Different health professionals, different parts of the world, same challenging experiences:
December 5, 2020
Six months since reopening, visits to the dentist have proven to be safe
Mark Grossman DDS
“COVID, COVID, COVID!”, to quote a soon to be ex-president. That seems to be all people are talking about these days, and given the seriousness of the virus it’s no wonder. With cases continuing to rise during phase 2, any good news regarding the pandemic is welcomed. Recent reports concerning vaccines seem hopeful, but other positive stories regarding COVID-19 have been few and far between.
One bit of encouraging news has been the relative safety of visiting the dentist since clinics reopened in Quebec and elsewhere beginning June 2020. With the profession initially flagged as a high-risk regarding potential transmission of COVID-19, many dentists were apprehensive about returning to work. Concern about safety for themselves, staff and patients was paramount, particularly during the early stages when less was understood about the virus .
Given the intimate contact with patients and frequent generation of aerosols during procedures, the absence of reports linking spread of the virus to dental offices has been reassuring to both dentists and the public. So how can we account for this seemingly good news?
Infection Control Protocols
Dentists by nature have been characterized as being perfectionists who pay close attention to detail. That dentists are reporting a low rate of COVID-19 (less than 1% according to a recent nationwide survey by the American Dental Association) should come as no surprise given the expertise they have regarding infection control. The additional measures employed in dental clinics since the pandemic only strengthen what have always been rigorous standards. The result has been a far lower incidence of infection compared to other health professions.
Masks & PPE
Having relied for so long on masks to protect both themselves and their patients, dentists were more likely to have adopted this along with other protective measures when out in public from the onset of the pandemic, further minimizing risk of contracting or spreading the virus.
Aerosols
Much of the focus by the dental community has centered around aerosols produced when water and air from equipment mix with saliva. These smaller particles of 5 microns or less can remain suspended in air for longer and travel further than larger droplets from a sneeze or cough. While a theoretical risk, a recent study at the University of Laval suggests in regards to the smaller aerosols such as those produced during dental treatment, that their low virus concentration and their inactivation at the time of aerosolization or shortly therefter, would explain why they do not seem to constitute an important transmission route.
Confidence
The public should feel reassured that the dental community has taken the COVID-19 pandemic very seriously and has adopted additional measures to further reduce the risk of spread to both personnel and patients. While research regarding potential modes of transmission is ongoing, six months into working with enhanced infection control protocols seem to be working well. And that’s certainly something to smile about!
May 27, 2020
Dr. Michelle Epstein MD, Lab Leader at the Medical University of Vienna’s Division of Immunology.
A good dose of fresh air and sunshine is what we all need right now. Relaxed pandemic measures, reopening of parks, and pleasant weather makes it tempting – not to mention essential for our sanity – to enjoy the outdoors with friends and family. But meeting outside doesn’t mean that we should be cavalier about the spread of SARS-CoV-2, especially because there are still no vaccines or treatments available.
COVID-19 transmission indoors vs. outdoors
Effective COVID-19 spreading occurs in one of two ways. The first is through direct transmission, which is when an infected person talks, sneezes and coughs and their respiratory droplets fly through the air, and a person in close contact inhales them. The second is when infected droplets end up on a surface that is touched by someone else who then touches their nose, eyes or mouth. Fortunately, these transmission routes are less problematic when you’re outdoors because there are wide-open spaces for you to keep the needed distance and fewer communal surfaces to touch. But we still don’t know the risks of outdoor COVID-19 spread.
And while most of us have read the basics, sometimes it’s good to review: The SARS-CoV-2 virus is about 0.1 microns in diameter, which means that an infected person through breathing, talking and coughing will produce 1-10 micron aerosol droplets that may contain many thousand live viruses. Even though aerosol is not the primary transmission mode of SARS-CoV-2, it is still a possible route of infection.
When indoors, an infected person who releases virus in their droplets may increase the risk of direct transmission to others based on the size of the room, ventilation, and air circulation. The higher the density of infected droplets in the air, the more likely the spread to one and probably more people.
Outdoors, it’s generally safer. Typically, infectious materials carried in the air, or airborne contagions, seem less worrisome. But there are several unanswered questions about this coronavirus and the risk of outdoor transmission because this virus is new and the science is still being developed.
For instance, we don’t know whether the virus remains viable in the air or how long it is infectious. We also don’t know how many are needed to infect another person. There are early reports that live virus is in the air in crowded public places. But when people are at least 1.5-2 meters away from each other, there is less of a chance for transmission because the virus needs to enter your upper throat or respiratory tract or land on your hands, which you then would use to touch your face. And being outside allows for easier social distancing without being anti-social.
There are other questions: If the virus is viable outdoors, then what are the effects of sunshine, for example, or wind, rain, temperature, and humidity on its degradation, infectivity, and spread? Other viruses degrade with high heat and moisture, and direct sunlight. But there is still limited information about SARS-CoV-2. So far, testing has revealed little impact of high temperatures and high humidity, and no clear answer about whether it will go away during a hot summer.
There is hope, however, when it comes to sunshine and the virus. UV light appears to decrease SARS-CoV-2 viability on surfaces. Most of us know about UVA and UVB in sunlight, but we know less about UVC, which is the best UV light for destroying viruses. High dose UVC is a sterilization method in hospitals and can kill most viruses, including SARS-CoV-2. But while there may be some destruction of this coronavirus on surfaces left out in the sun, it isn’t a reliable method for disinfection, because we don’t know what strength of UVC is necessary and how long it takes for it to work.
Planning outdoor gatherings
So the good news is, we can now meet up with family and friends. But there are still a few things that you should do to reduce the risk of COVID-19 infection.
First of all, no hugs and no handshakes – these gestures we love will have to wait. In fact, it’s best not to get any closer than 1.5 meters, and to limit the group to a maximum of 10 people. It’s also probably best for everyone to bring a mask to wear to protect others – use your good judgment on when – and have a stash of disinfectant and hand sanitizer.
Second, pick the place and time carefully. Ideally, it’s best to find an area without large crowds, or at least a time when fewer people are around, like between meals for a snack or a drink. Try to cordon off the area with extra picnic blankets or empty carry crates, to set up a space that allows for social distancing between groups of friends and family who are not quarantined together. Best also to choose a place that’s not too far from home to avoid having to use public toilets.
If it’s a picnic, all the guests should bring their own picnic blankets or garden chairs, their own food and drink, utensils, glasses, plates, and cutlery. The less passed around the better.
So at least for now, playing it safe means continuing to maintain that social distancing we all wish we could do without; it means washing your hands or using hand sanitizer. And it still means wearing masks, even when socializing outdoors.
Some day when this is all over, these will be the stories we will tell our grandchildren, who will think we’re making them up. But at least we’ll be there to laugh about it.
This article, "Pleased to Meet You | Carefully", was first published on the website of Metropole Vienna.
May 4, 2020
David Zlotnick MD, Medical Director, Urgent Care TEREM Clinics, Israel
So here we go; the openings have begun in Israel.
While I thought it would be a little slower and more cautious (a toe in the water rather than a foot) there are many people a heck of a lot smarter than me making decisions.
I would still certainly caution those at higher risk to take extra precautions... and for everyone to continue good practices... ie hygiene and keeping distance of 2 meters.
The release:
Phase 1 (today):
- No longer need to stay within 100m of your residence
- Ok to visit first degree relatives
- Gatherings of 20 people in open spaces
- Malls and markets (as of Thursday )
- Nature parks and zoos
- Sports/gyms (as of Thursday )
- Bed & Breakfasts and hotels (but no use of public spaces)
- Treatments like massages
Phase 2 ( May 10th)
- Ganim (Kindergartens)
- Gatherings of 50 people in open spaces
- Museums (as of May 17th)
- Non-contact sports up to 20 people (as of May 17th)
Phase 3 (as of May 31st)
- Gathering up to 100 people in open spaces
- Rest of school opens ( grade 4-10 likely from the 17th)
- Kids extracurricular activities
- Playgrounds
- Pools
- Competitive sports (might be delayed to phase 4)
- Restaurants (might be delayed to phase 4)
Phase 4 (June 14th)
- Domestic flights
- Theatre and cinema
- Gatherings no restrictions on numbers
- Institutions of higher learning
What is still not allowed:
- No going to beaches (if only in water for sport .. yes)
- No synagogues (prayer still outside with up to 19 people)
- Will we need to go back to restrictions at some point, possibly.
- We can expect some increase in cases and as of now, the health care system can handle it.
We have clear criteria when we need to move back:
- More than 100 new patients/day
- More than 250 patients in serious condition
- Doubling in 10 days of infection
I think we can be hopeful and optimistic that we will be ok as we continue to do the things I mentioned in my last post, such as:
- Tracking contacts
- Testing before being called recovered
- Isolating contacts
- Quarantine
- Tracking
And of course, maintaining hygiene and distance.
Stay safe.
Wash your hands.
April 27, 2020
Debbie Schwarcz, MD, Emergency physician, Lachine General Hospital, Montreal
So, it looks like Quebec has accepted the role of guinea pig and is the first province to take the plunge and move on to the next step: the reopening of elementary schools and daycares. The response to this plan is understandably controversial and has already incited some heated debates on social media. It is a brave move. I have been hoping for this move and here is why.
Schools have now been closed for 6.5 weeks. That is 6.5 weeks without our children’s normal routine and structure that they are accustomed to and thrive off of. It is a well known fact that routine is crucial for children, providing them with a sense of security, control and self discipline. While these past 6.5 weeks have definitely provided me with the beautiful silver lining of quality family time together, I know that underneath it all, and even if they won’t admit it, my children are craving the return of the usual rules and structure that school and daycare provide for them. I don’t think that I am alone in seeing the emergence of certain “unpleasant” behaviours that have certainly arisen from a combination of excessive time being bored, in front of the screen, with constant access to a fully costco-stocked pantry, and without the social interaction of their peers. While this is something that is manageable for my family, I can only imagine the hardships and strain that this is putting on families in more vulnerable socioeconomic positions with far fewer resources than I have. I have seen first hand the domestic violence that is spiking due to the excessive stress in the home. For many children, school is a safe zone, a place where they are assured at least 2 meals a day and caring teachers and peers. School is essential for their well-being.
It seems that at this point in time, we have reached the plateau of covid infections. Our ERs and our ICUs are not currently overloaded. This is what we set out to do when we instituted social distancing and we have successfully accomplished it. We never claimed that we could eradicate covid; unfortunately, that is not in the cards in the present time. But, we have managed to slow it down. Unfortunately, there is an outbreak in our longterm care residences that we are trying to get a handle on. But our children are not and will not be exposed to this. I don’t see how the timing of reopening of school will affect our current situation. We will see an increase in cases whether we return to school now or in September. We do have the capacity to care for more sick patients now; ventilators and ICU beds are currently available. We do need more PPE, but we have been promised this by both the federal and provincial governments and I do hope that we see this in the next 3 weeks prior to the return of students. We can easily take a few steps backward if the situation starts getting out of control too quickly since summer is around the corner anyway. Furthermore, ERs are notoriously less busy in the summertime whereas a return to school in September runs the risk of spilling over into influenza season.
A plan is in place for schools to apply the concepts of social distancing such as limiting the number of children per classroom to 15 with more hygiene precautions. Will they be installing plexiglass in front of children’s desks? Will they be ensuring students refrain from sitting too close to each other? Will they be checking for symptoms and temperature at the door? I anxiously await to hear the plans. I do believe that families who have children or family members with health problems causing immunosuppression should continue to keep their children home for now. Certainly every family is in a unique situation and one must assess their own risk accordingly.
Importantly, a return to school does not mean a return to “normal” life as we knew it. We must still continue practising physical distancing as limiting our interaction with others is still going to help mitigate the curve that will obviously rise again as our children emerge from our bubbles. This is not an all or nothing type of situation: We must proceed gradually and with extreme caution. We must also remember that these are unprecedented times and that the situation can change before May 19 so we will have to see how it plays out, both before and after the reopening of schools.
I will be sending my children back to school. For their mental health and continued personal growth, and also for my own and my husband’s. For a semblance of return to some sense of normalcy. I accept that there is some risk involved with this decision, but I am not risk-averse; I am an ER doctor after all. If your family is healthy and you feel comfortable with the inherent risk of stepping out of your bubble, then I will be there waving to you from my 6-foot distance at pick up.
April 21, 2020
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
My patient’s oxygen level started to drop, despite receiving 100% oxygen from the mechanical ventilator. Her blood pressure also started to tank. A STAT chest x-ray showed a tension pneumothorax, a life-threatening condition in which the lung is collapsed and the air has leaked out of the lung and is trapped in the pleural cavity. Here it compresses important structures in the chest, compromising cardiopulmonary function. In short, she needed a chest tube STAT to release all that air from the pleural space.
I yelled out “someone go grab me a chest tube tray!” While I was waiting for the right equipment to arrive, I inserted a needle between her ribs into her chest to try to decompress the air. But the needle was too short for her body habitus. The fellow (a specialist in training) who was working with me that day came back running and breathlessly told me: “We can’t find any chest tubes. We went to the MICU, the SICU, and the PACU, there aren’t any. This is all we could find,” and handed me a thoracentesis kit. It wasn’t what I needed, but it was all they could find for now, given the shortage of equipment and medications in the midst of this COVID-19 pandemic. The thoracentesis kit came with a large needle and a catheter, so I improvised and used that to release the air that was building up in the patient’s chest. This was last week, in New York City, the epicenter of this disease in the United States.
New York City will always have a special place in my heart. I lived there and trained there. Hearing how much New Yorkers are struggling during this pandemic, and how overwhelmed my old classmates and colleagues were, I felt that I had to do something, especially since I am only a few hours away. So I decided to use my time off from my regular job to volunteer in the city that never sleeps but is now in lockdown.
I was dispatched to NYU Brooklyn, a hospital that usually has an 8-bed Medical Intensive Care Unit (MICU). As of last week, when I was there, there were about 60 patients on mechanical ventilators, all with COVID-19, and they were expecting more. Different parts of the hospital were now converted into COVID ICUs: part of the Emergency Room, the Post-Anesthesia Recovery Units (PACUs), and the Neurology Unit. Each COVID ICU attending physician is in charge of 15-20 patients, all ventilated, many in multi-organ failure. On top of these ICUs, there were a number of Rapid Response Teams (RRTs) that responded to emergencies elsewhere in the hospital. RRTs and codes were announced overhead seemingly in a nonstop fashion all throughout the day, indicating that someone’s oxygen level is dangerously low, or that someone has gone into cardiopulmonary arrest. You can imagine how overwhelmed the system and the staff were.
In NY, I had to practice a different kind of medicine. This must be what war medicine is like. They had run out of the usual medications that we give to sedate patients who are on mechanical ventilators, so we had to improvise, with the help of pharmacists, with other types of medications. PPEs were provided, but you had to know where to hunt for N95 masks, or whom to ask. Many patients were in multi-organ failure, and the kidneys seem to go first. But the hospital does not have enough machines, enough tubing or enough staff to provide dialysis for everyone who needs it, so you have to choose who is “worthier.”
How do you decide that? Do you pick the sickest, thinking they need saving the most? Or do you pick the youngest and the least sick because they have a better chance of survival? Or does it just depend on where the patient happens to be located since not all rooms can accommodate dialysis machines. There is no right or wrong answer, you just have to choose, and then present your case to the nephrologist who then has to make a choice. You feel sad and slightly guilty for playing God, but you don’t have time to dwell on your emotions because the loudspeaker is already announcing a call to a room where yet another patient is crashing. You try to FaceTime family members who can’t visit their loved ones, make some adjustments on the ventilator, hoping that it makes a difference, and then move on to the next patient.
We were never trained to practice medicine under these circumstances, but nurses, physicians, respirologists and all sorts of other staff manage to come together to fight this cruel disease. Everyone was working extra shifts; even doctors from other specialties such as GI and cardiology came to help. I was really touched by local restaurants such as “Big D’s Grub Truck” that donated food to healthcare workers every day. And as I was trying to keep my patient with the pneumothorax alive, the patient right next to her started to code. Other doctors from other teams came to help.
Together, we will keep fighting.
April 16, 2020
Debbie Schwarcz, MD, Emergency physician, Lachine General Hospital, Montreal
Working in the emergency room over the past 10 years I have seen A LOT. It takes a lot to surprise or shock me and most encounters that may be embarrassing or anxiety-provoking for my patients do not even phase me. This is obviously helpful as a defense mechanism because if I didn’t have a tough skin, then I surely could not survive this job. But, these days I find myself more emotionally connected to my patients as they arrive in my ER, scared, anxious and alone. Whereas normally most patients have at least one family member with them to validate their distress and to advocate for them, these days the emptiness of the ER hallways is omnipresent. There are no family members calling out to me as I walk down the hallway asking for more pain killers for their relative, for a glass of water, for updates on their condition. And while this does make my job somewhat easier on the one hand, on the other, patients’ loneliness is palpable. Many patients are literally isolated in their individual rooms and cannot even leave to go to the bathroom. So, I try my best to connect with my patients, to reassure them, to ensure that I will call their family member and relay information. I try to show my patients my smile underneath my intimidating mask, visor, scrub hat, gown, and gloves. I can only imagine how terrifying it must be to be seated on a hospital bed, gasping for breath, surrounded by multiple fully masked strangers scurrying around the room to the sound of beeping monitors, plugging them into multiple machines.
One of the most important questions that I have for my patients in these urgent situations is how aggressive they would like me to be in my treatment. Obviously yelling out such questions through the muffle of my mask when you are gasping for breath and surely not thinking in a calm and rational way is NOT the ideal time to do this. Unfortunately, despite the pivotal role of patient level of care, it is a subject often gone undiscussed and unplanned for much too long. One thing that does shock me in this business is when patients upwards of 80 and 90 years old look at me like I am presumptuous when I ask them if they have thought about their level of care (of note, I will ask this of all of my patients, regardless of age). It is a well-accepted truth that we are not immortal and that we will all die one day! Have you thought about the way that you will die? How you would prefer to die? Would you want to be hooked up to a machine that is breathing for you, unable to communicate or move? Do you want us to do CPR, often fracturing ribs, and administer medicines that may restart your heart but not necessarily your brain? These are all crucial questions to consider as we age and I urge everyone to take the time to think these questions through NOW, when you are well, comfortable and able to think in a rational way. These are difficult questions to answer under the best of circumstances, and leaving this decision to the last minute, when you are scared, alone and sick, is not ideal. Just because we have the capacity to put you to sleep and put a tube in your airway and connect you to a machine to breathe for you, to do CPR and give you medicines that may bring you back to life does not mean that this is a good decision for you. Elderly patients with multiple co-morbidities often spiral rapidly once one disease process takes over, making it extremely difficult and sometimes impossible to remove them from the artificial ventilatory support or bring them back to a good quality of life once their heart has stopped. The question of the level of care is not a black or white one and I urge everyone to discuss this with their family members and their family doctor. Yes, it is an uncomfortable topic, but it is so necessary and having the decision made in advance and shared with your loved ones can bring a sense of comfort and calm to you in a tumultuous time. I want to do the best that I can for you while respecting your wishes. Rest assured that declining certain medical procedures does not mean that you will be neglected or that you will suffer. There are many ways that we can support you and ensure your comfort.
There is so much to learn from this pandemic and I can only hope that this experience will solidify our relationship with our families and improve our health care system in the long run. So, let us continue to distance ourselves from each other so that we can protect each other, wash our hands, stay safe and remind ourselves that this WILL all come to an end and we will come out of this stronger than ever.
April 4, 2020
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
We placed the GlideScope right outside room 1, thinking we might have to intubate the patient and place him on a mechanical ventilator soon. I have my paper bag with my ration of mask and goggle for the day nearby, in case I have to go into the room and intubate him. A GlideScope is a video laryngoscope that allows us to visualize a patient's larynx on a screen, this way the person performing the procedure doesn't have to lean into the patient to look for his airway.
The patient is a man in his 60s, and he had just flown to Pennsylvania from the West Coast to attend his father's funeral. He came to our hospital with shortness of breath, cough, fever, some abdominal discomfort and loss of sense of smell.
In a healthy person, blood oxygen should be between 95-100%; his oxygen saturation was only in the 80s% even with a High-Flow Nasal Cannula and a Non-Rebreather Mask on, both supplying him with 100% oxygen, so basically giving him as much oxygen as possible. Room air contains 21% oxygen. Under normal circumstances, this would indeed be the time to place someone on the mechanical ventilator. However, according to reports from Italy and anecdotal stories from my New Yorker colleagues, once a patient with COVID-19 ends up on the ventilator, they rarely come off it. It is therefore now recommended to exhaust all options and saving intubation and mechanical ventilation as a last resort (as opposed to earlier recommendations of early intubation).
One of these options to try is to prone the patient, meaning have them lie on their belly. This allows for better aeration of the back part of their lungs that is otherwise more likely to collapse due to gravity, amongst other things. So that's what we tried, and his oxygen saturation improved to the high 90s%! Proning actually worked! Granted, he is still requiring a lot of supplemental oxygen, but he is hanging in there, and we may have saved him days, even weeks of mechanical ventilation and possible eventual tracheostomy if he couldn't come off the ventilator. For now, my mask and goggle stay in the paper bag. But we just got a call from the Emergency Department that a woman in her 50s came with shortness of breath, hypoxia and cough. She had flown in for her father's funeral as well. She's my patient's sister. I hope we don't end up with the whole family with COVID-19 in the ICU.
Debbie Schwarcz, MD, Emergency physician, Lachine General Hospital, Montreal
It has been 3 weeks since our entire world as we knew it came to a jarring stop. Since then, it feels like we have just been waiting for the other giant shoe to drop; our ER is still oddly quiet, but we are getting more and more acutely ill patients, many of them actually not even related to COVID-19. While we have had a few such cases that required intubation and transfer out since we are still technically a “cold” hospital, we seem to be getting other very sick patients.
Is this a function of people staying home too long, not presenting as early as they otherwise would have, trying to avoid the ER? Is it because our other tools of non-invasive ventilation for patients in respiratory distress have been stripped from us? Is it possible that their coronavirus swabs are false negatives? There are just so many unknowns.
Each patient assessment seems to take so much longer since we have to ensure that we are dressed properly prior to entering the room, and we cannot exit and enter the room freely. This means that we can no longer easily multitask from patient to patient since this would waste precious PPE resources. Every single item that enters and exits the room of a patient who is “rule out COVID” (which is practically everyone now) has to be dressed and cleaned appropriately. COVID-19 itself is deadly in its own right, but, at least for now, it is the ongoing consequences of the disease that are playing such a central role in its morbidity: Proper PPE needs to be donned prior to entering a room, wasting valuable time, we can no longer use non-invasive ventilation tools like Bipap to avoid intubation, we can no longer bring a patient’s oxygen saturation up easily with a bag-valve-mask, we are not to provide lifesaving CPR until an endotracheal tube is in place.
Furthermore, valuable tests such as lumbar punctures, bloodwork, and urine tests are often being delayed until the COVID-status of the patient is confirmed. This obviously leads to potentially delayed diagnoses and treatment.
These truly are unprecedented times as we delve further into this uncharted territory. We all want to grab on to some concrete timeline of when this will all be over, but so much of what we have are, at best, educated guesses. The estimated peak of the disease keeps inching forward; I am hopeful that this is because we are succeeding in flattening that elusive curve and not because the other shoe is gaining momentum to plummet even harder.
April 3, 2020
Daniel S. Mishkin, MD, Chief of Gastroenterology, - Atrius Health, Harvard Medical School
The new normal is starting to settle in. People wearing masks whether it is at work or on the streets. Every day I wake up scared and wondering what will lie ahead. My day is spent divided between administrative responsibilities such as making sure shifts are covered, those providers that are ill are quarantined, as well as trying to manage the emotional issues we are all trying to “control”, in addition to patient care.
To be honest, the patient care is the easy part but has been made extremely complicated in so many ways. It is times like this that we want colleagues to remind us to do something in a certain way or the opportunity to share tips with others, as this constructive criticism will only help us. The problem is that I have to continue to remind myself this is not a drill, or a practice run, this is the real deal and there is really no room for error. I have previously used the expression to describe someone as a person I would want to go to war with or not, and this is what we are seeing now as many healthcare providers are stepping up to the challenge. The morale waxes and wanes and while there are many in healthcare whom I would want next to me on a battlefield like this, our comrades are starting to fall, and I hope there are enough left standing next to us when this all ends.
It is not all bad. It is times like this that we can actually recognize how lucky we are being given the opportunity to help others in their time of need. That is what pushed me to go into medicine, and every so often we all need to be reminded of that. Fortunately, I was walking through BJs Warehouse yesterday for a few items and multiple people came over to me while in my clean scrubs and specifically said, “thank you for your service”. That meant a lot.
March 31, 2020
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
I have been off for a couple of days. In rural Uniontown, PA, 75 minutes outside Pittsburgh, things are eerily calm. So far, not many people have come to the hospital, out of fear I suspect, and also heeding the mandate to stay at home and practice physical distancing. Will we be spared because we are outside the city, or is this just the calm before the storm? It is hard to tell. We did have our first inpatient confirmed case a few days ago. It is an 85-year-old nursing home resident who presented with shortness of breath. She has underlying chronic lung disease and was initially placed on BiPAP on arrival. She was placed in the corner isolation room in the ICU, the only negative-pressure room we have in the unit. When the COVID-19 test result came back positive, people were even more afraid of going into her room.
We peeked through the glass door to see how she was doing and was relieved to see that she was now off BiPAP, a non-invasive ventilation (NIV) tool that has not shown benefit in COVID-19 patients and can generate infectious aerosols in the air, putting healthcare workers at risk. I saw in her chart that her code status is "DNR/DNI," meaning that she does not want to be resuscitated or intubated. Someone had to let her know that if her respiratory status should deteriorate overnight, she would either have to be intubated and put on the ventilator, or just be made comfortable; we would not put her on BiPAP again. I put on my PPE, including a bonnet, goggles, N95 mask, gown and gloves, this time being even more careful, and went into her room.
As soon as I stepped into her room, I felt how sterile, lonely and isolating it was in there. The hospital had closed off family visits a while ago, and being in isolation, even nurses and doctors minimize the number of times they have to go into the room. I held her hand and explained the test result and its ramifications to her. Mary, what I'll call her, cried. She told me that she was scared and lonely, but was sure that she would not want to be on a ventilator, even if it means death. I told her I would respect her wishes. I stayed in there for a while, caressing her head and hand, giving her some human contact. If those of us who are social-isolating and quarantining at home feel stir-crazy and lonely, imagine being an elderly lady stuck in a hospital room under fluorescent light.
After I left her room, I called her family to notify them of the result and to instruct them to self-quarantine and watch for symptoms. Her daughter asked me if I could tell her mother that she loved her. Did I want to gown up again and expose myself again to give Mary her daughter's message? This could be the last time Mary hears from her family if she doesn't make it, and even if she does make it, she might not be able to see her family for a while. So I put on another bonnet, goggles, mask, gown and gloves and went in: "Mary, I spoke to your daughter and she wants me to tell you that she loves you." Mary smiled: "She's not upset at me?" "No Mary," I replied, "She's not upset at you, she says she loves you."
And now, I’m off to the hospital and I don’t know what changes I will find after being off for two days. I would not be saying the truth if I said I wasn’t scared. But I’m boosted by all the positive support that we physicians on the front lines are getting.
Christopher Labos MD, cardiologist, Montreal
Adapting to the reality of virtual visits
One of the biggest adjustments to practicing medicine during the pandemic is not actually seeing patients. Since we are trying to get people to stay home, almost everyone at this point is practicing some form of telemedicine either by phone or with video conference software of some kind.
The most surprising part of all this is that many health problems can probably be handled in this way. Most patients have blood pressure machines at home and can monitor their own BP. In fact, the blood pressure they take at home is probably more reliable than a blood pressure measurement in the office since those are sometimes falsely elevated, a condition known as white coat hypertension. Patients usually tell me if their blood pressure is too high, not the other way around.
Prescriptions can be faxed to pharmacies, test requisitions can be sent directly to the hospital, and results can be reviewed with patients over the phone. For stable patients, there might actually be no need to physically be in your doctor’s office.
My experience has been that most patients are more than happy to do their health care follow-up by phone. Most people do not want to venture out if they don’t have to because they are understandably concerned about catching the virus. There are a few exceptions where an in-person visit is necessary and emergencies are not simply going to stop happening because of COVID-19. I had the unfortunate experience of having to convince a patient they needed to go to the emergency room because they might be having a heart attack (thankfully it turned out they weren’t).
It will be interesting to see how telemedicine evolves after this pandemic is over. We may go back to our previous ways or we may end up embracing technology. Maybe sitting in a crowded waiting room waiting for your appointment will be a thing of the past. We shall see.
March 28, 2020
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
I just came off of a 10-day stretch of work, and on my first day off, I got in touch with some of my old colleagues from NYC and NJ. The situation is critical, conditions are dire. One colleague tells me that they have nowhere to put dead bodies; another tells me that they are running out of ventilators and are thinking of splitting one ventilator to several patients, despite multiple risks. My alma mater, Lincoln Hospital in the South Bronx, had 70 intubated patients as of March 26. There are no longer Intensive Care Units. Everywhere is an Intensive Care Unit. Two of my former attendings from NJ are infected and critically ill. These are people that I know, places that I used to call home. It doesn't feel right for me to be off but ten days in a row were trying.
March 26, 2020
Debbie Schwarcz, MD, Emergency physician, Lachine General Hospital, Montreal
It has been a draining week. Between having the kids home, trying to get clinic visits done from home, ER shifts and trying to keep abreast of the covid situation, I'm exhausted. I've been falling asleep pretty early the past few nights only to awaken at 3 am in a panic: when will the surge come? Are we well enough protected in our PPE? Will we have enough PPE? Are we prepared??
We have been practicing "donning and doffing" multiple times as a day as we screen more and more patients with symptoms of coronavirus. We are running codes in a protected fashion to prepare us for the real thing. We are learning from our mistakes and thankful that YOUR social distancing seems to be working and giving us the gift of TIME.
The screening tent at my hospital is up and running and many patients are coming, getting swabbed, and being sent directly home and being instructed to self-isolate. So far we seem to have things under control. Can we keep it this way?
We are so thankful for everyone's kind thoughts and actions. I came back to the ER today after a code blue on the ward, feeling drained both mentally and physically (and starving!), and was so touched to see pizzas gifted by Bar Deco and snacks from Basse nuts (thanks to the generosity of Bonnie Zylberberg). These kinds of thoughtful and generous gifts are beyond appreciated and truly raise the morale in our ER and give us the energy to get through the day.
One day at a time...
Alaka Mullick, PhD, National Research Council Cell Physiologist
The Challenge of Developing a Vaccine against COVID-19
When a foreign agent infects the human body, a battle ensues. This happens because “guard” cells are continuously sampling tissues for foreign substances. As soon as they sense an invader, the alarm bells go off and the army is called in. The army, in this case, is made up of specialized cells called phagocytes (from the Greek “phagein”: to eat and “cyte” commonly used to denote a cell) that are able to recognize invaders and “eat them” in a Pacman-like fashion. This is the first line of defense which may be sufficient to suppress a small invasion. But what if the infection persists and the infectious agent continues to replicate at a faster rate than what the phagocytes can deal with?
A second line of defense in the form of antibodies is called in. Antibodies are molecules that recognize the intruder with exquisite specificity and can trigger a series of reactions that help to recruit other defense mechanisms, raising the complexity of the war. But it takes time for the body to make antibodies and most importantly, the process cannot really start in earnest until the body is exposed to the foreign molecule. This is precious time during an infection. The idea of a vaccination is thus to introduce the body to the intruder in a safe and controlled fashion when it is still healthy so that it can be prepared for the invasion. So what happens during this period of preparation? The body produces many different antibodies, each recognizing different parts of the intruder and with varying abilities for recognition. Unfortunately, a small fraction of these also happen to recognize parts of our own body or “self”. These must be eliminated early in the process, failing which, the body directs the army against itself.
Since vaccines are a form of early introduction of the foreign agent to the body, the most straightforward approach is to inject a harmless version of the pathogen. It could be weakened, dead or just have its disease-causing elements removed. But not all parts of a pathogen are equally immunogenic, or, in other words, able to elicit an immune response that remembers the pathogen from the early introduction. So why inject the whole organism when only a part of it is really useful?
The strategy for most of the vaccines under development is based on identifying the best “target”, the part that will elicit the most effective response in terms of blocking the activity of the pathogen and killing it. To make that determination it is important to understand a little bit about the biology of the pathogen, in our case, COVID-19. Although COVID-19 itself is new to us, it is a member of a family of viruses, the coronaviruses, that have been studied for a very long time. Like other coronaviruses, COVID-19 particles are spherical and have proteins called spikes protruding from their surfaces. These spikes are crucial for recognition and invasion of human cells, which allows the virus to replicate and produce many more viral particles within the cell. Therefore, one strategy is to raise antibodies against the spike with the aim of blocking the ability of the virus to enter the cell.
In addition to blocking entry, these antibodies also help wage war against the virus in another important manner. They are instrumental in generating killer cells that recognize the same pathogen. Killer cells are crucial in the battle against viruses because unlike foreign particles in the circulation, that can easily be detected by antibodies, viruses invade cells and are therefore in hiding. There is thus a need for a strategy to identify cells harboring viruses. In order to respond to this need, most cells are continuously displaying a sample of their contents on their external surfaces. The contents of infected cells include, amongst other proteins, the spike protein and so they display little pieces of it on their surfaces. These little pieces are recognized by antibodies and killer cells, and as a consequence, these infected cells are destroyed. As a bonus, viral progeny that were being generated within the cells are also killed.
Although the process of identifying a target and selecting the appropriate antibodies can be long and laborious, at present we may have a short cut: we should be able to learn from patients who have recovered from the disease. These individuals clearly must have generated efficient antibodies and can provide valuable insights into the features that are key for efficacy against COVID-19.
In conclusion, there are several steps involved in developing a vaccine before the final step of testing, which is clearly the most critical part of the process. Health practitioners need not only ensure efficacy, but also safety. In addition to general safety considerations, vaccines against a virus have an additional complication. Unfortunately, instead of blocking, some virus-specific antibodies can enhance the entry of the virus, and in some cases the replication of the virus. These can therefore enhance rather than limit the infection and must be eliminated.
Therefore, yes it may seem that it is taking forever to get a vaccine, but considering all that needs to be done, and done successfully, a year or so is really not that long.
March 25, 2020
Helen Wicki-Nadler, Doctor of Veterinary Medicine, Nobleton Veterinary clinic, Nobleton, Ontario
On March 23rd, the Ontario government classified Veterinary Medicine as an essential service. The College of Veterinarians of Ontario has instructed us to follow public health recommendations, to be innovative in our care delivery, and to reduce all nonessential services. As such, we are permitted to continue caring for cases in which we are alleviating animal pain and suffering or are intervening to prevent imminent death. We are additionally restricting preventative health care to diseases that have long-term implications while continuing to treat and dispense medications for chronic conditions and providing necessary rabies vaccinations and parasite controls. Risks are being taken into account on a case-by-case basis and we are using telemedicine whenever possible.
As a small business owner and a member of the College, safeguarding members of our community is of utmost priority. However, these are very stressful, draining times. We have experienced both the hoarding of drugs and foods and the inability of our purchasing companies to deliver vital products due to massive demand. There have been reported thefts of surgical masks from clinics and we have been asked to donate our limited supplies to human hospitals. We have locked the front door of the clinic and one gowned and masked staff member is sent to collect the patient from a vehicle while the owner waits for a phone call from a vet to ask for more history and/or permission to perform diagnostics.
We are also driving foods and supplies to the client's home and placing items for pickup outside of the clinic. We are checking in on our senior clients who need supplies for their pets. Both animal and owner welfare have played important roles in these decisions, particularly as companion animals may serve as critical support mechanisms to people in these trying times.
My technical staff has been absolutely selfless and outstanding in their abilities to keep the vets on track and to ensure our safety. I have assured the staff they will get paid even if their hours are reduced and restructured to mitigate risk. These are challenging economic times, but I will worry about that aspect once this is all said and done.
My anguish and sleepless nights are due to the uncertainty of what is to come. My husband is on home oxygen, my mom is 91 years old, and my much-needed vacation booked on the Transmongolian railway was just canceled, which seems unimportant and inconsequential at this time. On top of all this, I now have to cope with putting in a 6-foot-long i.v. line to euthanize a dog, while masked and gowned, with only one family member allowed in the room --- using only my eyes to express my condolences.
March 23, 2020
David Zlotnick MD, Medical Director, Urgent Care TEREM Clinics, Israel
Keeping the national urgent care TEREM clinics open and functioning is a full-time job, with ever-changing protocols and keeping the staff of 28 centers across the country safe and updated. We have of this evening 1,442 patients positive for COVID-19 in Israel, of whom 29 are in critical state with one death. We have been experiencing gradual lockdown over the last 2 weeks. Last night the lockdown went from suggestion to an actual law with punitive consequences. Only allowed to leave the house for food, meds or essential work.
Homefront command has taken over control and directing the ministry of health. The Knesset passed a temporary and controversial law allowing Israeli military tech to track civilians through GPS and this allows them to force quarantine on anyone who was exposed to a known positive patient. There are close to 100,000 people in strict home isolation across the country, including many medical staff.
The epidemiology here is fascinating, it is a small enough country that authorities are able to track the whereabouts of every positive patient and be in touch with all those they were in contact with. All non-essential stores, all schools, and nurseries, national parks and beaches are closed. Most of the population is at home, physical distancing being taken very seriously ...( law and police help that).... But there is a lot of kindness, helping neighbors, singing from porches and the like.
Hospital staff are preparing. We have not had the major wave yet... and with Israel closing border very early on, and isolating people very quickly we hope to follow more the South Korean/Singapore model. Even with hospitals still well in control, we have prophylactically started getting stable patients out. We have home admissions - where a nurse follows a patient via telemedicine ( patient sent home with BP/ Pulse ox etc..) and if there is any deterioration, they get an MD involved. We have to be inventive in this unprecedented situation.
Donna Shore MD, Family Practice, Ottawa
I am a Family Physician practicing in Ottawa, a member of a Family Health Organization of 25 physicians. We all practice individually, but share responsibility for after-hours care for approximately 23,000 patients. As a group and individually, we have had to assess, address, and adapt to this crisis on a continuous basis as the situation has been evolving. Only a short nine days ago I was "on call" in our after-hours clinic, seeing sick patients in "real time", and worrying about how to triage them, reassuring those who had a fever and no travel history that probably everything was fine. (Now it seems that the more we know, the more we don't know).
By this past week, all patients were being offered telephone or "virtual"/video visits. Incredibly, this seems to be working well, at least for the moment. I am mostly dealing with acute illnesses and ensuring that people have ample medication, hoping to allow individuals to stay at home, keep out of the "medical system" and allowing those most in need to have attention.
I am concerned about the long haul, as that is most certainly where we are heading. How to optimally manage care of chronic conditions, prenatal care, immunizations... Ensuring that mental health concerns, which were a challenge before this crisis, are addressed in the best way. I am VERY concerned about the shortage of personal protective equipment, such as masks and gloves.
It is likely that we will NOT return to practicing medicine as we have done in the past. The new technologies, and the forced need to create more efficient ways of doing things, will be a positive impact of this devastating situation.
I applaud the Ontario Medical Association and the College of Family Physicians, who have been great at keeping community physicians like myself, abreast of new developments and in sharing info and suggestions on practical matters that impact our day to day professional responsibilities.
The courage and commitment of our front line health workers in this battle is awesome. However, unless a massive effort and total adherence to physical distancing, (and the other public health guidelines that follow from that), is adopted by the general public over the weeks and months to come, their sacrifices will be in vain. This is not a sprint, it is a marathon. Please do YOUR best to help us!!
Mark Grossman DDS
Dental emergencies can be very serious and even life-threatening. Just ask anyone who’s ever had a horrible toothache. As such, this is a very unsettling time for dentists who are accustomed to helping our patients in need. Providing urgent care is an essential part of our profession. The important restrictions and guidelines imposed by healthcare authorities as a result of COVID-19 must be adhered to, which presents particular challenges for practitioners. Understandably, dentistry and physical distancing are mutually exclusive. We get very up close and personal with patients as we are literally working inside of mouths. Unlike many other occupations, ours cannot be performed remotely. It is imperative to treat emergencies in the safest possible conditions so as not to endanger the health of patients and caregivers. Of particular concern are treatments in which bioaerosols are produced, namely when employing handpieces, air-water syringes, and ultrasonic cleaners. Recently, in conjunction with public health authorities, L’Ordre des dentistes du Québec issued an action plan to its member dentists in regard to dealing with dental emergencies. As the situation is evolving, this can change at any time. The public should soon be officially informed through press releases about comprehensive measures for dental treatments.
ELECTIVE APPOINTMENTS
Elective appointments have been postponed until May 1 and should be rescheduled at the appropriate time.
EMERGENCIES
Acute dental emergencies can pose a serious health risk to an individual. These include: Dental trauma / Infection / Acute uncontrolled pain
Patients suffering from any of these conditions should contact their dental office by telephone where instructions will be issued. Some emergencies can be temporarily handled with antibiotics, analgesics and other medications, while others may require an in-person intervention. Anyone who has tested positive for COVID-19 or falls into other at-risk categories must call local health authorities for direction as many private dental offices are not equipped with the necessary personal protective gear to treat such cases. For now, we can only hope that this too shall pass with minimal casualties. But as John Lennon described in one of his lyrics; these are truly “strange days indeed.”
Natalia Pasternak, PhD in Microbiology, Research Fellow, Biomedical Institute of the University of Sao Paulo, Brazil
Chloroquine and hydroxychloroquine are on the hype worldwide as a possible Covid19 medication. The whole story, however, should be taken with a grain of salt, if not a spoonful. While there is good evidence of antiviral properties of the drug in vitro (in laboratory cultured cells), the hope of a cure relies on a recent paper published by a French group of researchers. The French study is, unfortunately, full of serious methodological flaws.
The study was not randomized, meaning that in the treatment group and control group we have a very distinct group of patients. This is not a good way to compare treatment and control. Patients with exclusion criteria such as comorbidities were MOVED to the control group, which may have made the control group even more biased, with more severe cases. It was open-label, and not double-blind. It’s important to “blind” participants and researchers to minimize their confirmation bias. The groups were treated at different hospitals, so the collection of data and tests was not standardized. There were six dropouts from the treatment group, four because they got worse, and one died. Their data was excluded from the final result. This is very serious because it gives people the impression that everyone in the treatment group got better. It isn’t so.
The primary outcome tested was the viral load. This means that the researchers didn’t check if the patients actually got better. Indeed, the patient who died tested negative for viral load a day before. The viral load results are inconsistent, one day they are negative and the following day we see a positive, for the same patient. This suggests the presence of false-negative results, meaning the virus was still there but couldn’t be detected. If this is the case for various patients, we have to assume this might also be the case for the “cured” patients' results. The antibiotic azithromycin was used for the treatment group, to treat secondary bacterial infections, but the authors didn't include a control group for that. They also didn’t include a placebo group, another effective measure to reduce bias. The sample size (26 treatment + 16 control) is too small, making it a likely candidate for false-positive results. We need to replicate the study in a larger group, with the proper controls.
And finally, the attitude of the authors when communicating their results is highly questionable: they went on YouTube before publishing and announced 100% cure for Covid19, one of the authors is also the editor-in-chief of the Journal where it was published, and peer review was done in less than 24 hours, the paper was submitted March 16, accepted March 17. The result of such irresponsible bad communication led president Trump to announce chloroquine as a possible cure, and president Bolsonaro in Brazil to follow suit. Brazilian population took to the drugstores and bought all available stock of the drug, which also happens to be daily medication for patients with lupus or rheumatoid arthritis. These people are out of their meds because it’s sold out. Two hospitals in Brazil announced that they are going to run clinical trials with the drug, but they lack expertise and capacity, so we may end up with more incomplete data and more confusion. One pharmaceutical company started to produce, and the president wants the Army labs to also start producing. These decisions may divert scarce public resources that could be better used to buy protection equipment and diagnosis test kits. People using the drug without prescription or follow-up by a doctor are at risk of developing severe side effects such as blindness, anemia, and cardiac disease. It may also give these people a false feeling of safety and they might start to ignore containment and safety measures. During a pandemic, decisions must be made on solid evidence. People need hope, but they also need to feel safe that we scientists know what we are doing.
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
Just as I was ready to pack up and leave at the end of my shift, they call a code overhead. I rushed over and found the patient unresponsive but he did still have a pulse. He had very slow and agonal breathing and his oxygen saturation was low. If this doesn't get fixed immediately, he would go into cardiac arrest.
A few nurses were already in his room, getting the crash cart ready. "Who's running the code?" is always the first question I ask as I walk in and make a quick scan across the room to see who's available and what's available. Nobody. So I took over. I asked his nurse for a quick background on this patient whom I had never seen before: Man in his 40s, some kind of cancer, has a chest tube, became unresponsive. The respiratory therapist already started giving oxygen via a mask, and when the patient wasn't breathing on his own anymore, she manually bagged the oxygen into the patient through a bag valve mask, also known as Ambu bag. Despite bagging, his oxygen level remained low and his blood pressure started to drop. This man needed to be intubated, stat.
In this COVID-19 climate, I wanted to grab a mask for myself before intubating. The CDC (Center for Disease and Control) and SCCM (Society of Critical Care Medicine) both recommend wearing a respirator mask such as the N95 when intubating someone with or suspected of COVID-19. I asked for a mask but there was none nearby. I had a few seconds to make a clinical judgment and decide whether to wait for someone to go grab me a mask from who knows where, or to intubate now. His oxygen saturation kept dropping despite the bagging, and from the 3-second briefing I received from his nurse, he didn't come here for respiratory complaints, nor was he in the unit our hospital has reserved for COVID-19 cases, so I pried his mouth open with my hand, looked for his vocal cords, my face inches away from his, and intubated him.
Everything happened in a matter of seconds. After the patient had been stabilized, I had more time to think: Did I make the right call? I didn't think he had COVID-19, but did I know it for sure? N95 masks are scarce and therefore locked up somewhere to prevent people from stealing them (apparently some people were taking boxes of them home), but what happens when you need it in an emergency? Until this COVID-19 blows over, maybe I should be carrying a mask on me at all times.
March 22, 2020
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
Our hospital shut down an entire wing to reserve it for suspected COVID-19 patients. In order to minimize exposure and to preserve PPE (Personal Protective Equipment), I suggested that all those patients be managed by one single doctor. That is how I became the "COVID doc".
We have about 12 patients on the COVID floor now and because the labs are so overwhelmed with the number of tests to run, the turnover is at least 4-5 days. Our specimens are shipped to California, and one of my patients has been waiting for a week. Although he is stable and can technically be discharged, he lives in a Group Home so it is not deemed safe to send him back there without being sure that he won't spread it to other people.
Other patients are sicker, and maybe hypoxic, requiring supplemental oxygen or even a noninvasive ventilator such as a BiPAP machine. My PPE looks nothing like what I see on TV. I wear a pair of goggles, an N95 respirator mask, a polyester gown, and gloves. No helmets, no hazmat suits. Helmets and hazmat suits are probably not necessary anyway, but in a time of uncertainty like this, I still feel a bit exposed. And because we are short on respirator masks, I wear the same mask all day for all my patients; they are supposed to be good for 8-12 hours, but is there a risk of carrying particles from one patient's room to another? I don't know. Guidelines actually recommend only droplet precautions for the SARS-CoV2 virus, meaning that a regular mask should suffice, but certain procedures or processes can increase the risk of aerosolizing infectious particles that aren't filtered by a simple mask. Examples include during intubation, or even when the patient is on noninvasive ventilators.
The general population who are not in direct and close contact with COVID-19 patients definitely do not need a respirator mask such as the N95 in the US or the FFP in Europe. So if you happen to have stocked up on some, consider donating them to your local hospital. We are running short.
March 20, 2020
Debbie Schwarcz, MD, Emergency physician, Lachine General Hospital, Montreal
What's on my mind? Well, let me tell you just a little bit about what is on my mind. I had a 2-hour long teleconference with all the physicians in my small hospital today and while its incredible preparedness is impressive and reassuring (all thanks to Nicole Ezer, Emily McDonald, and Andrei Liveanu among others), the reality of what is looming ahead is omnipresent and daunting. This makes me feel anxious and scared about what is coming our way. But I am especially feeling ANGRY today. Angry at those that are not listening. It has been made very clear to us that we need to be practicing social distancing. We need to self-isolate and some need to self-quarantine. Is this mic on? This is not a test!
My nuclear family and I went out on a short bike ride today after dinner to get some much-needed air and exercise after my stress-inducing meeting (before we are advised against leaving our homes as has already been mandated in other countries such as Israel). We saw MULTIPLE clusters of people! I stopped at one group of two moms with their daughters and asked them if they were all part of the same family since they should be distancing themselves from each other and they looked at ME like I was the crazy one! We saw a group of teenagers walking down the street and one of them recognized my husband as a teacher at his school and started approaching him to shake his hand! Shock horror! Are parents not teaching their children? Are adults not understanding the gravity of this situation? No? Well, let me try to make this clear once again: My colleagues and I are leaving the safety of our homes every day, putting ourselves on the front lines, day in and day out, to care for sick patients, putting our own health and the health of our own families at risk. And you are looking at ME like I am the crazy one??
What is your job right now? To stay home. To stay away from people. To isolate yourselves. That's it! It is pretty easy actually. You can sit at home with your kids, try to teach them, don't teach them, put Paw Patrol on, try not to strangle them, hug them, put earplugs in, yell at them, lock yourself in the bathroom, bake with them, cuddle with them while watching a live feed from the Cincinnati zoo at 3 pm daily (my favourite), get a free online workout in from one of the many amazing trainers (Stacy Lelinowski) that are posting new workouts daily (God bless you), order in food (with no delivery fee!), and then watch Netflix at night in the comfort of your own bed. Yes, this is a big shift in your life right now and it sucks. But you know what sucks more? Death. Death sucks more. Trust me, this is hard on all of us. But by making this mandatory shift you are actually improving the chance that you and your loved ones DON'T DIE from this pandemic. You also happen to be making it easier on us, your "guardian angels" as our premier so lovingly referred to us (finally some love!), by slowing down the surge of acutely ill patients so that my colleagues and I can safely care for them and so that we don't burn out and get sick ourselves in the interim. And guess what? If we remain strong and healthy with an intact healthcare system, we can continue to care for you and your family and remain your "guardian angels". Get it now?
Please disseminate this message to everyone that you know: to those young and old and those in-between that are underestimating the gravity of this situation. This is NOT the time to hang out, to chill and to party together because then it is YOU that is propagating the rapid spread of this potentially deadly virus. The death of MANY will then be on YOUR shoulders. And why? Because you couldn't just stay on your damn couch.
Melody Ko, MD, Internist, Uniontown Hospital, Pennsylvania
We are a community hospital in Uniontown and had our first suspected case of COVID-19 at the end of February. He is a retired physician in his 80s who presented with fever, cough, and congestion. He had just spent some time in Asia. Our Infectious Disease specialist called the PA Department of Health and spoke to an epidemiologist who said that the countries he had been in were not on their watchlist. He also stated that as long as the patient continued to improve, regardless of whether a specific diagnosis was made, testing would not be offered and no special precautions would be necessary at discharge. The patient was discharged home on day 6 of hospitalization. His sputum culture, blood cultures, and rapid flu tests were all negative. We now have a few patients who are suspect and have been placed in a special ward but we have not received their test results yet. We are concerned about possibly not having protective supplies.
Daniel S. Mishkin, MD, Chief of Gastroenterology, - Atrius Health, Harvard Medical School
In Boston, we are also struggling to deal with this virus and reducing our interactions with others as non-essential services are limited but not completely shut down. I am the chief of our Gastroenterology division and we shut down all elective procedures for this week and the upcoming next three weeks as performing procedures places healthcare providers at a higher risk. We also need to save resources. We have limited protective gear and need to conserve them immediately.
I am always trying to find a positive spin on everything and I am optimistic that this will change healthcare forever for the better. Performing telephone interviews with patients or video virtual encounters are helping keep us to communicate with patients and prevent them from feeling abandoned. The overwhelmingly positive response from the patients is making the continued work worthwhile.
