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Battle Ready

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(Another) ER Doctor’s Ramblings on Coronavirus

INITIAL RAMBLINGS

Battle Ready

– My position on the pandemic continues to evolve…daily

–  Know Thyself: I was slow to take this seriously. I have high-risk tolerance. I’m an intrinsic optimist. I am not an alarmist. As consequence, I rarely over-react. But, I do occasionally ‘under-react’. I still thought I’d be going on my March ski trip to Europe up until days before when I obviously wasn’t. Whoops.

– If still on the ‘liberal media conspiracy’ bandwagon, you’re wrong. The Magic Kingdom didn’t close while trying to sort out where the aliens were at Roswell.

– That said, the pandemic continues to be used on both sides to score political points. This is shameful. Now is not the time to assign blame. You may or may not like our current leadership, but the office is publicly elected and it is their responsibility to find solutions to this novel and unexpected catastrophe. Our leadership will likely make mistakes, but are also destined to implement some highly successful policies. Be open to that. Bipartisan cooperation WILL be required. It is critical we remain united, not divided.

– Interestingly, this invisible microscopic threat provides ALL of humankind one common adversary. A virus has no respect for national borders, race, gender, or sexual orientation. All it wants to do is replicate.

– There will be time for critical analysis & assigning responsibility for errors in judgement and response AFTER the pandemic has passed. Leave it to the historians and the talking heads. Again, resist this urge for the moment.

 

ALL THINGS VIRUS

CoV-19: Frighteningly beautiful

– Here, the nomenclature gets a bit confusing. The World Health Organization (WHO) has owned the process of creating terminology. This virus was initially labeled novel coronavirus 2019 (nCov-19), but is now referred to as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) to differentiate it from the virus causing the original SARS. The actual disease this virus causes is known as COVID-19 or coronavirus disease 2019.1  I’ve gotten in the habit of calling the virus CoV-19.

– This virus is novel and uniquely dangerous due to its MODERATE mortality risk and MODERATE level of transmission. It’s not the perfect storm, but it’s a powerful tempest.

– This is not the common cold. True, other coronavirus strains cause 15-30% of common colds, but they don’t typically kill.2 This virus has real potential to kill people. People are dying daily in rapidly increasing numbers. ⁣

Mortality Risk (y-axis) vs Infectivity (x-axis)

– This is not influenza. But the differences here are more challenging. It is likely transmitted in a similar way but seems more infectious & with higher risk of death.  The fact CoV-19 is more infectious may have more to do with differences in human behavior by those infected than an inherent property of the virus itself.

– CoV-19 enjoys a long incubation time combined with an expression of mild or no disease in younger age groups, which combine to rapidly spread the virus through populations. Incubation time has been estimated to be anywhere from 2-14 days.3  In comparison, the influenza virus is only 1-4 days.4 If you get the flu, you feel terrible and stay home. If you get a mild cold with COVID-19 you go about your daily life all the while shedding virus and infecting others who may in turn develop the more severe variant of disease.

The Basics

– COVID-19 is often called a respiratory disease. The virus, CoV-19 (SARS-COV-2), seems to wreak havoc on humans by attaching to a tiny receptor called ACE2 found on cells in certain tissues. The symptoms experienced by patients with COVID-19 has to do with where these receptors are found in the body – these receptors are on cells most abundantly in the lungs, heart and the gastrointestinal tract.5, 6 As consequence, those infected with this virus often have respiratory symptoms, delayed cardiac injury and less commonly GI symptoms. The fever is due to the immune response trying to fight the invasion of a foreign virus. Other symptoms reported are sore throat, fatigue, muscle aches, and congestion/runny nose.7

 

– Many young people are blowing off COVID-19 stating it only affects old or sick people. It is clearly true that older populations with more pre-existing medical conditions are at higher risk, but this errs of false bravado. Additionally, although the analyses by the Chinese did show very mild disease in most young people, we are uncertain if this will translate well into American populations. I think it is safe to say that one’s ‘Biological Age’ is the biggest risk factor for this disease. This measurement differs from chronological age in that a 35 year old man with known diabetes, hypertension and a had a small heart attack may be biologically older than a 45 year old triathlete with no medical problems at all. Given our high prevalence of obesity and other lifestyle chronic medical conditions may make Americans biologically ‘older’ than our Chinese counterparts. We just don’t know.

– The first study to look at data from initial hospitalizations in the United States suggests that our younger populations may be at higher risk than we initially inferred from Chinese data. The CDC looked at all confirmed COV-19 cases between 12 Feb and 16 Mar. They  reviewed 4,226 cases. Only 2,449 had recorded ages. Of those, 508 patients were hospitalized and 121 were hospitalized in the ICU, sick enough to require critical care. 20% of all hospitalizations were in the 20-44 year old age group. 12% of all ICU admissions also came from the 20-44 year old group. That should be concerning. Albeit, these numbers are small.7B

12 Feb – 16 Mar: COVID Hospitalizations, ICU admits, & Deaths in USA

– It also appears that many who contract COVID-19 and recover do so with measurably poorer lung function. There is still a lot unknown about this disease, but definitely should provide caution to the “I’m young and invincible” mindset televised last week from Florida’s spring break destinations.7C

 

SOME EPIDEMIOLOGY FOR KICKS

– The mortality rate (number of deaths divided by total cases) continues to be a moving target. One difficulty in estimating an accurate number is the length of time it takes for a person to finally succumb to this disease and die. One study estimated time from symptom onset to death as long as 2-8 weeks 8, another CDC paper suggested 18 days.9 So, we really don’t know yet. The WHO initially declared a mortality rate of 3.4%. A more recent paper suggests a range of 0.25 to 3% are all plausible.9 If I was forced to guess, if the entire population was tested right now and we tracked all who died, I believe the mortality rate would be under 1%, but likely higher than 0.5%.

– Assuming a very optimistic mortality rate of 0.5% is still 5 x worse than influenza, which kills approximately 50,000 people annually in United States. If you do the math, that’s a lot of potential death & destruction. ⁣

– Influenza causes a lot of illness each year. It also causes a large number of hospitalizations and deaths. In the end COVID-19 may have a similar number of infections, hospitalizations and deaths. We really don’t know. But, the flu season typically lasts from October thru March.4B The true difference here lies in the fact we may be experiencing a completely NEW flu season over a much shorter time period. This is where flattening the curve seems to make sense…more to come.

US Daily Deaths by COVID19

– I am becoming much less interested in number of new cases per day. This may be a good proxy for spread of disease, but is also confounded by the fact that we are testing more people.  Many of these ‘positives’ may have mild or no symptoms. It will be very helpful later when determining when an outbreak is nearing a point of control.

– The current impact to our society and healthcare system lies in number of hospitalizations and number of deaths. I’ve been paying close attention to number of deaths per day. This data scares me. 117 new deaths by COVID19 recorded on 22 March. 140 deaths on 23 Mar, 225 deaths on Mar 24. 247 yesterday. This is up from 46, 49, 57 deaths recorded the 3 previous days. Pay attention to the slope of the curve above. It’s increasing. That’s a rate of change. At the time of writing this,  # of deaths in US are 1,143.10We seem to be following the trends of Italy and Spain. I hope these numbers level off soon, but the nature of this disease leads me to believe this will may much worse before improving. It’s also important to note that most of these deaths are coming from outbreak nodes. My fear is that these centers are not contained and may spread to other city centers.

– One well respected study I recently reviewed suggests the time from symptom onset to ICU submission is 11 days.9 This means the full impact of disease may be delayed by 1-2 weeks. As mentioned above, it’s possible that a person contracting COVID-19 won’t die until weeks after initial symptom onset.8 Its like realizing the light from a star in the night sky is a glimpse into the past and that star may not even still exist. In sum, our current real-time picture of the pandemic will only be fully appreciated weeks in the future.

– Numbers and math are really tricky to most people. Statistics and probabilities even more so. None of it is intuitive. Doctors are no different. And I’m no exception. We often instinctively consider only the outcome of the one patient in front of us. Predicting the future is even tougher. I’ve heard a lot recently about bell-shaped curves as a means to say we don’t need to worry about this pandemic by some highly intelligent contrarians. The argument is that once it peaks, number of cases will rapidly diminish. It should be noted they seem to be a minority position. Additionally, even if this will ultimately be bell-shaped, how many deaths can we tolerate during the rapidly rising phase? We also don’t know yet about reinfectivity.

Flattening the Curve

– This concept of ‘flattening the curve’ makes a lot of sense. Social distancing & home-quarantine can delay the impact so that the stressed healthcare infrastructure has room to breathe. It worked in China, where they are seeing almost no new cases. This may seem to be the reason for South Korea’s optimistic results. Interestingly, the United States and South Korea both confirmed their first case of CoV-19 on the same day, 20 January 2020.

 

 

– China implemented authoritative quarantine measures on 23 Jan. The inversion point for when the rate (slope of line) of new cases began to decline was 12 Feb. But it was not until more than a month later that they began to consider relaxing quarantine measures. It remains uncertain what will happen now after China slowly releases their restrictive social distancing tactics.

 

Daily CoV-19 Cases in China 22 Jan-24 Mar

 

 

MEDICAL INNOVATION & NEEDS

Wonder drug?

– The other benefit of delaying disease (flattening the curve) is that later cases may enjoy novel treatments and a vaccine that are aggressively being developed in a number of labs across the planet. A number of older known treatments are being studied for COVID-19. Some, such as the combination of hydroxycholorquine (an antimalarial drug) and azithromycin (the common antiobiotic aka Z-pak), have shown some promise in one small study.11 Convalescent serum treatments involves taking antibodies from those who have recovered and giving them with early symptoms or asymptomatic high risk patients to provide some passive immunity.12 This will almost certainly be done while we await a vaccine. Go science.

Add a Z-pack?

– Telemedicine and biometrics should be playing a larger role. Some hospitals are utilizing iPads and Facetime at intake to avoid possible exposure to workers. Virtual screening encounters are popping up everywhere. Laws have been modified to allow for healthcare systems to more easily implement telemedicine.13 Hoping innovative healthcare companies continue to step up their game.

– Testing less symptomatic worried well patients outside hospitals is ideal. I like the drive-up idea used in Korea. This is happening across the nation and the hospitals where I work in Las Vegas has set up tents to keep the stable patients that will eventually be discharged outside. ER’s are overwhelmed at baseline. Supplies are becoming scarce. If you’re having mild symptoms, please stay home.14 Home testing kits are coming your way soon enough. FDA recently approved a 45 minute test.15

Shortages of PPE

– There is a growing concern for a scarcity of needed medical supplies. This includes ventilators and personal protective equipment (PPE) for healthcare workers. We are the front lines battling this disease and statistically at much higher risk for developing more severe disease, even when controlled for our age and general health.16 This should worry you as much as me. Taking an ER or ICU doc out of the fight is equivalent to losing a special ops equivalent during times of war. It takes years we don’t have to train a replacement.

N95 vs Surgical Mask

– I have faith in human kindness and solidarity to assist us in filling this need. We are all in this together. Donations of medical supplies are pouring in from individuals, small businesses, and large corporations.

– I have faith in human innovation to also fill this immediate need. There is a strong incentive in terms of reputational and financial gain by private companies to rapidly increase inventories for N95 masks, ventilators and other life-saving equipment. Elon Musk has publicly stated he is converting assembly lines at Tesla and Space X. N-95 masks and ventilators instead of EV’s and spaceships. 1,200 ventilators Musk brokered from China were delivered yesterday.17 This is exciting news and many are doing similar. It reminds me of the effort to convert assembly lines during WW2, except instead of tanks we’ll be getting hand sanitizer. I remain patient yet cautiously optimistic that we will solve these shortages.

 

– I am beginning to see and hear more despair and panic arising from within the healthcare community. I get it and it is certainly well founded. But I also find these responses troubling. Of course, we need to advocate for our own safety.

Club Hero

But we must remain calm in times of crisis.

We must display the cool, confidence of the special operators that we are. The public is looking to us and seeing what we post on social media. We have individually spent nearly a decade training for this moment. We knew there would be risks reciting the Hippocratic Oath. None of us want to die or be maimed in the fight. But this is what we signed up to do.

This is a call for courage, bravery and trust.

Trust in ourselves, trust in our colleagues, and trust in the system. We won’t let our patients down and in turn we will not be let down by our patients and potential patients. Stand up proud as the hero you truly are.

– Panic NEVER helps. I am becoming increasingly concerned about the irrational behavior of individual people and the ever present simmering mob mentality even more than the virus itself. We can either rise up to be our best selves or descend down into our most primitive and selfish versions. Hoping for the former…

 

A DOCTOR PLAYS ECONOMIST

– As a disclaimer, I’m a doctor. I am not an economist. I did go to business school and received an MBA, but that’s where my qualifications for this discussion end. I’m about to venture way outside my typical area of expertise. You’ve been warned.

– In my original post on 17 Mar 2020, I questioned whether a more strategic and intentional approach rather than large-scale quarantine could be achieved with an acceptable risk to disease spread. Since that time, my thoughts have developed into more concrete ideas. Although I have not heard a detailed plan discussed from our political leaders, I have read multiple opinion pieces in well-respected publications that convince me I’m not alone with these concerns.18, 19 Our President has recently provided some commentary that is open to interpretation about a possible plan. Total opening of the economy by Easter?

Imperial College Results – A Wake Up Call

– A large scale report was released in the UK from the Imperial College using modeling software. The results seemed to be accepted as very strong evidence that inaction was not an option. The modeling software estimated that 2.2-4 million lives would likely be lost if no action was taken.20 This is the report that prompted President Trump to immediately take more aggressive actions such as advising Americans to not collect in groups larger than 10 people. This was also the preceding even that led to the UK to quickly dismiss a herd immunity approach. In short, large scale restrictions were likely required initially.

– Of course, the implications on our economy are huge. Mental and physical health are inherently tied to one’s financial well being.

Increased homelessness, poverty and unemployment

are also real public health emergencies.

 It is reasonable to ask how much economic destruction is worth the attempt to stop the spread of a novel disease.

– There is an inherent tension between ‘flattening the curve’ and ‘economic productivity’. Which tactic and at what dose will each lever inflict the least damage…in the short run…in the long run…and to the smallest number of people? Is the financial ruin of small businesses, self-employed persons, large corporations, and millions of others living paycheck to paycheck worth the benefit gained from drastic large-scale quarantines? These are the numerous questions running thru my head. There may be a third way.

– This virus is impacting different age groups and demographics with varying but measurable risk profiles. Each group can be risk stratified. This fact can possibly be leveraged when quarantine restrictions are eased.

Global Pandemic with Obvious Nodes

– This virus is impacting different geographic regions in very different ways. Although the virus has now demonstrated potential for real havoc (see Northern Italy, Spain, NYC), it is by no means an inevitable result (See South Korea, Singapore). We should not, however, be thinking about each country as one separate homogenous entity. The virus is instead mobilized across a number of regional nodes of accelerated outbreak. Each node has unique needs and  requires specific measures to address their own epidemic. This fact can be leveraged as we fight back.

 

– All domestic travel aside from mission essential people and those returning to their homes likely needs to completely cease. Now. This needs to be tightest with exit travel from serious outbreak nodes.

– At the state and federal levels, we need to continue to employ aggressive measures in the short term to stop the rate of growth and gain a full picture of any new developing nodes.. The math is too frightening to fail here. We don’t want to be the next Italy or Spain. As I write this I regret that it may be too late. Given our current rates of growth, being the next Northern Italy may be our destiny. NYC is Milan.

– Once all travel stops. We wait. We observe. We see where we need to send the resources. The characteristics of the virus dictate we should know in about 14 days. But domestic travel has yet to stop, so confounders remain.

COVID across the US is not homogenous

– We cannot let disease spread to new nodes. Once the virus is contained within particular regions, each region can develop unique ways to tighten or loosen the movement and productivity of individuals in order to restore or restrict valuable economic activity. Those with larger outbreaks will require stricter restrictions as their resources become overwhelmed. They will need to focus on rapidly bringing R0 (transmission rate) as near to zero as possible. Other less affected regions could possibly allow more freedom of movement with prescribed procedures for social interactions that radically minimize spread of disease. Many industries will continue to be performed remotely, some via delivery, others in completely new and novel ways.

– Looking at total populations and total number of cases is the wrong way to look at this. I keep on seeing people divide total numbers of cases by total populations within a nation. This makes no sense. In China, it has only been a very local problem. When at its peak, it was not a ‘Chinese Problem’. ‘It was a Wuhan problem’. Same with the US thus far. Right now, we are not suffering a national outbreak, we are suffering a catastrophic outbreak in NYC and a few other areas that are poised to potentially go down a similar path.  If this thing spreads to LA, Chicago, Detroit, Houston, PHX…the numbers you are quoting will be a huge underestimate.

– If another outbreak occurs in a large municipality it will likely follow the same trajectory of areas of northern Italy, Wuhan, NYC…rapid rise and overwhelming of all medical resources provoking extremely strict responses/quarantines and then a steadying of the numbers once transmission stops and vulnerable patients die 1-2 weeks later. The current restrictions in place are meant to the spread. We do not want to play viral wack-a-mole.

Death Rate by Age (China’s data)

– Similar to differences between regional nodes, each demographic (based on age and other known risk factors) needs to be designated a risk category and different rules can and should apply based on their vulnerability to COVID19. The youngest and those with lowest risk for severe disease will need to shoulder the economic burden and keep things moving. There will be some risk conferred to them, but it will be an acceptable risk given the circumstances and their mimcl risk. It’s a huge blessing that this disease seems to mostly spare children and young adults. Their interaction with more vulnerable populations would need to be minimized or absolutely prohibited. This is a plan that could be effective for a much longer duration than those yet enacted. We could likely do this until a vaccine is developed.

Risk from Pre-Existing Conditons

– It remains unclear what will happen once a quarantine is eased. China had enjoyed several days of no new innate cases of COVID. Yet I noticed today that some new cases are being reported from China. Is this a consequence of easing their quarantine? The fact that they have regained control (for the time being) is certainly due to their aggressive, authoritarian quarantine involving all affected regions. But, will their national epidemic resume immediately or as intensely? It seems this is unlikely given the knowledge gained and their ability to force changes within social interactions, but no one truly knows.

– Arbitrary dates such as Easter should not be used to decide when restraints will be lifted. This period of time should be defined by epidemiologists working WITH economists. We know the characteristics of the virus and how long it is known to remain infective in hosts. This information should be weighed against the amount of time economists feel would allow the greatest number of small businesses to survive, unemployment to remain manageable, and the housing and financial markets to not completely crash. But we do need to define specific time periods and clearly communicate these plans to the public. This will help recover consumer and investor confidence as well as provide significant psychological boosts to morale. The public is currently confused and scared. And for good reason. We know the virus likely lasts in carriers up to 14 days. It took China about 2 months of total lockdown to begin controlling their numbers. We have not yet seen our numbers level off. It may take a similar time period, but also possibly longer depending on how many regional nodes pop up.

 

SOME BAD NEWS & SOME GOOD NEWS

– There is one really weird aspect of this massive quarantine plan to prevent worst case scenario projections:

Success will continually be mistaken for over-reaction.

We need to be aware of that right now and daily remind ourselves that the areas suffering most right now (Italy, Spain, NYC) could be replicated in any of our hometowns tomorrow. Yesterday 683 people died in Italy from COVID. Italy has been losing 600-800 people daily for about a week. If (and it’s a big if) we are spared from Italy’s fate, we need to continually remind ourselves that inaction would have almost certainly forced us to replicate an experiment we never wished to be part of.

Fake News

– Its information overload right now. Not every doctor or healthcare worker is an expert. That includes this author. I have many more questions than answers. Trust, but verify. Gravitate towards those who admit their knowledge gaps. Follow those who reference large health organizations. Be cautious of those who provide guarantees, certainties or 100% knowledge claims.

– Thank God for organizations like the CDC, the WHO, and Johns Hopkins University. Anti-vaxers and others spreading conspiracy theories and slander against these organizations for decades will hopefully wake up full of regret and shame after this event passes. Though, I’m guessing this is unlikely.

Real Heroes

 

– Even more gratitude for the healthcare workers out in the field, emergency rooms, hospital wards and ICUs. I’m an ER doc and we get paid well to do our job. I can’t complain. What about the EKG techs, phlebotomists, EMT’s who make slightly above minimum wage, but are currently risking their health and possibly lives to care for the most vulnerable of our society?

 

To the firefighters, nurses, respiratory therapists, pharmacists, social workers, registration staff and the many others I’m forgetting:

Seriously. Thank you.

From the bottom of my heart.

Thank you. You’re a bunch of damn heroes.

– 2 ER docs are currently in critical condition in the United States. One is in their 40’s and supposedly previously healthy. This hits home for obvious reasons. Healthcare workers suffered a disproportionately high mortality when controlled for age/comorbidities in Italy and China.21, 22, 23 There will definitely be martyrs/heroes.  But this is what we trained for and some will certainly be called to give the ultimate sacrifice. I hope its not me. I couldn’t imagine a situation where it would be me. But it will certainly be some of us. It’s a statistical likelihood, albeit small. Keep up the good fight. Stay strong & healthy. Be balanced,  tenacious, and excellent in all you do.

34 yo Doctor Li Wenliang – died 7 Feb of COVID

– Of course, this too will pass. But it will likely never really be quite the same.

 

 

REFERENCES

  1. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it
  2. https://jamanetwork.com/journals/jama/fullarticle/2759815
  3. https://www.cdc.gov/coronavirus/2019-ncov/hcp/faq.html
  4. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt06-influenza.html, 4B: https://www.cdc.gov/flu/about/season/flu-season.htm
  5. https://www.ncbi.nlm.nih.gov/pubmed/15141377
  6. https://www.sciencedirect.com/science/article/abs/pii/S1050173802002335
  7. https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html   7B. https://www.cdc.gov/mmwr/volumes/69/wr/mm6912e2.htm?s_cid=mm6912e2_w   7C. https://www.sciencetimes.com/articles/25040/20200316/coronavirus-survivors-may-have-reduced-lung-function-hong-kong-doctors-say.htm
  8. https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30195-X/fulltext
  9. https://wwwnc.cdc.gov/eid/article/26/6/20-0320_article
  10. https://www.worldometers.info/coronavirus/country/us/
  11. https://www.mediterranee-infection.com/wp-content/uploads/2020/03/Hydroxychloroquine_final_DOI_IJAA.pdf
  12. https://www.fda.gov/vaccines-blood-biologics/investigational-new-drug-ind-or-device-exemption-ide-process-cber/investigational-covid-19-convalescent-plasma-emergency-inds
  13. https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
  14. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/steps-when-sick.html
  15. https://www.medscape.com/viewarticle/927396
  16. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa287/5808788
  17. https://www.usatoday.com/story/money/cars/2020/03/24/elon-musk-ventilators-tesla-coronavirus-covid-19-spacex/2905980001/
  18. https://www.nytimes.com/2020/03/20/opinion/coronavirus-pandemic-social-distancing.html?fbclid=IwAR06WvoLONII2Ahxj3c1E87I8anGZFDjAU1m37_0zhCUfgkup3x6hCcNEt8
  19. https://www.nytimes.com/2020/03/22/opinion/coronavirus-economy.html?fbclid=IwAR1D-8LnG5KBlQGRpQGJHF8k9S6MvY9k-bVQkxLFztP6aBVJWnoDqKGHKEw
  20. https://www.imperial.ac.uk/media/imperial-college/medicine/sph/ide/gida-fellowships/Imperial-College-COVID19-NPI-modelling-16-03-2020.pdf
  21. https://www.bbc.com/news/world-asia-china-51409801
  22. https://edition.cnn.com/world/live-news/coronavirus-outbreak-03-23-20-intl-hnk/h_8df53475be78f0280ae6eeebe098885a
  23. https://www.medscape.com/viewarticle/926816