Covid-19 Starting The Surge, April 18th

Hi, I’m here with my weekly FB missive as the Boston-cancer-doctor-who-writes-about-Covid. Feel free to share as you see fit.

In Massachusetts we are in the surge, still pre-peak. 1560 deaths (an all-time high of 159 deaths reported on Friday; 13 in Arlington), three times as many as last week. More than half in nursing homes. Horrid.

Particularly brutal emerging news: it’s sooooooo contagious in the asymptomatic. Maybe even the most contagious just right before symptoms.

The hospitals are brimming over with COVID patients. Seven times as many critically ill patients are at MGH as usual, 349 COVID-positive patients there right now. The hospitals have stopped all but the most critical of surgeries — unless you are an abject emergency there are almost no operations (MGH is using 7 of their 70 ORs), no colonoscopies, no mammograms, no hip replacements — it’s all-Covid-all-the-time.

All the hospitals have increased their number of ICU beds, some hugely. On March 13, MGH had 18 COVID ICU beds; now they have 206. Brilliant pre-planning and background work means these hospitals are currently keeping up (just) with this gigantic surge of super ill patients.

Many with super complex situations: at MGH and BMC in particular, scores of patients are from the extremely hard-hit Chelsea/Everett/Revere/East Boston areas with all the challenges of language and culture and how do you go home to self-isolate in a crowded apartment with a bathroom down the hall? Wicked hard stuff.

To take care of all these patients, most of the hospitals have now “deployed” doctors and nurses to work in COVID floors and ICUs . Medical students are “graduating” early to go and work. Think how brave your friends the health care workers are! They are all our heroes in yellow gowns. It’s all hands on deck, and it’s going to be like this for a long while, even if we hit peak as expected by next week.

The Brigham is now taking overflow cases from BMC and North Shore which have been hit very hard. (All the Metro Boston hospitals have a daily phone call to figure out flow.) Three new “base camp” hospitals have been set up in Boston and Cape Cod and Worcester with a new one in Lowell coming up.

Getting supplies continues to be a nightmare. The Commonwealth asked the federal government for 1700 ventilators; they received 440. Yesterday Children’s Hospital sent dozens of ventilators to MGH. Hospitals and nursing homes still, unbelievably, need PPE.

There’s a horrifying article in the New England Journal of Medicine about the craziness Baystate Hospital has gone through to get masks, including a run-in with the FBI while picking up masks at some unnamed “small airport near an industrial warehouse in the mid-Atlantic region”; it reads for all the world like a drug deal. https://www.nejm.org/doi/full/10.1056/NEJMc2010025… I mention Baystate because a number of Arlington residents have given me their extra masks and that’s where I’ve sent them, so thank you!

Should you wear a cloth mask out there? Sure. Should you get a swab test if you’re symptomatic? I would definitely try. Even if it doesn’t change your management or how long you’re in isolation, it will be important information for you and us in the future (see my facts-and-data-based comments below).

Should you get an antibody (blood) test? Not quite yet. The FDA let companies release antibody tests that haven’t been well-tested or validated and in fact we don’t actually know the exact antibody response to this virus. Wait just a bit til the science catches up and we can give you a test result that means something.

Last week I talked about what to pack in a go-to-the-hospital bag, scaring the heck out of many people (I said phone, long cords, chargers, face cream, ear buds). Even if it’s scary, I do think it’s important to plan like this because if you get Covid, a few days later you can get suddenly very sick (short of breath, dizzy, weak, really super ill) which means you need to go immediately to the ER.

So I asked a group of docs what they would bring to the hospital. One shouted in all caps: ADVANCED CARE DIRECTIVES.

Another, an ER doc, came home after a horrendous shift at a downtown hospital and wrote a heart-rendering post about how awful it is to have a super sick patient with widespread cancer or advanced dementia come into the ER with Covid.

These poor patients: they are too sick to express their wishes, they have nobody with them (no visitors are allowed in Boston hospitals), and the doctors are morally obligated to put them on a ventilator. This exhausted ER doctor wrote: “Bring multiple cards with your family’s name/number…especially for those who are demented, don’t speak English, are in terrible respiratory distress, etc. We do our best to communicate with families… but please if you have a meaningful relationship with someone like this, please try to have this hard conversation before I have to have it, shouted under an N-95 mask, with an interpreter on an iPad they can’t hear, while they are gasping for breath.“

Nuff said. PLEASE talk to your family members about what you and they would want done if you or they were to get super sick and need a ventilator. TALK TO YOUR PEOPLE.

The last couple of days my feeds have been full of itchiness to know when this is going to be over and all this talk about reducing limits. So much angst and the agonized waiting that comes from being in the middle of something.

It reminds me of how our ancestors thought a war would last a week and then they suffered through years of deprivation, or the women walking on widow’s walks who had sent men off on ships for a few months and then didn’t know if they were alive for the next two years, or our great-grandparents during the Depression who thought it would be a year at most and then their lives were profoundly disrupted for half a decade. Our people have been here before.

Because the facts are this: We’re not going to be normal for a long time, and the real question is not about “when normal” but more about “how abnormal.” The fact is, we still don’t have treatment or a vaccine. The fact is, the Boston medical system is brilliant and we are so lucky to live here and through incredibly clever hard work we are hopefully not going to end up having to ration care, this time, but if we’re not careful the next time will be upon us in an instant.

Because the fact is, if we ease up on social distancing willy-nilly, more people will get sick and some will die and we will again take the risk that the medical system will be overwhelmed and your doctors and nurses will not be able to give the care we are giving these poor suffering Covid patients now.

So we have to concentrate on trying to figure out next steps in a rational, fact-and-data-based, maximum-safety, minimum-angst kind of way. It’s a tall order. But any other direction is madness.

If you want to “do” something and help contribute to fact-and-data-based knowledge, there’s a number of easy studies you can enter:

https://eureka.app.link/covid19 https://redcap.idhs.ucl.ac.uk/surveys/?s=JD4RECJKDT https://covid.joinzoe.com/us

And in the meantime: SPRING. I can’t stop gazing at the blossoms: it’s like I’ve never seen them before. And I can’t stop thinking of midshipmens’ wives gazing at them while they waited as well.