Covid-19 In The Surge, April 25th

It’s April 25 and I’m back as Robin Schoenthaler-the-Boston-cancer-doctor-writing-about-Covid and we in Boston are in the surge.

All the numbers are in the thousands now, making it harder to wrap our heads around them Thousands of new cases a day. A thousand people in ICUs. 2700 deaths.

Boston, our magical medical megalopolis, has pulled off a miracle and it looks like we’re not going to run out of ventilators. The hospitals begged and borrowed and re-allocated. They transformed wards in a week-end into ICUs. They “deployed” scores of my doctor and nurse friends to take care of the thousands of critically ill patients.

Some of my friends sent their children away to live with relatives so they could take care of your relatives. Can you imagine? It’s like the Blitz in London. And every day, they helped 5 or 10 or 25 patients leave the ICU. And every day, 10 or 20 or 50 new patients filled those beds up again. It’s like the Civil War hospitals. Can you imagine?

Every place has all hands on deck and everything’s transformed. An ambulance garage is now a test swabbing unit (right next to the decontamination bay, a sight to see). The Brigham’s started using a robot. At MGH, an office space with gorgeous views is now a souped-up PPE-thick clinic exclusively designed to take care of Covid-positive patients who have other medical problems. So the hundreds of people who have the double whammy of cancer AND Covid — or Covid AND multiple sclerosis — or Covid AND a broken leg (can you imagine?)— they now have a safe place to go while keeping the rest of the clinics a safe place to be.

Speaking of safe places, the ERs are some of the quietest places around. Nobody but Covid patients are going to the ER these days leaving us scratching our heads — where’s all the other sick people? Unfortunately, people are so scared of Covid they’re not coming to the hospital which means appendixes are bursting and people who are having heart attacks or strokes just might be dying at home like in New York. PSA: it’s okay to come to the ER! They’ve got their PPE (well, mostly: the yellow gowns of all things are a critical shortage in MA but doctors and nurses are making do with garbage bags and Tyvek suits (!)) and people are there to serve you.

All this work on Covid, though — the hundreds of “deployed” docs and nurses and research assistants, the anesthesiologists working as ICU docs, the medical students helping with the records — it can’t continue at this crisis level for long.

Except it will.

We’re at surge In Massachusetts, maybe a couple of days past the ICU peak, but the curve going back to “acceptable” or “non-crisis” numbers — it’s very very gradual. If you look at the post-surge curves of other countries you see that it takes WEEKS AND WEEKS to get back below catastrophic. We went very high very fast — but then people stay sick and hospitalized and in the ICU a long time and we keep getting new cases — so for weeks we will have to work like this.

The closest analogy I can come to is it’s like a car in a circular garage that went up eight levels in a car elevator — whoosh! — but now needs to drive round and round and round down all the spirals to get down to ground level — and every minute of the way we have to hold on tight to the steering wheel or it will go out of control.

Lessons from the US experience so far:

  • It’s still mostly cough, shortness of breath, fatigue, fever, GI symptoms.
  • 85-90% of people get better on their own — some as sick as they’ve been in their life, some with no symptoms at all
  • Both are contagious.

The 10% of people in Massachusetts who get admitted often get sick at home very quickly, usually a week after symptoms start:

  • suddenly more short of breath
  • breathing faster (>24/minute)
  • very weak, maybe dizzy
  • bad chest pain
  • low oxygens on the pulse oximeter (less than 90)

CALL YOUR DOCTOR. GO TO THE ER. People who are starting to fade can fade very quickly and some people who don’t go in you die at home. It happened a lot in NYC and word is it’s starting to happen in MA.

Lessons from the ICUs so far:

  • People with hypertension and diabetes have more trouble.
  • There’s a problem with clotting and we’re seeing lots of strokes and blood clots and clots in weird places (even toes).
  • There’s a problem with kidney failure (and access to dialysis).
  • There’s a problem with people being so weak and debilitated after their hospitalizations that they can’t go home, so now we’re working hard on creating safe places for them to go.

Lessons from the ER, where people can get so sick so quick:

  • Bring your papers with you.
  • Bring your list of emergency contacts, your advance directives, your health care proxies. If you can’t breathe, you can’t talk. You can’t have any visitors, so no one can speak for you.

Write it down:

  • Do you want CPR (almost no one with Covid has survived after CPR)?
  • Do you want a ventilator (a machine breathing for you, possibly for weeks, during which you are paralyzed and sedated, with a recovery rate somewhere between 20 and 60% depending on your baseline health and age)?
  • If you are getting sicker, would you want to be enrolled in a clinical trial?
  • Do you want dialysis?

Freaking out/need help with this?

  • Google “Advance Care Directives and Covid-19”
  • Or go to…/2020/04/tcpcovid19guid…
  • Or…/Proactive_Care_Planning_for…

Just please, please, go have these difficult conversations with your elders and your kids because those written words can speak for you and give you the death — or the life — you choose.

As to the antibody testing that everybody’s crowing about, know this: the FDA let everybody and their grandmother make a test (I think there’s like 90 out there) and so far they’ve only vetted four of them. Some of these tests are probably okay, some are definitely bad, and some are a scam.

Bottom line: does a positive antibody test from most places mean you had Covid-19 and won’t get it again? The answer is currently no, the test could well be meaningless; we don’t have the science to say that. The science will come; the science is moving faster than it ever has in history. But first we need data and we don’t have it yet.

And as to When Will It End: nobody knows, nobody can predict, we need more data: we need to see how long it takes us to get out of this dang circular garage.

All we know is that releasing us (and our health care workers) from our current bindings can maybe possibly be done safely when based on data (when cases are down, when testing is up, when PPE is everywhere (eg when nobody is wearing scuba goggles or garbage bags), when ICUs can be re-staffed and re-supplied for the inevitable rise in cases.

But a state or city that does so without data has the potential to become a Living/Dying Case Study that will be published in medical journals for us to learn from at potentially horrible cost. My heart goes out to all.

One last note because I so love — so deeply love — the triumph of the human spirit at all times but especially now (also why I love memes): many of our hospitals throughout Massachusetts have begun to play music over the loudspeaker on the ecstatically happy occasions when a recovered Covid-positive patient is wheeled to the hospital lobby for discharge.

BMC and UMass have played Journey’s “Don’t Stop Believing” while Lowell General plays Aaron Copland’s “Fanfare for the Common Man.” The theme from Rocky is played at Baystate. Emerson and Melrose are playing “Happy” by Pharrell Williams. One hospital plays “Here Comes the Sun” and one is thinking about “Man in Motion” from St Elmo’s Fire (“I can see a new horizon underneath a blazing sky…gonna be a man of motion, all I need is these pair of wheels.”) One is (horrifyingly) playing Chumbawamba’s “Tubthumping” because, as one of my doc friends said, “simply working in healthcare during the pandemic is not torture enough” LOL. Sturdy is playing “Ain’t No Mountain High Enough.” Tufts has played “Beautiful Day” and their YouTube video showing some of their first discharged patients will bring tears to your eyes and more than anything will make you happy you can breathe.

Needing a playlist to get through your physically distanced days? Well, here ya go. Except for Tubthumping.