COVID-19 Update No.13: Being A Low-Risk Patient

6/29/2020

How long will this go on? Well, we had the worldwide 1918 Spanish Flu Pandemic, which cycled continuously, with about three major surges of disease and death more than two years. It is a fair guess that 1-2 years of COVID-19 will be prominently in our lives. However, we are physically interconnected across the globe in a matter of hours with air travel. And, this is a below-the-radar SARS-CoV-2 virus that is spreading most vehemently in the 48 hours prior to the onset of illness symptoms, when the unsuspecting host is shedding virus profligately and that person is going about their life with abandon, unaware of the danger they pose to family, friends, co-workers. So, the features of modern civilized society make predictive models of COVID-19 behavior and pandemic timelines tenuous at best.

The best thing has always been to avoid doctors and hospitals by maintaining your health and physical conditioning. More so now, with the extraordinary communicability of this virus as every place in the healthcare system is a trafficking funnel that concentrates the sick, medically infirm, and elderly… those at most risk for COVID-19 fatality. The healthcare system is the worst place to be, the frontlines.

What are you to do? You are not a habitual medical care seeker (there are those). But, you have blood in your urine, unexplained weight loss, fever, extreme new-onset fatigue, or cryptic chest pain. Problems that cannot wait-out COVID-19. And, the collateral damage of COVID-19 contagion is yet to be tabulated- people delaying seeing a physician or going to the Emergency Department because of COVID-19 fear- and die of a stroke, heart attack, septic shock, ruptured appendix, etc.

How do you balance the risk-benefit of being evaluated timely in the context of COVID-19 exposure risk? Below, I will give you practical ideas and actionable points that should provide a template for your medical care until all this is way in our rear-view mirror.

Telemedicine Appointments: Many medical offices are offering at-a-distance visits that may be effective for the problem (we do). Most certainly, the physician should lean strongly toward this type service for those over 65yrs and/or with underling medical conditions. Whether an in-person visit is in the patient’s best interests, and so necessary, is a medical decision by the physician. Ask your physician if they are set-up for this.

Minimize Time in Medical Facilities: This is intuitive on its surface. There are creative ways to do this aimed at infection control. It is all about pre-emptive communications, personal preparations for the appointment, and operational flexibility of your medical professionals. To limit your exposure time to other patients and the medical staff,

  • Complete all forms and provide all documents (updated insurance, prior medical records) prior to arrival.
  • Inform the office staff you will wait in your car until they call you to enter the facility so that you can be showed directly into an exam room, with no time among others in the waiting room.
  • Wear a mask (consider a double-mask, like I wear) and rubber gloves.
  • Have your story (onset, timeline, encounters with other physicians, medications and their impact on the problem or lack of it, prior diagnostic test reports- blood, urine, imaging) written out to present the physician. Optimal if this can be forwarded pre-visit (FAX, secure email).
  • Have your questions and concerns defined and written for the encounter.
  • Try to physically distance (other than the actual physical exam) during the visit (6 feet or more from others, including the physician and staff).
  • Do not be seen by medical professionals who are not wearing masks.
  • Clean your hands when exiting the medical facility, in a building restroom if needed.
  • Most of these measures are also relevant to an Emergency Dept, laboratory, imaging facility, physical therapy, pharmacy, and other medical service locations.
  • Wash your hands thoroughly as soon as you arrive home, touching nothing else (consider keeping hand cleanser in your car, as well).

Potential COVID-19 Illness Case: It is medically irresponsible to have a person who has an illness consistent with COVID-19 come into a medical office, potentially exposing staff and other patients to the virus.

  • Your physician’s staff should be asking each person trying to come in whether they have recently had symptoms consistent with COVID-19, exposure to a confirmed COVID-19 case, or themselves been found positive for COVID-19? These patients need to be turned away from an in-person office visit. The physician can arrange a phone or telemedicine (computer) visit. What if that person is really sick, with ominous symptoms, such as shortness of breath? They must be directed immediately to the hospital Emergency Department, with the doctor and the patient calling the ED staff to forewarn them of an arriving COVID-19 illness so they can sequester the patient into areas designated for such cases, protect themselves, and give directions. Such patients are not welcome at outpatient labs and imaging facilities- they do not want to be shut down because their staff have been compromised and/or infected. The rest of us do not want them closed down either, nor physicians’ offices. We need them up and running out of self-interest.

Conclusion: Stay away from medical professionals and medical facilities, but, with any problem that would normally bring you to contact your physician, do that and let them decide how to address the issue. Do not sit on something you normally wouldn’t. COVID-19 isn’t the only thing that can come to a very bad outcome.

Lastly, if your physician and staff cannot work with you in line with the aforementioned principles or they seem apathetic, dismissive, and/or ill-prepared, maybe it’s time to look for another physician.

Edward R. Rensimer, MD

COVID-19 Update No.12: “Surging” Case Numbers, Media Alerts, and Reality

So, COVID-19 “lockdowns” were eased and new COVID-19 case numbers “surged”? We should all panic. The pandemic is roaring back and we can do nothing but lockdown again. Texas’ governor, Greg Abbott, is giving that serious consideration. This, even though we know further, significant societal lockdown carries dire consequences for our economy and all Americans, while COVID-19 poses a death risk now approaching a small multiple of seasonal flu, and that for a small group of people, mostly the very elderly and medically infirm. The average age of COVID-19 death is 82 yrs, about the U.S. life expectancy for other causes. But, with the alarmist nature of the media and of breakneck, reflexive 24/7 “Media Alerts” and “Breaking News”, we don’t deliberate on the situation… we emotionally react with dread and borderline hysteria.

Lets’ try something new. Let’s calm down and think through the facts, like scientists, like physicians.

The Pandemic Goal: It never was to stop the virus. The cat was out of the bag in January and it was spreading with unprecedented speed and ease across the globe. Based on prior “novel” virus pandemics, we knew this would play out over 1-2 years until the virus slowly changed (mutated) to partner better with humans biologically, rather than kill them (which is against its own interests- a suicide virus). The virus would become the vaccine; eventually, once about 60% of the human herd had been infected and had immunity, the potential human hosts would be radically reduced, and so the pathway to those at most risk for death. The virus would become just another background occurrence in the human condition- like influence, West Nile virus, head colds.

So, we took measures to slow down the outbreak pace (“mitigation”) and to spread it out over many months, rather than over the initial 2-3 months, to allow us time to learn more about the virus and how to deal with it. More medications and management techniques. Maybe a vaccine (but don’t count on it). And, with the concern that the Fall season brings people to congregate more in close-ventilated spaces, as well as the certain annual rise of flu cases, the chief goal was to spread COVID-19 over months so the healthcare system could have staff, supplies, and equipment so no one received less than optimal care when both viruses hit.

Conclusion? Once we re-opened we knew there would be more COVID-19 spread, more hospitalizations, more deaths. It was acceptable, balanced against the sure devastation of lives and of the country with continued lockdown. So, what is happening was expected to happened, yet there is anxiety all about, fanned by the media.

Leadership needs to monitor COVID-19 hospital admissions and ICU occupancy, and adjust infection control measures to match the case numbers to resources. This is analogous to Harris County officials “bleeding off” water in phases threatening to burst the Addicks Dam during Hurricane Harvey to minimize flooding. Some property would be lost, but not all property.

Finally, despite increasing COVID-19 cases, the fatality rate has decreased, suggesting more of the cases may be in those under 65 yrs-old. If that continues, we could be moving toward the 45-60% “herd immunity” that will dramatically decrease the size of future outbreak “waves”.

Case Increases Across the South: It is unclear why this is so, but possibly the cases were at such a low number because of intelligent, effective lockdown measures initially such that we did not have the outbreak disasters seen in New York, New Orleans, etc, due to major errors in management (public transit, nursing home errors, Mardi Gras), and so less infections. As we eased lockdowns, COVID-19 is now getting to more people, but in the intended, measured way. Further, with increasing outside heat, people in Florida, Texas, and Arizona are naturally driven more indoors to air-conditioning, much like the effect of winter’s cold air arrival in the North. We know most COVID-19 infections are acquired among household members in close, prolonged contact, not people out and about.

COVID-19 Case Labelling: There is an incentive for hospitals and the medical profession to label a medical case as “COVID-19” diagnosis. Why? The government and insurers are processing payment for testing and care quickly and at good rates in order incentivize the system to prioritize care for COVID-19 cases as this has been termed “a national health emergency”- analogous to FEMA dollars for floods, hurricanes, tornadoes. The uninsured are even covered, where hospitals would normally eat the bill for them, other than a tax write-off.

So, I arrive at a hospital from a serious car wreck. Now, all patients arriving at the hospital are screened for COVID-19 to protect the staff. But, once that test is positive, I am labeled as a COVID-19 case. If I die from my injuries and was only carrying COVID-19, but not ill from it, I may be labeled as a COVID-19 death. There is a financial incentive to over-diagnose. There is also a political incentive. Make this a bigger, more ominous epidemic, governors, mayors, county judges are given more room to exert power. Be clear also that this is a presidential election year and many politicians have a big stake in not seeing the economy recover for fast and in making this natural disaster the result of mismanagement by current leadership to influence elections.

Social Distancing/ Politics: Somehow, over a thousand medical professionals disgracefully issued a letter stating that the specter of COVID-19 transmissibility during huge public protests across the nation took backseat to the cause of “systemic social justice”. I suppose the COVID-19 virus threat to individuals, which previously required draconian isolation measures by political fiat, now was not so much. I guess “Black lives DIDN’T Matter”, since many of the protestors were black and it is well-established that black death rates from COVID-19 are substantially higher than other groups. Even if mostly younger blacks were protesting, they could take virus to their families.

So, many medical professionals took a political position against their professional oaths to protect the health and medical interests of patients. This put people at risk for serious injury and death, in the name of a political protest movement which was based on a questionable, yet unproven, premise of “systemic social injustice”. Moreover, just weeks before, medical leaders advised and insisted on tight, protracted COVID-19 infection lockdowns with absolutely probable devastating effects on the lives and health across our entire population. It is unequivocal that “social distancing” is the most effective measure against COVID-19 propagation. You put yourself on a single-person raft in the middle of the Gulf of Mexico the next 2 years, you don’t get COVID-19.

Did anyone but me note that the incubation period for acquiring the COVID-19 virus to onset of illness is up to 14 days, and the uptick of cases in Houston occurred 1-2 weeks after the local mass protest gathering and funereal crowds for George Floyd in Harris Country? Yes, what was predicted and speculated is happening. But, the media has no interest in making this association, as apparently they are all-in with the “social justice” movement.

This must be stated. It will be remembered as a low-point for the medical profession and leadership who advocated against the public good, resulting in loss of “precious” lives (“Every life is precious” is, I think, what had been the mantra) out of political self-interest. A disgrace. Disgusting hypocrisy.

Edward R. Rensimer, MD

COVID-19 Update No.11-2nd Wave or Expected Blip

Recently, in some parts of the U.S., including here in Houston, TX, we have, just weeks after businesses have gradually re-opened, seen an uptrend in COVID-19 new cases. Think back to March. At that time there was a strategy of containment and mitigation of the pandemic curve’s upward tack. It was felt too late to stop COVID-19. Rather, the aim was to “flatten the curve”- to turn the new cases curve to horizontal and then gradually downward. That “mitigation” occurred by dramatic lockdown of human interactions and wearing masks, hand cleansing, and social distancing. The curve was bent and new cases as well as deaths declined.

As we saw the resulting economic devastation, a deliberate decision to re-open was made and it was presumed that with people out and about, COVID-19 activity would pick up. It had to. But, we had, for the country’s greater interests, to re-open and expect an increase in new cases.

That’s where we are. We are seeing an uptick in COVID-19 cases. Further, keep in mind that 100X more COVID-19 tests are being done than 2 months ago. This naturally will detect cases that before would have gone unseen. The result? An appearance of increased disease activity, which might actually be an increased detection of cases that were already there, all along.

In the month ahead, look to hear new information showing far more COVID-19 cases than before, many more subclinical or asymptomatic “infections”. Further, we should see the COVID-19 total case denominator grow substantially, which will decrease the mortality rate a good deal, perhaps just above seasonal influenza- say, 0.2-0.3%. If you have 10 deaths in 10 cases, the death rate= 100%. 10 deaths in 1000 cases is 1%. The denominator is everything.

Finally, if there really is some true increase in COVID-19 cases, the long-term benefit is “herd immunity”- much fewer people available to be infected for a large 2nd wave in the Fall.

So, don’t panic, even if the media have a political agenda in keeping this thing going. Wear your mask, wash your hands, and socially distance. Enjoy the gradual re-opening, but continue to be smart in playing your role in continuing to “bend the curve”, until we are told we can go back to “normal”, which I believe is 1-2 years away.

Ed Rensimer, MD

Director, International Medicine Center

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