Working as a physician on the frontlines of COVID-19 has been, and continues to be, a highly stressful experience in many ways. On a personal note, I am anxious about going to work at the hospital. I’m concerned about the level of sanitation there. We did not receive N95 masks until six weeks into the outbreak. Because of the scarcity of Personal Protective Equipment (PPE) in general, I purchased my own. On my off week, I found out the air system connected to the COVID-19 ward at the hospital had actually been piping air into to my call room during my shift the week prior. A hospital physician “call room” is a place where a physician relaxes (as much as one can) and catches up on paperwork without his or her protective gear on. Fearing for my family and for my own life, I nervously self-isolated and tested myself for COVID-19 antibodies with the FDA-approved Cellex
test. Since I was already 9 days out from exposure, I would have expected a positive IgM antibody test if I'd had the virus. Since the nasopharyngeal test results are coming back more quickly, I’m doing both the nasal swab and antibody tests before leaving self-isolation. Thankfully, everything has come out clear to date. Many others on the front lines have not been so fortunate.
Donning and Doffing PPE During a Pandemic
Donning and doffing (putting on and removing) protective gear during a pandemic is a time-consuming process. In the old days, we rightly used a new N95 mask for each room, but these days, I can only change my mask once every shift because of the lack of PPE. However, I change my gown, gloves, head covering and shoe covers between patients, and completely sanitize my CAPR (Controlled Air Purifying Respirator) each time. A CAPR is “advanced respiratory protection equipment approved by the US National Institute for Occupational Safety and Hazard (NIOSH) for protection against aerosolised and airborne particulates.”1
Here is a picture of my friend, Dr. Adam D. Mekonnen, in a CAPR:
It takes 20 minutes to sanitize a CAPR and fully gear up, and then another 15 minutes to properly remove and clean the CAPR for use by another doctor. If you can imagine doing this for many patients, it gives you an idea about how easily a medical system can become overwhelmed during a pandemic, and how care and safety can become compromised.
My Notes and Observations During the COVID-19 Crisis
It is paramount
the public understand that we’re in a pandemic with a novel (new – meaning we have never seen this before!) coronavirus with many
unknowns. Sadly, the entire crisis has become politicized, and conspiracy theories and misinformation abound on social media. Not taking COVID-19 seriously is a deadly mistake. And, as I’ve stated before in another blog post
, COVID-19 is not
“like the flu.”
is highly transmissible, and can be transmitted by a pre-symptomatic (having the virus but not yet exhibiting symptoms) person OR an asymptomatic (a carrier of the virus that shows no symptoms)2
person, which is the main reason everyone should wear masks in public settings
, and continue to practice social distancing. When contrasting COVID-19 asymptomatic transmission with that of the flu, pooled data from several studies suggests that the percentage of individuals with influenza who are asymptomatic is around 16%, whereas COVID-19 is 40%. This review of the literature
suggests that influenza transmission from pre-symptomatic and asymptomatic individuals is rare.3
Strange and Alarming Characteristics
COVID-19 exhibits a very unusual variety of characteristics that other coronaviruses do not, ranging from asymptomatic to profound, that can include rapid multiple organ dysfunction syndrome (MODS) and death.4
COVID-19 can initially mimic other diseases, for instance: a cold, flu, a stomach bug, diarrhea, pinkeye, whole-body rashes, or seizures.5
In severe cases, it causes Acute Respiratory Distress Syndrome (ARDS) from widespread inflammation in the lungs. A friend’s husband had a sudden seizure (who had never before had a seizure) in a restaurant several months ago, which sadly turned out to be COVID-19 from which he subsequently developed ARDS and died.
For a time, it was thought that COVID-19 bound to the beta chain of hemoglobin causing an altitude type of sickness. However, although hypoxia (low level of oxygen in the blood) is most certainly involved, and presents in very strange ways, the beta chain hypothesis is no longer thought to be correct.6,7,8
Coagulopathy and Cytokine Storms
Severe COVID-19 causes “coagulopathy” (hypercoagulability) which in turn causes blood clots in the lungs and elsewhere from something called “antiphospholipid antibodies” which are typically seen in autoimmune illnesses.9
Severe COVID-19 also causes something called a “cytokine storm,” which is an extreme immune response by the body that progresses rapidly, and is extremely dangerous.10
Coagulation and inflammation kind of go hand-in-hand;11
when the two overwhelm the body’s immune system and create a cytokine storm, it leads to multiple organ failure and death.12
Who's at Risk?
COVID-19 does not “only affect the elderly,” as first believed. Granted, it does cause the most fatalities for people over 60, largely due to pre-existing conditions. However, please bear in mind, two very prevalent “pre-existing conditions” in the United States are obesity and hypertension! We are having young adults hospitalized and dying of COVID-19 – most of whom (but not all) are overweight or obese. A lot of the protesting people out there are overweight and have hypertension–two things that are ending up being a bigger predictor of death from COVID-19 than age in the US, and yet they somehow consider themselves “low risk.” COVID-19 is also causing a new syndrome in children that mimics both an auto immune disease and a severe bacterial infection with toxic shock, which worries me where healthcare workers who have small children are concerned.
Stroke in Young Adults
Another alarming effect of COVID-19 is that it is causing stroke in young adults,13
even for those who are seemingly not very ill at all.14
There are really not yet any set protocols for anticoagulation in COVID-19 but many of the most advanced groups, like the Critical Care Group in Norfolk Virginia, have included low molecular weight heparin as part of their protocols for COVID-19 and I have taken this to heart. While in the past I might have let a younger person in the hospital under 40 without known coagulation risk go with just sequential compression stockings for their prophylaxis against blood clots, I start everyone with a COVID-19 diagnosis on prophylactic low molecular weight heparin on admission unless they have a contraindication like low platelets (blood-clotting cells).
Healthcare workers are at extreme
risk for COVID-19 infection because of the high amount of exposure resulting in heavy viral load,15
which is why the shortage of PPE has been absolutely devastating. I saw a Certified Nursing Assistant in her early 50s in excellent physical condition, die of COVID-19; it was heartbreaking to say the very least.
My Rebuttal of a Viral Video by Two Urgent Care Doctors
It is sad to have to spend time rebutting the abundant COVID-19 conspiracy theories out there. There is a “viral” video by two urgent care doctors (who will remain nameless) that was sent to me by several people arguing that COVID-19 is not anywhere near as serious as is being portrayed, and praising Sweden for not closing down thereby creating “herd immunity.” These reckless and untested musings do not speak for medical societies and are inconsistent with current science and epidemiology regarding COVID-19. These two individuals are releasing biased, non-peer reviewed data without regard for the public’s health.
First of all, their numbers are wrong! California had not “done 4 million tests to date.” At the time, they had done only done 500K tests. The death rate in Sweden is very high if you look at closed cases. Norway has half the population but has had 1/10 of the deaths because they did not overwhelm the medical system all at once secondary to social distancing. Social distancing has helped spread out how fast cases come in and help us find effective treatments. For instance, we now have convalescent plasma and Remdesivir which are showing promise.
I can promise you the deaths are unpredictable and I am seeing people like me who should have great immune systems, die. The biggest problem with COVID 19 compared to SARS or H1N1 or H1N5 or Flu is that there are 40% of people who are asymptomatic carriers and can infect others without knowing–a fact the two urgent care doctors in the video do not even mention one time in their presentation, but it is the single most important fact about this virus versus the others they are talking about. Also, NO ONE is pressuring us to add COVID-19 to the mortality list!
Unfortunately, “isolating the sick” will not work here because so many asymptomatic carriers will spread this disease which is much less true of other infections. We should lock down until we have effective treatments and won’t cause Armageddon on the health system as in New York and New Orleans.
As unnerving as this pandemic is, I find it interesting to witness a new disease firsthand and to see emerging therapies such as convalescent plasma, and to be able to use the skills I have taken many years to develop to help others.
1. MAXAIR CAPR System. Verdict Medical Devices.
2. Furukawa NW, Brooks JT, Sobel J. Evidence supporting transmission of severe acute respiratory syndrome coronavirus 2 while presymptomatic or asymptomatic. Emerg Infect Dis. 2020 Jul . https://doi.org/10.3201/eid2607.201595 DOI: 10.3201/eid2607.201595. Original Publication Date: May 04, 2020 https://wwwnc.cdc.gov/eid/article/26/7/20-1595_article
3. Patrozou E, Mermel LA. Does influenza transmission occur from asymptomatic infection or prior to symptom onset?. Public Health Rep. 2009;124(2):193‐196. doi:10.1177/003335490912400205
4. Parker B, Hart V, Rattan R. COAGULOPATHY IN COVID-19: REVIEW AND RECOMMENDATIONS. Division of Trauma Surgery & Surgical Critical Care, DeWitt Daughtry Family Department of Surgery. Leonard M. Miller School of Medicine, University of Miami. https://www.facs.org/-/media/files/covid19/umiami_study_uses_of_coagulopathy.ashx
5. Hansen M. What Doctors Are Learning From Autopsy Findings of Coronavirus (COVID-19) Patients. Doctor Mike Hansen. May 6, 2020. YouTube. https://www.youtube.com/watch?v=KzKvIYwqQkE
6. Read R. Department of Haematology, University of Cambridge, Cambridge Institute for Medical Research, The Keith Peters Building, Hills Road, Cambridge CB2 0XY, UK. Flawed methods in “COVID-19: Attacks the 1-Beta Chain of Hemoglobin and Captures the Porphyrin to Inhibit Human Heme Metabolism.” https://chemrxiv.org/articles/Flawed_methods_in_COVID-19_Attacks_the_1-Beta_Chain_of_Hemoglobin_and_Captures_the_Porphyrin_to_Inhibit_Human_Heme_Metabolism_/12120912
7. Contreras B. Lung Injury in COVID-19 vs. High-Altitude Pulmonary Edema. April 22, 2020. Managed Healthcare Executive.
8. Luks A, and Swenson E. COVID-19 Lung Injury and High Altitude Pulmonary Edema: A False Equation with Dangerous Implications. https://doi.org/10.1513/AnnalsATS.202004-327FR. PubMed: 32330073. Received: April 12, 2020 Accepted: April 24, 2020 Published Online: April 24, 2020.
9. Zhang Y, Xiao M, Zhang S, et al. Coagulopathy and Antiphospholipid Antibodies in Patients with Covid-19. April 23, 2020. N Engl J Med 2020; 382:e38. DOI: 10.1056/NEJMc2007575. https://www.nejm.org/doi/full/10.1056/NEJMc2007575
10. Ye Q, Wang B, Mao J. The pathogenesis and treatment of the `Cytokine Storm' in COVID-19. J Infect. 2020 Apr 10. pii: S0163-4453(20)30165-1. doi: 10.1016/j.jinf.2020.03.037. . PMID: 32283152 PMCID: PMC7194613 DOI: 10.1016/j.jinf.2020.03.037.
11. Esmon CT. The interactions between inflammation and coagulation. Br J Haematol. 2005 Nov;131(4):417-30. PMID: 16281932 DOI: 10.1111/j.1365-2141.2005.05753.x.
12. Ricardo J, Ari M. COVID-19 cytokine storm: the interplay between inflammation and coagulation. Published:April 27, 2020DOI:https://doi.org/10.1016/S2213-2600(20)30216-2. PlumX Metrics. The Lancet Respiratory Medicine.
13. Oxley T, Mocco J, Majidi S, et al. Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young. April 28, 2020. N Engl J Med 2020; 382:e60. DOI: 10.1056/NEJMc2009787. Metrics.
14. Cha A. Young and middle-aged people, barely sick with covid-19, are dying of strokes. April 25, 2020. The Washington Post.