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  1. Don’t get sick.  You don’t want to be a burden on others, as they are already burdened by the fall-out from the current crisis.
  2. The elderly (more prone to coronavirus) may not be in possession of all the information you are receiving.  Share any legitimate advice on this topic with them and watch over them.
  3. Practise ‘cleanliness’ like you have never practised it before.
  4. Rationally evaluate all the information coming to you.  So much is self-serving nonsense, but amongst it are some real gems that are worthy of sharing.

    Don’t believe politicians when they say they can ‘save jobs’.  Without profits and cash-flow there will be no jobs.  Talking of saving jobs, State Governments could stop ‘fining’ employers for creating jobs, by abolishing Payroll Tax.  John Gray (Mannkal Scholar) writes here.

    The planned large doses of “stimulus” in various forms, will do immense damage (over the longer term) to the Australian economy and will seriously reduce the purchasing power of the A$.
  5. Save up all your hugs and handshakes for later (don’t let them wither and die).
  6. Start a collection of ‘written items’ that leave you with the ‘essence’ of this crisis.  I have similar collections that allow me to review past ‘catastrophes’ and rank them by their true historic importance. 

    * The 1961 – 62 Menzies’ Credit Squeeze
    * The 1987 Stock Market Crash
    * The 1983 – 93 Western Australian Property downturn, coupled with 18% interest rates.
    * The 2002 Dot.Com Collapse
    * The 2008 – 2012 Global Financial Crisis (GFC)
  7. Redefine your career plans, bearing in mind the emerging opportunities of the next ten years.  Your experience with Mannkal travel and seminars will assist you. These current events will certainly test your resilience.
  8. Explore ways in which you can navigate the coming months.  Be more than an observer.  Be an activist.

Warm regards,
Ron

Note
For your consideration here are several items that I feel are worthy of sharing with you: –

March 25, 2020 by

11 Comments

  • Well said once again Ron. I’ll keep No5 in the safe place for much later as I feel this is going to be with us for a little while yet. All the best mate.

  • Dear Ron and the Mannkal team,

    From Madrid:

    More than ever, we hope this message finds you well. We hope your health is good and your institution is active. And we hope this, not just because we care a lot about you all, which we do, but because we also care for freedom and humankind, and we know that your continued struggle for our ideas, which was always important, is now crucial.

    Most governments, politicians and high bureaucrats have rapidly set to pursue their not-so-hidden agendas to reshape political governance, the economy and our liberties by taking advantage of the COVID-19 shock. This horrible nightmare is a dream come true for statist hardliners, left and right, as it provides them with a rare Overton window to dramatically increase state control and to smash individual and economic freedom at almost everyone’s applause. We libertarians and classical liberals, ancaps and minarchists, agorists and objectivists, should make up the non clapping minority, the conscience of a free humankind, as we navigate these times of fear, both justified and induced. May our global intellectual militia be strong enough to oppose efficient resistance to those selling easy, collectivistic solutions in the post-pandemic scenario.

    As we write these lines, our country is the second most affected by this tragedy, approaching seven thousand deaths already. We are now under total lockdown and all non-essential activity has been stopped. An appallingly incompetent cabinet of left and far left parties under prime minister Pedro Sánchez has made things much worse. Time and again, it has ruled out the necessary decisions, only to take them in the end, when it was already too late. With an overwhelmed government, it has been the private sector, civil society, the ordinary people, who have kept the country from collapsing by taking rational decisions.

    Learn from Spain’s horrific experience. If you have some degree of influence on your governments and on society, make sure that really strong social distancing, temporary confinement and even cease of activity are introduced at the right, early stage, not when they are no longer able to set an efficient firewall. It will happen anyway, and time is of the essence. Learn from our mistakes but also from the few successful countries: early massive testing is absolutely necessary. So are filtered masks and other protection for everyone, not just for those infected.

    It may sound contradictory to mistrust the state while still advocating strong measures to stop the pandemic. It is not. We know governments always lie, but this time around they haven’t lied to exaggerate COVID-19, but to play down its reality and impact. This was not the flu: a flu-like condition is just one of its effects. This was, of course, not a local issue: it soon became global. This didn’t take away our beloved grandparents alone: it threatens everyone. Although the devastating massacre of the elderly may hide this, younger and healthy people are dying as well.

    But of course, one thing is to accept exceptional government action and special powers, and a completely different story is to favour it as a lasting result of this crisis. The more power government gets to enjoy, the more it needs to be under stricter check by the opposition, by the mass media and by civil society, including of course institutions like yours. Parliaments should go telematic but remain active to keep cabinets in check. The media need to operate freely. Any special powers should be exerted with utmost transparency and even through exceptional cross-party cabinets, and any temporary exceptions should be lifted the very minute they expire. Seeing the military patrol our streets is certainly undesirable and, while it may now be justified as the last resort, it should end as soon as possible, not even one second later than that. Beware of all those who take advantage of this situation to attempt veiled changes on the institutions of political governance or the economy. Emergencies have always been their pretext, as Hayek taught us.

    The subsequent economic disaster should not lead us to central planned economies. The way to recover from the impending depression is not to flood the economy with stimulus packages. It is not to bail out everyone, nor would that be even possible. It is not to incur in an even deeper interventionism. It is not to nationalize anything. It is the opposite. Under catastrophic circumstances, private action and private property are quintessential to recovery. Taxes need to be reduced to almost nil, at least for small enterprises, freelancers and households. And this needs to be done by shrinking the state, not by printing money or devaluating it, nor by indebting us and our children and grandchildren. Starting a business, hiring and firing, providing services and trading goods, need to be more free than ever. Minimum wages and other economic hurdles need to disappear. The economy needs to be, more than ever before, a spontaneous order. The state, though, does have one important task to perform: step away! Leave enterprise to the entrepreneur, production to the producer, work to the worker, consumption to the consumer. Leave the economy alone because, under these circumstances, any state intervention will just make things worse.

    The geopolitical effects of this pandemic and the subsequent depression are also horrifying. Our think tanks and institutions share a common set of values that could hardly survive under a new global hegemony by the Russian or Chinese regimes. The free world must prevail. More than ever before, we need to stop a distopic future by going back to our basics and defending, at any price, Human Rights and individual liberty, freedom of conscience, free speech and free press, independence of the judiciary, separation of government branches, and the right to free enterprise and free trade.

    From a shocked and saddened Spain, we wish you strength and wisdom. We need you, and we’ll be there for you as well. Please stay safe, stay home, and stay vigilant. Watch your health and watch your government. An England besieged by totalitarianism once enshrined this well known words: keep calm and carry on. They overcame. So will we. So will Liberty.

  • Submitted for inclusion, by one of our contributors…

    “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.

    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.”

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