corona virus alerts - Latest cruising Information for vessels/locations/rules

[Don C L]

Originally Posted by valhalla360

See, this is the problem...a lot of hyperbole with very little real information.

Yes, for those who die it it's bad...just like for those who die in a car crash, it's bad...but we still keep driving. We make risk vs benefit decisions all the time but rarely so dramatic an impact with so little information.

Take car crashes. In the US alone there are around 35,000 deaths per year. I could eliminate 98% of those by simply putting a governor on all vehicles limiting the speeds to 10mph...but as a society, we've deemed the cost outweighs the benefits.

But that choice was made over decades with time to understand the choices costs and benefits. We simply don't have a clue how serious the disease is and a lot of panic driven reporting resulting in knee-jerk reaction to shut down the world with no real consideration of the costs.

There is data for those who are elderly (over 60) or with underlying conditions. The mortality rate range is 3 to 27% If that was the rate of folks dying when they drive, we would close down roads until they figured out why. You and I have the choice to get in a car (which is far safer than catching this disease,) the older victims of this disease did not make any choice to put themselves at risk. The younger ones may have, which is what is angering so many. Those kids went home and hugged their older parents and grandparents.
https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm

[Montanan]

It ain't over, until it's over. And this is far from over, even in China which is trying to inhibit a rebound.

China has announced a temporary ban on all foreign visitors, even if they have visas or residence permits.

The country is also limiting Chinese and foreign airlines to one flight per week, and flights must not be more than 75% full.

Although China reported its first locally-transmitted coronavirus case for three days on Friday, almost all its new cases now come from abroad.

There were 55 new cases across China on Thursday - 54 of them from overseas.

What are the new rules?
The Chinese Foreign Ministry said it was "suspending the entry of foreign nationals" because of the "rapid spread of Covid-19 across the world".

The suspension applies to people with visas and residence passes, but not to diplomats or those with C visas (usually aircraft crew).

People with "emergency humanitarian needs" or those working in certain fields can apply for exceptions.

[Lake-Effect]

Originally Posted by valhalla360

See, this is the problem...a lot of hyperbole with very little real information.

Yes, for those who die it it's bad...just like for those who die in a car crash, it's bad...but we still keep driving. We make risk vs benefit decisions all the time but rarely so dramatic an impact with so little information.

But that choice was made over decades with time to understand the choices costs and benefits. We simply don't have a clue how serious the disease is and a lot of panic driven reporting resulting in knee-jerk reaction to shut down the world with no real consideration of the costs.

We do have a clue how serious the disease is. More than a clue, actually.


You keep mentioning cost/benefit analysis... but you haven't yet told us much about how you think the pandemic should be handled, and provided your own cost/benefit analysis to justify your approach.

[hpeer]

Originally Posted by smbdyiam2

Does this have any effect on global warming . climate change. food shortages?

Anything good?

There are various answered to this, it’s not one sided. Here are some statements, each one stands alone to some extent.

On the one hand it will help clean up the atmosphere for a bit. It might make it worse later as we burn up a lot of cheap oil trying to restart the consumer economy.

If the current models are correct then we should see some increased warming th is summer. The various bits of pollution floating around, including contrails, tend to cool the earth hiding the full extent of GW. We saw a blip after 911 when planes were grounded. We should also see some change this time around that provides more evidence of how the atmosphere is working and that should inform the models. It will give us info no matter what the outcome.

Depending on the number must if deaths and how badly folks are maimed by this disease it may provide Social Security and Medicare some relief, but I’m not positive of that. We may decide to raid SS.

It may take a lot of high medical consumers out of the population. That may mean hospitals have fewer patients in the future. That’s good, but some hospitals may fail. It may make us less prepared for the next crisis.

Everything is a mixed bag. Very confusing.

[smbdyiam2]

Originally Posted by hpeer

There are various answered to this, it’s not one sided. Here are some statements, each one stands alone to some extent.

On the one hand it will help clean up the atmosphere for a bit. It might make it worse later as we burn up a lot of cheap oil trying to restart the consumer economy.

If the current models are correct then we should see some increased warming th is summer. The various bits of pollution floating around, including contrails, tend to cool the earth hiding the full extent of GW. We saw a blip after 911 when planes were grounded. We should also see some change this time around that provides more evidence of how the atmosphere is working and that should inform the models. It will give us info no matter what the outcome.

Depending on the number must if deaths and how badly folks are maimed by this disease it may provide Social Security and Medicare some relief, but I’m not positive of that. We may decide to raid SS.

It may take a lot of high medical consumers out of the population. That may mean hospitals have fewer patients in the future. That’s good, but some hospitals may fail. It may make us less prepared for the next crisis.

Everything is a mixed bag. Very confusing.

lots of effects on climate ,global warming, atmosphere, etc I catch that.
hospitols have fewer patients."
"That may mean hospitals have fewer patients in the future. That’s good, but some hospitals may fail."
I cannot find good in that. Not taking out high medical consumers. Sorry

[zeehag]

sent to a nurse friend from her friends nurse anesthetist friend from front lines:



"I am an ER MD in New Orleans. 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, anorexia, fatigue.

Day 5 of symptoms- increased SOB, and bilateral viral pneumonia from direct viral damage to lung parenchyma.

Day 10- Cytokine storm leading to acute ARDS 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 (even 75%) without dyspnea. I have seen Covid patients present with encephalopathy, renal failure from dehydration, DKA. 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 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 in the ED and rescue PCI at 60 minutes only if TPA fails.

Diagnostic
CXR- bilateral interstitial pneumonia (anecdotally starts most often in the RLL 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 low, Lymphocytes low, platelets lower then their normal, Procalcitonin normal in 95%
CRP and Ferritin elevated most often. CPK, D-Dimer, LDH, Alk Phos/AST/ALT commonly elevated.
Notice D-Dimer- I would be very careful about CT PE these patients for their hypoxia. 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, lymphopenia, normal procalcitonin, elevated CRP and ferritin- 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 and LFTs 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
Supportive

worldwide 86% of covid 19 patients that go on a vent 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 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, but are intermittently running out of IV.

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 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 stuff, low volume, permissive hypercapnia, 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- 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. 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.

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 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."
📷

A friends daughter who a nurse anesthetist sent this to me

[Lake-Effect]

Originally Posted by zeehag

sent to a nurse friend from her friends nurse anesthetist friend from front lines:

"I am an ER MD in New Orleans. Class of 98. Every one of my colleagues have now seen several hundred Covid 19 patients and this is what I think I know....

A friends daughter who a nurse anesthetist sent this to me

Wow, great report. Thanks.

It's the second report I've read where it's mentioned that pronation helps.

in this context I believe pronation means the patient is lying on their stomach, propped up by their arms.

Somebody who knows for sure - PLEASE correct me.

[zeehag]

yes pronation is flipped buttside up. weird position for lungs normally but this aint normal infiltration and gunk. is interstitial torture.

[GordMay]

The Thunder Bay District Health Unit (TBDHU), has confirmed the first case of COVID-19 in the Thunder Bay region.
According to the public health agency, a man in his 60s who lives in Thunder Bay has tested positive for the COVID-19 virus.
The TBDHU said in a statement Friday that his spouse is considered a probable case as well, and that the couple had recently returned from a week-long stay in Florida.
"Upon their return, they remained in isolation at home. Subsequently, both developed symptoms and phoned the TBDHU. They were tested the following day at the COVID-19 Assessment Center operated by the Thunder Bay Regional Health Sciences Centre," the health unit stated.

[Don C L]

Originally Posted by zeehag

yes pronation is flipped buttside up. weird position for lungs normally but this aint normal infiltration and gunk. is interstitial torture.

Did I read that right? 70% of people who go on a ventilator still don't survive?

[Montanan]

Originally Posted by smbdyiam2

lots of effects on climate ,global warming, atmosphere, etc I catch that.
hospitols have fewer patients."
"That may mean hospitals have fewer patients in the future. That’s good, but some hospitals may fail."
I cannot find good in that. Not taking out high medical consumers. Sorry

Indeed many private practices which work on slim margins are going to go belly up at least temporarily.

By way of example, Western Montana Clinics a consortium of about 70 doctors and a total of over 240 employes just shut operations yesterday and are not even paying the accumulated paid time off for the employees.

Over 90 years this broad based group health practice has been serving the community, today it is closed.

Critical care and hospitals likely to ride through this because of the Federal funding legislation but the routine care private practices are shutting down.

The private laboratories did get funding considerations for the COVID-19 but not private practices.

The USA for profit healthcare system lacking a universal care scheme is fundamentally unsound for this kind of event and this may be the game changer to finally join all the other major developed countries healthcare schemes.

[Singularity]

Originally Posted by Don C L

Did I read that right? 70% of people who go on a ventilator still don't survive?

Probably. Practically speaking the ventilator doesn't treat the infection at all...it simply helps air/oxygen get to the blood stream while the immune systems sorts things out on it's own.

While on the vent...the longer on the vent and/or the more systemic inflammation a person has...the greater the risk of bacterial infections to set in, other organ systems to fail (notably kidneys), etc, etc. Each successive "hit" exacerbates the initial perturbation as while also decreasing the body's capacity to overcome the entire challenge. More hits=much lower survivability.

To survive ventilation basically means the person's immune system comes to terms with the initial problem (i.e.controls the viral issue while calming itself down), and other organ system issues are being managed somehow.......AND the person must have enough ~muscular tone of all the breathing muscles that can be "coached" back into shape. Such muscles routinely waste away (a little bit) on a vent on a good day....but with ~SARS type stuff the muscles can waste worse than average on a vent ride.

[dannc]

Originally Posted by Don C L

Did I read that right? 70% of people who go on a ventilator still don't survive?

worldwide 86% of covid 19 patients that go on a vent die. Seattle reporting 70%.

is what was said.

The 8Xish% number I first read in quote from one or two Italian doctors. The Italian doctor(s) also said they would not put their 80sih year old father on a ventilator.

Later,
Dan

[smbdyiam2]

Originally Posted by Montanan

Indeed many private practices which work on slim margins are going to go belly up at least temporarily.

By way of example, Western Montana Clinics a consortium of about 70 doctors and a total of over 240 employes just shut operations yesterday and are not even paying the accumulated paid time off for the employees.

Over 90 years this broad based group health practice has been serving the community, today it is closed.

Critical care and hospitals likely to ride through this because of the Federal funding legislation but the routine care private practices are shutting down.

The private laboratories did get funding considerations for the COVID-19 but not private practices.

The USA for profit healthcare system lacking a universal care scheme is fundamentally unsound for this kind of event and this may be the game changer to finally join all the other major developed countries healthcare schemes.

Indeed many private practices which work on slim margins are going to go belly up at least temporarily.

Temporarily. but the dead is permanent. Again this is about money.

When the haves and have nots. change to the corona virus haves and have nots instead of money, then we will see a change in world economics, health care , food production and distribution, and wars.

If it doesn't change, then will go on as is W/ smaller population

[zeehag]

please research INTERSTITIAL PNEUMONIA. is a destruction of alveoli.
this is unlike pneumonia that is normal and has a high death rate and much sequellae of lung damage including interstitial pulmonary fibrosis. ipf i have had much experience with in cedars sinai testing a nasty cardiac drug in 1986. it aint loverly. 9 out of 10 patients could not be unvented and died as a result. yes it is sick yes it sucks. this is why i have been pushing the info i been pushing. you do not want it nor do you wanna give it to your momma.
there are not enough ventilators on planet for any nations needs. this is also sick. i have not gotten a clean answer yet as to number of vents in mexico--is either 2200, 4000, or 5200 or 5500. hahahahaha all numbers grossly inadequate for the size of nation.
best of luck to ye and yours. me'n' bubba and chico are holding on for our lives. and just in case i have a place for the boys to go if i get sick. they will live on a farm in utah? i da ho? with a stream. much different from bubbas usual cushy life, but if no momma--gotta adapt. mebbe chico catch bubba a fishie