Holding The Line
It feels as though we are collectively holding our breath, especially those doctors and nurses who will be frontline in the days and weeks to come. Hospital systems, public health officials, disaster preparedness teams and most especially, physicians and nurses, are working and planning and talking and sharing data literally around the clock. When this is done, #TrustDoctors and #TrustScience will become our national mantra.
We know a tsunami is coming, and we’ve begged everyone to race to higher ground (separately!). Meanwhile, physicians and other healthcare providers are deliberately remaining in the danger zone, holding the line as the water rushes towards our communities. They do so knowing there are extremely limited supplies of absolutely vital #PPE (Personal Protective Equipment) and critical limits and delays in #CoronavirusTesting.
They remain on the shoreline because a surge of very sick patients is coming, and this is the oath they took.
Anyone still saying the danger is overblown needs to get down to the water's edge and help try to hold back the tide. Do not be reassured by the “number” of cases in your community – testing in the United States remains an order (or more) of magnitude behind where it was at this point in the progression of the pandemic in other countries. We cannot diagnose what we cannot test for, and even those tests that are being approved are taking upwards of 5 (sometimes upwards of 8) days for confirmation.
Do your part to shut down those – especially community or religious leaders – who are pushing out the dangerous message that shelter in place orders are “draconian” or an overreaction. That messaging is both breathtakingly irresponsible and harmful, and it will ultimately endanger the public and, most especially, my frontline ER, ICU and Cardiology colleagues who are working tirelessly to prepare for worst-case scenarios under dire circumstances.
We know community transmission has been occurring for weeks, and the numbers in New Orleans today are worrisome. My colleague Dr. Aimée Marguerite has done some wonderful work tracking and graphing COVID19 cases in the U.S.. The trends – even with gross undertesting – put us on track with where other countries were as the pandemic progressed. Orleans Parish hit Italy levels of infection yesterday (>1000 cases per million). Detroit City is over 300 cases/million and Oakland Co (MI) close to 200. This is close to where Seattle was one week ago with regards to density of cases.
If you’ve not been paying attention to coverage of Seattle, New York etc., please know that hospitals in those areas that were leading edge in case presentation are already beyond capacity. COVID19 rates continue to skyrocket in New York. WA, NJ, LA, and DC are the remaining top five at this time, though once (if!) testing ramps up, we’ll likely see a marked increase in Florida and elsewhere.
I’ve included links to Dr. Marguerite’s work in the comments for those interested. She’s made her posts on this public if you want to follow her.
Many of you have seen the report from the COVID-19 response team at Imperial College in London. They plugged infection and death rate numbers into widely available epidemic modeling software and ran several simulations looking at what would happen if:
1) the United States did absolutely nothing (i.e. treat COVID-19 like the flu, business as usual, let the virus take its course)
2) the U.S. runs a Mitigation strategy (i.e. place all symptomatic cases in isolation, quarantine families for 14 days, orders all Americans over 70 to practice social distancing)
3) the U.S. runs #Suppression strategy (spoiler alert: Suppression results in the best outcomes by far)
A Suppression strategy means that, in addition to isolating symptomatic cases and quarantining their family members, we implement aggressive #SocialDistancing for the entire population. Shelter in place orders are the foundation of a suppression strategy.
Of the three strategies listed above, SUPPRESSION provides us with the lowest death rate by at least an order of magnitude. It gives physicians, nurses and hospitals a fighting chance to get COVID care operationalized and diminishes the overwhelm of our ERs, ICU beds and ventilators.
Radically #FlatteningTheCurve saves lives.
Please remember, too:
1) For most people, the coronavirus will just be a health disruption. You'll get sick, feel crummy and recover. However, this isn't true for everyone, and those who do become very ill often need significant, intensive medical support. Those most at risk are:
Over the age of 50y. Mortality from Coronavirus in those over the age of 50 doubles with each decade, and is significantly higher than the flu even in the 40-50y category.
Those who are medically fragile or have underlying cardiovascular or pulmonary conditions
2) Because we expect this infectious disease to spread throughout our population, we want to implement measures that slow the rate of infection, thus preventing a huge spike in infections in a short period of time which will quickly overwhelm our existing hospital infrastructure for those patients with severe complications.
The importance in slowing the rate of transmission is to give our doctors, nurses and healthcare infrastructure a fighting chance. If too many of us get sick at once -- and this is an extremely infectious virus -- even the small percentage of us who need intensive hospital care will quickly overwhelm the system with sheer numbers.
For ease of mathing, let’s pick a number in the middle: 50% infection rates (probably a very low estimate). And let’s pick a hypothetical population of 100,000. That means 50,000 people will get infected, most of whom will recover without any problem whatsoever. However, if even 1% (again, a low estimate if we look at trends in other countries) of that 50,000 require supportive care -- meaning hospitalization, supplemental oxygen, mechanical ventilation, ECMO -- we are suddenly talking about 500 people needing acute care.
We have about 90 ICU beds in Springfield.
This is why it is important to slow the spread of this disease and flatten the curve. If 500 people need ICU in the next 6 weeks, we're in big trouble. If 500 people need ICU over the next 6 months, we can manage.
We MUST slow the spread of this pandemic. We MUST flatten the curve. We do not have enough ICU beds. We do not have enough ventilators. We do not have nearly enough PPE – NOT NEARLY ENOUGH - Personal Protective Equipment to keep our doctors, nurses, and other healthcare providers safe. We do not have a vaccine, an effective antiviral or a cure.
All we have is us. What WE do - or do not do - in the days to come can change the trajectory of this. It will take several weeks to know if it is working, so your patience and long-term adherence is crucial, too.
#SocialDistancing is this generation's #VictoryGarden. Every single American has a role to play in protecting ourselves, each other and our country from the harm this pandemic will do if left unchecked. The more quickly we do what is being asked - no matter how uncomfortable - the more quickly we bring this under control.
We WILL find a vaccine, a treatment, a cure. We will.
But we desperately need to Buy Us Time.
American Individualism has always been a cornerstone of our national identity, but at this moment in history now we are called to something bigger than self. #Staythehellhome isn’t a typical call to action, nor is it a terribly satisfying one – we Americans like a good brawl. We like to face the enemy, kick its ass and know the faces of the lives we’ve saved. But we can’t pick a street fight with this virus: it requires that we heed the science and work together (separately!) if we are going to win.
The anticipatory fear in my colleagues is palpable. Make no mistake: when you or your loved one need help, they will be there. Physicians have been much-maligned in the U.S. in recent years; our profession diminished, our motives called to question, our “greed” highlighted, and our years of training and sacrifice demeaned.
Nevertheless, Physicians will show up. So will nurses, techs, transporters, sanitation, food services, and healthcare leadership.
More soon, my friends. Be courageous, be generous with your time and gifts, and be kind, always.
p.s. These posts are public on my page. If you want to share this information widely in your own circles, I suggest doing the same. Relevant links in the comments.