Hello, thanks for the useful tips. Any chance of an update? There seems to b a lot of new info around , eg on: chloroquine remdesivir, other antivirals smoking thrombosis/cardiac problems ventilator deaths symptoms (eg lack of fever) etc etc
I’ve now made updates, here and on the Google Doc version. They can be found by searching with ctrl-f for ‘Added Apr. 26’ and ‘Added Apr. 27’. Additions made:
___
2A. Avoid people
Evidence continues to accumulate that talking is an important vector. COVID-19 superspreader events have typically involved large groups of people talking, singing, or shouting indoors.
[...] I’d choose the thickest, most finely woven materials available and layer them as much as possible without making it difficult to breathe. Then I’d wear those outside, taking all other precautions (distance, goggles, etc), and breathe SLOWLY through my nose. Slowly because lower air velocity reduces penetration, nose because it acts as a filter as well. Then I’d wash everything immediately & thoroughly upon arriving home.
Source: Combine these studies about the effectiveness of cloth/DIY masks
The CDC recommends having a two-week backup supply of clean drinkable water. I would recommend stockpiling 1+ months of water (i.e., 30+ gallons per person) if you have room. The Guardianreports Apr. 20 that there’s an emerging shortage of CO2, and The Prepared notes that “CO2 is an essential input for the municipal water treatment process. (It’s also vital to many critical industrial processes–from agriculture to meat processing to food preservation).” The Prepared also notes other chemicals used in water treatment whose supply could be disrupted in various scenarios.
___
2H. Maybe stop taking ibuprofen/advil?
[Section renamed from “Probably stop taking NSAIDs like ibuprofen.”]
[Section rewritten. Summary: I now put less probability on NSAIDs being bad, and for reasons noted below, I specifically suggest taking the NSAID aspirin if you think you have COVID-19. I’ve added quotes to this section so it’s easier to see the complicated mess of claims that people are making.]
___
2K. Stay healthy: eat well, sleep well, get exercise.
And consider avoiding things that might put you in a hospital, like motorcycle races or getting pregnant; hospitals are risky during pandemics.
___
2L. Keep Vitamin K intake low/moderate.
[New section. Summary: on priors, vitamin -K-rich foods may increase clotting risk from COVID-19.]
___
3A. Prepare in advance.
Given the “silent hypoxia” update at the bottom of 3D below, and the blood clot update in 3G below, you should probably use the pulse oximeter regularly even if you’re showing no symptoms, and should stay alert for signs of stroke, heart attack, or pulmonary embolism even if you’re showing no other symptoms.
___
3D. Start monitoring your oxygen more often at the smallest warning sign.
… including if you’re asymptomatic but have exposed yourself to possible infection vectors in the last two weeks. If you develop a fever or experience significant chest tightness or difficulty breathing, definitely start monitoring your oxygen; but don’t wait that long if you can avoid it.
[Section renamed from “Start monitoring your oxygen immediately if you develop a fever or experience significant chest tightness or difficulty breathing.”]
[...] These patients did not report any sensation of breathing problems, even though their chest X-rays showed diffuse pneumonia and their oxygen was below normal. How could this be?
We are just beginning to recognize that Covid pneumonia initially causes a form of oxygen deprivation we call “silent hypoxia” — “silent” because of its insidious, hard-to-detect nature.
Pneumonia is an infection of the lungs in which the air sacs fill with fluid or pus. Normally, patients develop chest discomfort, pain with breathing and other breathing problems. But when Covid pneumonia first strikes, patients don’t feel short of breath, even as their oxygen levels fall. And by the time they do, they have alarmingly low oxygen levels and moderate-to-severe pneumonia (as seen on chest X-rays). Normal oxygen saturation for most persons at sea level is 94 to 100 percent; Covid pneumonia patients I saw had oxygen saturations as low as 50 percent.
To my amazement, most patients I saw said they had been sick for a week or so with fever, cough, upset stomach and fatigue, but they only became short of breath the day they came to the hospital. Their pneumonia had clearly been going on for days, but by the time they felt they had to go to the hospital, they were often already in critical condition. [...]
We are only just beginning to understand why this is so. The coronavirus attacks lung cells that make surfactant. This substance helps the air sacs in the lungs stay open between breaths and is critical to normal lung function. As the inflammation from Covid pneumonia starts, it causes the air sacs to collapse, and oxygen levels fall. Yet the lungs initially remain “compliant,” not yet stiff or heavy with fluid. This means patients can still expel carbon dioxide — and without a buildup of carbon dioxide, patients do not feel short of breath.
Patients compensate for the low oxygen in their blood by breathing faster and deeper — and this happens without their realizing it. This silent hypoxia, and the patient’s physiological response to it, causes even more inflammation and more air sacs to collapse, and the pneumonia worsens until oxygen levels plummet. In effect, patients are injuring their own lungs by breathing harder and harder. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure.
By the time patients have noticeable trouble breathing and present to the hospital with dangerously low oxygen levels, many will ultimately require a ventilator.
Silent hypoxia progressing rapidly to respiratory failure explains cases of Covid-19 patients dying suddenly after not feeling short of breath. [...]
There is a way we could identify more patients who have Covid pneumonia sooner and treat them more effectively — and it would not require waiting for a coronavirus test at a hospital or doctor’s office. It requires detecting silent hypoxia early through a common medical device that can be purchased without a prescription at most pharmacies: a pulse oximeter.
Relatedly, Paul Bohm notes, “54% of asymptomatic cases and 79% of COVID-19 symptomatic cases on the Diamond Princess had ground-glass abnormalities in their CT scans.”
This suggests that even if you seem completely asymptomatic (or have very mild symptoms), you should periodically use a home pulse oximeter if there’s a nontrivial risk you recently caught the virus. Additionally, unusually fast and deep breathing is a thing to watch out for, even in otherwise asymptomatic or mildly symptomatic people.
___
3G. Take aspirin prophylactically, and monitor for clotting problems.
[New section.]
Evan Hubinger says:
There have been a lot of reports recently of young people (30s and 40s) developing blood clotting complications due to covid19 infection, resulting in strokes, heart attacks, and pulmonary embolisms. Apparently this can happen even for people who are otherwise asymptomatic. Actionable items:
1. Monitor yourself for stroke, heart attack, etc. symptoms and get to the hospital ASAP if you have any—one of the major reasons these cases are so bad right now is that young, otherwise asymptomatic people aren’t used to looking for stroke symptoms and aren’t rushing to the hospital.
2. If you think there’s a high risk you might have covid19, consider taking a blood thinner such as aspirin.
[...] The link between COVID-19 and clots has led some hospitals to put all COVID-19 patients on low doses of blood thinners to prevent clots, according to CNN.
[...] A recent study from the Netherlands, published in the journal Thrombosis Research, found that out of 184 COVID-19 patients in the ICU, more than 30% experienced some type of clotting issue. [...]
[...] The new coronavirus appears to be causing sudden strokes in adults in their 30s and 40s who are not otherwise terribly ill, doctors reported Wednesday.
[...] Dr. Thomas Oxley, a neurosurgeon at Mount Sinai Health System in New York, and colleagues gave details of five people they treated. All were under the age of 50, and all had either mild symptoms of Covid-19 infection or no symptoms at all.
“The virus seems to be causing increased clotting in the large arteries, leading to severe stroke,” Oxley told CNN.
“Our report shows a seven-fold increase in incidence of sudden stroke in young patients during the past two weeks. Most of these patients have no past medical history and were at home with either mild symptoms (or in two cases, no symptoms) of Covid,” he added.
[...] “For comparison, our service, over the previous 12 months, has treated on average 0.73 patients every 2 weeks under the age of 50 years with large vessel stroke,” the team wrote in a letter to be published in the New England Journal of Medicine. [...]
[… At Mount Sinai there have been] several recent [large-vessel] stroke patients in their 30s to 40s who were all infected with the coronavirus. The median age for that type of severe stroke is 74.
[...] Many researchers suspect strokes in covid-19 patients may be a direct consequence of blood problems that are producing clots all over some people’s bodies.
[...] At Mount Sinai, the largest medical system in New York City, physician-researcher J Mocco said the number of patients coming in with large blood blockages in their brains doubled during the three weeks of the covid-19 surge to more than 32, even as the number of other emergencies fell. More than half of [them] were covid-19 positive.
[...] The covid-19 patients treated for stroke at Mount Sinai were younger and mostly without risk factors.
On average, the covid-19 stroke patients were 15 years younger than stroke patients without the virus. [...]
If you start showing COVID-19 symptoms or you think there’s a good chance you were recently infected, then especially if you’re young, I suggest that you start taking aspirin prophylactically, to reduce the risk of blood clots. (Don’t take aspirin if you have low blood pressure; do take it if you have normal or elevated blood pressure.)
Symptoms to watch out for:
For stroke, the FAST mnemonic summarizes the main symptoms: if one side of your face starts drooping or goes numb, one arm suddenly goes weak or numb, or your speech becomes slurred or garbled, it’s time to call 911. Other symptoms can include: sudden leg weakness or numbness, especially on one side of the body; sudden confusion, trouble understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; sudden severe headache with no known cause.
For heart attack in cis women, the Heart Foundation lists these signs: “(1) As with men, women’s most common heart attack symptom is chest pain or an uncomfortable pressure, squeezing, fullness or pain in the center of your chest. It lasts more than a few minutes, or goes away and comes back. (2) Pain or discomfort in one or both arms, the back, neck, jaw or stomach. (3) Shortness of breath with or without chest discomfort. (4) Other common symptoms in women include breaking out in a cold sweat, nausea/vomiting, or feeling lightheaded, palpitations; sleep disturbances and unexplained fatigue.”
For heart attack in cis men: “(1) Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. (2) It used to be thought that only chest pain was a sign of heart attack, but it’s possible to have discomfort that doesn’t register as painful. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. (3) Shortness of breath with or without chest discomfort. (4) Other signs may include breaking out in a cold sweat, nausea or feeling lightheaded.”
I don’t know of research on heart attack signs in people undergoing transgender hormone therapy; data may be scarce because this is a relatively young population.
The Heart Foundation adds: “Don’t wait to get help if you experience any of these heart attack warning signs. Although some heart attacks are sudden and intense, most start slowly, with mild pain or discomfort.”
For pulmonary embolism, Cedars Sinai says, “The most common symptoms include: sudden shortness of breath (most common); chest pain (usually worse with breathing); a feeling of anxiety; a feeling of dizziness, lightheadedness, or fainting; irregular heartbeat; palpitations (heart racing); coughing or coughing up blood; sweating; low blood pressure. You may also have symptoms of deep vein thrombosis (DVT), such as: pain in the affected leg (may happen only when standing or walking); swelling in the leg; soreness, redness, or warmth in the leg(s); redness and/or discolored skin.”
___
3H. Consider taking more extreme measures if you’re experiencing serious COVID-19 symptoms, or if you have the resources to take bonus precautions.
[Section renamed from “Consider taking more extreme measures if you’re experiencing serious COVID-19 symptoms, or if you’re at-risk (i.e., you’re older or have other health issues) or have the resources to take bonus precautions.”]
If you’re worried about blood clot risks from COVID-19 (discussed in 3G), you may want to use home coagulation tests.
I just finished a video appointment with a cardiologist where we discussed the clotting thing. Even though he seemed to think I had COVID, and I recently had an abnormal EKG and some mild chest tightness, he thought it was better to avoid blood thinners. Apparently he has been receiving Cochrane reports on COVID before they are publicly available. He said that the increased clotting is usually in patients w/ some kinda predisposition and tends to be worse with more severe symptoms. Even for low-dose aspirin, he thinks the risk of bleeding is larger than the potential benefits. “I’ve seen all these complications from blood thinners.” (I’m 28 FYI.)
Note that despite previous speculation on LW regarding prophylactic use of low-dose aspirin for longevity, a large clinical trial found it wasn’t useful in older folks (age 65+). Note this bit:
Significant bleeding—a known risk of regular aspirin use—was also measured. The investigators noted that aspirin was associated with a significantly increased risk of bleeding, primarily in the gastrointestinal tract and brain. Clinically significant bleeding—hemorrhagic stroke, bleeding in the brain, gastrointestinal hemorrhages or hemorrhages at other sites that required transfusion or hospitalization—occurred in 361 people (3.8 percent) on aspirin and in 265 (2.7 percent) taking the placebo.
At the very least, I suggest you change your recommendation from “aspirin” to “low-dose aspirin”. Overall, I’m more inclined to trust secondhand accounts of Cochrane preprints than collections of anecdotes in the media.
I’m not immediately planning any changes. If folks make things easy on me by saying specific sentences they want added, references they want linked, etc., that increases the probability I’ll make updates. :)
Hello, thanks for the useful tips. Any chance of an update? There seems to b a lot of new info around , eg on:
chloroquine
remdesivir, other antivirals
smoking
thrombosis/cardiac problems
ventilator deaths
symptoms (eg lack of fever)
etc etc
I’ve now made updates, here and on the Google Doc version. They can be found by searching with ctrl-f for ‘Added Apr. 26’ and ‘Added Apr. 27’. Additions made:
___
2A. Avoid people
Evidence continues to accumulate that talking is an important vector. COVID-19 superspreader events have typically involved large groups of people talking, singing, or shouting indoors.
From Scott Gottlieb: “Study of 318 outbreaks in China found transmission occurred out-of-doors in only one, involving just 2 cases. Most occurred in home or public transport. Raises key chance for states to move services outdoors (religious, gym classes, restaurants, etc). https://www.medrxiv.org/content/10.1101/2020.04.04.20053058v1”
[...]
Cf. quick thoughts about the COVID-19 endgame.
___
2B. If you do need to be around people, wear something over your mouth and nose.
For homemade masks, Hrothgar says:
___
2D. Have emergency supplies.
The CDC recommends having a two-week backup supply of clean drinkable water. I would recommend stockpiling 1+ months of water (i.e., 30+ gallons per person) if you have room. The Guardian reports Apr. 20 that there’s an emerging shortage of CO2, and The Prepared notes that “CO2 is an essential input for the municipal water treatment process. (It’s also vital to many critical industrial processes–from agriculture to meat processing to food preservation).” The Prepared also notes other chemicals used in water treatment whose supply could be disrupted in various scenarios.
___
2H. Maybe stop taking ibuprofen/advil?
[Section renamed from “Probably stop taking NSAIDs like ibuprofen.”]
[Section rewritten. Summary: I now put less probability on NSAIDs being bad, and for reasons noted below, I specifically suggest taking the NSAID aspirin if you think you have COVID-19. I’ve added quotes to this section so it’s easier to see the complicated mess of claims that people are making.]
___
2K. Stay healthy: eat well, sleep well, get exercise.
And consider avoiding things that might put you in a hospital, like motorcycle races or getting pregnant; hospitals are risky during pandemics.
___
2L. Keep Vitamin K intake low/moderate.
[New section. Summary: on priors, vitamin -K-rich foods may increase clotting risk from COVID-19.]
___
3A. Prepare in advance.
Given the “silent hypoxia” update at the bottom of 3D below, and the blood clot update in 3G below, you should probably use the pulse oximeter regularly even if you’re showing no symptoms, and should stay alert for signs of stroke, heart attack, or pulmonary embolism even if you’re showing no other symptoms.
___
3D. Start monitoring your oxygen more often at the smallest warning sign.
… including if you’re asymptomatic but have exposed yourself to possible infection vectors in the last two weeks. If you develop a fever or experience significant chest tightness or difficulty breathing, definitely start monitoring your oxygen; but don’t wait that long if you can avoid it.
[Section renamed from “Start monitoring your oxygen immediately if you develop a fever or experience significant chest tightness or difficulty breathing.”]
[...]
streawkceur writes, “According to this article, it seems clear by now that low oxygen is in fact dangerous even when you feel fine, so buying a pulse oximeter is useful. https://www.nytimes.com/2020/04/20/opinion/sunday/coronavirus-testing-pneumonia.html” Quoting the article:
Relatedly, Paul Bohm notes, “54% of asymptomatic cases and 79% of COVID-19 symptomatic cases on the Diamond Princess had ground-glass abnormalities in their CT scans.”
This suggests that even if you seem completely asymptomatic (or have very mild symptoms), you should periodically use a home pulse oximeter if there’s a nontrivial risk you recently caught the virus. Additionally, unusually fast and deep breathing is a thing to watch out for, even in otherwise asymptomatic or mildly symptomatic people.
___
3G. Take aspirin prophylactically, and monitor for clotting problems.
[New section.]
Evan Hubinger says:
From Live Science on Apr. 23:
From CNN on Apr. 23:
From the Washington Post on Apr. 25:
If you start showing COVID-19 symptoms or you think there’s a good chance you were recently infected, then especially if you’re young, I suggest that you start taking aspirin prophylactically, to reduce the risk of blood clots. (Don’t take aspirin if you have low blood pressure; do take it if you have normal or elevated blood pressure.)
Symptoms to watch out for:
For stroke, the FAST mnemonic summarizes the main symptoms: if one side of your face starts drooping or goes numb, one arm suddenly goes weak or numb, or your speech becomes slurred or garbled, it’s time to call 911. Other symptoms can include: sudden leg weakness or numbness, especially on one side of the body; sudden confusion, trouble understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; sudden severe headache with no known cause.
For heart attack in cis women, the Heart Foundation lists these signs: “(1) As with men, women’s most common heart attack symptom is chest pain or an uncomfortable pressure, squeezing, fullness or pain in the center of your chest. It lasts more than a few minutes, or goes away and comes back. (2) Pain or discomfort in one or both arms, the back, neck, jaw or stomach. (3) Shortness of breath with or without chest discomfort. (4) Other common symptoms in women include breaking out in a cold sweat, nausea/vomiting, or feeling lightheaded, palpitations; sleep disturbances and unexplained fatigue.”
For heart attack in cis men: “(1) Chest discomfort. Most heart attacks involve discomfort in the center of the chest that lasts more than a few minutes, or that goes away and comes back. It can feel like uncomfortable pressure, squeezing, fullness or pain. (2) It used to be thought that only chest pain was a sign of heart attack, but it’s possible to have discomfort that doesn’t register as painful. Symptoms can include pain or discomfort in one or both arms, the back, neck, jaw or stomach. (3) Shortness of breath with or without chest discomfort. (4) Other signs may include breaking out in a cold sweat, nausea or feeling lightheaded.”
I don’t know of research on heart attack signs in people undergoing transgender hormone therapy; data may be scarce because this is a relatively young population.
The Heart Foundation adds: “Don’t wait to get help if you experience any of these heart attack warning signs. Although some heart attacks are sudden and intense, most start slowly, with mild pain or discomfort.”
For pulmonary embolism, Cedars Sinai says, “The most common symptoms include: sudden shortness of breath (most common); chest pain (usually worse with breathing); a feeling of anxiety; a feeling of dizziness, lightheadedness, or fainting; irregular heartbeat; palpitations (heart racing); coughing or coughing up blood; sweating; low blood pressure. You may also have symptoms of deep vein thrombosis (DVT), such as: pain in the affected leg (may happen only when standing or walking); swelling in the leg; soreness, redness, or warmth in the leg(s); redness and/or discolored skin.”
___
3H. Consider taking more extreme measures if you’re experiencing serious COVID-19 symptoms, or if you have the resources to take bonus precautions.
[Section renamed from “Consider taking more extreme measures if you’re experiencing serious COVID-19 symptoms, or if you’re at-risk (i.e., you’re older or have other health issues) or have the resources to take bonus precautions.”]
If you’re worried about blood clot risks from COVID-19 (discussed in 3G), you may want to use home coagulation tests.
I just finished a video appointment with a cardiologist where we discussed the clotting thing. Even though he seemed to think I had COVID, and I recently had an abnormal EKG and some mild chest tightness, he thought it was better to avoid blood thinners. Apparently he has been receiving Cochrane reports on COVID before they are publicly available. He said that the increased clotting is usually in patients w/ some kinda predisposition and tends to be worse with more severe symptoms. Even for low-dose aspirin, he thinks the risk of bleeding is larger than the potential benefits. “I’ve seen all these complications from blood thinners.” (I’m 28 FYI.)
Note that despite previous speculation on LW regarding prophylactic use of low-dose aspirin for longevity, a large clinical trial found it wasn’t useful in older folks (age 65+). Note this bit:
At the very least, I suggest you change your recommendation from “aspirin” to “low-dose aspirin”. Overall, I’m more inclined to trust secondhand accounts of Cochrane preprints than collections of anecdotes in the media.
Thanks, John. Based on this, I’ve removed my recommendation that people take aspirin, and I’ve added your full comment to that part of the post.
I’m not immediately planning any changes. If folks make things easy on me by saying specific sentences they want added, references they want linked, etc., that increases the probability I’ll make updates. :)