Covid Journal 5. This Graph Shows Just How Fast Coronavirus is Moving in North Carolina.

It was beautiful weekend here in North Carolina. There was that magical rebirth in the air that only comes with Spring. The kind that makes you want to sit out on the porch with a glass of iced tea, keep the tv off and pretend that the world is doing just fine. After all, the daily and cumulative average of all COVID-19 tests in North Carolina had remained steadily, and somewhat reassuringly below 5% for the past few weeks.

But a look at the numbers on Saturday quickly showed the danger in that kind of thinking. Positive tests increased significantly here to 7.19% on Saturday, March 28. Naturally, I did what any semi-sentient being would do when faced with a catastrophic problem to which they can offer no solution. I ignored it and hoped it would go away. “Maybe it’s an outlier. Let’s see what it looks like tomorrow.”

But Sunday brought no relief. Positive tests on that day more than doubled to 16.36%. What’s equally disturbing is that testing here is significantly delayed. Our inpatient Coronavirus tests are taking about 8 days to return. The swabs sit and wait to be processed for 7 days, and the results are released the next day. Assuming that this is going on in other hospitals in the area, this suggests that the tests that are being reported today may actually have been performed on patients several days ago, or even a week ago.

This projection estimates that NC will have enough general beds to take care of COVID-19 patients, but there will be a shortage of about 300 ICU beds. Area hospitals including ours have been working hard to prepare for this by expanding our bed capacity. I am hopeful that if the number of patients we see falls within projections we will be able to handle the surge. But it will not be easy.

Deep Ramachandran, M.D. is a Pulmonary, Critical Care, Sleep Medicine physician, founding CHEST Journal Social Media Editor, and co-Chair of ACCP Social Media Work Group. He blogs at Caduceusblog. He is on twitter @Caduceusblogger.

We Can’t Build Our Way Out of the Ventilator Shortage. But There is a Solution.

“Hey buddy, can you spare some ventilators?” No, this is not an attempt at dark humor. This is the preamble of numerous calls that are going on across the nation right now. Whether the call is made to a ventilator manufacturer or to other medical centers, hospitals are busy stocking up on the highly technical devices that are anticipated to be in short supply. Here in North Carolina, where we’re still bracing for the coming wave of infections, our hospital managed to get a few extra to keep on hand in anticipation of future needs. When supplies like ventilators are anticipated to be in short supply, health systems like ours go out and try to buy a bunch of them. In essence, we are not unlike the hoards of people out there buying up toilet paper and hand sanitizer. A neighboring hospital was not so lucky, they only have a few spare ventilators. What’s worse, they’re in a larger city and are expected to be hit harder than we are. So when they asked us for a few ventilators, we obliged. That decision was not made without some trepidation. What if we end up needing them more than they do? Will they give them back? This crisis has turned hospital procurement into an art form. We’re all wheeler dealers now, often relying on the good will of our neighbors.

This highlights a problem with the approach taken by our disjointed health systems. Our hospitals are meant to take care of the patients in their own communities, it’s not their job to take care of patients in the next city or state, nor are they very good at thinking about those kinds of things. Yet this pandemic has made plain the problem with this piecemeal approach. Pandemics require a different type of thinking; we need to think about health care not in community terms but in terms that extend to our borders and beyond.

It is (poorly) estimated that there are maybe 160,000 ventilators in the U.S, with another 12,700 in the national stockpile. Estimates are that 960,000 people would require a ventilator. We doctors are not known for our math skills but even I can see that those numbers don’t seem to be working in our favor. With large swaths of the US population either practicing social distancing or being under shelter-in-place orders, we can be hopeful that the curve of infection will be considerably flattened. Remember the main purpose of flattening the curve is to reduce the rate of spread, not to prevent the spread indefinitely. So even with strict social distancing measures, we can expect that a large segment of the population, and by some estimates the majority, will still be infected by Covid-19 at some point. Social distancing only buys your local health system time to get ready for your inevitable arrival and for scientists to develop vaccines and treatments before that happens.

Does it buy us time to make more ventilators? Here’s the thing about vents. These are highly technical devices with sophisticated software and highly specialized hardware. You can’t just put them on a manufacturing line and strap them together quickly enough and in the volumes we need to solve the ventilator shortage. Many of the specialized bits are only made in a few places, and bottle necks will likely slow production. Even if we were to pump out ventilators at the rate of 100,000 per month just for our country, a number that seems unlikely, it would take a good 8 to 10 months before we had every ICU fully stocked up with the number of ventilators that they would need. Is that soon enough? In a word, no. At least not soon enough for the United States. Here, in the U.S. we’re already starting to ride up the steep part of the curve, that same curve that we’re trying to flatten. However even with all our efforts and with some flattening of the curve, the virus is going to cause a large surge of infections expected to overwhelm health systems over the next 1-2 months. There are parts of the world that will be desperate for vents in 8 months including the U.S. But that does not help all the people that will need them in the next 2 months, many of them will have perished by then.

So no,  Ford, GM, and Chrysler will not be breathing for you any time soon.  And honestly, do you really want a Ford Ventilator? Have you driven a Ford lately?

However, we do have one very important thing working in our favor that’s not relayed when you look at numbers about ventilator projections. That’s that the virus moves from region to region. So while a million or so people might in fact need a ventilator, they will not all need them at the same time. If we keep working at social distancing, we can turn this tsunami of disease into a steady rushing river that runs itself dry over a longer period of time. That rush will occur at different times in different places. As New York begins to calm down in a few weeks, other areas (like mine) are going to flare up. Viewed through that lens, the absolute number of ventilators is not the problem, the problem is that the ventilators that we have are inefficiently distributed.

The best short term solution to this problem, in addition to ramping up ventilator production, is to move the ventilators we have to where they are needed like a perverse national game of whack-a-mole. Ventilators, people and other ICU supplies have to be moved very quickly around the country. Normally we would rely on an organization like FEMA to manage this, but they’re good at managing one disaster in one area. In this situation they are clearly outmatched. Now I’m no military person, but I know enough to know that the U.S. military is the only organization with the command and control know-how and ability to manage a highly fluid situation like this in real time. Any army Major has more supply line ability in their little finger than a room fool of the smartest doctors and hospital administrators. The U.S. military is adept, experienced and professional. From Haiti to Djibouti there’s hardly a part of this planet that they haven’t conducted some sort of humanitarian mission.

This is a task that the U.S. military is uniquely qualified for. They are the organization that is best and most qualified to handle it and frankly are the only organization in the world that I would trust with a matter of this magnitude. Our present system places our hopes for salvation in the charity of businesses, kindness of fellow citizens and the zeal of competing health systems struggling to care for their communities. It is a system that is clearly failing. It is a system that is costing lives. The solution to our problem sits under our nose. It’s time to unlock the tremendous talent, knowledge, and logistical abilities of history’s greatest military.

Deep Ramachandran, M.D. is a Pulmonary, Critical Care, Sleep Medicine physician, founding CHEST Journal Social Media Editor, and co-Chair of ACCP Social Media Work Group. He blogs at Caduceusblog. He is on twitter @Caduceusblogger.

Covid Journal 4: Coronavirus Test Results are Taking 8 Days

Interesting Facts About Sirius, the Dog Star -

Getting home late the other night I spotted the Dog Star peaking out from behind a few clouds. The light emanating from Sirius took about 8 and half years to reach my eye. Looking up at a star is like looking back in time at an image of what it was like when the light first left it.

It served as a poignant reminder that during this Coronavirus crisis we’ve been constantly relying on old information to make decisions. Despite what politicians claim and media outlets repeat, testing for Covid-19 continues to be poor, with testing times swelling daily, if you can get a test at all. Here in North Carolina, we’ve essentially given up on outpatient testing. With few exceptions, we’re only testing selected inpatients at this point. And our wait times for those tests has grown to 8 days.

The infection rates in North Carolina remain low, currently only about 5% of all tests have been coming back positive. This would seem encouraging, but those tests likely reflect what the virus was doing a week ago. In a crisis that moves at lightning speed, 8 days might as well be 8 years, just ask any New Yorker.

The delay in testing, leads not just to poor or late clinical decisions, as we’ve seen, it can also lead to some catastrophically bad policy decisions. North Carolina’s Governor recently scorned the advice of numerous medical societies to issue a “shelter in place” order. They cited lack of PPE as well as potential pitfalls of current data as reason to take urgent action. That urgent action could prevent or at least blunt the surge of sick patients that seems increasingly inevitable.  The Governor instead sided with recommendations from the North Carolina Chamber of Commerce who’s essential message was (to loosely paraphrase) “we ain’t like those big city folk, we’re different”.

Meanwhile, as I look up at Sirius, I can’t help but think that if there’s someone looking back, what might they be thinking? Silly humans.

Deep Ramachandran, M.D. is a Pulmonary, Critical Care, Sleep Medicine physician, founding CHEST Journal Social Media Editor, and co-Chair of ACCP Social Media Work Group. He blogs at Caduceusblog. He is on twitter @Caduceusblogger.

Covid Journal 3: My Coronavirus Dream

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I had a dream last night, it was about the President of  the United States of America. In my dream the President addressed the nation in prime time. He looked at the camera and said “I make this promise to you, no American will die in this country from the corona virus because of a lack of healthcare” he stated.  “No physician will have to decide who lives and who dies because of a lack of ventilators. No family will have to have to be told by a doctor that there isn’t enough supplies to treat their family member. No healthcare worker will die because they didn’t have the equipment to protect themselves.” Then he revealed the plan, Operation Eradicate, it was a shock and awe approach. He explained the government would ramp up testing, conducting hundreds of thousands of tests in just a few days. They would know exactly how active the disease was in every part of the country. Then they could increase restrictions in more severe areas, and reduce them in areas with little to no activity.

They would work with companies to undertake a massive increase in the production of medical supplies like protective equipment and ventilators.  The President would use his Emergency powers to nationalize ICU beds and their supply chains. That way they would know exactly how many ICU beds, supplies, and personnel were in every region. Since they knew the viral activity in a given area, they could predict when there would be an increase in cases. He explained that they would preemptively surge equipment and personnel to those areas, and supplement them with additional mobile ICU units from the military. While he reassured us that there was a plan, he was also honest. He made it clear that there would be difficult times ahead. He told us that things would get far worse before they got better. But they would get better. 

The dream was preceded by a nightmare I had experienced a few hours earlier. In the nightmare I sat in a room packed full of some of the brightest and most talented physicians that I know. We talked about the challenges that loomed before us, a lack of protective gear, a lack of testing supplies, and a lack of ventilators and ICU beds to treat the coming crush of patients. Someone asked the question that was on everyone’s mind. “What do we do when there are more patients than ventilators?” We all looked sheepishly at each other, no one had an answer. 

I awoke in a fit. The dream and the nightmare. The sweat on my brow made it clear which one was real. 

Covid Journal 2: Lack of PPE Is Slowing Down Coronavirus Testing.

Cone Hospital COVID testing
Drive Up COVID-19 Testing in North Carolina.

It’s amazing how quickly how things have been developing and changing with this pandemic. To adapt something that @laxswamy posted on twitter;  so many of the things that we thought were unthinkable a month ago and a bit extreme a week ago now seem so urgent that we’re wondering why they weren’t done a month ago. 

In this past week most routine businesses closed their doors, restaurants became take-out only. Hospitals and health officials have been encouraging this in the communities that they serve, urging people to stay home, to practice social distancing, to avoid leaving home unless necessary. Yet inexplicably many health care facilities have kept their outpatient offices open, my own is among them.  I have been trying to call people to tell them to stay home, but many can’t be reached. Yesterday for example I saw an 80 year old man for a routine COPD follow up appointment, he had been keeping all of his appointments and even continued to go to pulmonary rehab! I urged him to cancel all of his upcoming routine appointments and call his physicians if he should have questions. I hope he listens, his age puts him at the highest risk profile of COVID-19, the very group that all these measures we’ve instituted are trying to protect. Yet there he was, moseying his way into the clinic and seating himself in a waiting room of sick people.  The eye of the storm. 

The supply front remains grim. Our hospital is down to a week supply of N95 respirators, despite the fact that we have not yet had a single COVID patient and only a few suspected patients that required isolation. Our shortage does not stem from us using the masks, it’s just that there are no masks to be had, and yet we’re still in better shape than many hospitals out there. To that end we recently received guidelines from the CDC, also adopted by our health system, describing how to re-use N95 masks. Subsequently our nurses received an email updating them on the leave and disability policy. It reminded them that if they are not able to work for 2 weeks because of a workplace COVID-19 exposure that they would not be paid. Yes folks PPE is in short supply in this pandemic, but irony, it appears, is in abundance. 

The testing situation remains woeful. In my last update I wrote about a hopeful development;  we were setting up drive through testing stations that could quickly screen patients. 

It lasted for a total of 4 days. 

It’s not that it wasn’t successful, in fact quite the opposite. The screening nurses were able to conduct numerous tests, but in doing so they also burned through quite a bit of protective gear. In light of the shortage of PPE, the hospital decided it would be more wise to save that gear for when people come in to the hospital. Think about that for a moment. We’re avoiding testing people in order to prevent spreading the virus so that we can take care of them when they get sick. That’s a terrible choice to have to make, and one that I would have never dreamed possible in this country. 

Deep Ramachandran, M.D. is a Pulmonary, Critical Care, Sleep Medicine physician, founding CHEST Journal Social Media Editor, and co-Chair of ACCP Social Media Work Group. He blogs at Caduceusblog. He is on twitter @Caduceusblogger.

Covid Diary 1: Plagued by Lack of Supplies and Misinformation, Coronavirus Testing Remains Elusive for Most Physicians.

Covid Journal 1: Plagued by Lack of Supplies and Misinformation, Coronavirus Testing Remains Elusive for Most Physicians.

As I sat in a meeting with hospital leadership, the speakerphone blared reports from various heads of departments about their state of preparedness for COVID-19. On the phone call was staff from the state health deparment . The conversation inevitably turned to the question of testing.

How many tests do we have available?” asked one of the speakers to the health department representative.

Currently we have three hundred tests available

The room sat in silence for a moment to take in the gravity of that number. While Covid-19 was starting to rear it’s head in our state, there were essentially only 3 tests for each of the one hundred counties in the state of North Carolina.  

There will come a time, once this crisis has passed, when we will be able to look back and better grasp how this country’s dramatic corona virus testing failure happened. (Some of it is documented here.)

Though testing has been ramping up, what remains true is that it is still remarkably difficult for any physician to order the test in the same way that they can order dozens of other tests.

My own experience in the maze of Covid-19 testing began when both LabCorp and Quest, two national and reputable medical testing companies, announced that they would be introducing their own tests. This was remarkable because up until that time, most testing was only being done in the setting of a hospital after consulting with the state health department. Getting the test therefore required a call to the hospital’s infection prevention hotline, who would then review the case, call the state health department, determine if the patient required testing and then get back to you. From speaking with my Emergency physician colleagues, this was a lengthy process that required several phone calls, often taking up to a couple of hours just to get a decision on how to proceed with testing. Contrast this to influenza testing, where results can be had in an less than an hour. Furthermore, the screening process for Covid-19 used restrictive criteria that carbon dated back to 2 weeks ago, a time before community transmission was being reported.

I do not have a lab in my office but being a pulmonologist I thought that it is important to be able to screen patients in the outpatient setting that might have the disease or even those that simply wanted a test. This proved more difficult than I realized. Speaking with my local hospital they recommended that I send my patients to their lab for testing. That was not going to work for obvious reasons. A potentially infected patient could not be sent on their merry way through the halls of the hospital to possibly expose others. No, I needed to be able to isolate patients in my office. If they were stable enough to go home, I thought, I could do a nasal swab, and ask them to self quarantine at home for the 3-4 days that it would take for the test to come back.

Another issue that came up was personal protective equipment. We didn’t have any. We have surgical masks and gloves but lacked facial protection and gowns. And that was just the beginning. To perform the test, we would need the proper nasal swabs. On asking the hospital where to get them, they advised me that this would be a problem. Due to a run on the swabs, the hospital did not have that many, and therefore wanted to restrict their use to patients in the hospital and ED. The other problem was transport. Labcorp I was informed, required the swab specimen to be transported frozen (this I later learned was not true). This would require that it be shipped on dry ice. Dry friggin ice. Where am I supposed to get dry ice?!

Having had enough of the inconsistent messaging, I called LabCorp and spoke with them personally. The swabs, they informed me, need only be frozen if sitting longer than 72 hours, otherwise they could be stored cold per their guidelines until Labcorp picked them up. They also informed me that they could supply me with the swabs. And as I sat in my office yesterday afternoon, a large pallet arrived with the PPE equipment that my nurse had ordered.

So it would seem that hopefully, after much effort, I can now test my patients for Covid-19. More help seems to be on the way. Our health center is currently constructing a triage tent in front of our ED to screen and test patients quickly, and we hope to have a drive through testing center in the coming week. In order to slow this outbreak, we need to understand it better, and that means testing as many people as we can. We handicapped ourselves by giving Covid-19 a head start, and we’re still playing catch-up.

Update on E-cigarette Vaping Associated Lung Disease.

States with Reported Cases of EVALI

Disclaimer: The information contained in this post is up to date as of this writing. For the latest information, visit the CDC website on outbreak of ecigarette related vaping associated lung injury.

In September of 2019, the Wisconsin Department of Health Services and the Illinois Department of Public Health published the results of their investigation into a new clinical syndrome. This initial series involved a cluster of 53 cases of ecigarette vaping associated lung injury (EVALI). Since the initial study, the syndrome was found to be a national epidemic. Nearly 1900 people have been affected by vaping associated lung disease, there have been 37 deaths. Cases have been reported in all states except Alaska.

Case Definition: The first step in evaluating a new disease is determining the characteristics that make up that disease. In the case of EVALI, CDC has issued this publication to define cases of Confirmed or Probable EVALI for surveillance purposes. In general, this involves the presence of pulmonary infiltrates in the presence of vaping in the past 90 days and in the absence of infection or other plausible causes.

Presenting Symptoms: Interestingly, patients with EVALI appear to present in a number of ways. These include not only respiratory symptoms, but also with constitutional symptoms and gastrointestinal symptoms. In the initial series of patients in Wisconsin and Illinois, all patients had constitutional symptoms at presentation, most commonly subjective fever. Nearly all (98%) had respiratory symptoms at presentation, and 81% had gastrointestinal symptoms, of which nausea and vomiting were most common.

Exposures: While the particular vaping component that leads to EVALI is not yet known, there are a few common factors. 87% of patients with EVALI reported vaping THC, while only a small minority (<15%) reported vaping nicotine without any THC. However as many have pointed out, vaping THC in most states is illegal. In addition many of these patients are under the age of 18, thus it is reasonable to think that many who claimed not to have used THC use simply did not want to divulge that they had. So why would vaping THC lead to EVALI, when people have been smoking THC for decades? Vape liquids contain several chemicals including propylene glycol, terpenoids, cutting agents, and flavorings. These solvents are used to keep THC and other components, such as flavoring agents in solution. These solutions are prepared in different ways in back yards, garages, and back seats, often cut with unknown substances to reduce their cost. They are then sold as cartridges to people who use them in a variety of different vaping devices which themselves which may heat the fluid at different temperatures and for a different duration.

Radiologic Findings: Ct findings are often heterogenous in EVALI. They can include mild infiltrates to diffuse findings suggestive of ARDS/DAD.

Spectrum of radiological findings in EVALI. Presented by Dr. Kevin Davidson M.D. at CHEST2019.

What do Asthma and COPD inhalers have in common with Mexican food fast food?

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A 67 year old man came to see me recently, he had COPD, and found that it was getting harder to breathe. “I wanted to make sure that I’m on the right inhaler. My doctor switched me from Advair to Breo– is that better?

GSK would certainly say so, in fact their reps often do. Speaking with drug reps about their inhalers often makes me think of food. Actually I think of food quite often, but that’s more of a personal issue. Thinking of inhalers for COPD and asthma make me think of cheap Mexican food, specifically of the fast food variety. I think it has less to do with my poor dietary habits than the fact that I believe expensive inhalers have quite a lot in common with cheap Mexican food. 

Thinking about that patient’s question from the perspective of cheap Mexican fast food, switching from advair to Breo would be like ordering  one beefy rice burrito, only to be provided with two; but they would keep you full all day. Surely that’s an upgrade if there ever was one, and one which I endorsed. The problem though, and the real reason why he was asking, was not because he doubted the expertise of the prescribing physician but something else entirely. “It’s costing me $450 for 3 months. That’s more than triple what  the other one was. I guess I’ll pay for it if you think it’s worth it”

This was an especially unexpected twist, and not of the tasty cinnamon kind. No, that kind of dough busts straight out of the fast food genre into those fancy big-city restaurants, where it’s been said that they don’t even serve french fries. Like, you can’t even order them.  Continue reading “What do Asthma and COPD inhalers have in common with Mexican food fast food?”

The IMPACT trial; What do we do about inhaled steroids in COPD?

 

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“B” is for Bias!

Pity inhaled steroids. Once a favored drug in the treatment of COPD, they were initially advocated to be used in combination LABA’s (long acting beta agonists) to have a “protective” effect against the harms of LABA’s which were,, back  in the day, proposed to have existed in the SMART trial. Things of course have change quite a bit since then. The black box warning for combination inhalers has since been dropped. Ironically it’s now the inhaled steroids that we worry about in the treatment of COPD, as mounting evidence implicates inhaled steroids as increasing the risk of pneumonia.

In the most recent GOLD update, steroids have been relegated as add on therapy to LABA for patients with an exacerbation. However GOLD recommends LABA/LAMA combination as preferred due to evidence that the combination reduces exacerbations better than LABA/ICS, as demonstrated in the FLAME trial. In fact ICS is recommended only as add-on therapy to LABA/LAMA in patients who are highly symptomatic and at high risk of exacerbations.

The Impact trial may be changing that. It compared a single inhaler triple therapy LABA/LAMA/ICS to dual combinations of LABA/LAMA and LABA/ICS. Interestingly, and also quite confusingly, the triple therapy group had reduced exacerbations and reduced COPD related hospitalizations. These results are of course in conflict with the results of the Wisdom Trial, which saw no significant difference in the rate of exacerbations between LABA/LAMA combination vs. triple therapy with LAMA/LAMA/ICS. GSK, of course, has wasted no time telling us this,  touting the results of their newest inhaler far and wide. Continue reading “The IMPACT trial; What do we do about inhaled steroids in COPD?”