Why things are much worse than you’re hearing.
Now that I have your attention, first off lots of people have been texting me, thank you. I’m fine. I’m not sick or infected (as far as I know!) I’m currently on “Supervised self monitoring” after a slightly increased risk exposure. I feel fine and have no symptoms, I just have to take my temperature twice per day, log any symptoms I might have, and report them. But I am not quarantined and still get to work. Anyone who knows me knows I am normally the opposite of “taking adequate precautions” but I’m treating this one differently. Joanne stocked me up with natural (aka grain alcohol and aloe) homemade sanitizers and everyone else is jealous. I feel fine, just tired from working overnights in a bit of a war zone.
So I wanted to give everyone an update.
1. The cases of COVID are far more than are being reported. We are not testing the majority of people. We are sending them home with instructions to self quarantine, and what to watch for.
2. The reason for this is three-fold
a. Tests are a limited resource…not just tests but the viral medium needed to collect the sample. We need to conserve for the people who we really need to know
b. For most people, it won’t change management. Results are taking 3-5 days. You look well, you don’t have severe disease, and have few or no risk factors: you will be sent home to be on self-quarantine regardless, with strict return precautions.
***c. This is a big one: It is a huge burden to test. Why you ask? COVID is a droplet and contact disease. It is generally not airborne. So standard PPE (Personal Protective Equipment) is adequate (surgical mask, eye protection, gown, gloves) plus having the patient keep a mask on at all times. BUT it becomes airborne during aerosolizing procedures, which include collecting nasal and oral samples. (Well, not technically during the collection, but when you collect the sample the patient’s mask is off and they often sneeze/cough after having the swab put in their nose/throat). At this point, airborne precautions must be taken to include N95 Respirator masks.
BUT we are on a massive shortage of all PPE nationally and worldwide…in many hospitals out west they are already bleaching and reusing N95s in between patients.
Our N95s are controlled by one person in the hospital. Not ideal at all, but better than nothing at all. We are also on shortage of gowns and surgical masks. Also, in between any COVID patient the room needs to be terminally cleaned which takes time, but if an aerosolizing procedure (even test collection) the room is supposed to be given one hour to let any droplets settle onto the floor/surfaces before terminal cleaning. It is simply not practical to test most people.
The only way to really do a lot of testing is outdoors, with a tent, where you have people outfitted in the proper PPE and just leave it on as cars drive through/people walk up. But we can’t support that right now due to supply shortages.
3. Speaking of aerosolizing procedures:
a. BIPAP/Non-invasive ventilation is basically out. It is highly aerosolizing and associated with one of the highest rates of healthcare provider contamination. So while traditionally we use BIPAP as much as possible to avoid intubation, the protocol is to move to intubation more quickly now
b. Nebulizers, a mainstay of respiratory disease/wheezing are verboten. Again highly aerosolizing. One person on a nebulizer in a non-negative pressure room with the door open can shut down a whole wing. I am worried we are going to see a huge number of EMS providers start testing positive, because they’ve been following their protocols and giving nebulizers right and left. The protocols are changing, but I suspect that horse is already out of the barn. Instead, we are using serial Metered Dose Inhalers with spacer devices.
c. For intubation, nasopharyngoscopes, and other high risk procedures, we are donning PAPR (Powered Air Purifier Respirator) basically a positive pressure sealed head cover that doesn’t allow any outside air in. It sucks because it’s hard to hear what’s going on, but intubations are too high risk otherwise.
I want to reiterate: THIS IS NOT THE FLU. I will freely say it, I was wrong. I downplayed this months ago, and cited how many people die of the flu every year, etc. I have had more critically ill COVID patients this week than I had critically ill flu patients all flu season. We’ve had 2 patients die in Williamsburg already just a few days into this, both in their late 60s/early 70s but otherwise actually healthy with no significant medical problems. Yes, most people will be fine, but for the subset that get very ill, it’s a bit stunning how quickly and dramatically they go downhill. There are already 2 ER doctors critically ill, one in Washington (healthy male in his early 40s) and one in New Jersey (also healthy but 70 years old, coincidentally he is in charge of Emergency Preparedness for a large health system). Most people don’t have anything to worry about with COVID-19, but if you are one of the people who it hits harder, it’s frightening how fast you go downhill.
But I really want to emphasize to everyone, do not be lulled into a false sense of security by the number of positive tests. The number of people infected is orders of magnitude more than reported, because we simply aren’t testing most people. As more tests become available hopefully that will change.
ANOTHER Key Point: There is a growing evidence that steroids and NSAIDS may actually be harmful.
Which is odd, because the patients that get the sickest do so because of ARDS, which is your immune system confusing your normal lung tissue with viral infected lung tissue, and attacking and killing it all. So you would think that anti-inflammatories would help, but there is evidence they make things worse. Also, there is a clear association with hypertension and diabetes being major risk factors for more severe disease, and some (controversial) suggestion that ACE inhibitors and ARBs, commonly prescribed for these two conditions, make things worse. If you get ill, please discuss with your primary doctor or cardiologist whether to continue them.
If I may brag, I am glad so many others are getting to see what awesome people choose to go into healthcare and especially my area, emergency medicine. No one is running away, everyone is working longer hours and longer shifts, people are covering for each other when they get quarantined. Nurses, medics, techs, housecleaning, some of whom make not much over minimum wage are all stepping up to volunteer to work “in the hot zone” for hours on end. They aren’t getting hazardous duty pay, or any special bonuses.
They’re just doing it because that’s what they do every single day and why they went into this line of work. ERs have been criticized by insurance companies for being expensive and greedy…but there is no other place where a group of the finest people I know can respond almost immediately to something of this scale and with this expertise, and do so willingly without question and without regard for their own safety.
I read a week ago several comments on international message boards that I’m on comments from Italian ER doctors who felt like they were watching a train wreck about to happen in the US, and despite telling us to slow down no one was listening. When I go for runs to clear my mind and see packed bars and restaurants, I now see what they mean.
Practice in-person social distancing, flatten the curve…yes they seem like overused buzzwords but it’s the only way we’re going to slow this train down.
#WeLoveShoreDrive 