Covid Journal 10: My own Covid test shows that our health system is still very sick.

Drive Thru Testing

About a week ago, while getting ready to come in to work, I noticed my left eye was red. This gave me pause for two reasons. First because pink eye has become recognized as one of the many signs of COVID-19, and second because regularly perform bronchoscopy, an aerosolizing procedures on patients. I was referred by employee health to get a COVID-19 test. Except I couldn’t because while our hospital does offer it’s employees the option of drive-thru testing, that test is only available for limited blocks during the day, and that time had already passed. It was a Friday afternoon, now I would have to wait until Saturday to get tested. But on the weekends employee health does not offer the test at my hospital, so instead I would have to drive to a site 50 miles away from my house in order to get the test on Saturday. Instead of waiting,  I opted to go to the outpatient testing center, the same place that I send patients to to get tested for COVID-19.  After a quick drive-thru nose swab (take heart, it’s no longer the terrible brain tickler it used to be) I was on my way to self isolation at home until my results came back from LabCorp. 

That process took 4 days. Fortunately they were negative, but let’s pretend that they had been positive.  In the days since the bronchoscopy I had been interacting with people, co-workers and patients all over the hospital. Had I been infectious, I could have potentially infected many of them, after all we know that asymptomatic people with COVID-19 can still spread the disease. All of those people whom I had infected at home and work had continued to be out in the community for the 4 days since the time I took the test. Many of them may have gone to church (now open), restaurants (now open) and to their own homes. Each of these people would have to be tracked down  and potentially tested, then  those tests would take another 4 days. If the tests in those contacts had been positive, many of their contacts in turn would have to be tested, who would also have to wait another 4 days to get their test results. At this rate, my one infection could easily cause a breakout cluster that could not be contained. It would only be a matter of time before the disease would find a vulnerable person and kill them. It does not matter how many surveillance  and tracking people we hire to track and isolate cases, if the tests take too long to come back, the disease will always be several steps ahead of us. 

The President said that we have “prevailed” on testing. We have not, and still have much work to do. Testing was initially constrained by a number of factors, most recently a lack of reagents. As we have solved that problem we have run into a shortage of swabs, and now we’re again running short of PPE, in particular gowns. Testing is just one part of many interdependent parts that we need to get right in order to control the infection. Until we prevail on all of them we have not prevailed at all.

Covid Journal 9: Low on N95 Masks, low on rapid testing, and other fun facts.

Everyone seems to want to talk about testing these days. The administration talked about testing when it, with much fanfare, rolled out it’s plan to reopen the country. “There’s plenty of testing”, they told us,  we just needed to find it. They even did the leg work for us, providing governors around the country with the phone numbers of various labs that had unused capacity. Imagine that, we were scrambling to find more COVID-19 tests, when all over the country, lonely lab techs sat idling on their lab stools, staring at bunsen burners  like modern day Maytag repairmen. The thing is, when they say capacity, it isn’t exactly the same things as ability. My high school guidance counsellor used to tell me all the time that I had the capacity to accomplish much more. And look how that turned out. 

Yes, capacity exists, and I’ve written previously  about how unused ventilators could be moved around the country when hospitals had a need. But ventilators and laboratories, I’m told by various somewhat intelligent people, are very different. Very very different. Labs for one, are made up of predominantly cinder blocks and have a tremendous number of people inside. Ventilators have no living things inside save for the 4 or 5 mice that make it run. Also they have wheels. So yes, there’s lots of capacity, but what good is that capacity if it’s on the other side of the state from me? The unused lab to which I send my COVID-19 test may take 2 to 3 days to provide a result. In the meantime, a patient is sitting in self quarantine at home, waiting for the results. That’s now 3 days of lost productivity, 3 days of worrying, 3 days of finding child care, multiplied by, oh I don’t know, let’s just say fifty thousand or so tests per day. When the country reopens, people need to be able to get tested quickly, efficiently, cheaply, and accurately. Right now I can’t that we even have one of those things.

Update on testing in my community. 

In my last update I told you that things were looking up, as we had gotten Cepheid’s rapid test, which takes 45 minutes. It went well for about 10 days, but then our supplies of the test cartridges started to run low. Cepheid has not been able to keep up with demand, presumably they have prioritized hot spots to be supplied with more tests, and NC is not a hotspot. So while we’re still using this test for inpatients, we use a LabCorp test for ED patients not being admitted. On a bright note, the LabCorp COVID-19 test  turnaround has come down to 2 days from its previous ludicrous time frame of 8 days. While that’s a positive development, it is still too slow. 

Outpatient testing continues to remain beyond the horizon. We simply don’t have the PPE to spare for it. NC DHHS reports that as of today the state has a 1 day supply of N95 masks.

In the President’s most recent home shopping network episode on 4/27, he announced that testing would double in one month, home testing kits would become available, and reliable antibody tests would be available too. The President has the capacity to talk a whole lot and make a lot of promises, let’s see if they actually turn into action. 

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.

Dear Doctors, Please Stop Dancing.

Over these past few weeks we physicians have been thrown into the national spotlight literally risking our lives to care for incredibly sick patients under terrible conditions. We are heroes, at least for the moment, as well as victims of the COVID-19 epidemic that has washed over our country. Social media has become alight with all manner of healthcare workers posting themselves festooned in their protective gear, dancing, hugging, celebrating to the adoration of an appreciative public. I am writing this to appeal to you, to all of you. Please stop posting selfie pics and dancing videos of yourselves on social media**.
I get it, the siren song of the selfie image of yourself wrapped in protective gear, the portrayal of  yourself as a selfless, courageous soldier answering the call to battle is too hard to ignore. Your social media posts bring you a form of hero worship that few people could ever hope to achieve. This is the validation that you’ve always known that you’ve deserved, and now it’s here, just like back in the Old Days. Doctors used to get a lot more respect back in the day, at least that’s what the older ones are always saying. Our profession used to inspire television shows,  like, Scrubs, House, E.R, and that other one where they’re always hooking up. Oh, that one’s still on? Dear Lord, why?
But anyway, most of them are off the air now, and Silicon Valley is mostly trying to figure out how to replace you with self doctoring robots. Hell, your employers won’t even refer to you has “Doctors” anymore, you’re “Providers” now.  I get it. Completely. Totally. Utterly. Get it. I know this because I am one of one of you. I too am a pulmonary, intensive care physician, and I too couldn’t resist the appeal of the self indulgent selfie. And yes, my posts also received the obligatory “your’re so brave, please be careful”-type of validation that I have never in my career experienced. But the fact remains. It’s time to stop.

Look at this idiot.
These days every healthcare worker is posting selfies with themselves dressed up in their gear whether they’re on the front lines, or the back lines. Even cafeteria lines. You got nurses and the TikTok Doc dancing like they just scored a touchdown.  I’m not sure if any of you folks are aware of this but maybe I should remind everyone. Nearly all of your vented COVID-19 patients died. 50,000 of them by my last count, probably a few thousand more by the time you’re reading this. We in health care have pretty much had our asses handed to us, so I really can’t figure out what y’all are celebrating. You should be as somber as a team that just got destroyed in the SuperBowl. Not only are we losing, when people are coming to us, we got nothing for them. We have no treatments, no proven medications, no procedures. The only advice we can give people is to avoid getting it, and that by literally eliminating any possibility of contact with all other human beings. This is why you must stop. Please.
 It’s gotten so bad that the President. . . The President of the United States. . . is now the nation’s greatest authority on “chloro, uh, hydroxy” something or other.. And yet, somehow, inexplicably, despite the deaths of more than 50,000 souls under our care, WE have been cast not only as heroes but also the victims of this tragedy. And so here it is, if you haven’t figured it out already. This is THE REASON why you have to stop. 
Symbols are powerful, they’re totems marking the passage of sentinel events in our history. People connect with them, and they help to humanize events, allowing us to empathize with the people involved in them. After 9/11 there was the imagery of the twin towers crashing. After Katrina there were the images of people stranded on roof tops. Both events spurred the American public to action with record levels of donations and volunteerism. What are those same Americans doing in the face of this tragedy? They’re making masks for healthcare workers, they’re donating money to buy PPE. Around the country church groups are organizing, girl scouts are canvassing, companies are volunteering machinery and equipment. . . to make you a new frigging face shield. Go right now to any of your social media feeds. What volunteer work and fundraising do you see? Have you seen anyone trying to raise money for the more than fifty-thousand victims families? No. People are mostly just trying to raise money in support of  healthcare workers. And that my friends, that’s why you need to stop. You have unwittingly taken on the victim role, instead of the true victims. 
There’s another tragic consequence to the role that we’ve taken on. People right now are protesting their stay-at-home orders. This pandemic’s lack of symbols has hurt not only fundraising for victims, it’s leading to people taking unnecessary risks.  This has been an invisible tragedy, a silent pandemic whose deaths occur in locked ICU wards where families can’t be with loved ones when they die. Tens of thousands of people have left  their loved ones to enter an ED or ambulance, only to never be seen by them again. Some can’t even have a proper funeral. People can not fear what they can not see, nor can they empathize with numbers on a screen. In place of the real victims, healthcare workers have become stand-ins, usurping America’s sympathies. And her dollars. That’s another reason that you need to stop. 
It’s not your fault, the media bestowed this mantle upon you. You took it to show people how dangerous your working conditions are. You were right to do that, it really should not have gone further than that. Yet it did. But it’s now time for us to return to our primary responsibility, taking care of people. If we can’t cure them when they come in, the least that we can do is shine a light on this tragedy to maybe prevent them from getting sick in the first place,  while also honoring the real victims. We have to make people out there understand what the true nature of this disease is. We must bring life to the cold numbers that people are seeing on their television screens, and to do that we need to speak for the victims and their families.  
So stop posting about yourself. Post instead about the victims of this tragedy, the real victims. The poor patients who came to us. The poor people who struggled and died. The poor people who pinned all their hopes on the chance that we might be able to save them. We couldn’t, we didn’t and now we should honor them by telling their stories. 
I hope that in this way we can move the media’s focus from us to the real victims of this tragedy, and get them the coverage, support, and empathy that they deserve. 
**Unless you’re a NYC healthcare worker. You’re a hero so please post whatever you want.
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 8: How Brown Paper Bags Are Being Used to Protect Healthcare Workers from Covid-19.

In my last post about the status of testing for Covid-19 testing, things were not going well here in North Carolina. Our inpatient testing time was up to 8 days through LabCorp, and we had completely stopped any outpatient testing, including drive-through testing

PPE supplies remain short for our health system, particularly N95 masks, and our hospital has been working tirelessly to acquire more but most of our orders have gone unfilled or partially filled. To that end we have adopted CDC guidelines on how to recycle the disposable masks to prevent us from running out completely. As you can see from the figure above, the system upon which our lives and our patients’ lives depend, hinges on the use of brown paper bags. This is not exactly the high technology we imagine when we think of American healthcare, yet that is where we are at now.

This is how the process works;  when leaving a COVID-19 patient room, we write our name on a brown paper bag as well as the number of times the mask has been used, then drop the mask in the bag and leave it at the entrance to the patient’s room. That mask is then only to be used by that healthcare worker with that patient. Each time they use it, we update the number of times the mask has been used. Once the mask has been used 5 times, the mask is discarded. We have supplemented this by using U.V. light to disinfect the masks between uses to help reduce the chance of spread.  

 In the meantime I am glad to report that at least our local testing situation has improved. Up until this week we were having to wait an excruciatingly long 8 days for inpatient COVID-19 test results (we’ve already given up on any semblance of outpatient testing). By contracting with a lab in Texas, we have gotten the test results down to 2 days. Sometimes it’s one day, and that literally depends on (believe it or not)  if the sample can catch the 8 pm out of RDU. 

Abbott released a 15 minute test on their IDNow platform. I discussed previously why that is not an option for us, and indeed not an option for many at all.  Our hospital uses the Cepheid’s GeneXpert system and they’ve come out with a test with a 45 minute turnaround time. Like Abbott they, too, have been focusing on supplying new test cartridges to hotspot areas, which fortunately we are not. Hopefully once these surges have calmed down we might have access to that test and, at long last, be able to actually start screening people outside of the hospital. 

Meanwhile, I’ll continue to soldier on with the testing and PPE that we have and do the best I can. 

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.

5 Reasons Why America Needs a National Day of Mourning

Faces of some of the US coronavirus victims
Faces of coronavirus victims (CNN)

1. This is a tragedy of unparalleled proportions.

The loss of life from COVID-19 in the U.S. has been astonishing. The Surgeon General described this as our 9/11 moment. Yet most of us who are old enough to remember 9/11 can tell you, with vivid detail, what we were doing during the 9/11 attack. Yet I can’t say that I remember where I was or what I was doing when the death toll in our country from COVID-19 passed twenty-thousand. Can you?

2. Not a Made-for-Television Tragedy.

Unlike past national tragedies in the modern media age, there is no national symbol for COVID-19. There are no images of burning buildings like in 9/11, no images of people stranded on rooftops like after Katrina. The deaths and suffering from this disease are largely ocurring behind closed I.C.U. doors. Families are often times not allowed to be with their loved ones as they die due to infection concerns. Families and friends are being denied access to funerals and are forced to grieve alone. Yet there is no national symbol to cyrstalize this tragedy. We need a moment around which to rally, commemorate, and grieve.

3. We need to raise money for families.

Flowers are left outside refrigerated trucks used as makeshift morgues at Wyckoff Heights Medical Center in Brooklyn. 
Flowers are left outside refrigerated trucks used as makeshift morgues at Wyckoff Heights Medical Center in Brooklyn. Credit…Sarah Blesener for The New York Times

American’s empied their hearts and their wallets for victims of previous tragedies. After 9/11 a record $2.8 billion was raised in donations for victims’ families. That record was broken after Hurricane Katrina which saw $5.3 billion in donations to victims. For families, the loss of loved ones could not have come at a worse time, just as the country tips into recession and millions of people have lost their jobs. They will need help, and we should be there for them.

4. Healthcare workers need a moment.

Stressed doctor
skaman306 / Getty Images

While the fear, misery, and heartache of this pandemic have been barricaded inside locked hospital wards, it does not remain there. It is carried out on the shoulders of the healthcare workers who stream in and out out of them. Often times they are working under harsh and dangerous conditions, worried about infecting their own families. Yet despite these conditions, they are under threat for raising issues of workplace shortages. Healthcare workers need a minute, just a minute, to look over our shoulder at the turmoil behind us. Then we can start moving again.

5. There are too many faceless victims.

John Minchillo/AP https://buff.ly/3b596oq

Despite the tremendous loss of life, there has been precious little talk of victims, save for the occasional mention of a celebrity death. The media has instead focused on political aspects of the pandemic, assigning blame for shortcomings in testing and treatment. In the meantime trenches are being dug in New York to bury unclaimed bodies. The media needs to stop the political drama and help us learn about who these people were. Their bodies may be unclaimed, but their stories should claimed by all of us. No one should die faceless and nameless in America because this is not that kind of country and we are not that kind of people.

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 7: Why Abbott’s 5 minute COVID-19 Test Is Not The Game Changer We Need.

Is it me or are presidential press conferences turning into infomercials? There is a reason that the federal government doesn’t  want physicians accepting gifts from pharma. There is a reason that we all thought that direct to consumer advertising is a bad idea. When medical company reps speak with physicians, they are tightly bound by laws that limit them from making false claims about a product. A physician with bad information can not only harm people, but they can waste lots of money in the process. It would probably make good sense to have similar restrictions in place when a CEO speaks with leaders in DC who hold sway over billions of dollars. But then we wouldn’t be able to have the direct to consumer advertising that is President Trump’s daily COVID-19 updates. It’s no secret that any company would love business right now, but know what else they’d love? How about free advertising with a side of ‘Murica. 

What better place to do that than a nationally televised Presidential press conference with incredible ratings in the middle of a crisis, where no one literally has anything to do except watch television? I mean if you can’t expect a physician to critically appraise a new medical product in the face of free salami, you can hardly blame the President for going gaga when Abbott told him they would save his beautiful, amazing, beloved, best-ever in history economy by pushing out half a million tests. 

One can only imagine the President’s excitement when Abbott Labs informed him that they planned to produce 50,000 tests per day. Also they gave him one of his very own to play with.  My contacts in the West Wing tell me that not only is he testing anybody who comes to visit him, he also tests Mike Pence several times per day just so he can see the lights change color. 

But there may be a few details that Abbott’s CEO kept close to the chest, such as the fact that just because you make half a million tests, this does not translate to half a million real life people being tested. 

To put it in terms the President might relate to, they would have to explain it like this. Making a COVID-19 test is like making an Atari game. Even if I give you half a million Atari games, you can’t play any of them unless you also have an Atari console.  A few hospitals out there have Atari consoles and will be able to run these tests. (Yes I realize I’m mixing metaphors but just stay with me). As for the rest of the hospitals, well I’m sure that Abbott would be just super excited to sell them one at some point in the future. Right now though Abbott only has a few, and they’re going to a few designated hot spots. But if you know nothing else, just remember that Abbott is making the rapid COVID-19 tests, no one else is, you can buy one eventually, and if you feel at all nervous about this plan please relax and listen to this soothing recording of Michael Bolton’s greatest hits. 

So really, what Abbott sold the administration is an imaginary number based on the potential tests they could make, not necessarily the actual number of tests that would be run. In their press conference on 4/8/20, Dr. Birx admitted as much, stating that the number of tests run are nowhere near the numbers that Abbott suggested. But more than selling the President on a plan, what they really sold was alot of future ID Now consoles. And in the end, isn’t that what’s most important?

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 6: Lung Cancer in the Time of Coronavirus.

My office practice has been slow here in North Carolina. I have been doing all of my patient visits via telephone, but even those are becoming rare. So I was glad when I got a call to see a patient with respiratory problems up on the wards. The patient herself was an elderly woman with an abnormal CT scan who had also undergone a test for Covid-19. Those tests are taking 8 days or more to come back unfortunately. Like many patients we test, it’s like that she would be discharged home before getting the results. Her doctor asked me to see her to see if the pneumonia they thought she had could be Covid-19. Looking at her CT scan I knew coronavirus was not the main problem, she had a lung mass which was probably lung cancer. 

In order to minimize our exposure time to infected patients many docs have been in the habit of calling in to the patient’s room to speak with the patient before entering the room for an exam. Impersonal yes, but probably safer. So picked up the phone and dialed into the room. As I pressed the phone against my ear I immediately regretted the decision. Thinking through the countless e-mails and meetings about Covid-19 preparation, I couldn’t think of one that mentioned anything about a phone sanitizer guy. Luckily I was bailed out by a busy signal. 

So I got up and walked over to the PPE station. This would be my first experience with PPE. Unlike NYC, New Orleans, and Detroit, Covid-19 is still new at relatively new at hospitals in North Carolina.

I had sat through a PPE demonstrations a few weeks  ago, there weren’t enough PPE for each of us to try it ourselves but I was pretty sure I got the jist of it. The process started with choosing a face shield or goggles. Apparently I’m a goggle guy. The patient was under droplet precautions, not airborne, which meant that the infamous N95 was not required, so I donned a surgical mask. Then it was the blue plastic barrier, finally gloves, and into the room I went. 

I’m always amazed at the resilience and courage of so many people when they hear that they have cancer. I do the best I can to be in the moment with them, there’s tears, touching, hugging, prolonged silence, questions, and more tears. It must be especially hard being told of this in such an impersonal matter. Our words competed with the loud device that recycled the air. As I hugged her I was somewhat self conscious about how it must feel through the cold shiny plastic that I wore. There was no way for her to see any of my expressions, my smile, my magnificent smile that everyone always compliments me about. I usually offer to call family for patients to help explain the diagnosis to them in the presence of the patient. I offered the same to her, but then I realized that taking out my phone would violate precautions, so the call would have to wait. 

I left the room, and was immediately met by a spotter who guided me through the doffing process. As I went through the steps I started thinking about what had just transpired. Covid-19 has just arrived and will be with us for at least several more months, if not longer. Lung cancer, too, is not going anywhere. I need to get better at this. 

We Are Losing World War C. It’s Time to Pool Our Resources.

It’s been heart breaking watching the scene unfold in New York. As bad as it is, similar scenes are playing out now in Louisiana, Michigan and Texas. Those healthcare systems are being overwhelmed by a crush of cases coming through their doors. Yet in stark contrast there are parts of the country that are seeing  minimal to mild activity of Covid-19 right now. They will likely see greater activity later but those peaks will not occur for several more weeks. Many states are projected to have minimal to no shortage of ICU or total beds, these include states like the Carolinas, Nebraska, Ohio, Vermont, Missouri, Oregon, and several others. I suggested previously that this extra capacity could be harnessed by the federal government by nationalizing the hospital supply chain and moving supplies around the country as needed. Taking advantage of existing supplies is the only way to deal with the current supply shortage because the federal stockpile does not have enough supplies of ventilators and PPE to help the entire country. While ventilators are being feverishly produced, they will not be produced in time to deal with the coming waves of patients in the next 1-2 months. The only way to manage this is to take a nationwide approach using the resources we have. It’s obvious that the President has no desire to do this, and seeing Governor Cuomo speaking the past few days he has come to this realization as well.

Governor Cuomo has thus sent out a call to workers from around the country stating that if they help New York, New York would come to their aid as well. Looking at the predicted surges in New York compared with other states around the country, this plan could work, other states could indeed come to the aid of the hardest hit states. However simply asking for their aid is not enough. The Governor needs to assure those other states that they can help New York without risking themselves in the process

To my mind there are 2 basic hurdles to overcome for this to work. First is trust. How do other states know that the state(s) that they are helping will return their supplies and people when they are needed. To overcome this issue, the borrower state would need to have some sort of reciprocity agreement in place with the lending state. The reciprocity agreement would need to stipulate an expiration date on the provided assistance. That “Give Back” date should correspond to the projected surge date of the lending state. Looking at the figure above, a reciprocity agreement between Missouri and New York would require that New York would return any borrowed supplies and manpower by a certain date which would likely be around the last week of April. After that date, help would then move in the reverse direction. This return of resources would need to take place regardless of how bad things still were in New York, that way Missouri would be assured that it was not short changing it’s own people to help New York. 

The second issue is manpower. Right now I work in one of those states that has not been hard hit but expects to have a surge of patients around the end of April and into May. While I would be happy to volunteer in a place that has an acute need right now, I would not go somewhere when my own home state is being overwhelmed. Additionally, before travelling somewhere else to volunteer, I would need to know that my job will still be here when I get back. Thus each state would have to have agreements in place not only to return supplies but also manpower. And they would have to stipulate that no health care worker will lose their employment when leaving their home to volunteer in the reciprocal state. 

It’s clear that we do not have the time to build the supplies and hire the people that we need in the hardest hit areas. People will die from the disease, there’s little we can do about that now. But people will also die from lack of supplies, and people. That is inexcusable. The only way to save lives now is to help each other by pooling our collective resources. This is now a world war, World War C, it’s time we fought together.

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.