Just wanted to share my experiences with COVID-19. I work in the ER so we are on the front lines of this stuff. My state has a large number of corona viruses but thankfully not NYC levels. Yet. I just want to share some thought processes with yall to see the struggles we are having.
The actual number of cases is much higher. For us, LabCorp is where we send our tests and they are 1-2 weeks behind. Tests that I sent out on 3/17/2020 have not yet resulted. Each shift that I work I see a minimum of 1-2 new patients with highly suspect coronavirus. There are very characteristic imaging and lab findings for coronavirus. For me, what I've seen is the patchy bilateral infiltrates on chest xray, and when you CT them you get the characteristic bilateral ground glass appearance. One today was so obvious the radiologist even basically called it. I'm also seeing on labs normal white blood cell counts with lymphopenia and elevated LDH levels, which fits the profile.
As for as how to treat these patients, basically what we are (a large number of us are on a facebook group) doing is if they don't need oxygen, then go home. So today I had a 72 year old female that had cough and fever for about 10 days. Seen by her doc originally with a negative chest xray and placed on antibiotics. Didn't feel any better, had a flu test that was negative, and then found out she had a known COVID-19 exposure via her friend at church who was a nurse that tested positive. Patient had a corona test sent off, but still has not resulted. Was sent for an outpatient chest xray today but somehow ended up in the ER. The ER showed the typical changes of coronavirus so I got a full workup on her while debating what to do as she had already been treated for a pneumonia and didn't get better (obviously because she was on antibiotics which do not help viral infections.) Her case doesn't count yet as a statistic because her test will take 1-2 weeks to come back. Her husband at home has similar symptoms. Thats two more cases that aren't even being counted yet.
My mental debate: we know that around 80% of people with corona infections have mild illnesses, and around 14% need oxygen in the hospital, and around 6% are fucking *sick* that end up intubated and/or dead. And we know that people can have characteristic changes on imaging and be totally fine, and then within hours worsen and end up intubated, and die by the next day. So the challenge I face is anytime I have one, how do I safely discharge them home, and what can I tell them to do at home and when to return to the hospital? Because we can't really just admit everyone with corona virus to the hospital just because they have coronavirus. Like the lady above, if I admitted here there is nothing to do for her. You would just feed her and watch her, maybe give her oral meds for her fever and cough, and you could go whichever way you want with chloroquine / azithro / kaletra depending on which studies you read (to be honest, I haven't dived into this yet because I don't do inpatient medicine.) We also know that the virus is worse in older patients, and this lady is 72.
So what do I do? What I did was cover her with two different antibiotics for a possible bacterial pneumonia, even though I know this is a coronavirus pneumonia and the antibiotics won't do anything, but I could be wrong, I counseled on home quarantine, making sure she has people that can bring her food / groceries, recommend getting a simple oxygen saturation monitor for home, and counseled her to return immediately if she starts to feel much worse or if her oxygen levels are consistently below 92%.
This has been the same situation for multiple patients. They come in, they have this disease that can wipe them out rapidly, and you send them home with instructions to return if anything gets worse. It's terrifying to discharge these people knowing they could crap out and die on you at home. But this is the standard that all of us are doing across the country. We simply don't have the resources to admit people to the hospital just to watch them "in case" they worsen.
Another issue we are all having is personal protective equipment. It fucking sucks. For me to enter a room that I am concerned of coronavirus, I wear a N95 mask, a surgical mask on top of it, eye goggles, a surgical hat, a gown, double gloves, and booties. This pales in comparison to the outfits they have in china, etc. Even the fucking janitor tonight had a better suit than I'm being given in the ER. We try to batch everything with the patient, and we are a lot less personal. For instance a patient may be sitting in the bed, and we will wear our N95s and open the door to the room and talk to them from the hallway without going in the room, to get basic patient history, etc. I will go in the room one time only to tell the patient what I found and what I think and what the plan is, because I can't waste all the PPE (personal protective equipment) to go back in a second time.
And hospitals are ran by idiots. One hospital I work in is trying to really ration out the most basic PPE, and are putting everyone at risk in doing so. For example, any patient that checks in to the ER with any type of upper respiratory infection complaint should be immediately masked and either bedded immediately or placed somewhere that isolates them from other patients. This hospital tonight isn't doing that, so a patient checks in with cough and fever, they sit there and infect everyone around them until they are in a bed. My coronavirus patient tonight, when I came on shift, she was already in the room and had no mask on. Who knows how many people she infected before I went in there and masked her. Insanity.
Another problem we are all facing is stress. This is very stressful for all of us. I know it's stressful for all of you too. We all have kids that are out of school now and placing more stress on out of work life. Work life is terrible. We all are worried about seeing these patients and don't want to get coronavirus. I'm at the age where I could easily be one of those that dies from this virus. We are stressed because we know our systems in place aren't perfect and that these people are just needlessly exposing us. And despite all this, we still have regular sick patients and patients with all sorts of other medical problems coming into the ER, and we also have all the trolls coming in for all of their bullshit (back pain, anxiety, toothaches, chronic pain, hemorrhoids, med refills, etc.) Everyone of them I ask them if they are aware we are in a pandemic situation, and if they've been watching the news that tells them to stay home. Sometimes it's unbelievable how stupid patients are.
And on top of the stress, everything outside of work is coronavirus too. It's constant emails from the state changing their testing guidelines and recommendations, constant emails from hospitals changing their policies daily, constant changes to how to workup and treat these patients, etc. I had three days off last week with my daughter and I neglected her half the time because we had constant coronavirus conference calls and had a coalition of physicians that met from all the local hospitals to figure out how we can come together as a community to help out.
And on top of all of this, you have malpractice to worry about. We all want to make the right decisions, but god forbid a novel virus comes in and infects a patient and you make a bad call and the person dies and now they want to sue you for not being able to accurately predict how a horrible virus was going to act in one specific person. There is no real "standard of care" for coronavirus patients. We've all mostly adopted a similar way to practice, but at this point it's just what seems reasonable. We may be completely wrong. It's stressful!
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