This letter from our local hospital ER doc has been circulating on social media in my town. It is applicable for anyone, anywhere, to read and heed. Note “the surge” section – Anthony
Dear Butte County and all the folks who may under the care of Enloe Medical Center,
I am one of your local Emergency Medicine docs at Enloe Medical Center. So I’d like to take a moment to explain Covid-19 and how and why it is impacting our community.
Specifically, I’d like to go through the basics of the illness and (as a consequence) what Enloe Hospital is doing to meet the coming crisis.The first thing I will mention is that the Covid-19 disaster is an extremely dynamic and changing situation.
Every day at the hospital we are meeting constantly and changing policies–directions from world, federal, and state programs change multiple times per day. This is an unheard of pace of change.Here are the basics about the Covid-19 illness. The virus is highly contagious. It is predicted that eventually, nearly everyone will be exposed and been infected.
A very few very lucky people may not develop any symptoms at all. The vast majority of people will get a mild syndrome of variable symptoms including “flu”–fevers, achy-ness, upper respiratory congestion (ie nose and throat symptoms). Then they will get over it. And probably wonder what the big fuss about it was. Younger children may have an even milder syndrome.
However, during the typical 7 days of mild disease and then another 7 days later, all infected patients will be spreading this virus. If you turn up to the Emergency Department with mild illness, you will be screened (important factors such as vital signs and your oxygen saturation percentage), and likely sent home with 2 important instructions: signs of worsening illness, and strict self-quarantining precautions.
However, if you are unlucky, after the initial mild syndrome, instead of getting better, you may get worse. You may develop worse “flu” symptoms and then pneumonia–filling of the lungs with infected fluid.
These are the patients that will be admitted to the hospital for general care and observation. Once again, the majority of these moderately ill patients will get better.
However, if you are very unlucky, over the next day or two, instead of getting better, some patients will turn for the worse and will develop a form of ARDS (Acute Respiratory Distress Syndrome) whereby the lungs will become completely saturated with fluid and will need to be placed on “life-support”, that is a mechanical ventilator. They will be transferred to the ICU (Intensive Care Unit) until their lungs can recover.
A large proportion of these patients will eventually recover, but some will not.There are some clear risk factors for ending up in the ICU. Older age and baseline medical illness (diabetes, chronic heart disease, chronic lung disease) make it much more likely to go on to ICU-requiring Covid-19 illness. However, even perfectly healthy adults can develop serious illness. Fortunately, younger children are almost entirely spared.The overall picture of this sort of illness is NOT new to the medical community. Most of what I have described above (mild/moderate/ICU levels of illness) can be applied to the Influenza virus, which we have been dealing with for years.
The concerning difference is the infectivity of the Covid-19 virus, and mathematics.Using some basic simplified statistics will yield math that is causing everyone in the hospital to enact drastic measures.
Enloe Medical Center covers roughly 300,000 people in Butte and surrounding counties. As I mentioned everyone will get Covid-19. If only 0.5% of patients who get Covid end up in the ICU, that will be 1,500 patients requiring an ICU. Prior to our Covid planning, Enloe had only 20 ICU beds. 1,500 patients will not safely squeeze into 20 beds. This, my friends, is the SURGE. This was what overwhelmed the hospital systems in China and Italy.
Make no mistake the surge is coming.
So pretty much everything we are doing- all this “social distancing”- is to even out this massive surge of patients and spread them out over time, as opposed to having all of them show up at our hospital at once.And the analysis of China and Italy has produced a clear message. The most effective strategy to mitigate the surge is strict quarantining. Not disease testing. Not experimental medications or specific treatments. Quarantining, social distancing, whatever it takes to slow (not stop, not cure) the spread of disease.
So take quarantining and social distancing seriously, because it will save lives.
And it may be hard to take seriously, because as I mentioned the vast majority of people will only get mild illness. And then they may ask themselves, why did I go through so much trouble, not being able to go to my favorite bar.
Even more seriously, the economy is heading downhill and many people are not getting paychecks. For a mild “flu”. Again, the answer is that all of the sacrifices are NOT for the mildly ill, but for the unlucky ICU bound. And that may be you or your loved one. Picture this:
Scenario One–your loved one is developing ICU level pneumonia. The team of doctors, nurses, and care-givers identify this, treat your loved one and move her to the ICU.
Scenario Two–your loved one is developing ICU level pneumonia. But there is no room in the ICU and she is put on a jury-rigged breathing contraption for life support in the hallway outside of the Emergency Department. Next to 60 other patients in the same situation.
And the message from China and Italy and other countries has been specific–the most effective strategy to avoid Scenario 2 is aggressive quarantining of the mildly ill and EVEN asymptomatic.Employing strong individual efforts to prevent contracting Covid-19 will slow the progression and buy time to smooth the ICU surge– and it may also buy time for doctors and scientists to develop and test treatments and vaccinations.Some common questions that I have been asked–Why can’t I be tested for Covid?
Every day, the hospital is attempting to obtain methods for rapid testing of Covid, but as you might imagine the supply of testing materials is a lot more rare and much more expensive than toilet paper.Another common question is: Does it seem that the hospital is over-reacting? The answer is “We hope so!”
And–don’t forget that hospital workers are at highest risk for exposure and spreading the illness. Which is why we are trying to be so meticulous about infection prevention–don’t be surprised if you end up in the Emergency Department, respiratory issues or other standard ER problems, staff are wearing gowns, masks, and greeting you from a distance. If a hospital worker starts to show symptoms of infection, this will remove him or her from a very limited working pool for a long period of time. And we need every hospital worker we have.
Another comment I would like to make: If you have an elderly family member or loved one with advanced illness, please take the time to appreciate them. And then discuss the possibility that they might develop severe Covid-19 illness. No decision at this time has to be final, but it is better to understand where everyone stands prior to the storm hitting.
Here is another question: When? This is a tricky one, because we do not locally have quick testing for Covid-19. The current wait time to get a test result back is over 1 week. Our first official Covid positive test in Butte County was on Saturday March 21. As of today (Mar 25) there are at least 4 documented positive cases in Butte County, though likely there are many more people who are infected but have not been tested, due to the shortage of testing kits and assays. So people in our community are right now progressing through the contagious but mild symptom stages. We anticipate pneumonia and ICU patients declaring themselves within the next few weeks.
Thank you for reading, and thank you for keeping Chico safer,
Ivan Liang
MD FACEP FACMT
https://www.enloe.org/find-a-doctor/find-a-doctor?id=232
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In the United States, the disease was first observed in Haskell County, Kansas, in January 1918, prompting local doctor Loring Miner to warn the US Public Health Service’s academic journal. On 4 March 1918, company cook Albert Gitchell, from Haskell County, reported sick at Fort Riley, a US military facility that at the time was training American troops during World War I, making him the first recorded victim of the flu.[38][39][40] Within days, 522 men at the camp had reported sick.[41] By 11 March 1918, the virus had reached Queens, New York. Failure to take preventive measures in March/April was later criticised.[42]
In August 1918, a more virulent strain appeared simultaneously in Brest, France; in Freetown, Sierra Leone; and in the U.S. in Boston, Massachusetts. The Spanish flu also spread through Ireland, carried there by returning Irish soldiers.[citation needed] The Allies of World War I came to call it the Spanish flu, primarily because the pandemic received greater press attention after it moved from France to Spain in November 1918. Spain was not involved in the war and had not imposed wartime censorship.
https://en.wikipedia.org/wiki/Spanish_flu
Rapid tests for the detection of antibodies should be developed to detect people who have immunity. These people can help a lot in the long run.
It will be difficult to get a vaccine, because you have to reckon with fast mutations.
Yes, we definitely need an antibody test. Then we can get a much better picture of where we stand. As infectious as this Wuhan virus is, there may be a lot of people who have already caught the virus and gotten over it and are immune, and they certainly can be used to get the economies going quicker.
Plus, if you take the test and find you are immune then you can relax a little bit.
All the things we are doing now will serve us well in the future when another one of these viruses comes along. the next one could be a really deadly one, but we will definitely be better prepared.
It will be difficult to get a vaccine, because you have to reckon with fast mutations.
A recent study found that the WuFlu virus doesn’t mutate as rapidly as most RNA viruses.
https://www.the-scientist.com/news-opinion/relatively-stable-sars-cov-2-genome-is-good-news-for-a-vaccine-67319
I’m sorry, but this is how nature works, and man has no influence on it. One outbreak of the virus will be extinguished, and new mutations will appear in other areas of the world.
Source: Pulse of Medicine
https://pulsmedycyny.pl/koronawirus-sars-cov-2-uszkadza-serce-986835?fbclid=IwAR22YMB6BEN5FGa-cRyCLfhHyIwr0Wqhf5ArNL8sDMPSgIip8F5NM7UFZRY
SARS-CoV-2 coronavirus not only affects the respiratory system. “People who have cardiovascular disease such as hypertension, myocardial infarction or diabetes are more likely to die from coronavirus infection than those who are not burdened with these diseases. Observations also indicate that the virus can irreversibly damage the heart in previously healthy people “- says prof. dr. n. med. Adam Witkowski, head of the Cardiology and Intervention Angiology Clinic of the National Institute of Cardiology in Warsaw, president of the Polish Society of Cardiology.
I think that all efforts these days are simply aimed at avoiding overload on hospitals. This is also what nearly most European countries do. If you listen carefully to most virologists and epidomologist this is exactly what they say. They don’t say “we need to stop the virus” or “we need to win the war”, that is politician talk. They carefully say words that come down to flattening the curve. They say that the virus will likely be around till there is a vaccine.
Most of the population understand it wrong, one shouldn’t be that much afraid of being contaminated for his/her own health, a majority of us will get it anyway. But we need to protect from it spreading to fast, or to much to the elder population
One should not have the illusion of being able to manage hospital capacity very accurately, this is not like tuning the radio.
Even with the (partial) lockdowns in place there is already impact on the health system. In many countries in Europe nearly all hospitals have postponed all non essential surgery. There is a lot of fear in hospitals that people needing care do not dare to come to hospitals, there is for instance an unexplainable decrease in number of hospitalizations for heart problems (beyond what one can expect because of lockdown effects)
In Italy already 63 doctors died, not a regular flu in any case. It will only become a regular flue once all those that are genetically disadvantaged have died…
Eddie
” I think that all efforts these days are simply aimed at avoiding overload on hospitals. ”
” They carefully say words that come down to flattening the curve. ”
Exactly. I have read reports from Italian and French medical staffs who all were horrified to lack personnel and material to such an extent that they really had to decide who would be helped to survive and who wouldn’t.
Who wants to have to make such decisions?
J.-P. D.
Where, oh where, is Damocles’ Sword of Truth for prognosticators?
“Make no mistake the surge is coming”
Make no mistake, if you are wrong and have destroyed the lives of millions, you should STFU and learn to code.
The medical system currently kills about 120/day on any normal day in the US.
If you wish to survive this, do anything you can to avoid a hospital.
-They give anti-virals with many serious side effects along with antibiotics. Never tested together. God forbid they give you Chloroquine which has serious listed interactions with antibiotics.
-They starve you
-They isolate you from family
-They put you on a mechanical ventilator which has a very well correlated relationship with mortality. Check it some time.
[Borderline paranoia? Publish or not? Mod]
New York had exactly half of all 558 US deaths yesterday. Of total deaths, NY has reported “only” 39%, because of Washington’s early lead. But yesterday, WA had only ten new deaths, vs. 279 in NY.
Total deaths by state and nation, as of March 30 (rounded to nearest whole number):
NY 69
LA 39 (Mardi Gras hangover)
WA 28
NJ 22
MI 18
US 10
CA 4
FL 3
TX 1
Deaths per million.
In US 558 new deaths yesterday.
Anthony, thanks for posting this letter. I have sent it on. It helps to remind everyone that this virus is not the flu, it is new, and has extreme infectivity – and that is the issue. Health care must be supplied and expanded for the extra load or no one will have available health care. We also have to care for health-care workers.
I am looking forward to the cures (e.g., the triad of hydroxycholorquine, zinc sulfate, azirothomyicin) working on a large scale, quick tests for the virus readily available, and antibody tests such that we can identify those with (new) immunity.
I think we are going to come through this stronger and better prepared than ever before. Certainly we will be more knowledgeable about those who are trying to help and those who are trying evade, lie, or destroy.
When Mainland China enjoys the blessings of liberty and good government like Taiwan, future potential pandemics originating there can be nipped in the bud.
Just a word of thanks to _Jim for kindly calling me an empty-headed liar. I am reminded of a question asked by Rex Stout’s Nero Wolfe in the debut novel: If a man makes a dummy, dresses it to resemble you and strikes it on the face, does your nose bleed?
Thanks also for the link to a series of papers, none of which gives outcomes for treatment with hydroxychloroquine and two of which refer to other drugs (remdesivir and teicoplanin.). Perhaps it is inevitable that those who are desperately grasping at treatments for a frightening condition will react with childish anger to anyone who points out the need for well controlled studies, and _Jim has my sympathy. He could try psychotherapy or anger management. I stand by my comments.
Let me add this. I am not going to follow any of these threads any longer, as too many armchair physicians are writing too much nonsense about a genuinely difficult pandemic. There have been several honourable exceptions, and my compliments to Bindidon, Andy Patullo, Nicholas McGinley and others.
Ridiculous. Every medical professional I know has been programmed with this narrative.
Lifeboat ethics: I’m guessing we see a death count in the USA closer to 50k. Should we sacrifice the lives of 327 million for the few who are vulnerable? Hell no. Totally absurd. But yet our governors are in a race to the bottom to show who cares more.
This will be remembered as the time when humans lost their minds to social diseases of political correctness, irrational fear, and socialism.
My biggest concern is the availability and use of the Hydroxychloroquine treatments. Ivan describes the point where patients are being admitted to the hospital:
“…if you are unlucky, after the initial mild syndrome, instead of getting better, you may get worse. You may develop worse “flu” symptoms and then pneumonia–filling of the lungs with infected fluid. These are the patients that will be admitted to the hospital for general care and observation. ”
These are the patients that Dr. Zelenko has been starting on Chloroquine treatments in his NY outpatient clinics. He says he would like to start patients earlier, especially if they fall into a vulnerable group, but the supply is too limited at present.
Just giving it to the people who are entering pneumonia/distress has kept all but 4 of his 700 patients from needing hospital care. Zero intubations. Zero deaths.
So it looks like treatments could well keep hospitals from being overwhelmed, even if infections proceed at high surge rate.
Thus I question Ivan’s view that the only thing that matters for preventing facilities from being overwhelmed is slowing down the contagion. It looks like treatment could do a large part of the work.
But for that to happen outpatient facilities (at hospitals, doctors’ offices and clinics) have to be stocked with the treatments and have to be prescribing them.
One of the most alarming things that has been happening is it looks like a lot of doctors/facilities will not prescribe the treatments unless they have a positive Corona test in hand, and as Ivan notes, those are still taking an alarmingly long time.
Zelenko isn’t waiting. If he can diagnose Corona by symptoms he will start treatment but there was the insane story out of MI the other day where a young man was dying waiting for his corona test to come in. It came in just in time to save his life and he came out publicly afterwards and said “this is insane.” There was a similar story from WA, and a Dr. who was fired for criticizing his hospital for taking 10 days to return corona test results.
The combination of slow testing and conditioning treatment on testing is a killer. This should be sent out as an alert across the country: don’t do this!
Drs using it are saying it is crucial to start before lung damage. Results are better earlier and even if late treatment saves the person’s life, they still have lung damage.
All of these problems would be greatly reduced if there was a big push to use the treatments in outpatient fashion to prevent hospitalization but I’m worried we are not there yet, with all the resistance that states and the FDA have thrown up, hating on a CURE because they associate it with Trump or something. Sheesh.
Hydroxychloroquine is going to the thing that saves lives and allows us to keep our hospitals from being overwhelmed, not social distancing. Of course that helps to, but it also has a gargantuan price. We right now have higher unemployment rate than at the bottom of the Great Depression, and I believe it is unnecessary.
For now, to get our systems of treatment up and stocked and ready, fine. Then we must let the treatments carry their major part of the load.
Why would an emergency department doctor have special insights into the epidemiology of the virus. If he was talking about first response and triage and emergency life support, then yes he would be worth listening to.