Month: April 2020

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COVID Typical Admission (CTA) Types 1-3

Every COVID week feels unique. The pandemic keeps reforming. This week I began to see patterns of admissions. I’m now thinking that they fall into one of a few types. And since I am a nephrologist and we love three letter acronyms married to a few subtypes I give you Covid Typical Admission (CTA) types 1-3

CTA Type 1 COVID Classic

The patient is either admitted with hypoxia or pretty quickly develops hypoxia. These patients have viral pneumonia and develop profound immune dysregulation. This week, here in Detroit, we are still seeing CTA Type 1 but at a much lower rate than what was crushing us a few weeks ago. A patient is admitted, and may even appear stable to go to the floor, but then they become hypoxic, get intubated, develop profound multi-system disease including ARDS, hypercoagulability, and often AKI. We sometimes can get them stable enough to begin a long, slow, recovery from ARDS or they die in an ugly cytokine storm.

CTA Type 1 Is really hard on the staff. I was talking to a resident because she was canceling a consult she had requested earlier because the patient had since been made comfort care. She commented, that’s it was her fifth death in two days. These kids are seeing more death compressed into a couple of months than I saw in my entire Med-Peds residency.

CTA Type 2. Come in. Get sick. Get better. Get sick again.

These patients are breaking my heart. I tweeted about this last week. (Boy, it feels like a month)

It is soul crushing to see a patient on the vent in kidney failure, and then to see them get better, get extubated, transfer out of the ICU, start discharge and disposition planning, and then see them slide back, get sick and die. Placement is difficult. Finding subacute rehab or long-term care is tough when you have COVID-19. Everything takes a few more days and I’m seeing people deteriorate during the delay. In my mind I have already tallied these patients as ones the virus didn’t get. These are patients that are a win, right up until they get snatched away.

It’s a sucker punch. And it hurts.

CTA Type 3. Patients being READMITTED with a previous diagnosis of COVID.

This week I started to see patients admitted who has already been admitted here or elsewhere and diagnosed with COVID-19. Apparently, the index hospitalization was at the beginning of the illness. They had pretty mild disease and were sent home without an oxygen requirement. But now 4, 8, or 10 days later they are being readmitted after they failed to shake the disease. Of course CTA Type 3 walks hand-in-hand with Type 2. These are the patients where there wasn’t a delay in discharge. They were able to make it home or a sub acute rehab facility. But the virus didn’t get better. They got sick again. The First discharge seemed like a win, but we were looking at a premature outcome.

A lot of these rE-admissions seem pretty benign. A fair amount of altered mental status. Some hypoxia that is easy to treat with nasal cannula oxygen. Some falls with mild trauma. I don’t have a good feel for how sick these people will get, but so far, it seems pretty mild. But this disease is teaching me not to turn my back.

Update on Remdesivir

And since I will always be chained to this infamous tweet, I will comment on the two remdesivir trials that dropped today.

It is these CTA type 2 and type 3 people where I hope that remdesivir has potential. People in the ICU, people that are in the middle of the cytokine storm are not going to benefit from an antiviral. We don’t care about the match once the house is on fire. But earlier in the course, the drug might abort future catastrophes. I hope that if we start treating future CTA Type 3 patients during their index admission we will derail them from severe disease.

Today’s Lancet paper

This Lancet publication was leaked last week, but today we get to see the manuscript. It is a negative study but it is not all terrible. There are some glimmers of hope peaking through the darkness.

I think the data teases that early therapy could be where this drug has promise. Giving the drug later could be like trying to give vanco and cefipime in the middle of sepsis:

an effective therapy given too late to be an effective therapy.

The other remdesivir data is more promising, this larger study of 1000 patients was stopped early because the drug was meeting it’s primary endpoint. The data safety monitoring board (DSMB) just met on April 27 (two days before the press release), so to say it is early is a bit of an understatement. The early bird is still hitting the snooze button. The positive finding was a shorted duration of illness: 15 days for placebo, 11 for remdesivir. Mortality did not meet significance, but the trend makes me excited. I also expect these numbers change as we get more follow up. See CTA Type 2 and 3 above.

I back calculated the number of deaths by using the percent mortality times half the N of 1063. 42 deaths with Remdesivir, 61 deaths with placebo.

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David “Bud” Rose has passed

Hanging with Dr. Rose in 2011 at Kidney Week

Nobel Prize

When I was a resident UpToDate was still incomplete and work in progress. I was an early convert and fan. l had become a disciple of Rose of the Yellow Book.

I remember talking with Sarah Faubel and she would convincingly argue that UpToDate is so important to medicine that Rose deserved the Nobel Prize. She explained that it was the best way to move information from the frontiers of science to the physicians providing care at the bedside. I think she was right.

I met my hero

I met Dr. Rose a few times, here is the e-mail I sent my (at the time) future wife about meeting him.

Bud and NephMadness

Burton Rose made two appearances in the inaugural NephMadness of 2013. That year the Thin Ascending limb was dedicated to educational resources (Matt and I have always been medical education nerds). Both UpToDate and Clinical Physiology made the Big Dance.

Here is how we described UpToDate

UpToDate is a juggernaut which rewrote the rules of medical publishing. It was the first successful electronic textbook. When textbooks were just thinking about gluing a CD-ROM to the back page as a multi-media extra, Rose had thrown out the whole book and just used the CD-ROM. This allowed him to ship the textbook before it was done. I remember ordering UpToDate in the mid-90s and internal medicine was not even complete. It was almost finished but some specialties were completely absent. However, every 3 months I would get a new CD with updates to the current files, newly written sections and cards and an update to the abstracts of Medline. In the days before PubMed, UpToDate shipped with a copy of index medicus.

The other freedom of the CD-ROM, was it allowed an 1all new editorial style. Instead of doling out strict word limits in order for the textbook to hit the length determined by the marketing department. Rose was able to go into as much detail as he wanted.

Completely disruptive. He outflanked all of the internal medicine textbooks and they still haven’t caught up.

And how we described Clinical Physiology of  Acid-Base and Electrolyte and Disorders

I was finishing my first month of my first rotation as a third year med student when I asked my resident what I should read to help me understand fluids and electrolytes and he told me to get Burton Rose’s book. This may have been the worst advice ever: 893 pages (excluding the index) of electrolytes. I bought the book and it went on my shelf. The book remained unopened for 2 years. During my internship year I finally started reading it.  His straightforward, mechanistic explanations of the physiology made everything logical. The yellow book (4th edition cover) taught me most of what I know about physiology. I don’t think my experience is unique. I have a feeling that lots of nephrologists out there and probably some endocrinologists and critical care doctors understand the body because of the clear, visual prose that is Rose’s gift.

Clinical Physiology went down to ASN Kidney Week in the first round but UpToDate beat Wikipedia. It then advanced to the Saturated 16 by vanquishing The Renal Fellow Network. UpToDate continued its run by destroying ASN Kidney Week 82% to 18% and advanced to the Effluent 8. The ride came to an end when Captopril defeated UpToDate, preventing a trip to the Filtered Four.

The following year NephMadness started using experts to help build the brackets. Edgar Lerma, who know everyone asked if Dr. Rose would help out. Here is his response. Classy. Totally classy.

We had an electrolyte bracket and invited Dr. Rose to be our selection committee member. We had a conference call, but legal entanglements prevented him from being part of the contest (at least that’s what he told us, it could have been that after talking to us he wanted nothing to do with NephMadness).

The first Second Generation Narins Award Winner

I won the Robert G Narins award from the ASN in 2017. When you get the award you give a short five minute acceptance speech during the big plenary session and a standard trope is to mention how you knew Robert Narins and how he inspired you in nephrology. But even though I’m from Detroit and work only a dozen miles away from where he was chief, our paths never crossed and I never met Robert Narins. My hero and inspiration in nephrology was 2009 winner, Bud Rose. So I think that makes me the first second generation Narins award winner.

I remember sometime in the early 90s when I was thinking about what my place in medicine would be. I knew I wanted to be involved in teaching but research wasn’t my bag and publishing in traditional academic journals wasn’t something I was interested in. I was explaining this conundrum to a senior resident and he suggested I look Rose up in PubMed. See how many publications he had. There is clearly at least one other Rose BD, but looking through the titles I can find nine articles by our Burton Rose. That moment crystalized what I wanted from my career, to be a medical educator without trying to excel at both medical education and research. I wanted to be Burton Rose.

This one is actually from 2019, it is worth looking at the replies.

The first thing I did after seeing that Rose passed was come to this blog and search for his name. Eight pages. There are 8 pages of posts that show up when you search for Rose. His presence looms large over my career.

He was a giant.

He will be missed.

He will never be forgotten.

Thank you for the teaching.

Thank you for the inspiration.

There is a lot of chatter on Twitter about his passing here are some of the tweets.

https://twitter.com/arebelo/status/1253851955614621696?s=20
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The magic of treating minimal change disease

I had this patient come to me with miserable nephrotic syndrome. Following a biopsy that revealed minimal change disease (MCD), I started her on prednisone and BOOM she got better.

A few months later I tweeted (since deleted, don’t ask) these pics with the caption:

If all I could find a job where all I did was treat minimal change disease all day long, I would sign up in a heart beat.

The point was that MCD is one of the most rewarding diseases nephrologists get to treat. The patients are miserable, you give them the medicine, and they get better. Yes, I know there is a terrifying relapse rate, and high dose steroids are no walking the park, but compared to the disease we typically treat in nephrology, this one is particularly rewarding.

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The COVID Diaries. The beginning

When it became apparent that COVID-19 would not just be a medical event that happened over there but was going to affect everything I started jotting some notes here. They have remained in Drafts for over a month. I am going to start publishing these diary entries.

I remember the first patient at St John Hospital that had COVID. We had been hearing about this disease. First in China, then in Italy and Iran. Then Americans had it, but they were on cruise ships. Then it was nursing home patients in Washington and then it was here, in Detroit. It was a long build up. I remember reading about the doctors in Italy and thinking, “Is it possible that I’m sitting comfortably in suburban USA and in two weeks it’ll be World War One Trench warfare”

Well the two weeks ticked off and here was the first patient. We already had a number of people that were getting ruled out for COVID. But we didn’t know what we were doing and the disease prevalence was so low we were ruling out some people that were low risk; people that obviously had alternative explanations for a fever. It was like we were sick of getting ready and just wanted to have a patient in isolation. So there were those “fake” covid’s and then there was the patient in the ICU, the patient with white-out on chest x-ray. The patient on a PEEP of 17, 100% FiO2 with PaO2 in the 70s. That was the real one. The test wasn’t back yet, but everyone knew, that was the disease. That was what was waiting for us.

That patient, patient zero, the first one with real bad ARDS also had kidney failure so they became my patient. A few days later we got PCR confirmation of the diagnosis. I took a screen shot of the report. It felt important. I remembered reading in the Italian reports how they were excited by the first positive reports and then a week later that was all they were seeing, positive after positive.

The patients began to trickle in. One by one and then two by two. Fellows were banned from seeing patients in order to conserve PPE, and protect them, so my fellow began carefully highlighting he patients on the list that were COVID-19. By the end of the week she shifted to highlighting the ones that weren’t COVID to conserve her pen, and the next week she stopped the ritual all together; our consult nephrology list was entirely COVID.

As our list mutated from the nephrology consult service to a COVID-Nephropathy service the hospital also transformed. We found ourselves taking a short cut to the inpatient dialysis unit and walking through a door and all of sudden we weren’t in our familiar hospital but some facsimile of a biocontainment unit. All the doors were shut. Everyone was in masks, hair nets and gowns. One wrong turn and you were transported to the set of Contagion. Same thing would happen in the ER. or the first week they segregated the ER to COVID and not COVID modules but the COVID patients quickly over ran their alotment and the whole ER became COVID-land.

Besides the isolation strategies the other part that made the hospital feel eerie was how quiet it became. Everyone assumes that the hospitals had to be crazy, but the truth was once they stopped allowing visitors and stopped elective surgeries, the wards became still. The cafeteria was empty. The hospital was quiet, still, and nearly empty.