The Anesthesia Consultant is written by Richard Novak, MD, an Adjunct Clinical Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University.
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California. emailrjnov@yahoo.com
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Today I’m posting a link to a video from an Italian hospital COVID-19 ward. For those of you who may doubt the severity or the danger of this pandemic, please watch this video which illustrates the crisis in Italy, and what could occur in the United States in the weeks to come:
If you’re wondering if the American response to the COVID-19 threat is over-exaggerated, this video should convince you that every measure of social distancing, personal protective equipment for healthcare workers, and expansion of ventilator/ICU availability is warranted.
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California. emailrjnov@yahoo.com
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I’m forwarding these excellent notes from the University of California San Francisco (UCSF) Medical Center on COVID-19. The most sobering data:
40-70% of the US population will be infected over the next 12-18 months. After that level you can start to get herd immunity. Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die. The panelists did not disagree with our estimate. This compares to seasonal flu’s average of 50K Americans per year.
Panelists
Joe DeRisi: UCSF’s top infectious disease researcher. Co-president of ChanZuckerberg BioHub (a joint venture involving UCSF / Berkeley / Stanford). Co-inventor of the chip used in SARS epidemic.
Emily Crawford: COVID task force director. Focused on diagnostics
Patrick Ayescue: Leading outbreak response and surveillance. Epidemiologist.
Chaz Langelier: UCSF Infectious Disease doctor
What’s below are essentially direct quotes from the panelists. Sections bracketed are the few things that are not quotes.
Top takeaways
At this point, we are past containment. Containment is basically futile. Our containment efforts won’t reduce the number who get infected in the U.S.
Now we’re just trying to slow the spread, to help healthcare providers deal with the demand peak. In other words, the goal of containment is to “flatten the curve,” to lower the peak of the surge of demand that will hit healthcare providers. And to buy time, in hopes a drug can be developed.
How many in the community already have the virus? No one knows.
We are moving from containment to care.
We in the US are currently where at where Italy was a week ago. We see nothing to say we will be substantially different.
40-70% of the US population will be infected over the next 12-18 months. After that level you can start to get herd immunity. Unlike flu this is entirely novel to humans, so there is no latent immunity in the global population.
[We used their numbers to work out a guesstimate of deaths— indicating about 1.5 million Americans may die. The panelists did not disagree with our estimate. This compares to seasonal flu’s average of 50K Americans per year. Assume 50% of US population, that’s 160M people infected. With 1% mortality rate that’s 1.6M Americans die over the next 12-18 months.]
The fatality rate is in the range of 10X flu.
This assumes no drug is found effective and made available.
The death rate varies hugely by age. Over age 80 the mortality rate could be 10-15%. [See chart by age Signe found at the top of this column.]
Don’t know whether COVID-19 is seasonal but if is and subsides over the summer, it is likely to roar back in fall as the 1918 flu did
I can only tell you two things definitively. Definitively it’s going to get worse before it gets better. And we’ll be dealing with this for the next year at least. Our lives are going to look different for the next year.
What should we do now? What are you doing for your family?
Appears one can be infectious before being symptomatic. We don’t know how infectious before symptomatic, but know that highest level of virus prevalence coincides with symptoms. We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).
How long does the virus last?
On surfaces, best guess is 4-20 hours depending on surface type (maybe a few days) but still no consensus on this
The virus is very susceptible to common anti-bacterial cleaning agents: bleach, hydrogen peroxide, alcohol-based.
Avoid concerts, movies, crowded places.
We have cancelled business travel.
Do the basic hygiene, eg hand washing and avoiding touching face.
Stockpile your critical prescription medications. Many pharma supply chains run through China. Pharma companies usually hold 2-3 months of raw materials, so may run out given the disruption in China’s manufacturing.
Pneumonia shot might be helpful. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
Get a flu shot next fall. Not preventative of COVID-19, but reduces your chance of being weakened, which makes COVID-19 more dangerous.
We would say “Anyone over 60 stay at home unless it’s critical.” CDC toyed with idea of saying anyone over 60 not travel on commercial airlines.
We at UCSF are moving our “at-risk” parents back from nursing homes, etc. to their own homes. Then are not letting them out of the house. The other members of the family are washing hands the moment they come in.
Three routes of infection
Hand to mouth / face
Aerosol transmission
Fecal oral route
What if someone is sick?
If someone gets sick, have them stay home and socially isolate. There is very little you can do at a hospital that you couldn’t do at home. Most cases are mild. But if they are old or have lung or cardio-vascular problems, read on.
If someone gets quite sick who is old (70+) or with lung or cardio-vascular problems, take them to the ER.
There is no accepted treatment for COVID-19. The hospital will give supportive care (eg IV fluids, oxygen) to help you stay alive while your body fights the disease. ie to prevent sepsis.
If someone gets sick who is high risk (eg is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use” of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China. Need to find a doc there in order to ask to enroll. Remdesivir is an anti-viral from Gilead that showed effectiveness against MERS in primates and is being tried against COVID-19. If the trials succeed it might be available for next winter as production scales up far faster for drugs than for vaccines.
Why is the fatality rate much higher for older adults?
Your immune system declines past age 50
Fatality rate tracks closely with “co-morbidity,” i.e. the presence of other conditions that compromise the patient’s hearth, especially respiratory or cardio-vascular illness. These conditions are higher in older adults.
Risk of pneumonia is higher in older adults.
What about testing to know if someone has COVID-19?
Bottom line, there is not enough testing capacity to be broadly useful. Here’s why.
Currently, there is no way to determine what a person has other than a PCR test. No other test can yet distinguish “COVID-19 from flu or from the other dozen respiratory bugs that are circulating”.
A Polymerase Chain Reaction (PCR) test can detect COVID-19’s RNA. However they still don’t have confidence in the test’s specificity, ie they don’t know the rate of false negatives.
The PCR test requires kits with reagents and requires clinical labs to process the kits.
While the kits are becoming available, the lab capacity is not growing.
The leading clinical lab firms, Quest and Labcore have capacity to process 1000 kits per day. For the nation.
Expanding processing capacity takes “time, space, and equipment.” And certification. ie it won’t happen soon.
UCSF and UC Berkeley have donated their research labs to process kits. But each has capacity to process only 20-40 kits per day. And are not clinically certified.
Novel test methods are on the horizon, but not here now and won’t be at any scale to be useful for the present danger.
How well is society preparing for the impact?
Local hospitals are adding capacity as we speak. UCSF’s Parnassus campus has erected “triage tents” in a parking lot. They have converted a ward to “negative pressure” which is needed to contain the virus. They are considering re-opening the shuttered Mt Zion facility.
If COVID-19 affected children then we would be seeing mass departures of families from cities. But thankfully now we know that kids are not affected.
School closures are one the biggest societal impacts. We need to be thoughtful before we close schools, especially elementary schools because of the knock-on effects. If elementary kids are not in school then some hospital staff can’t come to work, which decreases hospital capacity at a time of surging demand for hospital services.
Public Health systems are prepared to deal with short-term outbreaks that last for weeks, like an outbreak of meningitis. They do not have the capacity to sustain for outbreaks that last for months. Other solutions will have to be found.
What will we do to handle behavior changes that can last for months?
Many employees will need to make accommodations for elderly parents and those with underlying conditions and immune-suppressed.
Kids home due to school closures
Dr. DeRisi had to leave the meeting for a call with the governor’s office. When he returned we asked what the call covered. The epidemiological models the state is using to track and trigger action. The state is planning at what point they will take certain actions. ie what will trigger an order to cease any gatherings of over 1000 people.
Where do you find reliable news?
The John Hopkins Center for Health Security site. Which posts daily updates. The site says you can sign up to receive a daily newsletter on COVID-19 by email.
The New York Times is good on scientific accuracy.
Observations on China
Unlike during SARS, China’s scientists are publishing openly and accurately on COVID-19.
While China’s early reports on incidence were clearly low, that seems to trace to their data management systems being overwhelmed, not to any bad intent.
Wuhan has 4.3 beds per thousand while US has 2.8 beds per thousand. Wuhan built 2 additional hospitals in 2 weeks. Even so, most patients were sent to gymnasiums to sleep on cots.
Early on no one had info on COVID-19. So China reacted in a way unique modern history, except in wartime.
Every few years there seems another: SARS, Ebola, MERS, H1N1, COVID-19. Growing strains of antibiotic resistant bacteria. Are we in the twilight of a century of medicine’s great triumph over infectious disease?
“We’ve been in a back and forth battle against viruses for a million years.”
But it would sure help if every country would shut down their wet markets.
As with many things, the worst impact of COVID-19 will likely be in the countries with the least resources, eg Africa. See article on Wired magazine on sequencing of virus from Cambodia.
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California. emailrjnov@yahoo.com
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I’m forwarding this important healthcare news about the most common presentation of coronavirus. It was obtained from a colleague who took notes from a meeting of the Infectious Disease Association of California dated March 7, 2020:
1. The most common presentation of COVID-19 was a one week prodrome of myaglias (muscle pain), malaise, cough, and low grade fevers gradually leading to more severe trouble breathing in the second week of illness. It is an average of 8 days to development of shortness of breath and average 9 days to onset of pneumonia/pneumonitis. This is not like influenza, which has a classically sudden onset. Fever was not very prominent in several cases. The most consistently present lab finding was lymphopenia (a low level of lymphocytes). The most consistent radiographic finding was bilateral interstitial/ground glass infiltrates on chest X-ray. Aside from that, the other markers (c-reactive protein, procalcitonin) were not as consistent.
2. Co-infection rate with other respiratory viruses like influenza or respiratory syncytial virus (RSV) is <=2%, interpret that to mean if you have a positive test for another respiratory virus, then you do not test for COVID-19. This is based on large dataset from China.
3. So far, there have been very few concurrent or subsequent bacterial infections, unlike influenza where secondary bacterial infections are common and a large source of additional morbidity and mortality.
4. Patients with underlying cardiopulmonary disease seem to progress with variable rates to Acute Respiratory Distress Syndrome (ARDS) and acute respiratory failure requiring Bilevel Positive Airway Pressure (BiPAP) then intubation. There may be a component of cardiomyopathy from direct viral infection as well. Intubation is considered “source control” equal to patient wearing a mask, greatly diminishing transmission risk. BiPAP is the opposite, and is an aerosol generating procedure and would require all going into the room to wear Powered Air-Purifying Respirators (PAPRs).
5. To date, patients with severe disease are most all (excepting those whose families didn’t sign consent) getting Remdesivir from Gilead through compassionate use. However, the expectation is that avenue for getting the drug will likely close shortly. It will be expected that patients would have to enroll in either Gilead’s randomized controlled trial (RCT) . . . (5 vs 10 days of Remdesivir) or the NIH’s “Adaptive” RCT (Remdesivir vs. placebo). Others have tried Kaletra, but didn’t seem to be much benefit.
6. If our local lab ran out of test kits we could use Quest labs to test. Their test is 24-48 hour turn-around-time. Both Quest and ordering physician would be required to notify Public Health immediately with any positive results. Ordering physician would be responsible for coordinating with the Health Department regarding isolation. Presumably, this would only affect inpatients though since we have decided not to collect specimens ordered by outpatient physicians.
7. At facilities that had significant numbers of exposed healthcare workers they did allow those with low and moderate risk exposures to return to work well before 14 days. Only healthcare workers (HCWs) with highest risk exposures were excluded for almost the full 14 days. After return to work, all wore surgical masks while at work until the 14 days period expired. All had temperature check and interview with employee health prior to start of work, also only until the end of the 14 days. Obviously, only asymptomatic individuals were allowed back.
8. Symptom onset is between 2-9 days post-exposure with median of 5 days. This is from a very large Chinese cohort.
9. Patients can shed RNA from 1-4 weeks after symptom resolution, but it is unknown if the presence of RNA equals presence of infectious virus. For now, COVID-19 patients are “cleared” of isolation once they have 2 consecutive negative RNA tests collected >24 hours apart.
10. All suggested ramping up alternatives to face-to-face visits, telemedicine, “car visits,” and telephone consultation hotlines.
11. Sutter Health and other larger hospital systems are using a variety of alternative respiratory triage at the Emergency Departments.
12. Health Departments (e.g. California Department of Public Health) state the Airborne Infection Isolation Room (AIIR) is the least important of all the suggested measures to reduce exposure. Contact and droplet isolation in a regular room is likely to be just as effective. One heavily affected hospital in the San Jose, California area is placing all “undifferentiated pneumonia” patients not meeting criteria for COVID testing in contact+droplet isolation for 2-3 days while seeing how they respond to empiric treatment and awaiting additional results.
As an internal medicine doctor and anesthesiologist, I see the information above as remarkable for several reasons:
How quickly the symptoms progress in susceptible patients from malaise and cough to respiratory failure and intubation; how difficult it may be to staff adequate numbers of nurses, physicians, and respiratory therapists if the ICU case numbers grow because these healthcare workers will be both at risk and deserving of quarantine themselves; the risk that healthcare workers will stay home because of fear, thus depleting the staff of hospitals; and the paucity of specific medical information the Centers for Disease Control and Prevention (CDC) has has chosen to release either to the medical community or to the public to date.
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California. emailrjnov@yahoo.com
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The question isn’t how many people in the United States will contract the coronavirus COVID-19. The key question is how many of these coronavirus cases will become extremely ill and wind up in an ICU. Authorities tell us two criteria define the threat of a virus: how quickly it can spread, and how severe or virulent the cases are.
How many of the infected patients will develop respiratory failure, and how many will require admission to an Intensive Care Unit (ICU) to be kept alive by a ventilator? To date there have been 90,000 coronavirus cases in the world and 3,000 have died, for a mortality rate of 3.33%. To date there have been 127 coronavirus cases in the United States and 9 have died, for a mortality rate of 7%. This statistic deserves an asterisk, because the denominator is likely too low. We don’t have data as to how many patients have contracted coronavirus, because testing has been limited to date.
We also have no information the numerator, the people who died. The Center for Disease Control (CDC) has released minimal information on the fatalities. For example, how many of the Kirkland, Washington deaths were elderly patients who were Do Not Resuscitate (DNR) status? That is, they were to be denied ICU treatment, ventilator support, and cardiopulmonary resuscitation (CPR) if they became seriously ill? How many of the deaths were vigorous adults who succumbed despite a full ICU effort to keep them alive?
What would the cause of these deaths be in a coronavirus-infected patient? The coronavirus is a respiratory virus which primarily infects respiratory tissues, much like the influenza virus does. Symptoms could include sudden onset of fever, cough, headache, muscle pain, severe malaise (feeling unwell), sore throat, and a runny nose. With influenza illness may range from mild to severe and even death, but hospitalization and death occur mainly among high risk groups such as elderly patients or those with preexisting chronic illnesses.
A severe coronavirus infection would infect the lungs, and cause progressively increasing shortness of breath and dropping oxygen levels in a patient’s bloodstream. The medical treatment would be supportive, that is, a breathing tube would be placed in the patient’s windpipe (trachea) by an anesthesiologist, an ICU doctor, or an emergency room doctor, and the tube would be connected to a mechanical breathing machine, called a ventilator.
As of 2015, there were 94,837 ICU beds in the United States. Many or most of these beds are already filled by patients who need ICU support. If the new coronavirus were to become a pandemic which caused thousands or tens of thousands of cases of respiratory failure in the United States, each of these new coronavirus patients would require an ICU bed and a ventilator. This could quickly overrun our ICU capacity in America.
That is the real scare of the coronavirus issue—the fear that our hospitals could not handle the volume of severe infections. Could temporary ICU beds be set up? Each bed would require a ventilator, a set of monitors, and around-the-clock nursing staffing. The supplies of each of these is finite. In addition, with an infectious disease such as coronavirus, each of these ICU beds would ideally be an isolation bed, which kept that patient quarantined from other patients and staff.
Can an anesthesia machine in an operating room be used as an ICU ventilator? Yes. Read more about that topic here. An operating room can be converted into an ICU room with the anesthesia machine ventilator keeping the patient alive.
In week one of the pandemic in California, I went grocery shopping at my local Safeway. The parking lot was full. When I arrived at the front door there were no shopping carts. Inside the store I saw hundreds of shoppers elbow to elbow in all the aisles. I asked an employee why the store was so busy, and she said, “This is nothing. You should have seen it yesterday—even busier!” “Why is it?” I asked.
Her answer was two words: “The virus.”
She went on to say that customers were buying cleansing wipes, Advil, Tylenol, water, and food provisions that they could survive on for months. On my way out of the store, I saw my own primary care physician in the parking lot, and we discussed the shopping mayhem. He validated my views with the remarks, “It’s not if, but when, people will get infected. It’s just too soon to know how many severe cases there will be.”
The Safeway customers buying Advil and Tylenol are worried. If you have a severe infection, Advil and Tylenol are not going to save you. What you would need is an intensive care bed with a ventilator, equipment to support your vital signs, and doctors and nurses to care for you 24 hours around the clock.
I hope and pray the overwhelming majority of coronavirus infections in the United States will be mild and self-limiting. A search for a vaccine and/or useful treatment drugs are underway. But because American medical systems need to be prepared, those in charge of health care administration are no doubt preparing contingency plans on how they can manage thousands of new patients in respiratory failure if needed. For more information on this topic see Stockpiling Ventilators for Influenza Pandemics.
