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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

 
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03/25/2020 11:12 PM
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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
Not me, but the Dr at the link:

"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. "

[link to texags.com (secure)]
Anonymous Coward
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03/25/2020 11:24 PM
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Re: 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
sounds legit from the wording
Anonymous Coward
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03/25/2020 11:26 PM
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Re: 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
Doomy
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03/25/2020 11:27 PM
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Re: 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
Do you want an online anatomy lesson from Peter Pan?
75598709

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03/25/2020 11:33 PM

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Re: 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
Thank you for sharing that and your commitment to help so many when the world is in total chaos.

Stay safe out there.
Anonymous Coward
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03/25/2020 11:37 PM
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Re: 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
1 week and Indiana will be rum the fuck over
acinnc
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03/25/2020 11:39 PM
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Re: 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
How many of these patients had the flu shot prior?

I'm asking because this study shows that the flu shot significantly makes one more vulnerable to corona viruses.
[link to pubmed.ncbi.nlm.nih.gov (secure)]
Anonymous Coward
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03/25/2020 11:43 PM
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Re: 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
bsflag
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03/25/2020 11:46 PM
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Re: 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
1 week and Indiana will be rum the fuck over
 Quoting: Anonymous Coward 75209273


Negative, back to the evil marijuana tomorrow.
Anonymous Coward
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03/25/2020 11:57 PM
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Re: 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
Not everything is BS. We will get through this but it’s just something we will have to deal with for a while longer. Adapt and Survive.
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03/25/2020 11:59 PM
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Re: 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
Did I miss it, or was there no mention of hydroxychloroquine being tried? Or does pre-existing TDS precludes its use? I'm also wondering how many unnecessary deaths intubation has been causing (the "doc" quoted in the article says over 70% with a tube die, and nothing says the other 30% wouldn't have lived anyhow). It sounds like a very typical western medical practice, in that it's half-meant to kill you, but hell, "at least we tried." You're probably be better off hitting the sauna with a bag of herbal educated guesses from iherb than letting these half-wit egomaniacs get their hands on you.
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03/26/2020 12:09 AM
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Re: 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
Either that or... Ginger (reduce inflammation) honey (anti-viral) and lemon (keep ph alkaline) tea. Turmeric (reduce mucous), zinc (anti viral), vitamin C (boost immune system). And/ or Tsp baking soda in water to keep PH alkaline. Stay away from “acidic” foods sugar, meats and dairy for a while.
smokeandmirrors

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03/26/2020 12:23 AM
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Re: 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
Did I miss it, or was there no mention of hydroxychloroquine being tried? Or does pre-existing TDS precludes its use? I'm also wondering how many unnecessary deaths intubation has been causing (the "doc" quoted in the article says over 70% with a tube die, and nothing says the other 30% wouldn't have lived anyhow). It sounds like a very typical western medical practice, in that it's half-meant to kill you, but hell, "at least we tried." You're probably be better off hitting the sauna with a bag of herbal educated guesses from iherb than letting these half-wit egomaniacs get their hands on you.
 Quoting: Anonymous Coward 77684474


It was hidden, they used the trade name Plaquenil instead of the hydroxy.
Anonymous Coward
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03/26/2020 12:25 AM
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Re: 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
You’re just trying to make a self absorbed reality tv guy look like an incompetent President !
Anonymous Coward
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03/26/2020 12:32 AM
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Re: 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
5 stars! Thanks for posting.

- MC
Anonymous Coward
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03/26/2020 12:34 AM
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Re: 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
Did I miss it, or was there no mention of hydroxychloroquine being tried? Or does pre-existing TDS precludes its use? I'm also wondering how many unnecessary deaths intubation has been causing (the "doc" quoted in the article says over 70% with a tube die, and nothing says the other 30% wouldn't have lived anyhow). It sounds like a very typical western medical practice, in that it's half-meant to kill you, but hell, "at least we tried." You're probably be better off hitting the sauna with a bag of herbal educated guesses from iherb than letting these half-wit egomaniacs get their hands on you.
 Quoting: Anonymous Coward 77684474


It was hidden, they used the trade name Plaquenil instead of the hydroxy.
 Quoting: smokeandmirrors


Plaquenil (hydroxychloroquine) 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.
Anonymous Coward
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03/26/2020 12:35 AM
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Re: 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
How many of these patients had the flu shot prior?

I'm asking because this study shows that the flu shot significantly makes one more vulnerable to corona viruses.
[link to pubmed.ncbi.nlm.nih.gov (secure)]
 Quoting: acinnc 77856080


bump
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03/26/2020 12:39 AM
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Re: 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
This is an excellent forgery if not true. Sounds legit. Needs some research from us.
Anonymous Coward
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03/26/2020 12:40 AM
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Re: 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
You’re just trying to make a self absorbed reality tv guy look like an incompetent President !
 Quoting: Anonymous Coward 69958482


That reality tv guy is not sending 33,000 emails with SAP to Chinese intel.

Now is he, shill boy?
Anonymous Coward
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03/26/2020 12:58 AM
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Re: 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
Can u elaborate on asymptomatic shoulder dislocation
Karach123

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03/26/2020 12:59 AM
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Re: 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
I think it's legit these are Aggie doctors and they have to be in order to post on that board. But further down that thread was this:

In reply to TSUAggie
TSUAggie said:
Have either of you guys treated asthma patients that tested positive for COVID-19? My son has asthma and I'm scared as hell about him getting it.

From another thread

Based on what I'm hearing from colleagues in peds ID it seems like asthma is the theme of severe presentations under 20. Kids with asthma are the ones getting intubated, but thankfully this is more related to reactive airway disease and less so parenchymal lung disease. It basically causes a severe asthma exacerbation which is easy enough to fix once they're intubated.



---------
Can any medical people expound on what this means for children w asthma?
Anonymous Coward
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03/26/2020 01:14 AM
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Re: 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
I teach HS bio and alot of this makes sense but will have to look alot of it up.

What is your take on PPI & Diphenhydramine to stop out the cytokine storm if your unable to get to a hospital.

I am on day 6 or 7 after worst of it.. nearing day 10 is why I ask and I feel great now but now this aspect has me wondering
anonymous coward
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03/26/2020 01:19 AM
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Re: 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
To the person who wrote this post (OP),

I'm sure you mean well and are sending this message out to people who also work in your field to prevent things like steroids from making people worse so that you can pass on what you have learned from your work to other places in the hopes that somehow it will get there.

Anyone can tell you want to save lives and your intent is to do so.

That said, and I understand you went to school a while ago and now this is your chosen profession and the daily reality you live in and therefore what I may say may not be something you wish to process given it would take away your paycheck to leave that job and you have to survive on something yourself.

Here is what I am going to say:

The western medical approach has been hijacked and there is an agenda being followed that has nothing to do with whatever oaths doctors or nurses take and as such, folks above you who create policy or big pharma perhaps...are lying to you, the rest of the field you work in and the general public.

(a) All patented pharmaceuticals are based on tweaking something in nature so that money can be made on it. The tweaking makes whatever the substance is a bad fit for the body. If you had a choice between wormwood and the pharmaceutical anti-malaria drug to kill a virus or parasite, perhaps both would accomplish that task. The wormwood would simply do the task whereas whatever was tweaked in the western pharma patented version would maybe or maybe not do the task but it would have what is affectionately and inappropriately called a "side effect".

(b) There is no such thing as a side effect in reality. I like to compare analogies here. Anyone ever breathe second hand smoke? Nope. That's not second hand smoke. That's smoke, period. Nothing second handed about it. Yes, I know the "smoker" is not the second hand smoker, but the lungs aren't getting less kinds of toxic substances. Actually, they are getting all of the substances burning in the cigarette. The use of rhetoric (second hand smoke) is misused in a way that makes it sound like a smoker isn't forcing actual smoking on "non smokers". Similarly, a "side effect" is just an "effect". The use of the word side was originally misleading in that it was supposed to imply "unintended" as in not the task the medication was supposed to perform. However, if a scientist creates a drug that does other than, more than or in addition to the task assigned, that is in effect not creating the drug assigned, but rather something else which has harmful effects if those "side" effects are harmful.

(c) Natural cures do not have unintended side effects. They are perfect. So if you had to choose between the two and you choose only the pharma and not the natural, you have in effect chosen the thing that does not work correctly and can harm instead of the thing that works perfectly and does not harm. That goes against the oaths doctors and nurses take. Do pharmaceutical companies take these oaths to do no harm? No, they don't. Yet, the doctors prescribe these drugs and the nurses administer them. You can't follow an oath of no harm and follow direction from pharma and the CDC who do harm.

(d) The CDC is a known liar. They have already been whistle blown on for knowing MMR causes autism. More specifically, there are poisons in the vaccines. In effect, the vaccines are poisons. Mercury in any form whether you put methyl, ethyl or any other word in front of it IS admittedly poisonous to the body in ANY quantity. CDC is recommending what the world is following right now. A liar is writing the rules...a liar responsible for every case of vaccine damage that exists right now.

(e) Vaccine damage is real. There is a vaccine court. They have awarded a lot of money to people for vaccine damage. Therefore vaccine damage is real according to their own courts.

(f) The powers that be stay rich and in charge so long as we stay stupider, less able to organize, monitored, controlled psychologically, less able to arm, more likely to get ratted out and less physically able to overthrow them. They stay in power if we don't live as long, don't teach future generations what we've learned since they use the same tricks on every generation...The medical field has been hijacked by the powers that be to this end...to keep them rich and in charge by the means listed above.

(g) You can't find correct information about those that oppose vaccines through google because google scrubs it. Google was started by the CIA. The CIA runs the show. The powers that be run the CIA. That's where people get information. That's censorship and it is the reduction of the first amendment to free speech. This corona virus campaign is the reduction of freedom to assemble. That is the first amendment. Also, their religion they cram down our throats at gunpoint is pseudo science (pharma) and that is the end of freedom of religion or freedom of thought, the other part of the first amendment. They aren't saving lives. They are enslaving lives.

I could go on, but here's my point in a nutshell. If they gave a shit about our health, they wouldn't chemtrail the planet on a daily basis much less during a supposed pandemic. They made these viruses in their army bioweapons labs, they released them and they are using the spread of virus to change the laws and take away our bill of rights in action.

The only thing to do is remove these people by eliminating them. They are too powerful, rich and dangerous to try to deal with in a court system that is bought and paid for by them. The only way that is going to happen is when enough people who want to save lives (like yourself) wake up and realize you have been lied to. When they can't lie to the population anymore and we as a group are not buying their lies, there are more of us than there are of them and we can make up our own minds about what is good and bad, remove what is bad and support what is good.

I don't know when that day will be, but I know the rich and powerful don't want it to ever be and their agenda is to prevent it from happening. That makes them the enemy of every person who is not rich and powerful, whether they are awake to it or not.

It is a matter of ethics. It is wrong to enslave and lie to and make sick an entire planet. It should be stopped by whatever means necessary and it is ethical to overthrow them by those means as soon as is possible and the good karma of what will come of removing them will outweigh any bad karma that comes of the process involved in getting there.

I hope that woke you up even if you can't change jobs for a while. It's okay to wake up while still stuck working for the man. It gives you time to make a good plan for the future and be realistic about how you are going to get there. We are all a part of this puzzle. Who knows which part might be yours. A medical professional who comes to this site might have a more open mind than one who does not. That might lead to something good. Perhaps you will one day be a catalyst for waking up others or exposing what you have seen or just be someone who goes through a transformation and becomes a resource for others going through that afterwards who need moral support. Good luck in whatever path you choose that it may be for the good.

When we die, we see how we affected everybody. This is an ethical guide to learn from. Intent is important but knowing our impact is important too.
Anonymous Coward
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03/26/2020 01:20 AM
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Re: 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
bsflag
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03/26/2020 01:29 AM
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Re: 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
Hey Doc, why don't you i.v some vitamin C into your deathbed patients and get them some zinc vitamin D and some copper supplement too.. All I.V !! Then come back and tell us how you saved them..
Miss Bunny Swan

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03/26/2020 01:31 AM

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Re: 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
Too many acronyms
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03/26/2020 01:32 AM
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Re: 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
Hey asshole, I mean - “doctor”... Do the world a favor and begin placing your intermediate and worse cases on mega-dose IVs of vitamin C.. We’re talking anywhere from 30,000mg daily to 150,000mg daily for the worst cases. Do the same for your colleagues. Let me know what happens..

If you have a case that seems a sure death, give them up to 250,000mg of IV vitamin C and watch the magic work.. You want to be a “know it all”, or do ya want to swallow your pride and save lives? The choice is yours... There is NO virus that C cannot treat or kill.. End of story.

Choice is yours.
Anonymous Coward
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03/26/2020 01:34 AM
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Re: 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
Hey asshole, I mean - “doctor”... Do the world a favor and begin placing your intermediate and worse cases on mega-dose IVs of vitamin C.. We’re talking anywhere from 30,000mg daily to 150,000mg daily for the worst cases. Do the same for your colleagues. Let me know what happens..

If you have a case that seems a sure death, give them up to 250,000mg of IV vitamin C and watch the magic work.. You want to be a “know it all”, or do ya want to swallow your pride and save lives? The choice is yours... There is NO virus that C cannot treat or kill.. End of story.

Choice is yours.
 Quoting: Anonymous Coward 75610937


BTW, those dosages are for a 24 hour time frame for as long as it takes, which isn’t long... Keep it real.
Anonymous Coward
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03/26/2020 01:34 AM
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Re: 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
You’re just trying to make a self absorbed reality tv guy look like an incompetent President !
 Quoting: Anonymous Coward 69958482


trump-BHSalv
Brian Moran

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03/26/2020 01:34 AM
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Re: 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
Sounds word for word what's going down here in NorCal network, minus the 'small town' HCP thing. All staff and buildings of the larger network here have been converted to deal with covid-19 response. The EDs of the major hospitals have been setup with outside areas to diagnose and test for suspected covid-19 infections.

Staff that were 'it's just the flu' last week are bracing for the wave that's inbound as we creep closer to april, the entire hospital network is being focused on just this one event. Anyone capable of tele-medicine has been moved home as of today, well, starting tomorrow, that's all last week was was training. Everyone is making it up as they go trying to get ahead of this as best as they can.

PPE shortage is real, getting the Unions active, lots of tension between admin and nurses right now over this, protests out front of the hospitals. Could lead to a strike, will see. Not much time left to sort it out. Union has made it clear they will not let the nurses work if they can't get adequate PPE. Looks like about a week until we know how that story ends. Probably will require govt intervention if they can't get it provided.

And yeah, it's always double interstitial pneumonia, time and time again, same as Italy, same as this guy from New Orleans is stating.

You nothingburgers can BS flag all day, but it doesn't make the truth of this go away. There's a high likelyhood you'll get this, and it's these cats that will be saving your stupid asses when that day comes. None of your squealing will stop people from getting the info out, no matter how stupid you are.

And anyone flying that bs flag? I'd look into seeing if they can engrave that on headstones, it would be cute to see that on yours, because odds are you aren't taking this as seriously as you need to. Which means odds are you're fucked.
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03/26/2020 01:37 AM
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Re: 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
Too many acronyms
 Quoting: Miss Bunny Swan


bumpchuckle





GLP