MD meets Mom: COVID-19
#MDmeetsMom #globalhealth
There’s a difference between caution and commotion — and the way we discuss any outbreak or illness determines where on this spectrum we end up. Without transparency, trust, and timely messaging, we create commotion. Caution on the other hand is best encouraged in a calm, familiar, non-dystopian environment with a fact-based and rational conversation.
That’s why I followed my mother around the kitchen while she was making dinner, asking her what questions she had about 2019’s gift for us when we abandoned it for 2020: COVID-19.
“Aww, man, Pavitra, this isn’t a dinner conversation!” some of you will say. To which I’d like to remind you that my parents have not been able to ask me how my day went around the dinner table since I started medical school. Trust me, it’s only gotten worse since I started residency.
Nevertheless, my mother was my unofficial doctor growing up — in a lot of ways, she still is. I got the common cold last fall. Did I know I should rest and drink plenty of fluids? Yes. Did I still call my mom, complain, and ask how I should get rid of my cold? Also…yes. There’s just something so soothing and familiar about being able to hear it from that voice that comforted you as a child.
What I love is being able to reciprocate now and answer the questions she, as a non-healthcare professional, has for me. So without further ado, as my mother mills around the kitchen occasionally interrupting our conversation with the sound of our blender, we’ll commence this inaugural chapter of MD meets Mom.
Q: What is COVID-19?
A: COVID-19 is short for the COronaVIrus Disease of 2019, since the first case was reported in December 2019. It is a respiratory tract illness caused by a type of coronavirus called SARS-CoV-2 (or 2019-nCoV). Usually it attacks your upper respiratory tract, which is anything above your vocal cords — including nose, throat, and sinuses. In severe disease, it can affect your lower respiratory tract, which is anything below your vocal cords — so, windpipe and lungs. Though, at this time, we have little information on how this particular virus works, the virus has been observed latching on to the Angiotensin Converting Enzyme-2 receptors (ACE2 receptors) that are naturally present, much like other coronaviruses have in the past. We mainly have ACE2 receptors in our airways, lungs, and small intestines, though we also have some in our blood vessels.
Q: So, what are some other coronaviruses? How is this one different?
A: SARS and MERS are other notable coronaviruses. The SARS epidemic started in the Foshan municipality of China in November 2002 and is thought to have originated in a bat, with transmission to a civet cat before infecting humans. It was likely spread to humans through raising, slaughtering, or consuming the mammalian host and then transmitted between human beings. The last known case of SARS was in 2004. MERS is also thought to have started from a bat, with transmission to a camel in Saudi Arabia, prior to infection among human beings. Cases continue to be reported worldwide.
Though SARS and MERS are more deadly than COVID-19, this new coronavirus appears to be more infectious, with there being over 190,000 cases detected across 155 countries and regions in less than three months as opposed to 8096 cases of SARS in 1.5 years (though reporting and live tracking is certainly better today than it was almost two decades ago). We also have less notable coronaviruses that cause the common cold every year.
Q: How did COVID-19 get around to infecting humans?
A: COVID-19 has a similar transmission pattern as its predecessors. It was initially found in the city of Wuhan, where it can be traced back to a wet market, much like SARS. It is thought to have originated in bat, which transmitted it to its mammalian host, the pangolin, which likely spread to humans through the raising, slaughtering, and/or consumption of the wild animal. From there onwards, the highly infectious nature of this coronavirus led to person-to-person spread at a scale that threatens to break healthcare systems around the world.
Q: How does it spread between humans?
A: We’re still figuring out the details, but currently, the WHO consensus is that the virus spreads through droplet and contact transmission. Droplet transmission, the main mode of transmission for this virus, occurs when the virus sits inside people’s secretions and travel with those secretions when they leave the body, for example, when someone sneezes. This is different from airborne transmission, which means that the virus itself floats around in the air (outside of a droplet) until you breathe it in. This matters because droplets are larger than the virus itself and much heavier, which means they can’t go as far. That’s why we recommend covering your coughs and sneezes.
Certain procedures and things we may do in the hospital can lead to the virus being aerosolized and airborne, which is why the healthcare community is having a robust conversation on personal protective equipment at this point in time — it’s also one of the reasons why I, and other providers on the front lines like me, have a far higher chance of exposure to the virus than you. So, please don’t stock up on masks — we need them and, currently there’s a serious shortage of masks for the people who will need to care for you if you get sick. One of the details we’re trying to iron out is if there are other circumstances under which the virus is transmitted through airborne spread.
The virus is also transmitted when we touch someone or something on which it is living — this is known as contact transmission or spread through fomites, which are surfaces contaminated by the virus once an infected person’s secretions land on those surfaces. Though we don’t know exactly how long the virus can live on these surfaces, other coronaviruses such as SARS have lived on surfaces of 9 days, and sometimes longer (especially in colder environments). Lastly, the virus has been found in stool, which means fecal-oral transmission can also occur, especially when we do not maintain proper hygiene and hand washing, particularly when using the restroom.
Q: What are the symptoms of COVID-19 and what do I do if I have them?
A: The most common symptoms of COVID-19 are dry cough, sore throat, and a fever (temperature over 100.4). Patients also report body-wide aches. These symptoms can take up to 14 days after coming in contact with someone infected with SARS-CoV-2. Unfortunately, we’re in flu season and these are also the symptoms of the flu. Our healthcare system is not designed for the wave of patients we’re expecting from COVID-19, anxiety about COVID-19, and the stuff we normally see in our emergency departments. This is the position that the Italian healthcare system found itself in as well, and we are trying to shore up and conserve our supplies for the Category 5 hurricane we’re expecting will hit sometime soon. We need your help too. We need you to stay home if you have these symptoms to “flatten the curve” and turn a wave of sick patients into a trickle that our system can handle.
Remember, if you have a fever, cough, and body aches, it is not a guarantee that you have COVID-19. Try to take Tylenol and use over the counter cold and flu medications to help treat your symptoms. In case it is COVID-19, try to keep to yourself as much as possible and avoid Ibuprofen or anything with Ibuprofen in it (unless prescribed by your doctor). The most common formulations of Ibuprofen include Motrin and Advil. I know Ibuprofen is great for those aches and pains, but it may also increase the number of ACE2 receptors in your cells and give SARS-CoV-2 more opportunities to invade your body’s cells.
There are other medications that do this as well, but given how little we know about this phenomenon, continue taking all of your home medications as prescribed unless you are directed to do otherwise by the doctor who prescribed them. Avoiding ibuprofen is a precaution that may be helpful to take until we gather more data to clarify if it really needs to be avoided in this illness — unless it is prescribed to you, avoiding it poses little harm. However, stopping other medications could lead to serious health complications or death.
Symptoms you absolutely should not ignore are shortness of breath, coughing up blood, and chest pain. These can indicate severe or worsening infection, since they often occur with pneumonia (lung infections). If you experience these symptoms or have cold/flu symptoms that are not improving with over the counter medications, you need to get over to an emergency department to be evaluated. In the meantime, try to avoid your older contacts or those with asthma, diabetes, or other major pre-existing conditions, because those individuals have a higher chance of critical illness or death from COVID-19. Also avoid me, and your other friends in healthcare if you’re sick — we’re at a higher risk of developing critical illness as well, though we’re not sure why yet.
Though not a perfect science or a replacement for a medical evaluation, the Human Diagnosis Project has used multiple guidelines to create a tool that can help you decide what to do if you are worried about your symptoms.
Q: How can you distinguish between the common cold, flu, and COVID-19 without testing?
A: No perfect way in mild disease honestly. Coronaviruses, like influenza viruses and rhinoviruses (most common colds), cause the respiratory symptoms we’ve talked about already. Both the flu (which is still alive and well) and 2019-nCoV can cause fevers, chills, and body-wide aches and pains. Tamiflu can help decrease the length of flu symptoms if you have the flu, though there’s no evidence it can help with COVID-19. Some people with COVID-19 have had gastrointestinal symptoms as well, including diarrhea, before they have respiratory symptoms, although this does not guarantee a diagnosis of COVID-19.
Where COVID-19 looks different from other illnesses is in severe disease, when it causes a shortness of breath because of a pneumonia-type picture with CT imaging that can make physicians suspect SARS-CoV-2 in the right clinical context. The only real way of confirming the presence or absence of the SARS-CoV-2 virus in your body at this point is testing.
The thing is, testing doesn’t really change how your condition is managed (unless you have severe disease) and, because testing kits are in short supply, they are generally reserved for patients who are at high risk of severe disease, already showing severe forms of the disease, or who may spread the disease far and wide despite public health measures calling for social isolation. Testing for COVID-19 is essential for our public health and research functions as a society — they help us decide who to quarantine and understand how bad the problem really is at home. But, as a patient, it’s not worth worrying about testing at this time unless you are having the severe or persistent symptoms described earlier. In which case, seriously, please go to the nearest Emergency Department to get evaluated.
Q: How do we treat it?
A: For now, we manage COVID-19 with supportive care. That means trying all those things we talked about two questions ago to manage your symptoms. In severe disease, we may need to intubate patients and connect them to a ventilator to help them breathe. We are also researching the repurposing of other antiviral and antimicrobial medications to treat COVID-19, though there is not enough evidence at this time to endorse the usage of any of these medications in the treatment of this illness.
Vaccine development is also underway, though there are still several questions to answer as we start planning trials. Once a vaccine is deemed safe for use, it is likely going to be our best tool in preventing the spread of COVID-19, just like other vaccines have stop the spread of other contagious (and more deadly) diseases. I cannot stress this enough: vaccines do not cause autism. Multiple studies that were not funded by “Big Pharma” show this and research actually shows that vaccines save lives.
Q: Is it life threatening?
A: Yes, more so for our elderly population and those with pre-existing conditions such as asthma, heart disease, diabetes, or diseases that suppress the immune system. Additional risk factors include smoking, HIV, working in healthcare, and pregnancy. And young people? We’re most definitely not immune either. Rather, in the US, we’re requiring intensive care more often than anyone expected. This doesn’t mean everyone is dying from COVID-19, and much of the panic around this pandemic comes from exactly that belief. Most people make it through, though estimates at this time are still subject to change given the still high number of active cases around the world. In China, where the disease has mostly run its course to our knowledge, there has been a 4% mortality rate and an 87% recovery rate as of 3/19/2020. Though we don’t know what will happen to the other 9% of patients who are still ill, the country’s mortality rate seems to have leveled off.
However, different countries and regions have different survival rates because of their demographics, population risk factors for severe illness, available healthcare resources, and the spread of coronavirus in the region. Take Italy, for example, which shows an 8.3% mortality rate and an 11% recovery rate as of 3/19/2020. This data shows us that Italy is still in the thick of this outbreak, with the majority of cases (over 80%) still being active. Italy also had little warning to enact preventative measures such as social isolation before COVID-19 took root in the country. Additionally, the country’s demographic is the oldest in Europe, with 23% of its residents being 65 or older. Although this opinion is evolving based on new information, it has been thought from illness distribution in China that most deaths resulting from COVID-19 infection occur in people who are 65 years of age and older. With health systems quickly becoming overwhelmed by the high numbers of patients who were critically ill from COVID-19 all coming into the hospital at once, the health system’s resources were not enough to carry the weight of the country’s outbreak.
Percentages can also be somewhat deceptive because those numbers have to be a percentage of something. That something is the number of confirmed cases in a region. To be confirmed, the people in a region must be tested. South Korea has been most thorough in its testing, so their statistics are probably the most accurate for their region’s demographics and healthcare resources. As of 3/19/2020, South Korea has a 1.06% mortality rate from COVID-19 with an 18% survival rate. Because the country has tested a much larger cohort of people, it has picked up on the mild cases that other countries don’t necessarily place in their census — it’s data shows how many people actually recover from all forms of the disease, including mild illness. The country’s incredible surveillance alone will likely have a dampening effect on it’s final mortality rates once COVID-19 has run its course — so will the healthcare system’s ability to target people with the illness for quarantine.
The numbers in South Korea will paint a very different picture from our numbers here in the US. With our shortage of testing kits and our predilection for testing those with severe illness, we’re basically looking at survival in people who are more likely to die because of their illness’s severity. It’s easy to take a look at the numbers and pretend we don’t have a problem here in the US — we only have 11,274 confirmed cases with a 1.4% mortality rate as of 3/19/2020 after all! Don’t forget our recovery rate is a mere 1% as well. That means we don’t know how the 97.5% of active cases are going to progress. Furthermore, we only know about the handful of cases we’ve tested: not knowing someone has the illness doesn’t mean they don’t have it. For our data to be applicable for our population as a whole, we need to test more people to gain a clearer picture of this disease’s prevalence and its mortality in our country.
For comparison to the data we have on COVID-19, Ebola has a mortality rate of 40%, SARS killed 10% of the people who caught it, and MERS continues to kill 34% of the people it infects. Though COVID-19 is less deadly than these diseases, it is more infectious and has spread to over 150 countries whereas the others have only spread to under 30 countries. Though it’s unclear how contagious COVID-19 is compared to the annual flu, it’s very clear that it is more deadly than the flu, which has an annual death rate in the US of 0.1%. This season alone, there have been 36 million cases of the flu and 22,000 deaths resulting from it. Our low recorded numbers of COVID-19 in this country though are unfortunately more reflective of our lack of testing than our actual disease burden — which can be scary because COVID season is pretty much just starting. Those numbers are going to go up as we test more, not because more people are falling sick, but because we’re finally finding the people who are sick.
Q: What precautions should we take to avoid infection with COVID-19?
A: You don’t need to be scared of this disease, just cognizant of it. Being aware of it means working together and making some difficult lifestyle choices. We know that even though the majority of us are safe even if we get COVID-19, there is a large minority of our society that can fall critically ill. Social distancing, which is the policy that most affected regions have called for, helps decrease the chances that those people — you’re elderly employer, your girlfriend’s grandparents, your cousin with cancer, your asthmatic art teacher, and your diabetic doctor — don’t die.
Social distancing also “flattens the curve,” which means it can help us avoid the patient-physician mismatch that the Italian health system saw. If successful, it decreases the punch that a highly contagious disease like COVID-19 can deliver to our healthcare infrastructure. We’re preparing for the storm we think we’ll see, but how bad this is will be determined by how committed the public is to caring for others by staying away from them.
I know that none of this easy, but it is necessary. Our society isn’t used to (or built for) social distancing, particularly distancing that will likely be required for months on end. Paid sick leave is a new concept. Companies have only recently figured out how to use telecommunication services to shift their workforce home. Court systems are trying to walk that fine line between justice and public safety. Mostly, the idea of being forced to stay away from our friends, being told to avoid restaurants and bars, and having that freedom of movement we’re used to encroached upon indefinitely — is a difficult pill to swallow.
So, I’m going to try to define social isolation as some sort of strange mandatory staycation instead. All that planning, packing, and unpacking you have to do after a real vacation — you don’t have to do any of it. You can work from home, sleep in if you don’t have a morning meeting, and take a walk while staying 6 feet away from others if you’re able to. You can finally get to that home improvement project you’ve been avoiding. Or paint that picture you’ve been dreaming of. You can work out in the privacy of your own home to get ready for beach season without worrying what others think.
Though temporary, we also have to make sure this is sustainable, so you’re allowed to leave your house once in a while. Go to the grocery store to buy ingredients for that dish you always wanted to make at home. It’ll be open tomorrow too, so don’t panic and buy everything. If you absolutely have to travel, wipe down your surroundings with antimicrobial wipes and use hand sanitizer. Avoid crowded subways and public places like restaurants and bars — contact precautions are tough to keep when you don’t know who else has been in your seat. Instead of hitting the clubs, hang out in groups of 10 or fewer: invite a few friends over for game night, have a movie night with your family and make some popcorn at home. In cities with worse outbreaks, consider digital communication your best option and try to limit in person contacts altogether. Open a window and take in a fresh breath of air — the virus is not all around you.
And, if you’re sick, it’s really a no-brainer: say no to the invitations, don’t travel at all, stay home, don’t take that walk, and isolate yourself until you’re better. Come to the hospital if you have those red flag symptoms we talked about. Believe it or not, by engaging in social isolation, you get to protect me and my colleagues in healthcare as much as we get to protect you.
As challenging as it is, this isolated existence happens to be a luxury that my colleagues and I in the Emergency Department do not have. We’ll be here every day, every night and every weekend to greet you, care for you, and help you get better. We’ll see the concerns we normally see and new respiratory symptoms that some of our patients will come in with. We’ll hope that we weren’t exposed and stay home only if we can confirm exposure through symptoms or testing. We’ll hope that our hospitals can get the personal protective equipment that we need to do our jobs. We’ll hope that our policymakers step it up, though recent legislation threatening our jobs if we need to isolate ourselves to protect others is somewhat discouraging. But, most of all, we’ll hope that we never have to be in the predicament that many of our Italian colleagues found themselves in when they had to decide who would be granted access to life-saving interventions and who would be left to die.
Q: Do you have COVID-19?
A: No mom, not yet at least. As a healthcare worker, I have a much higher risk of exposure to the virus and, once exposed, I am at higher risk than non-healthcare workers of becoming critically ill. My attending physicians who are older and more experienced than I have an even higher risk of harm than me. Stories like those of the two EM physicians who are critically ill from COVID-19 infection at this time should serve as a reminder that our heroes on the front lines are literally putting their lives on the line to protect our patients — we badly need masks and other protective equipment to limit our exposure to this virus that we are going to come in contact with more often than anyone else. Most people with these masks at home have the option of isolating themselves, but our healthcare providers without access those masks do not have that luxury.
Any pandemic has the ability to make or break our society and, though social distancing is the best way of stopping exponential spread, emotional distancing doesn’t help. The bulk purchases I’ve seen at my local grocery stores leave precious little on the shelves for our sick and elderly neighbors. Forgetting them is emotional distancing — it’s this selfish belief that as long as we’re okay and the people we know are okay, life’s good.
However, being considerate means extending a hand out to those who we don’t know. It means buying what we need so our supply chains don’t collapse under the weight of our distress. It means remembering that others need to eat and use the restroom comfortably in this time of uncertainty too. It means leaving provisions behind for the sick, elderly, and marginalized members of society— all of whom may be more likely to die from this illness than otherwise young and healthy adults. We have to band together as a society and watch out for our neighbors if we wish to weather this storm. As long as we’re cautious, I have no doubt that this too shall pass, but our collective strength and consideration for each other is ultimately going to determine how much destruction COVID-19 leaves in its wake.
Pavitra P. Krishnamani is an EM resident physician with a background in global health interested in innovating how we deliver healthcare to our patients at home and abroad. To learn more about her and her work, check out her website.
