The Emergency Doc

09/10/2024

If you have an iPhone 14 or later it can now be used as a satellite phone for emergency calls and texting! You must update to iOS 18 and it only works when you do not have Wi-Fi or cellular service . Important PSA for anyone who might be impacted by the hurricane 

How to stay connected if you can’t get a regular signal

16/01/2023

Nurse practitioners are an important part of the ER care team, but their push for independent practice without appropriate training is dangerous for patients
https://richmond.com/opinion/columnists/column-virginia-patients-deserve-well-trained-nurse-practitioners/article_c575be02-92d2-11ed-acdc-07a7c8ffce27.html?fbclid=IwAR2zyzI2zXY1LveRJ-FmkgTi5mjh_tIV8_0icJc3G39hBMOgE9rSHOcAVKk

This is an opinion column from The Times-Dispatch opinion page.

14/09/2021

Over the last few weeks, hospital systems across Virginia have been sounding alarms over the latest coronavirus surge, largely driven by the highly infectious delta variant. In Southwest Virginia, Ballad Health is facing its “worst-case scenario” with more than 700 COVID-19 patients. In Northern...

07/08/2020

For those that are still asking about Hydroxychloroquine, please watch (or read the transcript). It explains why non-randomized observational trials are relatively meaningless, and why the randomized trials are the gold standard, and then provides a summary of each of the randomized trials performed to date

Again, we ARE getting much better at treating COVID...preventing intubation and deaths with proning, putting them on high flow oxygen (like 40-50L/min), and other uber cheap drugs like dexamethasone, zinc, and vitamin c and even azithromycin which is showing some benefit, likely from helping prevent bacterial superinfections plus a small anti-inflammatory effect. All of these medicines are helping (or at least in the case of zinc and vitamin c maybe helping, but at least not harming). We are hospitalizing fewer people because of aggressive home programs (ie sending patients home with oxygen) with paramedicine programs that check on them. With mask mandates, those that get sick are often becoming infected with lower initial viral loads, buying the immune system time to catch up and causing a milder illness. There are a ton of reasons for a lot of hope...HCQ is simply not one of them.

The vast majority of studies on hydroxychloroquine and COVID-19 are observational, but randomization is what shows its true effect, says Dr F. Perry Wilson.

02/06/2020

Yes, COVID is still here!

I never really understood why this "study" was gaining such traction, but it has been retracted. Far too underpowered, and their methods were both technically and statistically incorrect.

Source One of the world’s leading medical journals has retracted a widely circulated paper published in April that concluded that “both surgical and cotton masks seem to be ineffective in preventin…

29/05/2020

I posted a link below to the largest study to date on Hydroxychloroquine, with a couple of concerns, specifically that it was retrospective and not randomized. I also thought it odd that the study groups were so closely matched given the non-randomization. Turns out there are some potentially more significant flaws. I would not be surprised to see the Lancet issue a retraction

In an open letter the study authors and the editor of the lancet a number of concerns are raised.

1. The numbers in the study don't compare to official numbers
2. The research group is, so far, not sharing any of their data or hospitals. The Lancet is a signatory to an international consortium of research groups and publishers that any and all COVID data that is published has to be open source.
3. Hospitals that had to have been included are saying they were never contacted or gave permission for their information to be shared.

I think it's important to point out something that is important in trying to determine the veracity of scientific data...what are the underlying motivations of those that are posting/publishing? The signatories on this letter include people who are on record as being highly skeptical of HCQ. When any person or group doubles down on something "scientific" that a large group of people are questioning, that is a big red flag (in medical research at least) that there are motivations other than the truth. Scientists should welcome others attempting to replicate, criticize, and tear apart their work so that the truth can be had. So far, the study authors only public responses have been defensive. This, combined with some of the people who signed the letter, makes me think that there is more going on here and, if the group does not completely release all of their data publicly, I wouldn't be surprised to see the Lancet issue a retraction.

Here is the test of the letter

"Open letter to MR Mehra, SS Desai, F Ruschitzka, and AN Patel, authors of“Hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19: a multinational registry analysis”. Lancet. 2020 May 22:S0140-6736(20)31180-6. doi: 10.1016/S0140-6736(20)31180-6. PMID: 32450107and to Richard Horton (editor of The Lancet).

Concerns regarding the statistical analysis and data integrity

The retrospective, observational study of 96,032 hospitalized COVID-19 patients from six continents reported substantially increased mortality (~30% excess deaths) and occurrence of cardiac arrhythmias associated with the use of the 4-aminoquinoline drugs hydroxychloroquine and chloroquine. These results have had a considerable impact on public health practice and research. The WHO has paused recruitment to the hydroxychloroquine arm in their SOLIDARITY trial.The UK regulatory body, MHRA,requested the temporary pausing of recruitment into all hydroxychloroquine trials in the UK (treatment and prevention), and France has changed its national recommendation for the use of hydroxychloroquine in COVID-19 treatment and also halted trials. The subsequent media headlines have caused considerable concern to participants and patients enrolled in randomized controlled trials (RCTs) seeking to characterize the potential benefits and risks of these drugs in the treatment and prevention of COVID-19 infections.

There is uniform agreement that well conducted RCTs are needed to inform policies and practices. This impact has led many researchers around the world to scrutinize in detail the publication in question. This scrutiny has raised both methodological and data integrity concerns. The main concerns are listed as follows:

1.There was inadequate adjustment for known and measured confounders (disease severity, temporal effects, site effects, dose used).

2.The authors have not adhered to standard practices in the machine learning and statistics community. They have not released their code or data. There is no data/code sharing and availability statement in the paper. The Lancet was among the many signatories on the Wellcome statement on data sharing for COVID-19 studies.

3.There was no ethics review.

4.There was no mention of the countries or hospitals that contributed to the data source no acknowledgments to their contributions. A request to the authors for information on the contributing centres was denied.

5.Data from Australia are not compatible with government reports (too many cases for just five hospitals, more in-hospital deaths than had occurred in the entire country during the study period). Surgisphere (the data company) have since stated this was an error of classification one hospital from Asia. This indicates the need for further error checking throughout the database.

6.Data from Africa indicate that nearly 25% of all COVID-19 cases and 40% of all deaths in the continent occurred in Surgisphere-associated hospitals which had sophisticated electronic patient data recording, and patient monitoring able to detect and record “nonsustained [at least 6 secs] or sustained ventricular tachycardia or ventricular fibrillation”. Both the numbers of cases and deaths, and the detailed data collection, seem unlikely.

7.Unusually small reported variances in baseline variables, interventions and outcomes between continents(Table S3).

8.Mean daily doses of hydroxychloroquine that are 100 mg higher than FDA recommendations, whereas 66% of the data are from North American hospitals.9.Implausible ratios of chloroquine to hydroxychloroquine use in some continents.10.The tight 95% confidence intervals reported for the hazard ratios appear inconsistent with the data. For instance,for the Australian Data this would need about double the numbers of recorded deaths were reported in the paper.The patient data were obtained through electronic health records, supply chain databases,and financial records. The data are held by the US company Surgisphere. In response to a request for the data Professor Mehra replied:“Our data sharing agreements with the various governments, countries and hospitals do not allow us to share data unfortunately.” Given the enormous importance and influence of these results, we believe it is imperative that:

1.The company Surgisphere Provides details on data provenance. At the very minimum, this means sharing the aggregated patient data at the hospital level (for all covariates and outcomes)

2.Independent validation of the analysis is performed by a group convened by the World Health Organization,or at least one other independent and respected institution. This would entail additional analyses (e.g. determining if there is a dose-effect)to assess the validity of the conclusions

3.There is open access to all the data sharing agreements cited above to ensure that,in each jurisdiction,any mined data was legally and ethically collected and patient privacy aspects respected

In the interests of transparency, we also ask The Lancet to make openly available the peer review comments that led to this manuscript to be accepted for publication.This open letter is signed by clinicians, medical researchers, statisticians, and ethicists from across the world. The full list of signatories and affiliations can be found below."

Full letter at this link:

Link: https://zenodo.org/record/3865253 #.XtEi_jpKjZs

24/05/2020

Good high level overview. Obviously individual risks vary.

The weather is warming up and public spaces are starting to reopen. How do you decide what's safe to do? We have guidance to help you compare and evaluate the risks.

22/05/2020

Another large study on HCQ and Azithromycin, used both together and independently.

Bottom line: Ouf of over 96.000 hospitalized patients with COVID, almost 15,000 received CQ or HCQ with or without azithromycin. There was no benefit, and increased harm (especially cardiac dysrhythmias), in those that received the treatments as compared to control.

Major weaknesses: this is retrospective, and not randomized. Amazingly though, for a non-randomized study, the demographics and severity of illness of the various groups were fairly closely matched.

The Abstract:

Background
Hydroxychloroquine or chloroquine, often in combination with a second-generation macrolide, are being widely used for treatment of COVID-19, despite no conclusive evidence of their benefit. Although generally safe when used for approved indications such as autoimmune disease or malaria, the safety and benefit of these treatment regimens are poorly evaluated in COVID-19.

Methods
We did a multinational registry analysis of the use of hydroxychloroquine or chloroquine with or without a macrolide for treatment of COVID-19. The registry comprised data from 671 hospitals in six continents. We included patients hospitalised between Dec 20, 2019, and April 14, 2020, with a positive laboratory finding for SARS-CoV-2. Patients who received one of the treatments of interest within 48 h of diagnosis were included in one of four treatment groups (chloroquine alone, chloroquine with a macrolide, hydroxychloroquine alone, or hydroxychloroquine with a macrolide), and patients who received none of these treatments formed the control group. Patients for whom one of the treatments of interest was initiated more than 48 h after diagnosis or while they were on mechanical ventilation, as well as patients who received remdesivir, were excluded. The main outcomes of interest were in-hospital mortality and the occurrence of de-novo ventricular arrhythmias (non-sustained or sustained ventricular tachycardia or ventricular fibrillation).

Findings
96032 patients (mean age 53·8 years, 46·3% women) with COVID-19 were hospitalised during the study period and met the inclusion criteria. Of these, 14 888 patients were in the treatment groups (1868 received chloroquine, 3783 received chloroquine with a macrolide, 3016 received hydroxychloroquine, and 6221 received hydroxychloroquine with a macrolide) and 81 144 patients were in the control group. 10698 (11·1%) patients died in hospital. After controlling for multiple confounding factors (age, s*x, race or ethnicity, body-mass index, underlying cardiovascular disease and its risk factors, diabetes, underlying lung disease, smoking, immunosuppressed condition, and baseline disease severity), when compared with mortality in the control group (9·3%), hydroxychloroquine (18·0%; hazard ratio 1·335, 95% CI 1·223–1·457), hydroxychloroquine with a macrolide (23·8%; 1·447, 1·368–1·531), chloroquine (16·4%; 1·365, 1·218–1·531), and chloroquine with a macrolide (22·2%; 1·368, 1·273–1·469) were each independently associated with an increased risk of in-hospital mortality. Compared with the control group (0·3%), hydroxychloroquine (6·1%; 2·369, 1·935–2·900), hydroxychloroquine with a macrolide (8·1%; 5·106, 4·106–5·983), chloroquine (4·3%; 3·561, 2·760–4·596), and chloroquine with a macrolide (6·5%; 4·011, 3·344–4·812) were independently associated with an increased risk of de-novo ventricular arrhythmia during hospitalisation.

Interpretation
We were unable to confirm a benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide, on in-hospital outcomes for COVID-19. Each of these drug regimens was associated with decreased in-hospital survival and an increased frequency of ventricular arrhythmias when used for treatment of COVID-19.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31180-6/fulltext

20/05/2020

Deaths and COVID: What is the truth?

PLEASE NOTE: there are two charts pictured below. One is the CDC provisional/excess deaths chart from May 7th, and the second is the updated one from May 19th. They are posted for comparison and reference, but the statistics are from the May 19th chart.

I still see posts arguing that deaths are overcounted in COVID. I have maintained that, while there may be incidences of a non-COVID death being counted as COVID, this is more than compensated by COVID deaths not being counted as COVID (either because they died in the field or the clinical picture was too vague). The answer remains in the CDC provisional and excess deaths chart.

A reminder: each week this chart is updated. These charts are based on receipt/processing of death certificates by the CDC. The numbers cited in commonly used trackers like Johns Hopkins use state health dept data that is up to date within a few days. The CDC provisional deaths chart lags a couple weeks because it takes that long for death certificates to physically arrive at the CDC (see my previous posts on this for further information)

There are 3 critical points to consider:
1. Death counts lag. I attached the May 7 and May 19th charts. Every category continues to increase. Again, this is reflecting the CDC receiving more death certificates which can take several weeks to make their way to the CDC.

2. Excess deaths give the clearest picture: While deaths being inappropriately attributed has not been my experience, or the experience of anyone in the groups I am part of, there are almost certainly isolated cases of this. So the answer is in the "excess deaths". If, in fact, deaths from other causes are being attributed to COVID (for whatever reason), then there should not be a significant number of "excess" deaths. (Reference the May 19th chart)....Beginning March 28th, excess deaths begin to be reported. Beginning April 4, this starts to become significant. Keep in mind that most of us began to diagnose these patients in very late February to the first week or two of March, hospitalizations lag diagnosis by about a week, and deaths lag hospitalizations by 1-3 weeks. This data compares the May 19th update to May 7th.

Mar 28: Deaths 59714 (up from 58290 on the May 7th chart)
Percent Expected 107% (up from 104% on May 7th)
Expected Deaths 56048
Excess Deaths: 3,666

Apr 4: Deaths 67725 (up from 65768)
Percent expected: 120% (up from 117%)
Expected deaths 56.211
Excess deaths: 11,514

Apr 11: Deaths: 73,225 (up from 70.035)
Percent Expected: 130% (up from 131%)
Expected Deaths: 55583
Excess deaths: 17,642

Apr 18: Deaths: 69,145 (up from 63131)
Percent Expected: 127% (up from 116%)
Expected Deaths: 54423
Excess Deaths: 14,722

Apr 25: Deaths: 62,582
Percent Expected: 115%
Expected Deaths: 54,419
Excess Deaths: 8163

May 2: Deaths: 53,315
Percent Expected: 99%
Expected Deaths: 53854
Excess Deaths: -539

So that is about 55,000 excess deaths from the period of March 28 – April 25th. I included May 2nd for future reference, but it is too soon to extract meaningful data, so I will update those next week. But as of about 3 weeks ago, we were at >55,000 excess deaths as compared to the previous 3 years

3. Despite some media reports, many pneumonia deaths are not being counted as COVID. This is why the combined columns are important. Looking at the highest week, April 11th, there were 14,485 deaths attributed to COVID. There were 454 deaths attributed to influenza. There were 19,269 deaths attributed to COVID, Pneumonia, or influenza. So this means there were 4330 pneumonia deaths NOT attributed to COVID-19 or influenza. (19269-14485-454 = 4330). But how do we know that many of those weren't incorrectly attributed? Look at the chart in the weeks before COVID began appearing…there are roughly 3800 deaths from pneumonia not attributed to influenza or COVID every week. So now there are 10 % more pneumonia deaths than normal or that can be accounted for by COVID or flu. So this indicates there are likely still some cases of people dying of COVID pneumonia that aren't being attributed to COVID, or alternatively an increase in pneumonia deaths that aren't seeking treatment until it's too late (or likely some combination of both). This is applicable to all excess deaths: while there are some deaths that are likely being attributed to COVID, there are many excess deaths that are not. Some of these are likely undiagnosed COVID, some are likely those dying of other causes not seeking care due to fear of going to a hospital.

Regardless, given that (even with the lag) up until April 25th there were 55,000+ excess deaths, many not explained by COVID, there is no question this is unlike anything we’ve seen before.

19/05/2020

I posted a writeup a couple days ago about testing. Just found this article talking about the utility of testing in certain timeframes. The chart is very helpful for understanding when certain tests are likely to be beneficial

This Viewpoint discusses the 2 most common categories of testing to diagnose SARS-CoV-2—real-time PCR to identify viral RNA and serological diagnosis of IgG and IgM antibodies to assess immune response—and estimates time intervals for test positivity by specimen source to help clinicians interpr...