>Internet Book of Critical Care (IBCC) Online Medical Education on Emergency Department (ED) Critical Care, Trauma, and Resuscitation
Prepper here. Anons, i was given the link to a valuable resource pertaining to the Lung Pao. Please do your best to keep this thread bumped so anons can see the link and bookmark it. Its the medical treatment guide to CoVID19, it has fucking everything thing to date concerning the disease, symptoms, treatments, drugs, side-effects and precautions.
Ive been watching this shit from Jan 1 and I've never seen any of this posted before in one document. This is what hospitals and professionals are using to treat the chinkflu outbreak. Maybe it has been posted here maybe is hasn't, the board has been moving faster than a nigger bitch without an umbrella in a rainstorm. I'm saying ive never seen this so i assume there's anons out there who haven't either.
GET THIS, COPY OR ARCHIVE BEFORE SOMETHING HAPPENS TO IT.
There seem to be different stages of illness that patients may move through. (#1) Replicative stage – Viral replication occurs over a period of several days. An innate immune response occurs, but this response fails to contain the virus. Relatively mild symptoms may occur due to direct viral cytopathic effect and innate immune responses. (#2) Adaptive immunity stage – An adaptive immune response eventually kicks into gear. This leads to falling titers of virus. However, it may also increase levels of inflammatory cytokines and lead to tissue damage – causing clinical deterioration. There is a suggestion that this could lead to virus-induced hemophagocytic lymphohistiocytosis (HLH)(Mehta et al.). More discussion about this entity and possible therapy here. This progression may explain the clinical phenomenon wherein patients are relatively OK for several days, but then suddenly deteriorate when they enter the adaptive immunity stage (e.g. Young et al. 3/3/2020). This has potentially important clinical implications: Initial clinical symptoms aren't necessarily predictive of future deterioration. Sophisticated strategies may be required to guide risk-stratification and disposition (see below section on prognosis). Anti-viral therapies might need to be deployed early to work optimally (during the replicative stage). Immunosuppressive therapy (e.g. low-dose steroid) might be best initiated during the adaptive immune stage (with a goal of blunting this immunopathologic response slightly, in the sickest patients). But this is purely speculative.
Adrian Cox
transmission
large droplet transmission
COVID-19 transmission can occur via large droplet transmission (with a risk limited to ~6 feet from the patient)(Carlos del Rio 2/28). This is typical for respiratory viruses such as influenza. Transmission via large droplet transmission can be prevented by using a standard surgical-style mask.
airborne transmission ??
It's controversial whether COVID19 can be transmitted via an airborne route (small particles which remain aloft in the air for longer periods of time). Airborne transmission would imply the need for N95 masks (“FFP2” in Europe), rather than surgical masks. This controversy is explored further in Shiu et al 2019. Airborne precautions started being used with MERS and SARS out of an abundance of caution (rather than any clear evidence that coronaviruses are transmitted via an airborne route). This practice has often been carried down to COVID19. Guidelines disagree about whether to use airborne precautions: The Canadian Guidelines and World Health Organization guidelines both recommend using only droplet precautions for routine care of COVID19 patients. However, both of these guidelines recommend airborne precautions for procedures which generate aerosols (e.g. intubation, noninvasive ventilation, CPR, bag-mask ventilation, and bronchoscopy). The United States CDC recommends using airborne precautions all the time when managing COVID19 patients. Using airborne precautions for all patients who are definitely or potentially infected with COVID19 will likely result in rapid depletion of N95 masks. This will leave healthcare providers unprotected when they actually need these masks for aerosol-generating procedures. In the context of a pandemic, the Canadian and WHO guidelines may be more sensible in countries with finite resources (i.e. most locales). However, infection control is ultimately local, so be sure to follow your hospital's guidance regarding this.
Ryan Gray
contact transmission (“fomite-to-face”) This mode of transmission has a tendency to get overlooked. This is how it works: (i) Someone with coronavirus coughs, emitting large droplets containing the virus. Droplets settle on surfaces in the room, creating a thin film of coronavirus. The virus may be shed in nasal secretions as well, which could be transmitted to the environment. (ii) The virus persists on fomites in the environment. Human coronaviruses can survive on surfaces for up to about a week (Kampf et al 2020). It's unknown how long COVID-19 can survive in the environment, but it might be even longer (some animal coronaviruses can survive for weeks!). (iii) Someone else touches the contaminated the surface hours or days later, transferring the virus to their hands. (iv) If the hands touch a mucous membrane (eyes, nose, or mouth), this may transmit the infection. Any effort to limit spread of the virus must block contact transmission. The above chain of events can be disrupted in a variety of ways: (a) Regular cleaning of environmental surfaces (e.g. using 70% ethanol or 0.5% sodium hypochlorite solutions; for details see Kampf et al 2020 and CDC guidelines). (b) Hand hygiene (high concentration ethanol neutralizes the virus and is easy to perform, so this might be preferable if hands aren't visibly soiled)(Kampf 2017). (c) Avoidance of touching your face. This is nearly impossible, as we unconsciously touch our faces constantly. The main benefit of wearing a surgical mask could be that the mask acts as a physical barrier to prevent touching the mouth or nose. Any medical equipment could become contaminated with COVID-19 and potentially transfer virus to providers (e.g. stethoscope earpieces and shoes). A recent study found widespread deposition of COVID-19 in one patient's room, but fortunately this seems to be removable by cleaning with sodium dichloroisocyanurate (Ong et al 2020).
Bentley Diaz
This is some real medical shit.
Kevin King
when can transmission occur?
(#1) Asymptomatic transmission (in people with no or minimal symptoms) appears to be possible (Carlos del Rio 2/28). (#2) Transmission appears to occur over roughly ~8 days following the initiation of illness. Patients may continue to have positive pharyngeal PCR for weeks after convalescence (Lan 2/27). However, virus culture methods are unable to recover viable virus after ~8 days of clinical illness (Wolfel 2020). This implies that prolonged PCR positivity probably doesn't correlate with clinical virus transmission. However, all subjects in Wolfel et al. had mild illness, so it remains possible that prolonged transmission could occur in more severe cases. CDC guidance is vague on how long patients with known COVID-19 should be isolated. It may be advisable to obtain two paired RT-PCR tests (one of the nasopharynx and one of the pharynx), with each pair collected >24 hours apart, prior to discontinuing precautions.
R
R is the average number of people that an infected person transmits the virus to. If R is 1, the epidemic will increase exponentially. Current estimates put R at ~2.5-2.9 (Peng PWH et al, 2/28). This is a bit higher than seasonal influenza. R is a reflection of both the virus and also human behavior. Interventions such as social distancing and improved hygiene will decrease R. Control of spread of COVID-19 in China proves that R is a modifiable number that can be reduced by effective public health interventions. The R on board the Diamond Princess cruise ship was 15 – illustrating that cramped quarters with inadequate hygiene will increase R (Rocklov 2/28).
Isaiah Bennett
>It's controversial whether COVID19 can be transmitted via an airborne route (small particles which remain aloft in the air for longer periods of time). Airborne transmission would imply the need for N95 masks (“FFP2” in Europe), rather than surgical masks. This controversy is explored further in Shiu et al 2019.
Anti-maskers BTFO.
Brandon Turner
personal protective equipment (PPE)
(back to contents) gear
(1) Contact precautions (waterproof gown and gloves) (2) Some sort of mask (discussed above in the transmission section) N95 mask or a powered, air-purifying respiratory (“PAPR”) Surgical mask for patients not undergoing aerosol-generating procedures (based on WHO & Canadian guidelines) (3) Goggles or eye shield Note: The exact gear used is probably less important than using it correctly.
applying and removing PPE (donning & doffing)
Understanding how to put on (don) and remove (doff) personal protective equipment is extremely important (especially if contact transmission is a dominant mode of transmission). Removing soiled PPE is the most critical and difficult aspect. Applying and removing PPE should ideally be practiced before patients arrive (e.g. using simulation). The video below describes how to use PPE (you may skip the first 5 minutes).
Pay attention to the junction between gloves and gowns. The gown should be tucked into the gloves (leaving no gap in-between). Using gloves with extended cuffs facilitates this (similar to sterile surgical gloves). Gloves with long cuffs may facilitate removal of the gown and gloves as a single unit (see 12:30 in the above video if this doesn't make sense). When removing PPE, always start by first applying alcohol-based hand sanitizer to your gloves. After fully removing PPE, sanitize hands and wrists with alcohol-based hand sanitizer again. Create a step-wise protocol for PPE removal. Two examples are shown below, but this may very depending on your exact gear. Follow the steps slowly. Consider doffing with someone watching you (to ensure good technique). If this isn't possible, doffing in a mirror may be helpful.
(1) Recent travel to affected areas. Areas with community-based transmission are increasing rapidly. The incubation time is up to 14 days, so travel within that window is relevant. (2) Contact with anyone with known COVID-19 (defined as a prolonged period of time spent
COVID-19 may cause constitutional symptoms, upper respiratory symptoms, lower respiratory symptoms, and, less commonly, gastrointestinal symptoms. Most patients will present with constitutional symptoms and lower respiratory symptoms (e.g. fever and cough). Fever: The frequency of fever is variable between studies (ranging from 43% to 98% as shown in the table above). This may relate to exact methodology used in various studies, different levels of illness severity between various cohorts, or different strains of the virus present in various locations. Additionally, some studies defined fever as a temperature >37.3 C (Zhou et al. 3/9/20). Regardless of the exact numbers – absence of a fever does not exclude COVID-19. Gastrointestinal presentations: up to 10% of patients can present initially with gastrointestinal symptoms (e.g. diarrhea, nausea), which precede the development of fever and dyspnea (Wang et al. 2/7/20). “Silent hypoxemia” – some patients may develop hypoxemia and respiratory failure without dyspnea (especially elderly)(Xie et al. 2020). Physical examination is generally nonspecific. About 2% of patients may have pharyngitis or tonsil enlargement (Guan et al 2/28).
Sorry user, doesn't seem like this thread is getting any visibility. Bumping.
Carter Phillips
typical disease course
Incubation is a median of ~4 days (interquartile range of 2-7 days), with a range up to 14 days (Carlos del Rio 2/28). Typical evolution of severe disease (based on analysis of multiple studies by Arnold Forest) Dyspnea ~ 6 days post exposure. Admission after ~8 days post exposure. ICU admission/intubation after ~10 days post exposure. However, this timing may be variable (some patients are stable for several days after admission, but subsequently deteriorate rapidly).
well fuck it i tried. if this starts getting replies ill continue to post, at least i tried.
Levi Williams
Bump for curiosity.
Isaiah Carter
I'm still here user. I bet people have filters that are blocking this post. Thanks for your help.
Sebastian Rodriguez
Have you not seen the countless clips of public health officials and media saying “masks don’t do anything”?
Ian Gomez
Bumperino Thanks OP good bread
David Wood
complete blood count WBC count tends to be normal. Lymphopenia is common, seen in ~80% of patients (Guan et al 2/28, Yang et al 2/21). Mild thrombocytopenia is common (but platelets are rarely
PCR for influenza and other respiratory viruses (e.g. RSV) may be helpful. Detection of other respiratory viruses doesn't prove that the patient isn't co-infected with COVID-19. However, an alternative explanation for the patient's symptoms might reduce the index of suspicion for COVID-19 substantially. Conventional viral panels available in some hospitals will test for “coronavirus.” This test does not work for COVID-19! This PCR test for “coronavirus” is designed to evaluate for four coronaviruses which usually cause mild illness. Ironically, a positive conventional test for “coronavirus” actually makes it less likely that the patient has COVID-19. Blood cultures should be performed as per usual indications.
specific testing for COVID-19
(back to contents)
Currently in the United States, all testing is done by state reference labs. Specimen collection and testing should be coordinated with the department of health. specimens
(1) Nasopharyngeal swab should be sent. (2) If intubated, tracheal aspirate should be performed. (3) Bronchoalveolar lavage or induced sputum are other options for a patient who isn't intubated. However, obtaining these specimens may pose substantial risk of transmission. It's dubious whether these tests are beneficial if done for the sole purpose of evaluating for coronavirus (see the section below on bronchoscopy).
Christopher Johnson
limitations in determining the performance of RT-PCR
There are several major limitations, which make it hard to precisely quantify how RT-PCR performs. (1) RT-PCR performed on nasal swabs depends on obtaining a sufficiently deep specimen. Poor technique will cause the PCR assay to under-perform. (2) COVID-19 isn't a binary disease, but rather there is a spectrum of illness. Sicker patients with higher viral burden may be more likely to have a positive assay. Likewise, sampling early in the disease course may reveal a lower sensitivity than sampling later on. (3) Most current studies lack a “gold standard” for COVID-19 diagnosis. For example, in patients with positive CT scan and negative RT-PCR, it's murky whether these patients truly have COVID-19 (is this a false-positive CT scan, or a false-negative RT-PCR?). (Convalescent serologies might eventually solve this problem, but this data isn't available currently.)
specificity Specificity seems to be high (although contamination can cause false-positive results).
sensitivity may not be terrific Sensitivity compared to CT scans In a case series diagnosed on the basis of clinical criteria and CT scans, the sensitivity of RT-PCR was only ~70% (Kanne 2/28). Sensitivity varies depending on assumptions made about patients with conflicting data (e.g. between 66-80%; figure above)(Ai et al.). Among patients with suspected COVID-19 and a negative initial PCR, repeat PCR was positive in 15/64 patients (23%). This suggests a PCR sensitivity of
Bottom line? PCR seems to have a sensitivity somewhere on the order of ~75%. A single negative RT-PCR doesn't exclude COVID-19 (especially if obtained from a nasopharyngeal source or if taken relatively early in the disease course). If the RT-PCR is negative but suspicion for COVID-19 remains, then ongoing isolation and re-sampling several days later should be considered.
CXR & CT scan
(back to contents) general description of imaging findings on chest x-ray and CT scan
The typical finding is patchy ground glass opacities, which tend to be predominantly peripheral and basal (Shi et al 2/24). The number of involved lung segments increases with more severe disease. Over time, patchy ground glass opacities may coalesce into more dense consolidation. Infiltrates may be subtle on chest X-ray (example above from Silverstein et al). Findings which aren't commonly seen, and might argue for an alternative or superimposed diagnosis: Pleural effusion is uncommon (seen in only ~5%). COVID-19 doesn't appear to cause masses, cavitation, or lymphadenopathy.
Limitations in the data Data from different studies conflict to a certain extent. This probably reflects varying levels of exposure intensity and illness severity (cohorts with higher exposure intensity and disease severity will be more likely to have radiologic changes). Sensitivity of CT scanning? Sensitivity among patients with positive RT-PCR is high. Exact numbers vary, likely reflecting variability in how scans are interpreted (there currently doesn't seem to be any precise definition of what constitutes a “positive” CT scan). Sensitivity of 86% (840/975) in Guan et al. Sensitivity of 97% (580/601) in Ai et al. Among patients with constitutional symptoms only (but not respiratory symptoms), CT scan may be less sensitive (e.g., perhaps ~50%)(Kanne 2/27). CT scan abnormalities might emerge before symptoms? Shi et al. performed CT scanning in 15 healthcare workers who were exposed to COVID-19 before they became symptomatic. Ground glass opacification on CT scan was seen in 14/15 patients! 9/15 patients had peripheral lung involvement (some bilateral, some unilateral). Emergence of CT abnormality before symptoms could be consistent with the existence of an asymptomatic carrier state (discussed above). Chest X-ray Sensitivity of chest X-ray is lower than CT scan for subtle opacities. In Guan et al., the sensitivity of chest x-ray was 59%, compared to 86% for CT scan. Quality CT/XR images on proven COVID-19 provided by Prof. Dr. Filippo Cademartiri, Chairman of Radiology , Marche – Italy. pic.twitter.com/MchsLQMf8z
In order to achieve sensitivity, a thorough lung examination is needed (taking a “lawnmower” approach, attempting to visualize as much lung tissue as possible). A linear probe may be preferable for obtaining high-resolution images of the pleural line (to make the distinction between a smooth, normal pleural line versus a thickened and irregular pleural line). COVID-19 typically creates patchy abnormalities on CT scan. These will be missed unless ultrasonography is performed overlying the abnormal lung tissue.
findings
The findings on lung ultrasonography appear to correlate very well with the findings on chest CT scan. With increasing disease severity, the following evolution may be seen (see corresponding images in the figure below)(Peng 2020) (A) Least severe: Mild ground-glass opacity on CT scan correlates to scattered B-lines. (B) More confluent ground-glass opacity on CT scan correlates to coalescent B-lines (“waterfall sign”). (C) With more severe disease, small peripheral consolidations are seen on CT scan and ultrasound. (D) In the most severe form, the volume of consolidated lung increases. Other features: Peripheral lung abnormalities can cause disruption and thickening of the pleural line. Areas of normal lung (with an A-line pattern) can be seen early in disease, or during recovery. Tiny pleural effusions may be seen, but substantial pleural effusions are uncommon (Peng 2020). As with CT scans, abnormalities are most common in the posterior & inferior lungs. For excellent examples of the correlation between CT scan and lung ultrasonography see Huang et al.
from here it gets very technical with the drugs used to treat this. there seems to be a combo of drugs that shows efficacy against LUNG PAO
Treatment Key principle: supportive care for viral pneumonia Potential anti-viral therapies? Background on antiviral therapy emcrit.org/ibcc/covid19/#remdesivir emcrit.org/ibcc/covid19/#lopinavir/ritonavir_(KALETRA) emcrit.org/ibcc/covid19/#chloroquine Oseltamavir and other neuraminidase inhibitors Anti-bacterial therapy Steroid Cardiovascular Pulmonary Noninvasive respiratory support High flow nasal cannula (HFNC) BiPAP Awake prone ventilation Intubation procedure Invasive mechanical ventilation Renal failure ECMO
Noah Myers
biology
(back to contents) basics
COVID-19 is a non-segmented, positive sense RNA virus. COVID-19 is part of the family of coronaviruses. This contains: (i) Four coronaviruses which are widely distributed and usually cause the common cold (but can cause viral pneumonia in patients with comorbidities). (ii) SARS and MERS – these caused epidemics with high mortality which are somewhat similar to COVID-19. COVID-19 is most closely related to SARS. It binds via the angiotensin-converting enzyme 2 (ACE2) receptor located on type II alveolar cells and intestinal epithelia (Hamming 2004). This is the same receptor as used by SARS (hence the technical name for the COVID-19, “SARS-CoV-2”). When considering possible therapies, SARS (a.k.a. “SARS-CoV-1”) is the most closely related virus to COVID-19. COVID-19 is mutating, which may complicate matters even further (figure below). Virulence and transmission will shift over times, in ways which we cannot predict. New evidence suggests that there are roughly two different groups of COVID-19. This explains why initial reports from Wuhan described a higher mortality than some more recent case series (Tang et al. 2020; Xu et al 2020). (Ongoing phylogenetic mapping of new strains can be found here.)
READ THE TOP LINE IN THE IMAGE
There's actually no such thing as COVID-19....there are innumerable different viruses evolving over time There's actually no such thing as COVID-19....there are innumerable different viruses evolving over time There's actually no such thing as COVID-19....there are innumerable different viruses evolving over time There's actually no such thing as COVID-19....there are innumerable different viruses evolving over time
Steroid should not generally be used. Steroid hasn't demonstrated benefit in prior SARS or MERS epidemics. Steroid may increase viral shedding (Lee 2004). Nearly all articles recommend against the use of steroid. However, steroid may be used if there is another clear-cut indication for steroid (e.g. coronavirus plus asthma exacerbation, refractory septic shock). WHO guidelines summary the relevant evidence regarding steroid; for further information read them here (see bottom of page 4).
ascorbic acid ??
Ascorbic acid did appear to improve mortality in the multi-center CITRIS-ALI trial. However, interpretation of this trial remains hopelessly contentious due to nearly unsolvable issues with survival-ship bias (discussed here). Extremely limited evidence suggests that ascorbic acid could be beneficial in animal models of coronavirus (Atherton 1978). Administration of a moderate dose of IV vitamin C could be considered (e.g. 1.5 grams IV q6 ascorbic acid plus 200 mg thiamine IV q12). This dose seems to be safe. However, there is no high-quality evidence to support ascorbic acid in viral pneumonia.
Ascorbic acid did appear to improve mortality in the multi-center CITRIS-ALI trial. > Ascorbic acid did appear to improve mortality in the multi-center CITRIS-ALI trial. Ascorbic acid did appear to improve mortality in the multi-center CITRIS-ALI trial. > Ascorbic acid did appear to improve mortality in the multi-center CITRIS-ALI trial.
(1) It remains unclear what fraction of patients are hospitalized. There may be lots of patients with mild illness who don't present to medical attention and aren't counted. The vast majority of infected patients (e.g. >80%) don't get significantly ill and don't require hospitalization. (2) Among hospitalized patients (Guan et al 2/28) ~10-20% of patients are admitted to ICU. ~3-10% require intubation. ~2-5% die. (3) Longer term outcomes: Prolonged ventilator dependency ? Patients who survive the initial phases of the illness may still require prolonged ventilator support (possibly developing some radiographic elements of fibrosis)(Zhang 2020). As the epidemic progresses, an issue which may arise is a large volume of patients unable to wean from mechanical ventilation. (Caveat: There are numerous sets of numbers published and they vary a lot. However, from the clinician's standpoint the precise numbers don't really matter.)
epidemiological risk factors
Risk factors (Zhou et al. 3/9/20). Older age Coronary artery disease Hypertension Diabetes Chronic pulmonary disease The largest series of mortality data comes from the Chinese CDC (table below). The absolute numbers may vary depending on whether some cases were missed, but the relative impact of various risk factors is probably accurate.
(back to contents) avoidance of unnecessary emergency department or clinic visits
Health systems should ideally be put in place to dissuade patients from presenting to the clinic or emergency department for testing to see if they have COVID-19 (e.g. if they have mild constitutional symptoms and don't otherwise require medical attention). Korea has developed a system of drive-thru testing, which avoids exposure of other patients in the emergency department. Outdoor testing also ensures ongoing circulation of fresh air.
Drive-thru coronavirus testing clinic in South Korea.
The vast majority of patients with coronavirus will recover spontaneously, without requiring any medical attention (perhaps >80% of patients). Patients with mild symptoms can generally be discharged home, with instructions to isolate themselves. These decisions should be made in coordination with local health departments, who can assist in follow-up. Features favoring home discharge may include: Ability to understand and comply with self-isolation (e.g. separate bedroom and bathroom). Ability to call for assistance if they are deteriorating. Having household members who aren't at increased risk of complications from COVID-19 (e.g. elderly, pregnant women, or people with significant medical comorbidities). Lack of hypoxemia, marked chest infiltrates, or other features that would generally indicate admission. For more, see CDC interim guidance for disposition of patients with COVID-19 here and here.
questions & discussion To keep this page small and fast, questions & discussion about this post can be found on another page here. emcrit.org/pulmcrit/COVID19/
Delayed consideration of COVID19, leading to delayed initiation of precautions (e.g. in a patient presenting with gastrointestinal illness). Treatment of COVID19 based on Surviving Sepsis Guidelines (e.g. with 30 cc/kg fluid). This is wrong on so many levels, for example: Broad application of 30 cc/kg fluid is often detrimental in septic shock. COVID-19 patients don't actually present with septic shock anyways. Large volume fluid is extremely dangerous in ARDS. Inadequate attention to contact precautions (e.g. hand hygiene and sterilization of surfaces). Admission of patients to hospital for COVID19 who could be safely managed as outpatients. Use of the emergency department as a COVID-19 screening area. Be careful of making major changes to usual treatment approaches for viral pneumonia, based on limited evidence. Ultimately the key here is simply high-quality supportive care for viral pneumonia.
Thats really everything aside from the listing of individual drugs, their efficacy and side-effects. It seems there are drugs to combat this chink shit. the rumors and posts surrounding choloroquine/ vitamin C /Remdesivir seem to have been factual and accurrate.
Background on antiviral therapy Remdesivir Lopinavir/Ritonavir (KALETRA) Chloroquine Oseltamavir and other neuraminidase inhibitors
checked and hortlered
Asher Thomas
This is good shit user, time to share this to my paranoid boomer family now so they will stop using facebook as their medical handbook.
Daniel Gomez
thanks anons. i wish you all the very best.
Xavier Lewis
I'm archiving at the moment but it will take a while Meanwhile download PDF and mirror it somewhere
youre very welcome. a lot of this shit is very technical i have looked up some terms for you guys:
Myalgia - body aches rhinorrhea - runny nose dyspnea - shortness of breath Hemoptysis - coughing up blood hypoxemia - low concentration of oxygen in the blood.
no prob. because of you and all of us helping each other i was totally prepared for this. i can only thanks everyone by sharing what i get when i get it.
I'm not as prepped as I'd like (low on food and I'm fucked without power) but at least knew to buy PPE and sanitizer back in January. Thanks anons.
Easton Harris
Wat does that 1post by id thing supposed to mean I’m new here, my coworker at the forklift drivers union told me to come to check out the latest q happening “Arrests incoming”
Oliver Torres
Bump for justice
Dylan Lewis
Means user only made 1 post in the thread, typically indicative of hit-and-run shills It shows when you hover over the ID field Also: > ID: QQey > talks about Q happening
Lucas Rivera
no thanks for the bump and help heres some prep shit save it >Q qtards are going to be the first to cough blood witnessed
