Recent COVID 19 experience from an DFW ER doc

I didnt want to make a whole new thread but since the original thread is locked and this is important information it might be easier for everyone to see. It is a little lengthy but very interesting if you can get through it.

"So it has been a while since I have been on this website. When Covid started to hit back in March-April, going to work and then coming home and interacting/reading more about Covid just stressed me out even further. I had a few occasions where I would lash out and say rude things to other users for no reason, so I put myself in timeout for a few months.

That said, I did want to just share my own personal experience in the ED over the past few months.

So I am an ER doc in one of the major hospitals in Dallas. I work about 13-14 shifts a month and have logged probably 500 hours in the ER since all this started. I want to also preface this by saying, all of what I am going to say is based on my own personal experiences in Dallas. I have been following the numbers like all of you have, but my opinions are strictly anecdotal. I know for a fact some of my ER doc friends in Houston/SA have had different experiences. I guess I will start with what I am seeing now, start riffing, and see where this goes.

So as of the month of June, we are definitely seeing a higher volume of positive tests. The reason for seeing a higher volume of “positive tests” is twofold, #1-more people are sick aka the disease is spreading, and #2-we are pretty much testing everyone who walks through the door now. Now back in March/April, I was still seeing a ton of people who I thought had Covid, but we weren’t testing any of them. I would shoot a chest xray of the patient, look at their vitals, and if they weren’t toxic appearing, I would explain the disease process to the patient, would give azithro at the time, discharge them, and basically would tell the patient to come back to the ER when they were too short of breath to talk, or too weak to walk to the bathroom. For that reason, I believe we are definitely seeing a higher volume of covid + patients as the disease is now more prevalent, however I don’t think the “positive cases” is a true accurate reflection of how bad it has gotten, because I was rarely testing those people back in March-Early May. I think it is getting bad, but not as bad as the numbers reflect.

Of note, there is also a handful of patients who have come to the ER for something unrelated to covid (broken arm, car accident, missed dialysis, kidney infection), who we automatically test for covid because they are being admitted to the hospital. I’ve seen a handful of these patients test positive, even though their reason for being in the hospital has nothing to do with the disease. To my knowledge, these patient’s are still being counted as “covid admissions” even though they aren’t there because of covid, they were asymptomatic carriers, but its now a positive patient and we move them to the covid area of the hospital.

Why are less people dying if the disease is spreading more? I have two theories. Probably the number one thing is our understanding of the disease and the treatment strategies. My hospital has learned a lot by what happened in Italy and NYC. The big thing has to do with intubating patients and putting them on vents.

So back in March/April, our agreed upon treatment method, was if a patient was requiring more than 6 liters of supplemental oxygen, we would just intubate them. The reason for this was the fear that giving higher flows of oxygen, including CPAP/BiPAP/Hi Flo O2, would aerosolize the oxygen through out the entire ER/ICU thus spreading it to more patients and staff… We are now realizing that early intubation is a bad thing. Previously we were using O2 saturation (a vital sign) to determine when someone should be intubated. We are now using other assessments such as how hard someone is working to breath, their mental status, or acidosis in the blood. The reason for this is because Covid is causing something called silent hypoxemia. Meaning, when you take the patient’s oxygen saturation, it could be 70% but the patient looks fine and is not having any shortness of breath (usually we get worried when its under 88%). You would think someone with an O2 sat of 70% would be turning blue and huffing/puffing, but they aren’t with covid. We are now letting these patients basically just ride on supplemental O2 and not intubating them. I think this is saving lives. We also know hydroxy doesn’t work, dexamethasone may help, and we have covalescent plasma.

2nd theory.- the virus is becoming less deadly. Now my microbio/infectious disease docs could probably correct me on a lot of this, (I am going off first year of med school here) but it seems like the virus is becoming less virulent. It seems like we are seeing a higher volume of patients, but they are less sick. I haven’t intubated a patient since April. I’ve probably sent 10 total to the ICU since May. So one idea is that NYC got hit with a more deadly strain of Covid, and we got the less deadly version. Or we got the same version, but over long periods of time, as the virus enters thousands of people, it goes through millions of RNA replications within our cells. And every time the virus replicates in our body, there is a very small chance the virus mutates. And over four months, is the virus slowly mutating out of a less deadly version of itself until it is finally gone?

Kinda going back to hospitalization numbers. One thing we are seeing is a high number of “covid admissions”. Yes this is true. But a majority of these patients are staying in the hospital 1-3 days and getting discharged home. We aren’t having a prolonged stay in the hospital for most patients. Basically what is happening is we get a big batch of covid patients one day, while at the same time a big batch from a few days ago are being discharged. It is a revolving door. They aren’t stacking up on each other and clogging our hospital up. We are definitely very busy but we aren’t overflowing. To my knowledge my hospital has aprox 15-20% of our beds occupied by Covid.

So to summarize, I feel like I am definitely seeing a higher volume of patients with covid. They are less sick than they were in early March/April. This thing could turn on a dime at any moment. I feel our hospital is busy but we aren’t drowning. I feel the numbers are increasing but the numbers given out to the public are not an accurate representation about what is actually going on. Would also like to say I am by no way trying to downplay the disease. We are still seeing the disease do amazing things. I am 100% still seeing young healthy people get sick to the point that they need to come in the hospital. Have had two 30 year olds in the past month who presented with covid symptoms and were in complete renal falure (Crt of 15-19 for each), had a 40 year old who was positive with a celiac artery thrombosis, a few elderly adults who presented with encephalitis, and a guy who had a massive heart attack. The disease still isn’t to be taken at all lightly and it continues to surprise me everyday. Luckily myself and my fiance (ER nurse), have all been healthy. We have probably taken care of a combined 500 covid patients to this point and I have only had one coworker who has gotten covid, and she is doing great now., aka masks work. Sorry for the long article. Stay safe everyone."

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Latest Ag doctor update:
Coronavirus Update 7/02/2020 - T-cell Response

BTHO COVID-19

So today at the time of this writing there are 51,097 new cases and deaths are at 676. That is a record number of new cases for one day. Nationwide cases are still way up over the past week or so, going from 26k to now over 50k per day . Deaths are actually still steady or trending down slowly. We also have now had 1,484,475 people recovered from this virus and should now have some degree of immunity from this horrific disease.

Locally, in Texas cases are still rising rapidly. We had 7,690 new cases which again is one of the largest numbers we have ever had in Texas. In addition we had only 46 new deaths with a still declining mortality rate of 1.5%.

There are 74,628 active cases in Texas. The number of active cases continues to rise at a steady rate. We have risen significantly over the past 2 and half weeks now. Cases here in Texas along with hospitalizations have risen sharply over the past two and half weeks and another 400 today. Which is actually down from over 450 yesterday so that is a little good news. We now have a reported 6,904 patients in the state hospitalized currently with Covid-19 and we were below 2,000 on 6/8. As I have said previously we now have 50% of hospitalized and 30% of critical care Covid-19 patients are under age 50 now. So while most in this age group live many still get very seriously ill and require significant hospital stays prior to recovery.

In addition we have 89,101 recovered now. While we still have plenty of hospital and ICU beds they are filling up at too fast a rate with now over 400 per day for the past 5 days.

Today in Dallas county with 544 new cases and 7 deaths. Harris county with 1,442 new cases and 6 new deaths. Collin county with 115 new cases and no new deaths being reported. Denton county with 105 new cases and no new deaths. Tarrant county with 606 new cases and 3 new deaths. Brazos county with 122 new cases and 2 new deaths. Travis county with 558 new cases and 1 new death. Fort Bend county with 60 new cases and 1 new death. Bexar county with 439 new cases and one death.

For the newbies we have been predicting an overall fatality rate somewhere in the 0.3 to 0.7 range when we finally correct the denominator.

Study showing that some unexposed individuals may have some T-cell response to the SARS-COV2 virus.

In this study they found that 81% of unexposed individuals still had a T-cell response to the SARS-COV2 virus. So it is proposed that coronaviruses causing the common cold could cause a T-cell response giving individuals who have not been exposed some inherit immunity. Here in a previous blog we proposed that some type of cross over immunity from coronaviruses causing the common cold could be an explanation as to why some patients are asymptomatic. This appears to be some evidence of that hypothesis.

In addition they found that the severity of the disease correlated to the levels of antibodies that were found in patients. Meaning that patients with severe disease had higher levels of antibodies. However, this was not the case with the T-cell response as even mild cases still mounted a strong T-cell response.

So this is good news meaning that it is very possible that many people already have some immunity to the SARS-COV2 virus. In addition this is good news on the possible development of a vaccine since it could provoke a strong T-Cell response in addition to antibodies.

The Dallas doctor is a must read.

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Thanks. Good update.

First, thank you for your service in the ER.

Second, thank you for your report.

I always enjoy reading the views and perspectives of professionals out in the battle field dealing with the day to day challenges and problems regardless of profession. If they are smart, they realize they are speaking to their world and not to everyone’s world and the Dallas ER doctor sees it that way for he mentioned what he is experiencing is from his perspective and what his counter-parts elsewhere down in Houston and other places are experiencing a bit different world.

Thanks for posting both. Very valuable and refreshing from the views we get from the published articles that sometimes brings with it their agendas.

The reason for lower death numbers despite more cases is two-fold.
First, early on we had less of a good picture of how many people had it. Our daily numbers were off. If we use a 2% death rate and we capped out at 3,000 dead in a day. That mean at our peak we had 150,000 new cases in a day. That is a lot more than our current record of 57,000 (which is probably also an inaccurate count)
The second, and main reason, is that death number lag behind new case numbers. You don’t catch it and die the same day. I believe I remember reading in March or April that the typical result of death happens about 24 days after diagnoses. So we wouldn’t see an increase in deaths per day until at least 24 days after the increase in daily cases. But there is actually more!!! it also takes time to fill out the paperwork and get the death reported. It takes about a week. So death numbers lag behind cases by about a month.
We wont’ be able to tell if we are really treating it better until another two weeks go by. Then we can start looking at the death number each day and see what the trend is.
To put it simply, the increase in death numbers wont’ start to go up until two weeks from now.

I’m worried about the lag too. We will know over the next couple of weeks if that holds up. I hope that’s not it but think it may be part of it.

Another theory - many more younger people are getting it right now (multiple sources saying this) causing the death rate to go down. That works ok unless they start spreading to older folks.

Are we now saying that it’s possible that we didn’t have a good picture of what the actual death rate was/is? Because I seem to remember people acting like the 12th century catholic church and branding people heretics if they questioned the models and the modelers.

Yep to have an accurate percentage you have to an accurate dividend and divisor. If you don’t have those numbers it is just a wild guess.

The majority of modelers weren’t using deaths / confirmed cases as the death rate for this even early on. Some probably were but likely not those with any kind of an epidemiological background.

People in the media and social media are a different story. I’m sure there was plenty of that.

Your second theory is where I am at.

I think it’s a combination. Not sure if all 4 theories on this thread are true but all are reasonable.

I believe more than 1 are true and maybe all 4.

I noticed that COVID 19 deaths in Texas are trending up over the last couple of weeks. Not trying to be alarmist, but it’s a trend. In absolute numbers, the number of deaths per day in Texas is nowhere near what we saw in NYC a couple months ago.

I think it’s clear that more experience has led to better treatments, and better mortality rates. I’m also intrigued about the theory that we’re seeing spread of a new “less deadly” strain of COVID 19. I might be too optimistic here, but that could bode well as we move forward. It would be a positive development if COVID 19 morphed into something like the flu (which I know is still very deadly, but an improvement over COVID 19 so far).

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It could become less deadly which could make it more effective. I hope it goes too far in that direction and turns into something closer to the seasonal flu though.

One of the points that many miss is viruses have to balance high death rate with ability to spread. The higher the death rate, the less it can spread. That said, too low of a death rate and it’s also not very effective.

That’s part of what makes this one so nasty. It has a low enough death rate that it doesn’t take a ton of people out as a percentage, yet high enough that a lot of people still die in total because more get it. It’s a very good balance in terms of effectiveness.

Compare that to SARS which had a death rate of nearly 10% and was only contagious with symptomatic carriers (unlike COVID-19). It burned out quickly. That’s not going to happen here.

The asymptomatic and milder cases is also a huge part of the problem with this virus. So many don’t feel anything or have very mild symptoms yet can still spread. A much smaller percentage get hammered by it.

That’s an incredibly effective mix for a virus. You didn’t go to work or out to play if you had SARS. You stayed home because it was kicking your butt. People are out and about a ton with COVID-19 spreading it around. All of this also causes people to be all over the place in terms of opinions on it and makes it very hard to defeat.

Moral of the story is this guy isn’t going to burn itself out easily or disappear. So wear masks and be smart about being in close contact with those outside of your household. And, hope for an effective treatment and/or vaccine.

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Good explanation and I would argue that this type of virus is the worst for a country like the US. People wont change their lifestyle if they aren’t sick and will help spread it. If you don’t have eye popping death rates then people here will ignore it. 500-700 deaths a day is somehow getting written off even though it will lead to over 200k dead in less than a year. The crazy thing is if death rates were much higher and we lost 200k people in just the month of April, the virus would probably be gone by now. People would have taken it more seriously and it would have burned out quicker. We could easily see a muti year battle with over half a million dead now.

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