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
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.
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
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
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
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
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
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
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.