bad news getting worse?

Quote

Mike Silverman
Department of Emergency Medicine at Virginia Hospital Center,
Friday night update from the ER in Arlington, VA

Before we get into the vaccine news, I need to tell you that it’s been rough for healthcare workers. We’re 9 months into a pandemic, people are tired and emotionally drained. We’re in a surge with record high numbers of cases and deaths across the US and everyone within the hospital community is feeling this. Although it seems that the DMV is doing better than a lot of the country, we’re also seeing records set for new cases, deaths, and hospitalizations.

Locally, hospitals are full or getting full. EDs are pushed to capacity and beyond. I worked 3 shifts this past week. As a chair with administrative responsibilities, that’s more than usual for me but still less than a full-time doc. About 40% of the patients I saw had COVID. Overall, about half of my patients required admission to the hospital which is a much higher rate than normal. What was a bit different from the first surge is that I saw several patients who came in already knowing they had tested positive and were now sick enough to require the hospital. COVID is so prevalent in our patients that I actually switched to wearing an N95 for the entire shift. For most of this year, I was in the typical surgical mask and would put on an N95 as indicated. But over the last couple of weeks, I feel like I’m seeing so much COVID and so many patients are presenting with other complaints unrelated to shortness of breath and fever, that I needed to better protect myself. We routinely see elderly patients with confusion or decreased eating and patients sent in after having abnormal labs. Routinely, now, these patients are testing positive for COVID and that’s the source of the confusion, delirium, kidney failure, etc… The pictures are me wearing my N95 covered by a regular mask for easy changing and to keep my N95 clean, and then my face after an evening shift. I wore my N95 for 9 straight hours during my last shift. I typically try not to remove it, even to eat or drink, unless I’m starving. I’m not sure my face is any more beat up than normal but it sure feels rough after a shift.

I had a patient die while they were in the ER this week. Over my career, I’ve had countless talks with families about end of life and giving families news that their loved one has died. While I can usually tell if someone is imminently close to death, long ago I stopped trying to predict whether I thought they would die in 6 or 24 hours. Prior to COVID, it was extraordinarily uncommon for a patient to come in awake and talking and then die in the ER. Most of the deaths that we do arrive in cardiac arrest. For those who arrive critically ill, even if we expect them to die, we can usually stabilize them enough to get them to the ICU or elsewhere and they die outside of the ED (I always felt that this gave families a little extra time to prepare themselves and certainly gives them a better environment to grieve). COVID is different. People die in the ER. I anticipated the patient was going to die during this hospitalization. What upsets me so much is that they died alone. I wasn’t able to reach family after the patient arrived to let them know how sick she was, but even if I had, they would not have been at the bedside. The whole thing is awful.

Let’s switch gears and talk about the vaccine, because that’s pretty good news. The FDA said the Pfizer vaccine is safe and effective. Yesterday, the independent review board recommended that the vaccine get emergency use authorization (EUA) for those 16 and older. FDA approval should come tonight or tomorrow. There were a few from the independent review who voted against EUA for the vaccine but those “nay” votes had to do with limited data with the teenager crowd. Overall, data was extremely favorable with a 95% success rate. The data was also broken down by age groups (16 years old and up), sex, race, and to some extent country, and the results are extremely favorable with a >90+% success rate. Side effects were also presented. Most common was fatigue (63%), headache (55%), muscle pain (38%), chills (32%), joint pain (24%), and fever (14%). About 84% of people had some side effect with most resolving over 1-2 days. There is some protection after the first dose but really, getting the second dose is critical.

Early experience in the UK showed that a small number of patients had severe allergic reactions to the vaccine. This has led the UK to recommend that patients who have a “history of anaphylaxis to medicine or food” not get the Pfizer vaccine. Although the testing was great (18,000 people received it), when you think about the type of people who don’t volunteer to be a test subject, you’ll likely find that includes people with a history of severe allergic reactions. This is certainly something to follow. Other things to follow will be recommendations for kids <16 years old (need data) and what happens with pregnant and breast-feeding women or those who might get pregnant in the months following the vaccine.

Testing has gotten really challenging both inside and outside of the hospital. It’s hard to get outpatient testing and as numbers continue to increase, testing becomes more critical. A friend’s kids were exposed this week and they had a hard time getting tested. In last week’s post, I mentioned the Pixel test by Labcorp. I’ve used it before on my family when they needed a test. This week, the FDA approved it for over the counter purchase. It’s simple to use, reliable, and not a deep swab, but will require the patient to mail in the swab (the one I used had everything you needed for shipping in the original package and was simple). Turn around in my experience was about 48 hours so not perfect if you’re sick, but really good for exposure or return to work/school. I don’t know when it will show up to your CVS but it should be easier to order online.

“The U.S. could see around 1,005,486 coronavirus cases per day by January 10, according to the latest forecast by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.” The IHME predicted the “daily case count could be reached if ‘governments do not re-impose mandates if cases increase’ and ‘vaccine distribution is scaled up over 90 days.’” With a 1% mortality rate, that’s 10,000 deaths a day. Currently we’re around 3000 deaths a day. As a country, so many people seem numb to the deaths because it hasn’t hit their immediate circle of friends or family. But, if we all don’t do something, the numbers say that at some point, COVID will hit close to home.

While the vaccine certainly seems very promising, keep in mind that for most Americans, vaccination won’t be available until mid-2021. If we don’t get control over the current surge, the daily deaths numbers will continue to escalate.
Science matters. Wear a mask. Practice physical distancing.

Mike