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The Reopening is a Gamble Based on Terrible Metrics.

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I’ve never been a gambler, so I don’t really know anything about the game of craps. I just see how it’s portrayed on the big screen–it always seems so fun and dramatic. A guy rolling the dice, surrounded by a group of cheering fans. He says something like  “Seven, c’mon seven!” and tosses the dice in the air. For that moment, a drawn out moment, all the faces freeze in gleeful anticipation, watching the dice fly through the air, waiting with hope and anticipation to see where they land. It’s completely left to chance, or maybe luck, or perhaps prayer. For that moment everybody waits, everybody dreams.  They live in that moment, waiting to celebrate. 

The scene is very much like the one we find ourselves in now. The decision to reopen the economy has been made, the dice have been cast into the air, waiting to land. Already we’re seeing signs that the economy is improving, people are venturing out again for summer getaways. Restaurants and shops are reopening, and there are predictions of improvement in several economic metrics like jobs, and consumer spending. While we have metrics to measure progress on the economy, metrics that measure the concurrent COVID-19 risks are, unfortunately, terrible. In other words, while the potential winnings at the craps table are plain for all to see, the participants in this game are simultaneously blind to the downside risks. Like I said, I’m no gambler, but it would seem to me that a good gambler always knows their risks. Let’s have a look then, at the metrics we’re using to warn us of the risks in the gigantic game of chance.


COVID-19 Testing.

 The media has never been very good with numbers, and the statistics heavy reporting during the pandemic has done nothing but reaffirm this. Media outlets continue to highlight “the new cases of coronavirus” without really putting them into the context of the increase in testing. Over this past Memorial Day weekend, media outlets reported that North Carolina experienced a record high number of new cases, with 1107 new cases reported on May 23rd. However they did not report the dramatic jump in testing that had also occurred. Looking at the graph below, you can see that testing has been increasing steadily over the previous weeks. Though if you look closely, you would rightly question my point, because on the day of the record spike, 5/23, there was a relative reduction in testing compared to previous days. This highlights another serious problem with testing, one that CDC director Dr. Robert Redfield recently eluded to when he said “testing sucks, bro”. Ok so he didn’t actually say that. But he did note that there are serious problems with data reporting, he stated that by the time the data reaches the CDC, “regularly the data is delayed and it’s incomplete.“

And for that, I hereby nominate him for the award of “Greatest Understatement of the Pandemic by Physician or Scientist”. To put it more simply, test result data is a freaking mess. The data on test results are reported by various different labs, at different times, and in different ways. Some of them might take a week to come back, some might take a few hours. While all  labs report all of their positive results, not all labs report negative tests, or report them at the same time. Taking all of this together, if I were to look at that record number of new positive cases on 5/23 could I say with confidence that the data portray an accurate depiction of what was happening on that day? Not at all. The sad thing is that nobody really knows.  We’ve taken to using moving averages of data not just because there is day-to-day variability in the data, but because there is a significant variability in the reporting of the data. 

Percent positive tests. 

The White House guidelines for “Opening Up America Again” called for a 2 week decline in the number of new cases to be achieved before proceeding to a phased reopening. However, it was apparent that as testing volume increased, case numbers would continue to climb. So as an alternative to this they also proposed that a 2 week decline in percent positive COVID-19 tests could also be used as a gating criteria. As with many things in life, this seemed like a good idea at the time, but later had us scratching our heads and wondering what we were thinking. COVID testing initially focused on high risk patients who presented to health care settings. As the pandemic has progressed and testing numbers have increased, we’re now testing more people who are not at the same high-risk profile. We’re performing more surveillance testing at group settings like nursing homes, prisons, and meat processing facilities. We’re screening people before surgeries and outpatient procedures. Screening these lower risk groups has the effect of reducing the percentage of positive tests. This in turn has the effect of making it seem like the prevalence of the disease is decreasing, when it may not be, and very likely going in the opposite direction. Now then, we find ourselves in a rather bizarre situation with two COVID-19 test-based metrics, total positive tests, and percent positive tests. Both of these metrics are telling us two different things yet both are somehow incorrect. 

CLI: Syndromic Trending. 

Every flu season, people start going to emergency departments and physicians’ offices with flu-like symptoms like fever and cough. Several of these locations are part of a statewide and nationwide network that track the seasonal flu. This system of patient care sites tracking symptoms of flu collectively make up the Influenza Like Illness Network, or ILINet. It’s a great system for tracking flu and gives clinicians a valuable tool as they make preparations for seasonal flu. Sometime in March, someone had the bright idea of using this network to help track COVID-19. It made a lot of sense, after all many of the symptoms were similar, cough and fever, and there was an obvious shortage of testing which perhaps this network could help make up for. At that time, it was the only way for officials to monitor COVID-19 activity. Thus ILINet was rebranded and the COVID-Like Illness Network, CLINet was born. 

But there’s a number of reasons why this system, while great for tracking flu, is an imperfect tool for COVID-19 surveillance. First, the system requires that patients present to their doctors offices and ED’s with illness when they are sick. We know that around the country, patients are shunning visits to the health system, my own office visits are down about 50%. Even people with COVID-19 are delaying going to the hospital, and by the time they get there, they tend to be very sick. People are presenting to the hospital often a week or more after their first symptoms.  This tells us that there is a considerable time lag between when people are infected and presenting to the ED. By the time CLINet tracks an upward trend, there will already have been a several week backlog of people who have been infected but haven’t yet presented to the healthcare system. In other words, CLI is what we call a lagging indicator, it’s not so much of an early warning indicator as it is an alert that screams “brace for impact!”. 

Antibody testing.

Sars CoV2 antibody testing is emerging as an important way to tell if people have been exposed to COVID. It can’t really tell if there’s an uptick in infections, but knowing whether people have been infected is an important part of modeling. Knowing how many people have already been infected reduces the number of susceptible people, and thus the number who could potentially get sick from Covid. The antibody tests have a lot of positive things going for them, they’re  relatively quick, painless, point of care, widely available and have fast turnaround times. As such, you’d think that they were the perfect test. Except there’s some issues with them. A positive test certainly could mean that you have had coronavirus, or it may also mean that you haven’t. Or maybe you’ve had another coronavirus that’s cross reacting with the test. With the current test we don’t truly know.  But at least if you’ve had a negative test you can be sure that probably maybe have not had it. Or maybe you have. Again, it’s a tough call. For now, it appears that the antibody test will need to wait until the CDC determines that they’re no longer nearly useless. 

Hospitalizations

Hospitalizations is probably the only indicator that we have that is not subject to errors from the various sources above. The obvious problem of course is that hospitalizations data is that they are a lagging indicator. If we wait until people start landing in the hospital, it’s probably too late to prevent more people from landing in the hospital. Aside from deaths, it’s the ultimate lagging indicator. Lagging indicators are not useless, they can help tell us when a surge has peaked and provide valuable data for modeling future outbreaks. But they’re not the indicator we need to help us determine when and where the next outbreak will happen and allow us to act in time to stop it. 

What are the Metrics we Need?

Tests, tests, and more tests. In order for testing to be a more valuable metric, there needs to be many more of them. Testing sites need to be ubiquitous, and we shouldn’t have to wait 4 days for the results. Currently in the U.S we’re testing about 400,000 people per day, that’s much better than we were a few weeks ago. But several groups who look at the numbers of tests required to safely monitor the public are calling for much higher numbers, and there are a number of estimates that cover a very wide range. On the low end you have a group from Harvard  calling for 900k tests per day at a minimum. At the high end there’s another group, also from Harvard, calling for 2 million tests per day to start, ramping up to 5 million tests per day by early June. Harvard apparently has a very large campus and it was too far for the two groups to walk and meet each other.

By increasing the numbers of tests in this way, we could more easily know the true prevalence in any given community, and see when it is increasing. In lieu of widespread COVID patient testing, we could be helped by some other metrics that give us clues about disease activity, and thus help in predicting disease outbreaks before they happen. Testing of wastewater samples, for example can identify the presence of coronavirus in a community even before the first case is identified. Kinsa, a smart thermometer, has shown that it’s aggregated data can predict disease activity 3 weeks in advance. Increased community mobility, as monitored by tech companies like Facebook and Google, can show that a community is at higher risk of a COVID outbreak. In fact IHME is now using mobility data in constructing their models of COVID activity. 

Maybe we’ll finally get testing to where it needs to be. Maybe some of these other metrics will help in predicting future outbreaks before it’s too late to stop them. Maybe coming weeks will see more effective treatments for sick people and meaningful progress towards a vaccine. These are the only things that change the trajectory of the dice as they fly through the air. As healthcare workers all we can do is prepare, and wait for the dice to fall where they may. 

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.

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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.

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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.

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This is our Dystopian Future: Brought To You By COVID-19 Antibody Testing.

(Omar Marques/Getty Images)

Right now pulmonary critical care physicians are fielding myriad calls and texts from all over the country. These callers come with frantic questions. Questions like “Hello Deep this is Minnie, your aunty. Your uncle’s toe is hurting and I read on the internet that  it’s a sign of coronavirus. What should we do?” Notice that they don’t ask “could I have coronavirus?” because they are absolutely convinced that they have it. What they want to know is “what should I do about my coronavirus”. Of course I give them the usual measured, sober and socially acceptable response; You’re ok, stay at home, wash your hands. 

But here’s what I WANT to tell them.

You beat coronavirus? Celebrate, CELEBRATE, YOU’RE FREE! Throw away your hand sanitizer! Run to the grocery store and grab an unsanitized cart, feel free to touch every cereal box. Use the bathroom and dry your hands with the air dryer. Take in a movie, get some popcorn, and go ahead and lick those buttery fingers. No need to be afraid.

Soon,  we’ll be through the initial hellish phase of this pandemic with it’s spiraling death counts. But the fight won’t be over. Until we have an effective vaccine or treatment, we’ll enter a prolonged stalemate with the disease. Now that we’re looking at opening the country back up again, people have been contemplating what that might look like. 

That future will inevitably split us into two groups based on whether we have immunity from the disease or not. Immune people will have their status bestowed on them from previous infection or documented by results of antibody testing. Eventually someone will come up with a catchy title for Immunes and Uninfecteds. Perhaps there will be a Twilight-esque movie about a forbidden romance between the two. Spoiler alert, one of them dies.

Life for Immunes is going to be good, their lives will look, to the Uninfected, like an unending party. They are going to go out early, and stay out late.They will restart their lives, and live them like it was the last day of their lives, such will be their appreciation for their rewon freedom. 
Uninfecteds will still be staying at home, watching the glamorous lives of the the Immunes as if from behind prison bars.  While people will know their own status there will be no way to tell who is who in public. For that reason, governments will still require some form of social distancing to protect these people. Many Uninfecteds will with violate that, and they will get sick and die. 

Immunes will feel sorry for the Uninfecteds, “I feel really bad for Uni’s” they will say,  “but I have to work and feed my family. Why should I go on with the quarantine when I’m not sick and there’s nothing wrong with me?”
Life for Uninfected’s will be tough. They will eventually need to go back into the workforce. But in order to work they will need to have protections against infection.So they’ll ask for accomodations from their employers based on the American with Disabilities Act. And as they are accomodated, workplaces will become increasingly segregated as Uninfecteds seek protections  like individual spaces with appropriate physical distancing. They’ll have different restrooms, different lines in the cafeteria and different dining tables. In some cases an Uninfected worker will be paired with an Immune for their own protection. The Immunes will naturally resent the social isolation. The Uninfecteds will see the Immunes new found freedoms and resent them right back. 

Meanwhile the employment pictures will look very good for Immunes, particularly health care workers. While employers will insist that they do not discriminate based on immune status, everyone knows that they do. Employers know that Uninfecteds could get sick and then require time off that could range from a few weeks to a few months. Even worse, they might die. For that reason, insurance premiums, including life, disability, and health insurance, rise astronomically for Uninfecteds.  For all of these reasons Uninfecteds have a much harder time finding work especially obese men over 50 who appear to be more affected by the virus. 

After the tragedy of the intial part of the health crisis in the U.S., healthcare workers were seen as heroes and had enjoyed a new found solidarity. That quickly falls apart as health care systems bid up the prices on Immune workers. Across the country every one is tested for antibody status, laws are passed requiring that everyone have their COVID-19 Antibody status determined. 

Health disparities that existed before the crisis become wider, while new disparities emerge.  Covid-19 antibody status becomes a ticket to a better life. Illicit dealers emerge to sell samples of the virus to people who want to infect themselves.  Political differences emerge too, one political party declares itself a champion of Immune freedoms. SImultaneously they accuse the other party of promoting a socialist agenda by promoting accomodations for Unifected.

The Immune party blocks a bill in the House stating that it is an invasion of privacy, but it’s really about blocking funding needed to build factories to make the vaccine. The vaccine is now the only thing that separates the Immune from Uninfected. Facebook posts appear showing the dangers of vaccination, stating that the vaccine come from a WHO plant built by the Chinese. The vaccine, it is rumored, contains another secret virus. This virus, they say, is even deadlier than COVID-19. And the new virus would do things to our country that no one could imagine. 

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.

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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.

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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.

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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.

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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.

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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.