Given the events of this week, I thought it might be a good time for a brief update.
AS ALWAYS, THIS IS MY PERSONAL OPINION AND EXPERIENCE. I DO NOT REPRESENT A HOSTPIAL OR SYSTEM IN THIS CAPACITY AND YOU SHOULD FOLLOW THE GUIDENCE OF YOUR PHYSICIAN AND THE CDC AT ALL TIMES.
**Originally composed using Johns Hopkins numbers from their website on Thursday, 10/15/20
Coronavirus, a summary of my experiences, thoughts, and putting the pandemic in context.
First my credentials for those unfamiliar: I am board certified by the ABIM and ABMS in Internal Medicine, Pulmonary Medicine, Critical Care Medicine, and Hospice and Palliative Care Medicine. I am also board certified in Pediatrics by the American Board of Pediatrics. I work mostly as a Pulmonary and Critical Care doctor and I am or have been the medical director or co-medical director of two different hospital’s intensive care units during the entire COVID 19 pandemic. I have personally cared for hundreds of infected coronavirus patients ranging in severity from mild hospital cases to severe ICU cases on life support, many of whom sadly did not survive. I offer this information as a matter of personal opinion and experience. It is in no way meant to be personal medical advice and if you think you are infected you should seek treatment from your local physician immediately.
Where things stand as of today:
Worldwide Cases: 38,326,891
Global Deaths: 1,088,804
Global Mortality Rate given Known Cases: 2.84%
This represents a reduction in mortality rate of roughly 1.4% since July 19, 2020
US Confirmed Cases: 7,883,392
US Deaths: 216,323
US Mortality Rate given Known Cases: 2.74%
This represents a reduction in mortality rate of 1% since July 19, 2020
A reasonable estimate of the number of unknown cases is at least double the number of known cases, and possibly much higher. The reason for this is that a large number of people that are "exposed" to COVID 19 and "catch" COVID 19 either never have symptoms or have very mild symptoms and do not get tested. If we use double the number of known cases (which is a very conservative estimate) then the mortality rates change:
Global Mortality Rate: 1.42%
US Mortality Rate: 1.32%
I want to point out I’m not talking about the number of coronavirus cases. There will be surges in the number of coronavirus cases. The key thing to watch is the mortality rate.
So why has the mortality rate gone down? The answer lies in several dynamics in this case:
A) Improved Treatments
B) Reduced Viral Virulence
C) Group Immunity (intentionally avoiding the phrase "Herd Immunity" which is used incorrectly by the media)
D) Improved Testing
Let’s explore this some more.
My current treatment approach:
1) Asymptomatic positive: Nothing.
2) Mildly symptomatic positive with no respiratory symptoms: Supportive care (Tylenol, Hydrate, Chicken Soup, Rest).
3) Symptomatic with respiratory symptoms w/o hypoxemia: Supportive care plus Zithromax and Steroids (Dexamethasone or Prednisone).
4) Symptomatic with respiratory symptoms with hypoxemia and chest-Xray changes: Admit to hospital, convalescent plasma (IgG antibody to COVID from donors), Remdesivir, High Dose Dexamethasone, and the Vitamins (Zinc, MVI, possible Vit D).
5) Severely Symptomatic with Respiratory Failure: Everything listed under 4 plus high flow oxygen first, then BiPAP if need. Self-prone position as much as possible. Avoid intubation and positive pressure ventilation if at all possible. If intubated and ventilated, adopt ARDS treatment protocols and/or Airway Pressure Release Ventilation and prone 18 hours a day. Heavy sedation when on vent, often with addition of paralytic agent.
***All hospitalized patient should be put on double the standard dose of anticoagulation for DVT prevention as these patients do tend to be hypercoagulable***
Patient with risk factors may be bumped up a number depending on presentation.
**Risk Factors can be divided into one of five categories in order of importance in my experience: Age, Morbid Obesity, Diabetes, COPD, other comorbidities.
A) Improved Treatments.
Key in treatment is early recognition of those with hypoxemia and Xray change and quick treatment with plasma, anti-viral (Remdesivir), and high-dose steroids. In my experience and in the experience of my colleges, the early treatment with this combination really does seem to save lives. Prior to these therapies and back when COVID 19 first started, it was not unusual for me to have 10-12 ICU patients with COVID 19 on the ventilator. These days, for the last 2 months, I have averaged about 3 ventilated COVID 19 patients a week. That represents a tremendous improvement. Keeping the patient off the vent is key. If you don't go on the vent, you have a substantially higher survival rate. If you do go on the vent you have a 55-60% "survival" rate nationally. This mirrors my experience. I caution that "survival" simply means survival to discharge, but it doesn't quantify what shape you may be in at discharge.
How does this combination therapy work? Why is it such a game changer?
When you get COVID 19 infection your body has a natural immune response to the infection. In a small percentage of people, the immune system is hyper-responsive and attacks not just the virus but also the human body, most frequently in COVID, the lungs. This leads to Acute Respiratory Distress Syndrome (ARDS) which causes the Respiratory Failure through shunt physiology in the lung. This leads to severe hypoxemia (low oxygen levels) and eventual scaring of the lung. At its fullest expression, this leads to death due to suffocation.
So, the COVID IgG antibody, either from plasma from donors who have recovered from COVID or the new monoclonal IgG COVID AB soon to be on the market (the one the president received), binds to the Coronavirus preventing it or killing it before it infects more airway and lung cells thus preventing infection and the potential hyper-immune response. The more IgG AB you have to COVID, the less virus is left to worsen the infection. The anti-viral Remdesivir kills the Coronavirus that infects your body thereby reducing the number of virions left alive, something in medicine referred to as lowering your viral load. How well Remdesivir works remains unproven. The high dose Dexamethasone reduces your immune response (which is what Plaquenil does as well in theory, but not as effectively as steroids).
So, in summation, after exposure and infection, if you are treated with this "cocktail," the IgG binds to much of the Coronavirus in your body rendering it less infectious and eventually killing the virus. Most of the small percentage of virus that eludes the IgG will likely be killed by the Remdesivir. If there is still enough virus left (live or dead) to cause a hyper-immune response in the susceptible population, the dexamethasone greatly reduces the immune response. This combination seems extremely effective if given early. If given too late in the course (when they are already near 100% oxygen requirements or on the vent) it is seldom effective and often too late.
B) Reduced Viral Virulence.
Reduced viral virulence is the natural evolution of every viral plague or bacterial plague throughout history. The purpose of a virus is to reproduce its genetic code, which is an RNA code in this case. Therefore, it serves no purpose for the virus to kill its host which it is using to reproduce its genetic code to then be released by millions of viral particles through the host. The host in this case being us. If a virus mutates in such a way that it becomes more virulent, and kills off its host, then less of that virus is replicated and released. Those mutations therefore die out. The mutations that allow the virus to replicate with little-to-no damage to the host are replicated and released in much higher numbers and win out over time. This is a key reason why, historically, most viral and bacterial "plagues" weaken over time and you see a generally predicable decline in mortality rate within the first few years. There is no reason to suspect that COVID 19 will be any different, and we are—indeed—seeing lowering mortality rates. The key here is to realize the mortality rates are declining not just in the US (where we have all these amazing treatments at our fingertips as doctors) but also around the world, including many countries with little access to quality healthcare.
If you want further proof of how super-virulent viruses die out before they spread, well, ever wonder why all Ebola outbreaks are very time limited and geographically limited? They kill off the host too fast and at too high a percentage to spread.
Continue.............
AS ALWAYS, THIS IS MY PERSONAL OPINION AND EXPERIENCE. I DO NOT REPRESENT A HOSTPIAL OR SYSTEM IN THIS CAPACITY AND YOU SHOULD FOLLOW THE GUIDENCE OF YOUR PHYSICIAN AND THE CDC AT ALL TIMES.
**Originally composed using Johns Hopkins numbers from their website on Thursday, 10/15/20
Coronavirus, a summary of my experiences, thoughts, and putting the pandemic in context.
First my credentials for those unfamiliar: I am board certified by the ABIM and ABMS in Internal Medicine, Pulmonary Medicine, Critical Care Medicine, and Hospice and Palliative Care Medicine. I am also board certified in Pediatrics by the American Board of Pediatrics. I work mostly as a Pulmonary and Critical Care doctor and I am or have been the medical director or co-medical director of two different hospital’s intensive care units during the entire COVID 19 pandemic. I have personally cared for hundreds of infected coronavirus patients ranging in severity from mild hospital cases to severe ICU cases on life support, many of whom sadly did not survive. I offer this information as a matter of personal opinion and experience. It is in no way meant to be personal medical advice and if you think you are infected you should seek treatment from your local physician immediately.
Where things stand as of today:
Worldwide Cases: 38,326,891
Global Deaths: 1,088,804
Global Mortality Rate given Known Cases: 2.84%
This represents a reduction in mortality rate of roughly 1.4% since July 19, 2020
US Confirmed Cases: 7,883,392
US Deaths: 216,323
US Mortality Rate given Known Cases: 2.74%
This represents a reduction in mortality rate of 1% since July 19, 2020
A reasonable estimate of the number of unknown cases is at least double the number of known cases, and possibly much higher. The reason for this is that a large number of people that are "exposed" to COVID 19 and "catch" COVID 19 either never have symptoms or have very mild symptoms and do not get tested. If we use double the number of known cases (which is a very conservative estimate) then the mortality rates change:
Global Mortality Rate: 1.42%
US Mortality Rate: 1.32%
I want to point out I’m not talking about the number of coronavirus cases. There will be surges in the number of coronavirus cases. The key thing to watch is the mortality rate.
So why has the mortality rate gone down? The answer lies in several dynamics in this case:
A) Improved Treatments
B) Reduced Viral Virulence
C) Group Immunity (intentionally avoiding the phrase "Herd Immunity" which is used incorrectly by the media)
D) Improved Testing
Let’s explore this some more.
My current treatment approach:
1) Asymptomatic positive: Nothing.
2) Mildly symptomatic positive with no respiratory symptoms: Supportive care (Tylenol, Hydrate, Chicken Soup, Rest).
3) Symptomatic with respiratory symptoms w/o hypoxemia: Supportive care plus Zithromax and Steroids (Dexamethasone or Prednisone).
4) Symptomatic with respiratory symptoms with hypoxemia and chest-Xray changes: Admit to hospital, convalescent plasma (IgG antibody to COVID from donors), Remdesivir, High Dose Dexamethasone, and the Vitamins (Zinc, MVI, possible Vit D).
5) Severely Symptomatic with Respiratory Failure: Everything listed under 4 plus high flow oxygen first, then BiPAP if need. Self-prone position as much as possible. Avoid intubation and positive pressure ventilation if at all possible. If intubated and ventilated, adopt ARDS treatment protocols and/or Airway Pressure Release Ventilation and prone 18 hours a day. Heavy sedation when on vent, often with addition of paralytic agent.
***All hospitalized patient should be put on double the standard dose of anticoagulation for DVT prevention as these patients do tend to be hypercoagulable***
Patient with risk factors may be bumped up a number depending on presentation.
**Risk Factors can be divided into one of five categories in order of importance in my experience: Age, Morbid Obesity, Diabetes, COPD, other comorbidities.
A) Improved Treatments.
Key in treatment is early recognition of those with hypoxemia and Xray change and quick treatment with plasma, anti-viral (Remdesivir), and high-dose steroids. In my experience and in the experience of my colleges, the early treatment with this combination really does seem to save lives. Prior to these therapies and back when COVID 19 first started, it was not unusual for me to have 10-12 ICU patients with COVID 19 on the ventilator. These days, for the last 2 months, I have averaged about 3 ventilated COVID 19 patients a week. That represents a tremendous improvement. Keeping the patient off the vent is key. If you don't go on the vent, you have a substantially higher survival rate. If you do go on the vent you have a 55-60% "survival" rate nationally. This mirrors my experience. I caution that "survival" simply means survival to discharge, but it doesn't quantify what shape you may be in at discharge.
How does this combination therapy work? Why is it such a game changer?
When you get COVID 19 infection your body has a natural immune response to the infection. In a small percentage of people, the immune system is hyper-responsive and attacks not just the virus but also the human body, most frequently in COVID, the lungs. This leads to Acute Respiratory Distress Syndrome (ARDS) which causes the Respiratory Failure through shunt physiology in the lung. This leads to severe hypoxemia (low oxygen levels) and eventual scaring of the lung. At its fullest expression, this leads to death due to suffocation.
So, the COVID IgG antibody, either from plasma from donors who have recovered from COVID or the new monoclonal IgG COVID AB soon to be on the market (the one the president received), binds to the Coronavirus preventing it or killing it before it infects more airway and lung cells thus preventing infection and the potential hyper-immune response. The more IgG AB you have to COVID, the less virus is left to worsen the infection. The anti-viral Remdesivir kills the Coronavirus that infects your body thereby reducing the number of virions left alive, something in medicine referred to as lowering your viral load. How well Remdesivir works remains unproven. The high dose Dexamethasone reduces your immune response (which is what Plaquenil does as well in theory, but not as effectively as steroids).
So, in summation, after exposure and infection, if you are treated with this "cocktail," the IgG binds to much of the Coronavirus in your body rendering it less infectious and eventually killing the virus. Most of the small percentage of virus that eludes the IgG will likely be killed by the Remdesivir. If there is still enough virus left (live or dead) to cause a hyper-immune response in the susceptible population, the dexamethasone greatly reduces the immune response. This combination seems extremely effective if given early. If given too late in the course (when they are already near 100% oxygen requirements or on the vent) it is seldom effective and often too late.
B) Reduced Viral Virulence.
Reduced viral virulence is the natural evolution of every viral plague or bacterial plague throughout history. The purpose of a virus is to reproduce its genetic code, which is an RNA code in this case. Therefore, it serves no purpose for the virus to kill its host which it is using to reproduce its genetic code to then be released by millions of viral particles through the host. The host in this case being us. If a virus mutates in such a way that it becomes more virulent, and kills off its host, then less of that virus is replicated and released. Those mutations therefore die out. The mutations that allow the virus to replicate with little-to-no damage to the host are replicated and released in much higher numbers and win out over time. This is a key reason why, historically, most viral and bacterial "plagues" weaken over time and you see a generally predicable decline in mortality rate within the first few years. There is no reason to suspect that COVID 19 will be any different, and we are—indeed—seeing lowering mortality rates. The key here is to realize the mortality rates are declining not just in the US (where we have all these amazing treatments at our fingertips as doctors) but also around the world, including many countries with little access to quality healthcare.
If you want further proof of how super-virulent viruses die out before they spread, well, ever wonder why all Ebola outbreaks are very time limited and geographically limited? They kill off the host too fast and at too high a percentage to spread.
Continue.............
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