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 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.

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. 

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.