone who caught coronavirus in hospital which does show the risk. Last I heard only 10% of ICU patients were actually because of coronavirus, so it's still such a risk for the rest of the patients who will be particularly vulnerable whatever their age.

Something which probably only Shelf will take a polite interest in:

The six London borough I've all been keeping an eye on all have very similar case rates Brent, Lambeth, Southwark, Westminster, Kensington and Chelsea all have between 58 and 65 cases per 100,000. Oddly Haringey is the outlier with a rate of only 28.

But it's the rest of the country is worrying me, there seems to be a great deal of inexplicable variation.

For instance the conurbation here, Bournemouth, Poole and Christchurch has just 15 cases for 395,784 people, a rate of only 3.79 p100th. And yet this is a big urban area with good connections to London, only 1.5 hrs drive.
For comparison it's surrounding rural county of Dorset has nearly double that.

Maybe it's the sea airs in the UK because some other 'conservative' coastal counties have suspiciously low rates, East Sussex 3.97 - no major city called Brighton and no London links.

I'm beginning to think London has a better set of testing regimes and some other areas don't consider testing that important or are turning people away from hospital

I think it's interesting - especially the Dorset number because when I spoke to my mum last week they had 8 cases and they're now up to 23.

There could be a difference in testing and in capacity to actually run the tests. As I say I read that the West Midlands has a specific bottleneck in their pathology department getting results out. I read something yesterday about NHS England now starting to spread widely things that London NHS Trusts have learned from dealing with this so far so that may change.

Some of it will be that, especially this early, if there is a local hotspot or mini-super-spreader that will still look like a significant difference. So Deveon was for a long time one of the worst hit counties which is bizarre and, even now, it's got 50 cases which is more than Bristol. Similarly Sheffield seems to have a lot more cases than Liverpool, Manchester or Leeds which is odd.

I also wonder about how these are being recorded and how it relates to hospitals because - I don't know them all obviously - I think all of the London boroughs you mention have a big hospital (Guys and St Thomas's, St George's, King's College, Chelsea and Westminster, St Mary's), but the only one I can think of in Haringey is the Moorfields Eye Hospital. Similarly a lot of those hospitals - definitely St George's and King's College are major trauma centres so when I was in one recently they dealt with cases all over South London but also surrounding counties and probably have a lot more ICU capacity than most hospitals. I'm not sure how they're recording stuff but it may be that they're still acting as hubs for the surrounding areas.

The other thoughts are that London's about two weeks ahead of the country and we're currently still on the doubling every three days track - so if you do the maths on those counties and towns they get to a bad situation within a fortnight, hopefully given lockdown by then the curve will be flattening. Also I wonder if the cities are more self-contained so Brighton, Bournemouth etc have more people who live and work in those cities while lots of Londoners who live in towns/villages outside just commute through there. If you look at the tracker and zoom in on counties it looks sort of like that and maybe like you'd expect so the commuter counties around London have lots of cases (Kent, Surrey, Hampshire, Hertfordshire etc), but the urban areas (Reading, Slough, Windsor, Brighton) don't. If you've moved out of London it seems more likely you'd move to the country than to another, smaller, city?

[celedhring]

"Better" numbers from Spain today. Deaths increase by 655 or +19% versus yesterday. It's the first time the number of new deaths decreases day-to-day (it was 738 yesterday) since the quarantine began. Number of UCI cases has increased very little, too, but that # sees a lot of day-to-day fluctuation I guess because of reporting (some days it increases by just a little, and then it jumps the next day).

[Duque de Bragança]

Restricted métro service as of today in Paris: only from 0600 (head of line) to 2200 (end of line). It is way more empty than usual but I fear at peak time it could be cramped as in the tube photo shown previously.
Buses are now far fewer like every 30 min or so on some lines; as during the strike except they are far from full.

[Josquius]

Really think there's a big cultural difference in corona rates. The more educated and more socially conscious being more likely to report it if they've anything short of a serious condition. But then it stands to reason these people would also be travelling more, both for leisure and in daily life.
I think we will be getting a lot of under reporting in poorer areas. And we have yet to see the worst of it in those areas with the disease originating with richer people.

[jimmy olsen]

US is getting hammered

https://mobile.twitter.com/BNODesk/status/1243015680045256707
Over the past 24 hours, the U.S. reported 14,024 new cases of coronavirus and 265 new deaths, raising the total to 68,347 cases and 1,037 dead

Same for Spain
https://mobile.twitter.com/BNODesk/status/1243125614250524673
BREAKING: Spain reports 6,673 new cases of coronavirus and 442 new deaths, or 8,578 new cases and 655 new deaths over the past 24 hours

Belgium taking off
https://mobile.twitter.com/BNODesk/status/1243118570910908416
NEW: Belgium reports 1,298 new cases of coronavirus and 42 new deaths, raising total to 6,235 cases and 220 dead

[HisMajestyBOB]

The Virginia Department of Health has been releasing number tested, confirmed cases, hospitalized, and deaths. It's interesting and troubling that only 5%-6% of those tested actually have it, which suggests that there's not yet a large number of people who have it but have mild symptoms. The hospitalization rate is 10% so far, so most confirmed cases are relatively mild.

[Iormlund]

I won't be suprised if retrospective analysis of Italian death rates is 2x higher than what we originally saw because thousands will have died of preventable non-COVID causes due to an overwhelmed system and not directly of COVID-19. In addition there are a lot of people in Italy who die before they reach the hospital so they don't get labeled COVID-19 because no test was run on them. Don't rest your laurels on what we see today. One day we'll be looking at dreadful "excess mortality" rates for the period of December 2019 - July 2020 versus the same timeframe in the previous few years and realize the true scope of this disaster.

Apparently this is being looked at now for some towns in or around Bergamo.

Long story short, directly or indirectly, the pandemic is killing between 4 and 10 times more people than official figures would suggest.

[Zanza]

Germany's top virologist was in a press conference with the science minister today and claimed that Germany could by now do 500.000 tests per week.

They debate about an exit strategy for the current shut down measures is starting in Germany as the current situation is not sustainable.

[celedhring]

A workmate is down with it, the first person I know that gets it. I was scheduled to have a daylong group meeting with him on the 16th - which my idiot boss still wanted to go forward with - until the quarantine was imposed.

He feels ok, he says. Moderate fever, cough, short breath.

[Fate]

Now this is grim.

https://www.washingtonpost.com/health/2020/03/25/coronavirus-patients-do-not-resucitate/?utm_campaign=wp_main&utm_medium=social&utm_source=twitter

I know it sounds awful but the value of CPR in the public's mind far outstrips its utility in saving lives. Only 10-15% of those who need to receive CPR ever leave the hospital alive afterwards and that's during non-pandemic conditions.

In a pandemic it's an extremely dangerous procedure for healthcare workers due to the risk of not having appropriate PPE and the risk of aerosolizing COVID-19.

[Sheilbh]

So in people being dicks news there's been a spate of "coronavirus coughing" where people are coughing or threatening to cough on people - such as RSPCA workers trying to rescue a swan (really), shop workers, emergency services.

The CPS have issued a statement reminding everyone this is common assault and could result in a jail sentence of two years and that the CPS would absolutely prosecute as much as they could on this given the situation those key workers are already in.

Amid the heartening news of people being good - some people are just pricks.

Also Scotland is starting to loosen restrictions on PPE being used after it is "out of date" after they've been testing "expired" masks and found they're still effective. So this will apparently release 1.5 million extra masks for Scotland from their central stockpile.

Edit: Apparently retailers have looked at their data and basically the people stockpiling and hoarding = 3% of people. Everyone else was just buying a little bit extra/more than normal.

[Legbiter]

Germany's top virologist was in a press conference with the science minister today and claimed that Germany could by now do 500.000 tests per week

That's good otherwise you're only playing defense while blind. Here the problem is we're running out of test kits because they're kinda popular right now and now we're scrambling trying to cobble together a local production facility in world record time. Otherwise we'll have no choice but to just lockdown completely.

[Legbiter]

I know it sounds awful but the value of CPR in the public's mind far outstrips its utility in saving lives. Only 10-15% of those who need to receive CPR ever leave the hospital alive afterwards and that's during non-pandemic conditions.

In a pandemic it's an extremely dangerous procedure for healthcare workers due to the risk of not having appropriate PPE and the risk of aerosolizing COVID-19.

Yeah. One thing I'd like to know too is how many of those who have to go on ventilator actually survive and recover?