Coronavirus: Real Time

Coronavirus is an unprecedented organism, and we’re learning about it in real time. We hope that we learn, anyway, from the lived experience of other communities around the world.

I’m thankful to work at an incredible teaching hospital*, where experts have come together as high-functioning teams to meet the unknown challenge ahead, and on an unbelievably tight timeline. (The Washington Post covered some of this intense, complex preparation in Sunday’s edition.)

Now Coronavirus has arrived and community spread is happening, but we have a shortage of test kits (a deadly bureaucratic bungle well-reported by the New York Times) and we’re unable to confirm and then trace every case. If we could, we could better direct care advice and quarantine measures.

So without a test to make the diagnosis, providers want to know: How do I recognize when someone has it?

And, of course: How do I protect myself from getting it?

I certainly have wanted to know. I’ve seen symptoms charts, and Our World in Data has one of the best (as well as generally awesome graphics and explanations):

And I suspect that we’ve been seeing Coronavirus in clinic the past few weeks. All of us on the outpatient side have had patients with fever and cough, but negative influenza swabs. It’s possible it’s been Coronavirus circulating in the community. We’ve been wearing masks, wiping down surfaces, and washing hands ’til they’re cracked, of course. That’s what you do when it’s flu season.

But Coronavirus is incredibly infectious, and especially severe in certain populations: The elderly, and people with underlying medical conditions. That’s why we want to prevent the spread so badly. The vast majority of people who get infected don’t get that sick, really. But about 10% are sick enough to need oxygen and other treatments, and some of those will need more advanced breathing support, sometimes for a long time. If thousands of people get infected, then all the ones that need breathing support will quickly overwhelm our resources. There’s only so many ventilators, folks.

So we don’t want to become infected and spread it around, or take ourselves out of the healthcare provider pool. Sick doctors can’t take care of sick patients. For these reasons, additional measures, including more protective gear, is required. All that gear is now standard in order for us to see any patient with fever and a cough, an alert that went out this past weekend.

This weekend the hospital also sent an urgent email asking for volunteers to staff the emergency Coronavirus screening and testing clinic, aka the COVID-19 surge clinic. This is a huge ambulance bay that has been converted into a very specialized clinic, only for seeing patients with a high likelihood of having the infection.

I put my name in. I know we’ve probably already been seeing people with the virus. I expect that we’ll be seeing many more cases, and I wanted to gain familiarity with the actual disease, so I have a better chance to make the diagnosis, to better counsel people. And, I wanted to get extra training in “donning and doffing” all that protective gear.

They called me to fill in for a shift, and I said yes. Here is provider entrance to the clinic, where we “don” the gear. I couldn’t take my phone into the actual patient care area, so it wouldn’t get contaminated, so no photos of that area. The disaster response team had thought of that and provided us with dedicated hospital cell phones for the shift.

And we needed those phones. We had to page the on-call infectious disease testing expert several times to find out if we could test suspected cases that didn’t meet the strict criteria. The criteria still include travel to countries like China and Italy; employees at Biogen; and known exposure to a Coronavirus-positive contact. Some of those are obsolete, and though my team strongly suspected eight of our patients were suffering from Coronavirus, we could only get testing approved for a few. Tests are still so limited, and in reality it may be several more weeks before we have more.

The patients we suspected had the infection all had fevers (mostly above 101 degrees) and cough. Many complained of chest “burning” or tightness, some kind of discomfort with breathing, if not frank shortness of breath. Even though we weren’t able to test everyone for Coronavirus, we did test for Influenza A and B as well as RSV (respiratory syncytial virus), and counseled people that no matter what it was, they really needed to stay home to get well and avoid infecting others.

I also feel like I mastered the donning and doffing of the gear. Donning the gear: First gown, then N-95 mask, eye protection next, gloves last. Doffing the gear: Pull gown loose at the waist, remove gloves with the gown and using the gown, toss and sanitize hands, remove eye protection from the back don’t touch shield, the remove mask from the back straps and sanitize hands again.

Taking it off correctly is WAY more important than putting it on. I felt like a medical student in the operating room for the first time, trying desperately to maintain sterility and inevitably touching something. The head of infection control was there observing, and reprimanded me for a “doffing” (removing gear) transgression. You’re supposed to yank the gown off in one fast, strong movement pulling from the waist, NOT the top. Well, I only made that mistake once!

It was only a four-hour shift, but likely the first of many. It’s get real time, folks.

More on this to come.

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For solid information on Coronavirus prevention, this article in USA Today by epidemiologist Malia Jones is excellent.

For a very good argument for social distancing, this article by Yascha Mounk in The Atlantic is highly recommended.

*Edited to add that anything I post reflects only my opinion and never that of my employer.