Coronavirus Pandemic Update 44: Loss of Smell & Conjunctivitis in COVID-19, Is Fever Helpful?

welcome to another MedCram COVID-19
update we are headed to a half a million total confirmed worldwide over 20,000
deaths and 115 thousand total recovered with most of that growth outside of
China at this point if we look at the world ometer website most of the deaths
that are occurring are in Italy and Spain with the United States starting to
move up as well the number of new cases in Italy looks as though it might have
peaked will have to see more in the future in terms of its direction while
the total deaths in Italy continued to escalate over in the United States the
total number of cases continues to grow total number of deaths is over a
thousand here in the United States already New York City seems to be the
epicenter of what’s going on here in the states and they are predicting that the
peak number is still about two to three weeks away in New York and remember that
New York is ahead of just about everybody else of course if we were able
to flatten the curve then that’s gonna delay that even more but hopefully the
peak won’t be as high okay I want to talk to you about a couple of updates in
terms of signs and symptoms this is from the American Academy of Ophthalmology
which is warning us that there have been several reports that the virus may cause
conjunctivitis and possibly be transmitted by aerosol contact with the
conjunctiva and the Academy is recommending protection from the mouth
nose and eyes when caring for patients potentially infected with SARS Cove –
also there are recommendations there on how to sterilize the equipment that’s
used the other name for conjunctivitis is pinkeye it’s not uncommon to have
conjunctivitis when you have an upper respiratory viral infection so be aware
of that the other sign in symptom is related to the loss of smell as a marker
of Cova 19 infection this is a letter that was written by the president of the
ear nose and throat Association in the UK dar
Kumar and he’s talking here about post-viral anosmia that by itself is not
unusual what they’re seeing however is they’re seeing a huge rise in the number
of patients that are complaining of the inability to temporarily smell after a
viral infection they mentioned here that in South Korea where testing has been
more widespread 30% of patients testing positive have had anosmia as their major
presenting symptom in otherwise mild cases on the flip side of that they’re
also noticing that patients without any other signs or symptoms consistent with
asymptomatic kovat 19 are presenting with the only sign being anosmia and
that may be suggestive of an asymptomatic infection with covin 19 and
he’s talking about him personally having seen four patients in one week all under
the age of 40 and otherwise asymptomatic except for recent onset and nas mia and
he usually sees only about once a month so this is something to be on the
lookout for he also has some recommendations at the bottom of the
letter he says that there is potential that if any adult with anosmia but no
other symptoms was asked to self quarantine for seven days in addition to
the current symptom criteria used to trigger quarantine we might be able to
reduce the number of otherwise asymptomatic individuals who continue to
act as vectors not realizing the need to self isolate it would also be an
important trigger for healthcare personnel to employ full PPE or personal
protective equipment and help to counter the higher rates of infection found
amongst ENT surgeons compared to our other health care workers and of course
we’ll put links to these articles as well as other ones in the description
below so we’re going to talk about the immune system as promised and remember
what we talked about how a good immune system in both of these situations could
help not only the person having the good immune system but also reducing the
number of people going into our healthcare system so here is what is
represented as the population at whole and then there is a certain amount that
will catch the infection which is here infection and then about 80 percent
those people will not need to go to the hospital because they have a sufficient
immune system but the 20% here we could improve and perhaps if we had a good
immune system we might be able to not even become infected in the first place
and we talked about in our last update what they were doing by giving a BCG
vaccine even if there were given one earlier life to give another one they’re
hoping to see that their immune system will be heightened not just against
tuberculosis as it’s designed for but also an improvement in your innate
immune system so that’s your lymphocytes your leukocytes your natural killer
cells your neutrophils etc what is it that we can do to improve our own immune
system so the first thing I want to talk about is fever fever is one of those
signs that you get when you have a viral infection and it’s one of those things
that you might see also with kovat 19 although it’s not universal so here’s a
paper that was published in 2017 looking at the presence of fever in adults
versus children and one of the things in the article that’s interesting to note
is they looked at a number of different viruses and you can see here for corona
virus if we were to take this as a representative of the current kovat 19
cases only two out of seven cases presented with fever giving it about a
twenty eight percent incidence of fever in the discussion they say here we have
shown using prospectively collected data that the rate of fever in adults with
confirmed viral respiratory infections is much lower than described in children
nevertheless it is present and it would behoove us to take a look at the
mechanisms of fever both in adults and children so here’s another paper that
was published in the world Journal of Clinical Pediatrics back in 2012 titled
fever management evidence versus current practice and I found it to be a very
good source of some interesting studies regarding fever and under the heading
that says evidence that fever is beneficial they had a number of points
it talks about fever having an adverse effect on back tear
on viruses how it improves the activity of a lot of signaling like interleukin 1
also cells that are involved in the immune system that we’ve talked about
including T cells B cells and antibody production a lot of these things are
mediated at temperatures that are just above normal around 38 39 40 degrees
centigrade 38 degrees correlates to about 100 point 4 there’s also some
studies here that show that interferon which is of course in antiviral agents
has enhanced antiviral activity above 40 degrees centigrade so there are a number
of references here and I’ll include all of those papers in the description below
in those references we can see here in vitro that as we increase the
temperature here on the x axis the percent yield in this case of poliovirus
starts to drop similarly if we look at the development of poliovirus at 37
degrees centigrade in that paper it was quite prolific over a period of time
repeat the experiment here at 40 degrees centigrade there is a precipitous drop
again these aren’t in vitro studies so let’s look at some human studies so
while there have been a lot of bacterial studies I wanted to highlight a viral
study with Rhino virus which is a virus that causes a common cold as well this
paper was published back in 1990 there was 56 healthy subjects and all of them
had Rhino virus introduced into them but then there were forearms there was an
aspirin arm there was a Tylenol arm there was an ibuprofen arm and then
there was a placebo arm and in each of these arms they measured something
called a serum neutralizing antibody response so we’re looking for the
antibody response after these people that were infected with Rhino virus and
what they found is that in the aspirin and in the tylenol group these together
were statistically significantly lower in terms of that antibody response when
it was compared to placebo and that p-value was less than point zero five and what we’re finding more and more of
recently is that temperature is intricately related to the immune
function of the cell here’s a paper that was published in 2018 that shows that
temperature regulates certain cellular messaging systems that allow the immune
system to respond to infections this signaling pathway known as NF kappa-b is
a signaling mechanism that allows the cell to respond to these infections and
it was recently highlighted in an article in medical news today a
signaling pathway called nuclear factor Kappa B plays an important role in the
inflammation response in the context of infection or disease this protein helps
the expression and the production of certain immune cells these proteins
respond to the presence of viral or bacterial molecules in the system and
that is when they start switching relevant genes related to the immune
response at the cellular level they also note here that this NF kappa-b
becomes more active at higher temperatures and less active at lower
temperatures so the question is is it the fever that’s causing the NF Kappa
beta to go up or is it the NF Kappa beta that’s causing the fever well they did
some experiments and they found this protein called the a20 protein is what
tells the NF kappa-b protein to go up and so if you knock out
this a 20 then that is gonna prevent the NF kappa-b from activating and when it
doesn’t it’s no longer going to be doing the things that it needs to do to
augment the immune system so in essence fever somehow stimulates a twenty which
then stimulates NF kappa-b an NF kappa B is essential for immune system how do we
deal with fever well remember what we talked about a couple of lectures ago we
have something called arachidonic acid which is converted into prostaglandin
and specifically prostaglandin e2 that’s mediated through something called the
– enzyme and what are one of the big inhibitors of the cox-2 enzyme but
NSAIDs remember what NSAIDs are aspirin ibuprofen and indomethacin so because of
this in other studies many scientists and many practitioners especially in the
pediatric population are advocating that fevers based on known viral infections
shouldn’t be treated just based on the number itself and the fact that the
temperature is elevated that in fact the fever may actually be beneficial to the
recovery of the patients and unless the fever is excessive or the patient’s
dehydrated or there’s lethargy which means that the patient doesn’t want to
move very much then fever shouldn’t be treated couple of points here to
remember number one a fever is not hyperthermia hyperthermia is what one
might get if they were running on a very hot day and their temperature was 105
106 107 those are clearly very dangerous temperatures and they need to be treated
aggressively otherwise someone could die but in the sense where there is a viral
infection and a fever is being caused and there’s no other complication as a
result of that fever there is a question about whether or not that fever should
be treated the other point I want to make and it’s very important is that
there are a number of adults in this country that are on aspirin for very
good reasons and this is not a reason to stop it you should never stop any
medication without consulting your physician
there are people with stents people with strokes for which aspirin is life-saving
not to mention that people take ibuprofen and in the medicine for
rheumatological conditions as well I’m simply saying that perhaps an elevated
temperature in your body may be part of the solution to getting better over the
viral infection and not part of the problem I would be interested in your
comments below regarding this issue I think one of the conclusions that I draw
from this is that there is a benefit in infectious disease to having an elevated
body temperature okay we’ll see if our next update please take a moment to
leave a comment and subscribe to this channel
haven’t already thanks for joining us


  1. Thank you for supporting our COVID-19 video updates by subscribing to this channel, and visiting us at
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    Quick links to our other videos on this coronavirus pandemic:
    – Coronavirus Pandemic Update 43: Shortages, Immunity, & Can a TB Vaccine (BCG) Help Prevent COVID-19?
    – Coronavirus Pandemic Update 42: Immunity to COVID-19 and is Reinfection Possible?
    – Coronavirus Pandemic Update 41: Shelter In Place, FDA Investigates Hydroxychloroquine for COVID-19:
    – Coronavirus Pandemic Update 40: Ibuprofen and COVID-19 (are NSAIDs safe?), trials of HIV medications:
    – Coronavirus Pandemic Update 39: Rapid COVID-19 Spread with Mild or No Symptoms, More on Treatment:
    – Coronavirus Pandemic Update 38: How Hospitals & Clinics Can Prepare for COVID-19, Global Cases Surge:
    – Coronavirus Pandemic Update 37: The ACE-2 Receptor – The Doorway to COVID-19 (ACE Inhibitors & ARBs):
    – Coronavirus Pandemic Update 36: Flatten The COVID-19 Curve, Social Distancing, Hospital Capacities:
    – Coronavirus Pandemic Update 35: New Outbreaks & Travel Restrictions, Possible COVID-19 Treatments:
    – Coronavirus Epidemic Update 34: US Cases Surge, Chloroquine & Zinc Treatment Combo, Italy Lockdown:
    – Coronavirus Epidemic Update 33: COVID-19 Medication Treatment Trials, Global Testing Remains Limited:
    – Coronavirus Epidemic Update 32: Important Data from South Korea, Can Zinc Help Prevent COVID-19?
    – Coronavirus Epidemic Update 31: Mortality Rate, Cleaning Products, A More/Less Severe Virus Strain?
    – Coronavirus Epidemic Update 30: More Global COVID-19 Outbreaks, Vitamin D May Aid Prevention:
    – Coronavirus Epidemic Update 29: Testing problems, mutations, COVID-19 in Washington & Iran:
    – Coronavirus Epidemic Update 28: Practical Prevention Strategies, Patient Age vs. Case Fatality Rate:
    – Coronavirus Epidemic Update 27: Testing accuracy for COVID-19 (CT Scan vs. RT-PCR), California Cases:
    – Coronavirus Epidemic Update 26: Treatment Updates, Stock Markets, Germany & San Francisco, Pandemic?
    – Coronavirus Epidemic Update 25: Vaccine Developments, Italy's Response, and Mortality Rate Trends:
    – Coronavirus Epidemic Update 24: Infections in Italy, Transmissibility, COVID-19 Symptoms:
    – Coronavirus Epidemic Update 23: Infections in Kids & Pregnancy, South Korea, Spillover From Bats:
    – Coronavirus Epidemic Update 22: Spread Without Symptoms, Cruise Quarantine, Asymptomatic Testing:
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    – Coronavirus Epidemic Update 20: Misinformation Spread, Infection Severity, Cruise Ship, Origins:
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    – Coronavirus Epidemic Update 18: Cellphone Tracking, Increase in Hospitalizations, More Sleep Tips:
    – Coronavirus Epidemic Update 17: Spike in Confirmed Cases, Fighting Infections with Sleep (COVID-19):
    – Coronavirus Epidemic Update 16: Strengthening Your Immune Response to Viral Infections (COVID-19):
    – Coronavirus Epidemic Update 15: Underreporting, Prevention, 24 Day Incubation? (COVID19):
    – Coronavirus Epidemic Update 14: Hospital spread of infection, WHO allowed in China, N-95 masks:
    – Coronavirus Epidemic Update 13: Li Wenliang, nCoV vs Influenza, Dip in Daily Cases, Spread to Canada:
    – Coronavirus Epidemic Update 12: Unsupported Theories, Pneumonia, ACE2 & nCoV:
    – Coronavirus Epidemic Update 11: Antiviral Drugs, Treatment Trials for nCoV (Remdesivir, Chloroquine):
    – Coronavirus Epidemic Update 10: New Studies, Transmission, Spread from Wuhan, Prevention (2019-nCoV):
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    – Coronavirus Outbreak Update 8: Travel Ban, Spread Outside of China, Quarantine, & MRSA:
    – Coronavirus Epidemic Update 7: Global Health Emergency Declared, Viral Shedding:
    – Coronavirus Outbreak Update 6: Asymptomatic Transmission & Incubation Period:
    – Coronavirus Update 5: Mortality Rate vs SARS / Influenza:
    – How Coronavirus Kills: Acute Respiratory Distress Syndrome (ARDS) & Treatment:
    – Coronavirus Update 3: Spread, Quarantine, Projections, & Vaccine:
    – Coronavirus Symptoms, Diagnosis, Treatment:
    – Coronavirus Outbreak – Transmission & Updates:

  2. I always advise my daughter to allow my grandson to let the fever go as long as possible that it’s good for him and helps destroy the illness. Of course super high must be treated.

  3. I usually let fevers run their course. I was taught fevers are your body's attempt to burn something out of your system and they are usually controlled not to kill you.

  4. hi , very good video. Thanks. I live with my mom, in Chile. shes 72, very healthy, nice and dinamic. But she has always smoke…i am afraid. She does not hv any other medical issue. Nothing. What are the chances that she can get very ill if she gets covid19?. And the last question, how many can you deal with fever, before going to emergency?. Or the vriteria is the grade? thanks a lot.

  5. I always believed moderate regular exercise where core temperature remains elevated but at safe levels could enhance immune response. I very seldom get sick and the last time infected with influenza I didn’t mitigate fever and recovered fairly quick but was noticeably symptomatic. That was over ten years ago now, no influenza since.

  6. I hope one day there is some form of lifetime achievement award for people like you. I know you're probably not in it for the accolades, but I feel safer using you as a role model for my kids versus the DC mob. Outstanding!!!

  7. Another great video Doc. Zinc inhibits corona and RNA polymerase activity in Vitro and Zinc Ionophores block the replication of viruses in cell culture. BTW I believe Vit D, Selenium, Zinc and Atragalus is protecting me. Deep breathing exercises daily to keep the lungs healthy.

  8. Dang! I've had COVID19 every year around this time for the past 7 years. Iwas originally told it was allergies, but I have all of the symptoms except fever. But, I guess it should be called COVID13 then.

  9. Dear Dr Seheult, I am off for a day after working straight 12-15 hrs for 8 days..we are doing prone for most of our patients and some have been on CVVHDF..still on 30 minute breaks but we’re not complaining, we love saving lives..we have been given free eccommodations in selected hotels which we are very grateful for..and thank you for your lectures, we always watch your videos over and over again..bye!

  10. Aerial chemtrailing…biowarfare? Respiratory, olfactory, opthalmic…no diarrhea or fever's tho, as with other flus etc Hmm…

  11. You mention loss of smell. Huh. What about the LOSS of TASTE?? last year about this time, my husband came down with some really bad virus which went to his chest. He didn't see anyone, but was quite miserable. I got it, not as severe, but it kept me home, with a fever. Days later, maybe a week later, my husband began to loose his taste buds. Gradually, his taste was dead. Then, mine followed. I think it was a full month before we could taste again. Any comment on that?

  12. This has been known by people for a long time…fever kills the germs when the fever breaks you get better. Why has old school understandings been lost???

  13. 21,000 deaths means over 2 million are walking around with the virus because there Is a 1-2% mortality rate. And I don’t think New York can flatten the curve, it’s too populated with people who don’t listen

  14. When young and before I became an RN I was intrigued with the relationship between reptiles intentionally-infected with a pathogen and differing temperatures of their environment. Those that were able to raise their body temperature through the use of a heat lamp fared better than those without a way to raise their body temperature above normal. Extremely simplistic but it had impressed upon me so, that when fighting a respiratory infection I would put up with the discomfort of a fever as much as I could tolerate believing I was benefiting from the increase in body temperature.

  15. Is there any test doctors can do that has a high chance of showing the Covid-19 virus in minutes? My point is if a couple tests show as a negative for a person is there a need for a 14 day isolation?

  16. Thank you for providing these clear and concise videos. Good to have a trusted source of information in these confusing times.

  17. Can you go into some fake news about Covid-19 and what is fact and false such as drinking water kills it, or 5g network has something to do with it. etc.

  18. How can they contain this virus when they don't fully quarantine these hot zones like New York and tristate areas. California and Washington. Why didn't they stop Airlines from flying into and out of these states. People are getting on planes and spreading the virus….. why would they keep these big box stores like Walmart and Costco open and have 500 people jammed inside spreading the virus when on the other hand they close a barber shop. Nothing makes sense…..

  19. China lied from the beginning,. they are lying about how many really have dies from this China Virus today,.. I wouldn't truth what China says from now one I would look at Italy South Korea and NYC on what really going on with this China Virus,..

  20. DECOMPRESSION THERAPY, puts oxygen Straight through the skin, not only through Damaged Lungs, this means people survive.

  21. 2 day old video. Why are you waiting for upload, you make a video and then waiting 2 days to upload it? Dont see the reason, meantime it is old news.

  22. Thanks A LOT for your invaluable work in these videos. Even non md's, like myself, can get it because of your perfect way of explaining things.

    Question: What percentage of non-symptomatic infected pacients is there for respiratory diseases in general?
    Is there anything different in this regard for covid-19?

  23. Completely agree with you that fever is beneficial against viruses . It is the body's response to stimulate the immune system to fight off the infection caused by the virus.

  24. Great video, I think also you should clarify in the video that the Aspirin dose for anti inflammatory effects is much higher than the very common dose for anti platelets effect activity that most patients are taking.

  25. I’ve always let my kids fevers run if they’re not dangerously high. Mine, as well. Have always believed that our bodies run fevers for a reason. Nice to see some back up to my mom theory 😉

  26. I have listened to other doctors from other countries and they said exactly the same thing about a fever during a virus. Let the immune system do its thing during fever that's not life threatening. Thx. For the informative video.

  27. This video is outstanding as per you usual, Dr. Simply engaging and a true blessing to us all. It’s become standard practice to watch your videos during commute and on replay until the next one is published.

  28. Back in the '80s when I had young children, I would panic if my kids got a fever. He told me back then that fever means it is the body fighting the infection whatever it may be. I thought he was trying to get me to not run to the doctor every time they ran a temp.

  29. I was doing some numbers yesterday and I believe this will prove to have been the most expensive exchange of resources for human life.

    The flu (influenza) kills 1 in every 1k that get it. Every year around 55k people in the US die of the flu. If Covid was 5 times more lethal it would kill 275k people. Every year 2.8 million people die in the US. 175k, for example, in car crashes. obesity is much worse. 70 million Americans are obese and they live between 6 and 10 (dep on the source) years less than everyone else.

    Imagine that the Covid will require 2.4 Trillion in stimulus package. Imagine that the stock market has wiped maybe a similar figure. Add to that the effects on the real economy, maybe another couple of trillion. Let’s say overall you smashed 5 trillion to save 275,000. Not even so, because had you spend 500 billion in advertising to tell people to go out safely (wearing a mask, not touching their face, washing their hands) deaths could had been, say 100k. So if you smash 4.5 trillion dollars (4,500,000,000,000) to sabe 100k lives, each life is costing you around 45 million dollars. Since mainly older people die, every year of life expectancy is costing you maybe 5 to 10 million dollars.

    People will say “every life is sacred”. Well, why didn’t you save the people taking opiates a year ago? I bet you with 100 thousand dollars you could turn around the life of every addict or most of them.

  30. With a diameter of over 2.5 miles long, 1998 OR2 will certainly have devastating effects on the plane . Despite the safe distance between the Earth and the asteroid, a collision between these two can still happen

    due to certain factors in space such as the Yarkovsky effect. This is a type of force that is exerted on an

    asteroid due to heat from internal or external sources such as the Sun. This could affect how the asteroid

    spins, which could then alter its path and send it hurtling towards Earth. The 2 Trillion is 2% of the GDP , The asteroid is officially called 52768 (1998 OR2) and is as big as the

    Himalayas. Get ready for Earthquakes , a 45yr old trucker came back from Germany, and was put in home-quarantine – they did not tested him – when

    police came to verify that he is still at home … they found him dead. Don't test – don't tell. 🙁 QC

  31. I have a question dear Dr. I getting have few fever several times, like im working in a call center sometime im feelling Hot like 37c in sometime 28c coming tday i was ok, do you think i got covid-19 for that or That's might be a simple infection?

  32. Swedish anesthesiologist/ICUdr here. I am watching all of your videos currently. Impressive content – i must say that you manage to explain everything you take on very clearly – from vent management to cellular biology. This is by far the best part of my internet routine! Keep going

  33. Excellent video as always. One question: how does Acetaminophen impact the immune response as it’s not an NSAID, but it does reduce fever—it wasn’t specifically mentioned in the video? When I get a fever, it’s often the body aches that are far more problematic than the fever itself. Is it even possible to keep a fever while simultaneously treating the aches?

  34. Brilliant work and Thanks a lot for useful info..
    Please talk about the amount of virus exposure vs disease severity afterwards.. as well as immune response. Why health workers get apparently more severe one?

  35. Doctor, what type of zinc supplement or vitamin would be able to be transferred at a cellular level to help build your immune system against viruses as you mentioned in one of your videos talking about the zinc.

  36. My question is about exercise heating up the body. Would there be an immune benefit to prolonged exercise. I ride a bike for transportation. I have ridden with competition bike riders, so I can compare. In my routine I ride much slower, But when I arrive at my destination my whole body is hot. The heat, noticeably, last only for a half hour or so. Is there a benefit to the immune system.

  37. First off please excuse my name in this professional setting…extremely fascinating and totally logical from a physiological standpoint but I was also under the impression that what makes a lot of these diseases fatal is an overreaction by the immune system which I heard from a well respected infectious disease expert who said that could be the case here as well. So how to know when to let the body do it’s job or when to intervene? (short of IC of coarse) Thank you for all your work

  38. Whenever i get the flu i turn the heat in my bedroom way up(like 85-90f) and just sweat it out in a night or two. I obviously check my temperature frequently and drink a tons of water. Everyone else who gets it complains about how it just just drags on and on for a week or more. This is pretty much what i figured was happening by letting the fever run its course.

  39. Yes it is a civilization populated with walking Zombies…cuz there will be 7 years world wine Famine..Look no further..humans will look like Borgs ..not sure though why its a Woman Vurg that will lead the collectives!

  40. How is this news? It's always been my understanding that a fever is one of the body's ways of fighting a virus and that one shouldn't treat a fever. Also ties in with why one shouldn't eat when there is fever. Our bodies know what to do if we would just get out of the way.

  41. Hi, I'm a nurse working in Alberta Children's Hospital, Calgary, and I've been watching your videos to get the recent updates on Covid 19. I'm a part of HCW facebook group and today I came across an interesting post that pretty much covers all of your recent presentations. Hope it's fair to share one ED MD's chronology of the illness…Very concise, to the point, and touching many aspects you previously covered in your lessons…Copied from an APRN group I’m in. Medical friends-thoughts?

    “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.


    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.


    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.



    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."

  42. Thankyou doc. I am so lucky to discover this channel. Great contribution to a temporarily depressed humanity.

  43. Would there be benefit to artificially elevating temperature? Seems as though this might augment immune response.

  44. at the 6:40 point, roughly you talk about how fever can be a good thing against some bacterias or viruses but isn't it the virus that causes the fever?? not very clear, a bit confused, please explain.

  45. Side effect is fever….. quinine based drugs….
    "Quinidine is a medication that acts as a class I antiarrhythmic agent (Ia) in the heart. It is a stereoisomer of quinine, originally derived from the bark of the
    ++++++cinchona tree.
    The drug causes increased action potential duration, as well as a prolonged QT interval."
    Chloroquine fever side effect……
    Curious is malaria treatment with fever reaction (side effect so only works for some) may be the success of treatment….. Medically prescribed fever as treatment??? Not to cook the virus, because corona is resistant but…… what you mentioned… "Novel" triggers low to no fever, jump to 102˚ F and the immune system detects it.

  46. I was an ER nurse 20 years ago. Never medicated a child with a mild fever…only high for fear of a seizure. Always knew a fever is the body’s natural way to fight the infection.

  47. If the fever is good for viral infections to go down so how much should be the range that could be left untreated and could be beneficial for the immune system to function properly and reduce the viral load in the body?

  48. Personally I came to the conclusion that fever is a healing affect of the body, so I don't take NSAIDs to lower a mild fever increase. Dehydration would be an exception. This n=1 is age late 60's. Appreciated the confirmation, thank you.

  49. I’ve been sick for three weeks. As I have lupus I already take hydroxychloroquine. My doctor put me on azithromycin and I am feeling better. It’s too bad I’m not part of any study.

  50. Can I PM you? There's something that I'd like to find out if you can put some light on specific to this topic.

  51. At the end of the day its obvios Corona 19 is a man made Bio management tool that got out of hand or maybe tested to see the best way for such a thing to be used in future.

  52. Recall taking Quinine for flu as a child .A very bitter taste raising body temperature causing sweating and soaked bed sheets, but low and behold it cured my symptoms.

  53. Question: is Paracetemol an NSAID? Does that play a role in depressing the fever/immune response too? Paracetemol is a common substance given to kids in Australia.

  54. Great video!
    I have a question.
    Is there any chance that someone affected by COVID 19 can transmit the SARS-COV 2 to someone who is using the same soap. Even if the other person is washing hands for 20 sec but the same soap the affected person is using?

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