Posted on

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.

Posted on

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.

Posted on

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.