Update on Corona 3/20/20
Hey everyone thought I would give an update on the past weeks events in my ER.
I wanted to start it off with if you are feeling flu like symptoms DO NOT GO TO THE ER.
The best place for you to be is home unless you are feeling shortness of breath.
Your likelihood of contracting corona virus is much worse by sitting in a room with multiple possible PUI (persons under investigation).
At this particular juncture if you test positive or negative for the corona virus there is no change in treatment.
There are multiple drive through stations if you really want to get tested I would recommend going to one of these.
My hospital has taken everything to the next level. We currently have a multiple screening situation.
We have a tent outside with an MD who triages possible PUI’s to particular stations within the ER.
It is great to see diplomacy thrown out the window our hospital is getting stuff done.
Usually its takes forever for hospitals to make changes but management has been working 24/7 around the clock and has added multiple stations of negative pressure rooms
I am currently stationed in the COVID zone. Where i have 16 reclineable chairs.
Over the last week my team consists of Me, one nurse and a tech.
We have a quick Viral panel ( FLU / RSV ) and also strep testing kit that gives us results in 5 – 15 min. An EKG machine and also a portable CXR.
For patients who are short of breath it should be noted that using inhalers / nebulizers ( the mist used for asthmatics ) is not a good idea : it aerosolizes coronavirus and spreads the virus into the air.
In the first few days in the zone I was swabbing everyone for FLU / RSV / Strep just to see how many cases there were and very few came back positive so we scrapped that idea and now are only testing for corona.
After seeing hundreds of patients with coronavirus over the last week I came to some more observations.
First I will lay out the timeline of what I have been seeing with patients
Day 1 : sore throat
Day 2 : cough / runny nose / body aches
Day 3 : mild fever ( low grade 100 – 101) / Headaches
Day 4/ 5 : SOB and some pleuritic chest pain ( tightness in your chest thats hard to describe by most people who have it : an uncomfortability )
Day 4 – 10 : This is what I consider the danger zone : Some patients with shortness of breath are deteriorating in this time frame not quickly though.
it is taking multiple hours to even a day where their oxygen saturation is decreasing. Most patients are tachycardic ( fast heart rate ) and tachypnic ( fast breathing ).
Day 10 – 14 : Everything levels out and patients are starting to improve
My initial observations were pretty inline with what everyone else is stating :
I originally posted the sickest patients I saw after 3 days were ages 20 – 40 females.
I will change this to 20 – 55 and due to the small sample size in patients I have been seeing a lot more males now but the split is probably 50 /50.
Over the last week my ER has intubated a handful of young healthy patients.
If i were to put a number on this I would say its probably 1 / 3000 people with that number getting smaller every day.
Our ICU is currently filled with nursing home patients who have contracted the virus.
The majority of them are not doing well and will probably pass from this.
It should be noted that in FLU outbreaks this is something that we commonly see.
To further strengthen my original observation of children not contracting corona virus …
I have seen hundreds of people over the last week and only seen one child who was probably 12 years of age who I think may have had it.
Otherwise children under the age of 17 again are not being affected by the virus. ( in my previous email i was suspicious of the virus invading lymphocytes causing an immune mediated response which I am now more certain is probably whats going on. )
I have been seeing clear chest xrays unless patients have been symptomatic for about 6-7 days.
I have included a picture of a normal Xray and a chest Xray of a healthy 40 year old with coronavirus.
I have also included some photos of a CT scan of a healthy 50 year old female with coronavirus.
All of these have been in line with what everyone else has seen diffuse patchy viral like infiltrates on chest xray and also peripheral ground glass opacities on CT scan.
Currently there are no direct treatments for coronavirus.
I have discussed with infectious disease specialists in my hospital and for the intubated patients they are still giving Chloroquine and keytruda.
There are multiple studies coming out every day with varied results.
The healthy 27 year old who was intubated and on ECMO ( lung device used to help with oxygen saturation ) is now off of ECMO.
Still intubated but she is improving. She is currently on chloroquine and keytruda.
One point that I wanted to bring up was on the contagiousness of the disease. Current reports say that corona virus is rated as a 2 – 4.
I have never seen a virus spread like this in the 20 – 50 year old demographic.
As previously stated I was concerned that the virus is indolent at the beginning phase ( walking around assymptomatic ) and that’s how people are spreading it.
Again the smartest thing for this is the 2 week mandatory self quarantine / social distancing.
Overall summary : I have seen hundreds of patients with coronavirus.
I have upgraded my concern from mild to mild – moderate for the sole reason that I have never seen young healthy patients with such terrible chest Xrays.
I have been an attending physician since 2013 and in normal circumstances I would never send home a person with such a drastic chest xray.
Usually I would admit them to the hospital and observe them for 24 – 48 hours however these are unprecedented times where I am sending home multiple people with this similar problem.
I have heard of some NYC hospitals admitting every person with radiological evidence this would lead to multiple hospitals being overwhelmed with patients.
My hospitals current criteria is if your oxygen saturation is close to 90 % and if you are tachypnic ( breathing rate over 20 ) we will admit you and we round on you every 4 – 6 hours.
My current recommendation is to wear an N 95 mask if you are going into crowded areas or just avoid them altogether.
I have asked my own parents to stay at home at this particular juncture and if they need anything for me or my siblings to get them things.
I am practicing self distancing myself . I haven’t had a beer in 10 days and for those of you who know me probably my longest tenure since Villanova ????
I was supposed to be flying to florida right now to visit my best friend Brian but I have to practice what I am preaching.
It is very interesting to me because where I work is a few miles out from New Rochelle supposedly the epicenter of the first coronavirus case ( i have heard the lawyer is extubated and doing well ).
It should be noted that the same lawyer is part of a jewish congregation that many of my fellow colleagues attend.
I know multiple doctors who have contracted the virus over 2 weeks ago and are back to full health.
Again my real concern is for younger patients who have been presenting with an ARDS ( acute respiratory distress syndrome ) picture.
Also to reiterate the point that people who have mild symptoms like cough / low grade fever are probably spreading the virus without even knowing it.
I again think the smartest thing we did is the quarantine to ” flatten the curve.” Overall though with the rate of the disease spreading I agree this is going to be around for a while.
Another point to make is. Coronavirus is not new. Every winter I diagnose multiple cases however every winter the strain mutates.
If you recall H1N1 it basically means that the subtype of the virus is changing.
This is the theory behind the flu vaccine : every year the flu vaccine consists of the 2 most common subtypes of the flu from the previous year and then they throw in another random subtype.
For my family and friends who are concerned about me. Don’t be : ) Life works in mysterious ways. I have been trained by the best city in the world.
My hospital has provided me with the safest work environment. Our staff is vigilant, my focus is on point.
I am doing what I have always wanted to do. Help those who need it most and provide them with reassurance that everything will be just fine.
Stay safe everyone !
Manny Fajardo MD