Author’s note: This is the 9th diary in a series on medical topics related to emergency care. If you want to check out the first diary in the series, you can find it here, on the topic of insider tips to improve your ER visit, and the second one here, on the topic of heart attacks. Some of these diaries will focus on the medical system or process, and some will be disease-specific. My goal, as your friendly neighborhood ER doc to the Daily Kos community, is to provide useful information for this community to stay healthy and get the best results from our medical system. I hope you find it helpful!
I apologize for my hiatus from writing these diaries for the past 6 months — with the COVID19 pandemic, I felt it was my duty to get back to it. I wanted to provide some observations from the world of emergency medicine in which I live, and some practical thoughts and links to key resources. One of the best ways to stay safe, and to reduce panic, is to be armed with information about the virus and what you can do.
Notes from around the US and the world emergency medicine community
It must first be said — I am so impressed with the tireless work of healthcare providers in the face of this disease. It is no easy thing to show up to work knowing there is a poorly understood and contagious disease on the rise. Through emails and tweets from my ER friends in Asia and Europe, is it clear that they are showing immense strength and resolve as they struggle under challenging conditions. Hospitals around the world (and in the US, for that matter) were already under huge pressures of crowding and overtaxed critical care resources, and the COVID19 pandemic has only added to the strain. I have friends who lost colleagues to the SARS epidemic in the not-to-distant past, and physicians in China and elsewhere have succumbed to COVID19 — I pray for their safety as they tackle this new danger.
Here’s the situation in the US from my vantage point: while hospitals are working hard to prepare as best they can, it is very evident that the lack of a national coordinated response, and the inconsistent and slow actions of the current administration, have really set us back. One of the biggest challenges: testing. Testing for COVID19 is inadequate, both regarding supply of test kits and guidance on who should be tested. Another big challenge: space. To properly manage patients with suspected COVID19, we need rooms and wards equipped for “respiratory isolation”, usually meaning rooms with negative pressure (air gets gently sucked out of rooms into filtered air systems, as opposed to pushed into the room from HVAC units, to prevent spilling contaminated air into hallways and other patient areas). These rooms exist in most ERs, but are in very short supply. In the major city in which I practice, there are no plans that have been shared on establishing isolation hospitals or quarantine spaces, as has been done in other countries. This takes will, and coordination, and funds.
Another looming problem from the front lines: danger to healthcare staffing. Aside from the risk of illness and even death for healthcare providers, there is a much more likely and problematic risk of staffing shortages from quarantine. Just today, I learned that the ER physician involved in the care of the first COVID19 patient in the NJ suburbs of Philadelphia was placed in quarantine for 2 weeks (this has not been reported, to my knowledge, but I have solid information that it is true). Staffing in most ERs is razor thin, so imagine the almost inevitable shortages that will occur when 5%, 10% or who knows how many more physicians and nurses are plucked from the workforce to remain at home for 2 weeks each? How are we to take care of the patients with heart attacks, strokes, and countless other emergencies with many of our physicians and nurses in home isolation? No adequate answers to this problem yet — although Italy is pleading for retired physicians to suit up and return to the field, and they are graduating nursing students early to join healthcare teams.
Some important information and myth-busting
Some basic facts: COVID19 is in the family of corona viruses, which mostly cause respiratory symptoms and fever. COVID19 often presents with dry cough, fever, muscle aches and difficulty breathing, much like the flu or other common viral illnesses. While the World Health Organization (WHO) has reported a case fatality rate of over 3% (much much worse than the flu), it is important to parse out this number. The risk of death is much higher in the elderly and those with chronic lung disease or immune compromise, and lower in healthy non-elderly patients. It is reasonable to estimate that for most healthy people under 60 years old, the risk of death is 1% or less — but this is truly a moving target, so don’t quote me on it. The reason? Calculating the risk of death depends on the number of people actually confirmed to have the disease, and given the lack of testing in the US, we really don’t know how many people are currently infected.
Transmission: COVID19 is transmitted in most cases by close contact and respiratory spread — that is, viral particles are shed in a patient’s cough, sneeze and saliva, either directly to another person’s respiratory tract or via hand contact. While the virus may live on surfaces, there is little evidence that transmission can occur from contact with surfaces touched by infected patients. This is important: you most likely CANNOT catch COVID19 from handling mail or shipping boxes from China, Italy or other areas with currently high prevalence rates of the disease.
Key fact: COVID19 is probably all over the US, more than we realize: given that testing has lagged, and cases have cropped up in the majority of states, it is highly likely that thousands, if not tens of thousands, of people in the US carry the virus as this blog is being written. This is important for another key myth to bust: this is no longer a disease located in specific regions of the globe. The reports of suspicion (and even violence) towards ethnically Asian people are terrible, with all the baggage of associated racism and xenophobia. We have to start thinking of this disease like the annual flu — assume it is everywhere. But this is not a reason to panic; just because it is everywhere, just like the flu, there are practical actions that can greatly reduce risk.
Viral life cycle and patient course: The incubation time for COVID19 is 3-7 days — with a mean of around 5 days. The vast majority of patients will show symptoms by two weeks. This means two things: (1) if you are exposed to a patients with known COVID19, and if self-isolation or quarantine is recommended, it needs to be for two weeks before you are in the clear, (2) if you were exposed, and you feel fine after 2 weeks, you very likely didn’t contract the illness. The great majority of patients with COVID19 have a mild course, meaning some fever and cough, but generally able to eat, walk, and function normally. Less than 10% of patients require hospitalization for supportive care. Currently, there are no medicines to treat COVID19 — tamiflu, a common medication for influenza, will not work to treat COVID19, nor have any nutritional supplements (vitamin C, zinc, etc) been shown to have benefit, at least at present time.
Some key tips and things you can do:
1. Washing hands. It really works! You don’t need to spend gazillions of dollars for price-gouged Purell and other hand sanitizer products. Good old soap and water can do the trick. The key thing is that you should wash, with vigorous hand rubbing, for 20 seconds — a quick rinse is not enough. Soap well, and rinse. If you wash your hands after coming home from stores, and riding buses, etc, this can dramatically reduce the risk of viral transmission. Between washing hands and or wearing a face mask, my emphasis would be on washing — most face masks are ineffective for COVID19 as the virus particle is much smaller than the pore size of typical over-the-counter masks.
2. Good respiratory hygiene. What if you have viral symptoms and don’t know if you might have COVID19? If you need to sneeze or cough, don’t do it into your hands. Cough or sneeze into your elbow, or a napkin, or tissue. And then wash your hands.
3. “Social distancing”. If you must interact with someone who has a fever or cough, don’t share cups, utensils, and avoid hand shaking. When possible, keep several feet of distance for most interactions. Obviously, for family members and others this just may not be possible. But viral concentration falls away rapidly with distance.
4. Avoid unnecessary visits to the elderly or infirm. Again, this may be unavoidable in many cases, but if you have a fever and/or cough, protect the elderly by not visiting unless needed. They are at much higher risk from this illness. If you must visit, wash hands before contact, and wear a mask if possible.
5. Think carefully about using medical resources. This is a good time to be judicious about ER visits, both to spare you from possible exposure and to help relieve strain on the emergency medicine system. Consider visits to urgent care clinics or your primary care physician for less serious complaints such as a twisted ankle or sore throat — I appreciate this is not easy or even possible for many, including those without insurance. For symptoms that are consistent with possible COVID19 (fever, cough, aches), seek attention promptly so that you can get tested (if possible) and also receive recommendations on whether self-quarantine is needed.
6. Keep up to date. It is important to stay informed about local COVID19 activity in your city, neighborhood and local health systems. Daily scans of the news can help you understand your local exposure risks.
7. Do not panic. This is a significant global medical problem, to be sure. It will likely get worse before it gets better. BUT: there are trusted sources of information available, and the vast majority of patients recover after only mild illness. Testing will become more available, and it is possible that antiviral treatments will be developed.
Here are some key informational resources I have curated from trusted sources:
1. Excellent map of COVID19 cases, updated daily, managed by scholars at Johns Hopkins University.
2. World Health Organization (WHO) public educational resources for COVID19
3. US Centers for Disease Control (CDC) resource site for COVID19
4. More geared for health care providers, but may be of interest: a webinar from the American College of Emergency Physicians (ACEP) recorded March 5, 2020, on COVID19 management.
5. One of the best general news articles on COVID19, with helpful graphics, from the Seattle Times
I am happy to take questions, and will try to check back often to the discussion. Ask your COVID19 questions; the “doctor is in”!
(addendum, I wrote this last night and found that AKAlib has also posted a very nice diary this AM with more scientific information about COVID19 — it can be found here)