Google maps puts your closest cases (Clark County, Nevada) pretty near. In your position I would be concerned, despite the temperature.
The USA has done only a fraction of the testing that other countries have, so I expect the disease will be a lot more prevalent in your neck of the woods than the figures currently suggest. This is a slow disease. The deaths are likely to start in earnest in a few weeks.
My parents have gone into isolation. I’m having a week’s holiday as the opportunity arose and I’m not sure when it will next be available.
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Two letters which are doing the rounds, the first of which my colleagues tell me is bona fide. The second is anonymous but sounds plausible. You don’t quarantine millions of people without very good cause.
“Dear Colleagues
Everyone is closely watching and monitoring the COVID-19 outbreak. This global emergency is presenting major challenges for our profession as we attempt to anticipate, tackle and eventually get ahead of it.
As there are many new experiences with this type of virus, we need to learn from those with more experience. Information is vital. As you will have seen, Northern Italy is in the middle of a crisis and Lombardy in particular has been severely affected. Our colleagues coordinating the emergency ICU response in Northern Italy have sent me the following message which they wish to convey to all our members.I salute all the work our colleagues are doing, globally, faced with this situation. ESICM will endeavor to do its part to share accurate information and resources.
Wishing you all the strength needed in the coming months,
Yours respectfully
Prof. Jozef KeseciogluPresident, ESICM
Milan, 4 March 2020
Dear friends,
At this moment in time, we believe it is important to share our first impressions and what we have learned in the first ten days of the COVID-19 outbreak.
We have seen a very high number of ICU admissions, almost entirely due to severe hypoxic respiratory failure requiring mechanical ventilation.
The surge can be important during an outbreak and cluster containment has to be in place to slow down virus transmission.
We are seeing a high percentage of positive cases being admitted to our Intensive Care Units, in the range of 10% of all positive patients.
We wish to convey a strong message: Get ready!
We also want to share with you some key points from our experience:
Get ready now – with your ICU’s networks – to define your contingency plan in the event of an outbreak in your community
Don’t work “in silo”. Coordinate with your hospital management and other healthcare professionals to prepare your response
Make sure your hospital management and procurement office have a protocol in place about which personal protection equipment (PPE) to stock and re-stock
Make sure your staff is trained in donning and doffing procedures
Use education, training and simulation as much as possible
Identify early hospitals that can manage the initial surge in a safe way
Increase your total ICU capacity
Get ready to prepare ICU areas where to cohort COVID-19 + patients – in every hospital if necessary
Put in place a triage protocol to identify suspected cases, test them and direct them to the right cohort
Make sure you set clear goals for care with the patients and their families early on
With our best regards
Prof. Maurizio Cecconi Prof. Antonio Pesenti Prof. Giacomo GrasselliPresident elect, ESICM University of Milan University of MilanHumanitas University, Milan"
~~~~~~~~
“Dear friends,
I am writing you because of the current situation in Italy. As you may know the country is struggling with a very quick and acute SARS-CoV-2 outbreak. I am in contact with many friends working in the ICU in the Milan region andI know personally people in Rome who are managing the crisis at the Ministry of Healthcare.
The situation is extremely critical and I am not sure that this is actually well reported by media. In Milan and surroundings PICUs are treating adult patients and all routine activities have been blocked. New ICUs have been created in other hospital areas but they start to have a shortage of ventilators and personnel. The Milan Region is especially affected by the ICU shortage and it is clearly not possible to send these patients far away. In that area with a high viral pressure it seems that some young people also have ARDS and I know of some young intesivists who got intubated. Regression say that by end of the month there will be 36000 infected people and 3000 intubated, if the contagion is not contained.
A further problem is that COVID ARDS is not so severe (medium PEEP around 13, with low driving pressure, rare need for ECMO but very often need for pronation) but it takes 10-15 days to be extubated…this blocks the ICU bed and the ventilator and prevent others to be cared for. Not to mention the burden of care due to isolation (which risks to be less accurate with the consequences you can imagine).
The Italian Society for Anesthesia and Critical Care (SIAARTI) yesterday issued a letter where colleagues are advised to consider a sort of simplified NATO triage, that is, decide to intubate or not according to patient’s age and comorbidities.
The measures undertaken by the central government seem insufficient so far also because of the different regional government powers and now they are trying to catch up in order to limit the diffusion from the North. I do not know if this is an achievable objective. My former hospital (Gemelli) in Rome re-opened a building to exclusively dedicate it to COVID patients with 150 beds and 50 ventilators recently purchased.
Because of all this and the messages I receive from many friends fighting on the first line I feel myself in a terrible moral distress. I am a medical officer in a corps of the Italian Army Reserve and it seems likely that we are going to be called to give a hand in the hospitals and/or to contain the contagion. There is still not official call but I declared my availability and, as you can imagine, we are all actively following the situation to understand how it goes and what is the best timing to act.
I am currently trying my best to do whatever I can for my hospital in Paris and for other work duties I have here, in order to be ready for a quick recruitment if this will happen in the incoming days/weeks.
Life is giving us priorities and we have to follow them for the good of us and our beloved ones."
PICU is paediatric intensive care unit. ICU is an intensive care unit.
kwlf wrote:
Google maps puts your closest cases (Clark County, Nevada) pretty near. In your position I would be concerned, despite the temperature.The USA has done only a fraction of the testing that other countries have, so I expect the disease will be a lot more prevalent in your neck of the woods than the figures currently suggest. This is a slow disease. The deaths are likely to start in earnest in a few weeks.
We just got the first case of Covid-19 in Sweden where it is not known how the patient got the disease – but (s)he had recently returned from the US…
I wish “they” released numbers on those who got it and without an obvious route. That is what really counts IMHO. If you got ill and just got back from a ski trip, it is kind of obvious, and that part of the infected population should be well controlled.
That said, the UK, and every other country in Europe, is having tens of thousands a day coming back from ski holidays right now… and nothing is done there.
Peter wrote:
I wish “they” released numbers on those who got it and without an obvious route.
Up to last week that is what we did get. Most were still primary infections which were traceable but since about a week there are more and more who got it either from unconfirmed sources or who got it from confirmed primary sources.
I am not sure about the skiing claims, the way it was communicated earlier the focal centers were places around Milan imported by people returning from China, spreading all over the Po flatlands and from there elsewhere. Not sure how many cases were reported in the resorts, but right now there is nowhere in Northern Italy which is safe at all and I would include southern Switzerland into this (Ticino) where thousands of Italian workers are commuting day by day.
Google maps puts your closest cases (Clark County, Nevada) pretty near. In your position I would be concerned, despite the temperature
Heading there tonight. I’m not in the least bit concerned. My biggest concern at the moment is that I won’t be able to take my scheduled ferry between Italy and Corsica (twice) in mid-June, or to visit friends in north-eastern Italy. We’ll probably come to Europe anyway but hanging around in Germany for three weeks is not on my wish list.
PS A lot of French people at Death Valley at this time of the year (the Germans come in summer!) one guy with what sounded like a French accent flying an old Bonanza into the airport. I asked him about the runway condition and he said “not as bad as I expected, one side of the runway OK”… We should have flown!
LeSving wrote:
Italy also has 7.3k cases, but 366 deaths. How come?
in short… a pretty ‘challenging’ hospital system.
Various explanations put forward, as posted earlier. I’ve just read that 1 in 4 are over 60, and perhaps 90% of them are (or have been) smokers.
kwlf wrote:
One reason Germany may be doing well is that it has a very high number of ICU beds compared to other countries. I have to wonder what they do with them when there are no epidemics! (MedEwok?) In the UK, by contrast, we often cancel surgery because there are not enough.
Thank you for posting this, I didn’t know we were so far ahead of the pack when it comes to ICU beds per capita…we always seem to have a shortage anyways.
But yeah, when there are no epidemics, a lot of those beds are actually filled by elective surgery patients. People don’t have to wait more than a year just to get hip replacement surgery here. On the contrary, the media often reports that we arguably operate too much, too often and too early – which in some cases certainly is true. In times like these, the “spare” capacity is a boon though.
Today, the first two deaths from SARS2-CoV were reported in Germany, a 89-year old woman and a 78-year old man, both with a medical history of chronic cardiorespiratory illnesses. These two might as well have died from any other random virus infecting them. They both died in North-Rhine-Westphalia (NRW), the largest state and the one with the most cases. Total cases are at over >1100 now in Germany.
Do you know if the virus could be weakened by high pressure altitude like we used to do with whooping cough? I know this last one is a bacteria but … Just in case nobody ever thought about this. It could help promoting GA to solve this crisis :)
All Italian ski resorts now shut.
And UK schools are still sending kids to Italy…
And now Over 60s should stay at home. Hmmm that will ground, what, 74.5% of GA 
