Tuesday, July 21, 2020
Friday, July 17, 2020
Covid19: When the Pandemic becomes Endemic – Spoiler Alerts
Okay, friends and family – I have been asked by many folks to share my thoughts about Covid-19 not only because I am a “front-line” person who goes to work to take care of Covid-19 people every day but also because I am an MD/PhD educated, board certified pulmonologist who has been operating ventilators and reading science long before it was cool. Fine – I am happy to share my expertise but… first a disclaimer…
I don’t care about convincing anyone of anything. I’m not interested in a debate or trading references or anything of the kind. If you think I’m wrong on something – that’s great – I am not encouraging a debate. This is my perspective given my education and experience. If something is confusing or needs clarifying, then I will try to clear it up but honestly, if you don’t want to read more – don’t. It’s not a big deal, and I don’t really need to educate anyone about anything outside of work. Secondly, some of what I will relate/suggest is my approach alone (and my opinion alone! Based on my own thinking about Covid-19) – you won’t find it in “current guidelines” or UpToDate or anywhere else (especially not the avalanche of bullshit – ahem, expert opinion coming out of XYZ). Again, no need to debate and feel free to ignore this whole post and we can go on being friends as usual. Third, some of what I have to share is upsetting – so be it – this is intended for an adult audience only.
For practical reasons I have divided this up in sections – and I will try to employ a brief Q & A, or FAQ approach – if you have a legit Q or FAQ, I might add it to the FAQ – you never know. And finally, unlike Tony Fauci – I don’t have to worry about offending Trump or Trumpers with a little reality and/or my political opinions such as they cross-pollinate with this subject. Again, these are my thoughts and your feelings about MY opinions do NOT interest me, this is strictly a public service for those that want it.
Practical Stuff – i.e. What do I do WHEN I get Covid-19
Q –Will I get Covid-19?
A –Yes. There is enough community spread of this disease that we will all get exposed sooner or later, and we basically all get it when we are exposed with an adequate inoculum (more on that later).
Q –If I have to get Covid-19 – why take any precautions at all?
A – A few good reasons – collectively, we cannot afford to get it all at once – since it is really hard to guess who will need hospital oxygen and ICU level care (ventilators and other sexy stuff), we don’t want to run out. The whole point of “Flattening the curve” was not to prevent any spread (or new cases). That’s impossible – but if we slow down the rate that people get it – then we can treat those who would die without good treatment. Also, the longer you avoid it – the better we get at treating it. I’m already better at treating this than I was three months ago, and I have access to better information about using steroids, ventilator strategies, anticoagulation, blah blah blah all the time so the longer you and your family avoid getting sick, the more experience and tools I will have when I treat you.
Q –How do I know if I have Covid-19?
A –You will have fever (get a digital thermometer) and you will feel crummy. If you have a fever and feel crummy, you have Covid until proven otherwise. Act accordingly (see below). If you are still too stupid to get a $10 digital thermometer while there is a global pandemic and you think you are gonna die – send me a message, I’ll loan you one, but that’s pretty stupid. Hahahahha.
Q –Should I get tested if I have a fever and feel crumby?
A –Sure – won’t hurt. But if you don’t get tested then still assume that you have it.
Q – I feel okay (no fever, nothing really new (out of my usual hyperaware state now with every little throat scratchy or sneeze making me crazy). Should I get tested?
A –No. On a symptomatic day – the RT-PCR test (Nasal swab test) is only 65% sensitive so a negative test doesn’t mean much and it only is a snapshot for that day. A lot of people think they can get tested and then be okay visiting old relatives. That’s a silly waste of a test. If you’re symptomatic you shouldn’t visit vulnerable people and if you’re not, you only have (at best) about a fifty-fifty chance of detecting your infection and you can still get infected as you travel. As of now, tests for the “worried well” are just wasted tests.
Q –I’m sick (I have Covid) – what should I do?
A –Rest. For reelz. Isolate. For reelz. If you are symptomatic it takes 1-2 weeks to really get better. Plan on that. Do not take a lot of weird bullshit you’ve never taken before. If you do that you won’t know if you are sick from being sick or sick from the new weird bullshit. Weird bullshit includes hydroxychloroquine (or anything that sounds the same), mega dose of any vitamin or anything you read about that is being used to treat another disease that doctors are “investigating.” You CAN take half a full-size aspirin a day (since Covid causes blood clots and strokes) unless you have had issues with bleeding and you SHOULD take STROKE symptoms seriously (even if you are young).!!!!! So facial droop, slurred speech, can’t move my arm – don’t blow that off. That’s a real emergency– go to the emergency room right away – you may need to get a clot fished out of your lucky head and there are strict time limits before that kind of thing stops helping.
Q –I’m sick (I have Covid) and I’m having trouble breathing. What should I do?
A –Go to the emergency room or at a minimum check your oxygen blood saturation (digital monitors are $20-$40 on Amazon). If you are reading less than 92% on room air then you need oxygen – suck it up and go the emergency room – you have Covid already – and you need oxygen. If you don’t trust the reading (i.e. It reads 60 or 70 or 80 %) test it on another human (who feels okay) and if it works on them, but it reads less than 92% on you, then again, go to the hospital. You might not feel that bad, but your body is short of oxygen and you could collapse at any time. If you can’t spend that kind of money on a O2 monitor and you think you are dying/hypoxic send me a message and I’ll loan you a monitor. But honestly – it’s like $30.
Q –How do I avoid/delay getting Covid?
A –Wear a mask (over your nose). While wearing one under your nose might prevent you from spreading it – the limited protection you get from wearing one with your nose exposed is zero. Avoid hanging out indoors with people you don’t want to get Covid from. Everyone you spend time with indoors should be a person you don’t mind getting Covid from – if fact, you should just assume that you will get it if they have it (they might not know it).
For the record, isolating amongst people you live with next to impossible. Same with cars. You won’t get it from touching random doorknobs or street signs or even shopping cart handles. Way way too much time and bullshit has been spent trying to “sterilize” objects. Put your effort into thinking about your direct contact with people – especially inside. In case it isn’t obvious yet, outside is better. Air flow is good (it reduces the concentration of any infectious agent/inoculum) and sunlight kills Covid pretty quick. 10 minutes in the sun kills 90% of the virus. You won’t get it from a casual walk-by contact while you are outside exercising – that’s very unlikely, you’re going to get it from a party or at work or delivering a very large pizza to a very small person in a medium sized elevator.
Q –How do I reduce my chance of dying when I get Covid?
A –Delay your infection as long as possible. Stop yelling at everyone else for not keeping you safe – it’s not their job and it’s not really possible and it raises your blood pressure. You are part of an endemic infection attacking our species and that’s not going to change anytime soon – so stop attacking your friends (the only people who will listen to you anyway) and start being proactive. Get your chronic health bullshit under control –if you smoke – quit. If you have high blood pressure – stop with the salt/junk food. If you’re fat – lose some weight. If you’re diabetic, take your meds. You can’t make yourself younger or change your blood type but you have had (and will have) literally months to address this stuff and if you face this disease with your chronic health bullshit out of control, you have blown off the things you could have done to help yourself get through it more easily.
Q – I don’t want my sick-old-obese-immunosuppressed-diabetic-friend-lover-mom-dad-kid-mailperson to get Covid – what can I do besides pointing fingers at everyone else and being a pain in the ass?
A –Keep the vulnerable isolated and interact with them yourself in low-risk/transmission ways – Assume it is in the community. I’m sorry to say but those with real risk factors have to seriously consider that they will be in isolation for a very long time – perhaps indefinitely. Even with a vaccine (or more likely many suboptimal vaccine options) they will still face a difficult choice about how much risk to allow into their lives balanced against how much they want to interact with their friends-lovers-moms-dads-kids-mailpersons. The risk from small groups of people (or a single person) on a given asymptomatic day is really pretty low and we should keep in mind that some of our “vulnerable” people would rather risk dying than miss out on years of the kind of in-person hugs and visits that make life worth living.
Q –My (insert person here) died and there is a funeral – should I go?
A –No. Avoid large gatherings period but even more concerning – if you have a person in your family that got really sick, you are playing with fire – I have seen multiple members of the same family get destroyed by this disease – there is a genetic susceptibility that we haven’t really characterized yet so take your Covid family history seriously.
Q – I had to go to the hospital – am I going to die?
A –No. The vast majority of people will not have to go to the hospital. Of the people that have to get admitted to the hospital for oxygen, only a small portion need the ICU (around a quarter of them) and only half of those will need a ventilator, and only half of those will die – and I’ve had lots of old people get this and come out okay on the other side, but having said that – if you are helping to make decisions for an old sick relative, especially if they had kidney failure beforehand (have been on dialysis treatments) that’s a really bad set-up. People with kidney failure from either diabetes or high blood pressure or both have had those diseases for a long time – and their bodies and blood vessels are far older than they look. Don’t neglect the suffering they may be enduring in the ICU. Especially if their quality of life was not so great beforehand –they often suffer for weeks in the ICU before dying and sometimes it takes a clearheaded person in the family to say that so-and-so might “be a fighter” but that doesn’t mean that if they could make their own choices that they would choose to die in pain.
Science and Epidemiology
Q –How important are masks?
A –Hard to say for sure but they do slow down spread so we should be embracing them. Having said that, masks when you’re alone, when you’re outside alone, in other words when you’re in low risk situations just doesn’t make that much difference and if it keeps you from complying in high-risk (indoor, crowded) situations – then refocus you energies on those high-risk situations. There is such a thing as alarm fatigue, compassion fatigue, concern fatigue, stress fatigue, fatigue fatigue. Embrace the mask when you need it so you can do the most good. However… don’t kid yourself – even if everyone had masked up right away, we still would have this disease to deal with and we’d be having similar conversations off and on for the next few years.
Q – I read a lot about the R0 – (pronounced R’naught). What is the R0 for this virus?
A –The overall R0 (the number of new cases each confirmed case is likely to generate) will change based on the social context – part of avoiding large events/super-spreader events is to reduce spread (not eliminate – that’s impossible kids). So when we change our exposures/behavior as group, this also affects the R0 and that’s why outdoor events are better than indoor and small events are far less worrisome than large from a public health standpoint.
Q –Why is the mortality always changing, and/or going down when more people are getting infected?
A – A few reasons. 1) we are getting better at treating covid19, 2) the people who are getting it are generally younger and healthier so fewer (not zero) are dying 3) it’s too soon – diagnosis lags 1-2 weeks behind the infection event, and the deaths lag 2-4 weeks after the diagnosis, and the reporting lags a week after the deaths. So depending on the data you are looking at, it's always already somewhat behind. That’s okay – it’s true of the night sky too – if you don’t know what I mean, I recommend a “A Brief History of Time” by Stephen Hawking.
Q –Why are we doing worse than the rest of the world on Covid measures?
A –We are a large heterogenous country, with lots of tolerance for individual liberty which simply prevents us from doing the draconian public health measures that are needed to really control a highly transmissible respiratory illness. We also have had no leadership (or counterproductive anti-leadership) on a Federal level so our responses and decision making have all been on a local level. This is not good but it is also not all bad - the good news is that your local environment i.e. Your local ICUs and hospital capacity are a good measure of how well your local area is dealing with the pandemic/epidemic and opening and closing the tap (see below) can and should be done a hyperlocal level. In addition, and I cannot emphasize this enough – any reckoning of “how we’re doing” needs to account for the fact that we are still very early on in this pandemic – this is a new disease for our species (more below) and it will be a long time before we get a real handle on the health, economic (also important!), and psychosocial (also important!) impacts.
Q –Why don’t we just hunker down and wait for a vaccine – it’ll be here by the end of the year.
A –Already we’ve shown that we can’t do that. Not only is it really hard on our economy (just ask any of your friends and family who are unemployed how their pandemic is going and you’ll have more insight) but be aware that we have never had a vaccine for this type of virus before and furthermore, vaccines have their own problems (some can actually make diseases worse) and often offer only partial protection to some of the population. Usually older sicker people have less robust reactions to vaccines if they do at all. I think we will generally have access to some partial protection in about 2 years and a large portion of our population will be nervous about getting it - in this case, rightly so since any of these vaccine candidates will have been vetted far less for safety than previous vaccine efforts. In addition, as I said, many vaccines only lessen the impact of an infection and do not prevent infection and it is very hard to tell how any given person will respond to an inoculation. So again, eventually we will all be rolling the dice. I do think that in 5 years or so we will have a lot of the data we would like on a couple of different vaccine options and our antiviral and complication therapies will have improved, but by then you will have been inundated with so many Covid “horror” stories, dead celebrities, as well as recession fatigue and mental illness, that it’s hard to predict where most people's heads will be.
Q –If I get Covid can I get it again? Am I safe if I had it before? I think I had it in January or February – actually I’m sure I did, I was really sick.
A –No one really knows. You probably wouldn’t get it again immediately and probably never quite as bad, but that’s a guess. Also, if you think you had it before April and live in San Diego, you didn’t. There was a very nasty strain of para-influenza virus that swept through the US this winter and in the early Spring. That was what you had (probably). While it is tempting to think a sizable fraction of the population has already been infected even outside of the New York area – they haven’t. And for my San Diego peeps – that’s definitely true of you. We simply didn’t have the body count to support that and now independent antibody testing here confirms that our population still remains largely unexposed. That will shift over the course of the next two years. Hopefully not all on the same week! Also a quick word about antibody testing – as of now, it’s not helpful for an individual – until there’s a larger pre-test exposed population amongst us there is still a 50/50 chance that any positive is a false positive– so don’t be a sucker for that either. You can look up specificity and pre-test probability for extra credit on your own time.
Q –You are talking about time frames like 2 years… 5 years… are you crazy?!
A –No, I’m not. Which brings me to the point – if you are living in a way right now that you can’t sustain for that period of time, you probably have to tweak your personal behavioral code to match your personal risk/benefit calculation. It’s probably not reasonable for most of us to not meet anyone new in person for 2-5 years (or to demand that people do so). Likewise it probably is reasonable to limit indoor events to just small groups of participants and to ask everyone to mask up in those contexts.
Q –California has like tons of metrics to measure what we should be doing/opening, etc. why aren’t we hearing more about that and blah blah blah.
A –As I’ve said before – the only metric that really matters is hospital/ICU space. If you have hospital/ICU space then people who would survive with good care won’t die from inadequate care. The rest is all gobbledygook that are best-guesses for surrogate endpoints. Think of it like a tap. When the hospitals get full you close the tap (risky social interactions: multi-people and indoors) until they are less full and when they are less full you open the tap (more interactions) until they start to fill up again. It is trial and error and it’s the best way we have to minimize avoidable death. Notice I said “avoidable” deaths – not all deaths. This will kill quite a few people and while that’s sad it's also part of life. Everyone gets sick and everyone dies – what is so scary is that this is a brand new way to get sick or die.
Q –What about my kids?
A –They’ll be fine. In fact, we should all be super thankful to our gods and monsters that this doesn’t affect kids more severely – there’s no obvious biological reason that should be the case – imagine for a minute if you were asking people to go to work (and feed you) if there was even a 5% chance this disease would kill their children or put them in the hospital. Now take a deep breath and be ecstatic that almost all kids will shrug this off. Having said that, we don’t know much about kids as transmitters and/or reservoirs but they probably are, and that is just another reason this will be with us for a long time. Oh, and you cat people – probably your cat is a reservoir too – ah well, nature is funny. One thing that is a rotten shame is that keeping your kids super isolated is probably not a great idea (they need peers for their brains to grow, and you – as much you’d like to be – are not a peer). So you might need to let them out into the world even if it puts you (and the adults they interact with) at some risk, but again that’s a decision each parent has to make.
Q –No seriously, what about that Kawasaki thing that happens to kids?
A –It happens really rarely – like barely at all, and it’s pretty easy to treat with steroids. But this brings up a good point – this is a new disease, and so as it affects so many people (literally hundreds of millions of people will be infected this year and billions in the next 5 years or so). We will see lots of unusual cases and unusual outcomes and unusual stories – but these shouldn’t dramatically impact your thinking about what you should or shouldn’t be doing. You don’t stop flying because of a crash and you shouldn’t stop eating because a friend got food poisoning. There are lots of horrible, kill-you-tomorrow-with-no-warning things that pop out of nowhere (google aneurysmal subarachnoid hemorrhage if don’t feel like sleeping tonight) but we live our lives by basically internalizing and then largely ignoring that we are all going to suffer and die. That’s been tough to do the last few months since Covid has dominated everyone’s every waking moment – but we do need to remind ourselves that just because we are gonna die doesn’t mean we shouldn’t live and that to be alive is an inherently unsafe state of being. It always was.
Q –Why didn’t this just “go away?”
A- There are so many things that do just “go away.” But this actually points out some very interesting things about the times in which we live. First of all, if you put in place leaders that want to hollow out and dismantle the government (and they do that) then you don’t have government available to deal with a real crisis. And that’s what this is – a real crisis. Many crises are non-sense. Trade wars, real wars, the price of a paperclip – these are all things that humans agree to disagree on, and because of that – they are hugely impacted by perception. These joint delusions about whether a piece of paper (dead trees with ink) can really make you rich or poor is a function of our agreement that it does, and therefore is subject to the “reality distortion fields” that Steve Jobs used to motivate engineers to make the iPhone and motivates the Instagram Universe to make Kylie Jenner a star. However, there is a layer of reality that doesn’t care what you agree to or not – it just is. This objective reality is reminding us in gentle terms that we can throw whatever tantrums or parties we’d like – nature does not care. There are basically two human responses to nature – Faith which helps us to appreciate and accept nature, and Science, which helps us to understand and influence nature. When we turn our backs on Science we are basically throwing our hands up and saying to nature – do whatever, I give up, my Faith and Philosophy will help me accept whatever comes. That’s a totally okay thing to do – it’s just not what I want to do. So, in the future you will find me a more vocal advocate for Science – and I hope you will be too.
I hope this was somewhat helpful and if not – no big deal. Try to remember that everyone is suffering, each of us in a slightly different but equally valid/terrible way, and if it’s possible to be nice to someone – especially someone who is suffering in a way different than you, it might be good karma to do that. Just a suggestion.