DENVER — 4/3/2020
I woke up yesterday with a scratchy throat and sneezing and immediately, my heart sank. “This is it” I thought. “I have COVID-19. Am I going to be one of those young people who end up dying connected to a ventilator? I’m just not ready to go yet!” After taking an antihistamine, checking my temperature and noting that my symptoms had completely resolved with Allegra, my panic settled and I realized that the symptoms were likely to represent seasonal allergies rather than COVID-19 infection. In that moment, I realized I wasn’t a doctor, I wasn’t a cardiologist, I wasn’t a scientist… I was a person who was scared. I was a person like all the other people around me who regardless of profession, background, age, race have felt the havoc this pandemic has wreaked on all of our lives. Some fear is normal. Acknowledge your fear, don’t push it away. But, after giving it a few minutes to breathe, try to let it go. If it persists and starts to interfere with your functioning, you may need to reach out to get connected with mental health resources. Check out a mental health screening at www.9healthfair.org - click on eTools.
Today is National Doctor’s Day and I want to give a “shout-out” to what I call our #CoronaHeroes. Just imagine the day in the life of a #CoronaHero. Wearing head-to-toe personal protective equipment (PPE), which is hot, humid and not breathable. Worrying not just about your patients but about taking the virus to yourself or your family. Washing your hands over and over until they are chapped and cracked. Even having a sip of water, checking your phone or going to the bathroom is an ordeal and increases your risk of contaminating yourself or your PPE or using valuable and scarce PPE.
I’ve always known firsthand that what healthcare providers do – helping someone at their most vulnerable time, working long hours and holidays so others can stay home to celebrate with their families, exposing themselves to the risk of respiratory illnesses and infectious diseases so that others can breathe easier ... This pandemic has now made the rest of the world realize this.
I cannot share how relieved I was to hear that the national social distancing mandate was extended to April 30. By now, we are all starting to experience the challenges of social distancing. And, the question we all have on our minds is, “when will our life go back to normal?”
I more than anyone else am ready for that “normalcy.” Ready for seeing my friends and colleagues without being covered in PPE. Ready for hugging someone without thinking twice about it. But the time is not now. Our president has already extended the social distancing to April 30. And, we really can’t relax the social distancing until we are not only beyond our “apex” but back down on our curve. Because, by experience, we know that as soon as we relax our social distancing, we may get an uptick in the number of cases again. So, we can’t do that until we are ready for this. Let’s find ways to keep ourselves motivated at home because we are running a marathon, not a sprint.
Sorry for the LONG delay in updating my blog. It’s been a roller coaster of a week… so many ups and downs… some steps forward…some steps back.
- We are now the country with the most number of cases in the world – sadly, not an accomplishment we ever wanted to have.
- The reality of providers not having PPE hit home as my beloved Brigham and Women’s Hospital (where I trained as a physician) and other Boston hospitals, where >100 providers have been diagnosed with COVID-19 infection. Dozens of my friends work in the NYC hospitals, which are increasingly becoming like war zones. The thought of losing my friends makes me sick to my stomach.
- My brother and his wife and my two-year-old nephew live in NYC, the epicenter of the United States. I worry about them every day. I call them twice a day. I think about them dozens of times during the day. At times like these, I feel helpless against this virus.
- I am filled with dread about “opening things up” even in counties/locations with “few cases”. This fills me with fear and panic that any progress we have made in the past week may be lost.
- The first vaccine went into Phase I clinical trials. A beacon of hope for us? Perhaps. Although we do know we are still about 1 year away from a vaccine that is available for widespread use. Silver Lining #1.
- NY Governor Andrew Cuomo’s response is inspiring and should be emulated by leaders all over the country. Our very own Mayor Hancock and Governor Polis issued “stay at home” orders. #StayHomeandSaveLives. Silver Lining #2.
- The first data from NYC that our social distancing efforts are working and rate of doubling of the number of cases is slowing down (the slope of their curve could be starting to flatten). #SocialDistanceNow. Silver Lining #3.
Personally, I was very saddened to hear about the death of a “doctor hero” in Italy today. This man was 67 years old and a remarkable person, as he decided to take care of patients without having personal protective equipment. This is one of many stories coming from all around the world of physicians who are neglecting their own safety to take care of those who are ill. One as young as 40 years old hospitalized in the ICU in Washington. True heroes. Isn’t it our duty as a community to protect our healthcare workers? Many in the medical field are saying this is akin to sending soldiers into war without their armor. Anecdotally, some local hospital administrators have instructed healthcare workers to use simple surgical masks (which are not fully effective) in the setting of exposure to patients with COVID-19. The White House Task Force and Gov. Jared Polis have both publicly acknowledged there may be an anticipated shortage of personal protective equipment (PPE). If we don’t protect our healthcare workers today, will there be enough healthcare providers who are well enough to care for our sick patients in 1-2 weeks?
Let’s remember to avoid elective doctors' and dentists’ visits at this time. Put off the hair appointment for now. Get your nails done later when this has all settled down. In the last day, we had a 44% increase in the number of cases from ~3500 to >5000, we crossed into triple digits for the number of deaths in the United States and we heard that San Francisco announced its citizens to “shelter in place” and NYC mayor also may be ordering people to “shelter in place”. This is a huge storm and we do need this “shelter.” #SocialDistanceNow #FlattenTheCurve.
3/14/2020: The number of cases here in Colorado continue to increase and we are now clearly on the “steep” part of the curve. At this point, in my opinion, there are only two options the government has left. Option #1: Test, test, test very aggressively (including asymptomatic spreaders, who are now thought to be playing a role in transmission and asymptomatic healthcare workers) and quarantine those who test positive. However, if we are not able to ramp up our testing capacity as a country into the millions as quickly as we need to in order to contain this, we may be doing what they are doing in Spain and Italy, which is asking all business to close and people to stay home. This is Option #2. Although more drastic, this has proven to be an effective option for “flattening the curve” and slowing the spread of the virus.
Another thing that has been bothering me that I want to be sure to EMPHASIZE. Yes, the most vulnerable population is those who are older, have chronic medical conditions or are immunocompromised, there have also been many deaths in young people. It is hard to predict which young people will have a mild illness and which could have life-threatening complications. So, it is very important that even the young and healthy take this seriously and don’t “blow this off”.
3/12/2020: The last few days have seen a wide adoption of “social distancing” as more and more events get canceled. And, I have to be honest, it really hit a chord when I heard that Tom Hanks and his wife have been diagnosed! I have been trying to wrap my head around just how much this thing could impact our lives. If we do nothing, in the worst-case scenario, estimates say that up to 60% of the population could get infected with this virus. Even in the best-case scenario, with a 1% mortality rate (which is very conservative), that means millions of deaths and outstripping hospital capacity, outcomes which are unacceptable. So, I commend our community for really jumping into the “social distancing”. But remember, we all have to do it… and we can’t be “halfway in” (it’s not ok to go to the movies but skip that concert). This means “all hands-on-deck” today with full buy-in to really make this work. I have canceled my plans for the next two weeks and plan to stay at home and lay low. As they said in Korea, “Let’s not be social!”
3/11/2020: Sorry I haven’t been able to get to my blog in a few days as the tensions surrounding the virus mount. Today, I am so fascinated with the idea of “emotional contagion”. This means that our emotions are contagious, just like the virus, and in some cases, spread faster than the virus. These are the emotions of panic and fear that seem to be permeating. But, I couldn’t help but wonder, why don’t we turn this on its head and use “emotional contagion” to spread empowerment and community togetherness. This is the time to help out elderly neighbors or sick friends. This is the time to use this incessant amount of information to empower ourselves to be prepared rather than scared. This is COVID-19’s silver lining.
3/9/2020: We have had a major inflection point this weekend! Former commissioner of the FDA Scott Gottlieb wrote today on social media that we are beyond containment of the virus and now must focus on efforts directed at mitigation (reducing the impact of the virus on our community). Here in Colorado, we are slowly getting an increase in the number of cases and I believe this is the window for us to practice “social distancing” in order to flatten the curve, mitigate and minimize the impact on our healthcare resources and our communities. This “social distancing” won’t last forever, but for now – avoid large crowds, cruise ships, sporting events or places with close contact with lots of people, where “super spreading” of the virus could occur.
3/8/2020: Today, I am incredibly frustrated! Earlier today I got a call from a family friend who is 72 years old with a history of heart disease, who traveled to Phoenix (where there is community spread of COVID-19) 2 days ago and now has a fever AND shortness of breath. Without hesitation, I had him call ahead and then sent him to an urgent care facility in Lone Tree. There, a physician’s assistant evaluated him, did a flu swab and then sent him home without a COVID-19 test or a chest X-ray. Now, as a physician, I am not a fan of “Monday Morning Quarterbacking” since I did not directly assess my family friend. However, I can’t help but wonder if healthcare providers either don’t understand the criteria for testing or don’t understand the update made to the criteria, which relaxes the strict requirement of having BOTH symptoms and exposure history. In this case, this patient did have documentation of both and yet didn’t get a test. Judicious use of resources were used as an explanation for not offering him a test, yet we are hardly at capacity so why not test more widely?
If this isn’t the type of patient we are testing (someone who has classic symptoms, history of possible exposure and is a high-risk patient), then who exactly are we testing? Is this the explanation for the low number of tests?
3/7/2020: I can’t help but wonder how fundamentally this virus has changed the way we live our lives. It has changed the way we interact with each other, the way we travel, the things we think about every day. It has affected our economy, our recreation, our peace of mind. We have become fearful of social interaction. But, we can’t let this happen. Now is definitely the time for heightened caution and being intelligent of the choices we make. Don’t take it lightly as COVID-19 is a serious threat and our behaviors will certainly influence the ongoing spread of the virus. Don’t travel unless you have to, have your prescriptions on hand for 2-3 months, have at least 2 weeks worth of food and paper products. Be smart. Own your health and preparedness. But, let’s not allow this virus to change our outlook in the long term. #ColoradoStrong.
3/6/2020: Now is the time for our community to come together to fight this thing. We all have a common enemy! We all are have our own distinct opinions on politics, on sports, on other national controversies. But, this is one of those things we all can stand against…. United regardless of age, race, education or socioeconomic status. I hope we all in the Colorado community can come together to protect each other and emerge victorious.
3/5/2020: Today was a big day for our community in Colorado. The first two presumed positive cases of COVID-19 are here in Colorado. I feel like it has been a “dress rehearsal” until now and “showtime” is here. We are now going from talking about the virus to facing the reality that it is here. I expect the next few days to see an ongoing trickling in of cases as the virus spreads in our community and we are testing more people now.
3/4/2020: I heard today that dozens of healthcare workers in Hillsboro, Oregon were being quarantined due to potential exposure to COVID-19. My friend and colleague, Cardiologist Dr. C. Michael Gibson (@CMichaelGibson) tweeted out an important question afterward that got me thinking…
“After first responders and the healthcare system are exposed to numerous #COVID-19 cases, how will the system function with so many people in quarantine? This is a major issue.”
I agree. How do we are a healthcare system strike the balance between protecting and serving our patients and protecting ourselves? How do we ensure that we are part of the solution (i.e. stopping the spread of COVID-19) rather than part of the problem (i.e. spreading it to more patients?). At this time of crisis, how do we allocate appropriate resources?
This question had me feeling uneasy all day because the healthcare system is only as strong as the workers in it. And, these healthcare workers are human… and susceptible to all the same viruses as the patients they treat. So, if this virus attacks the infrastructure of the healthcare system and creates a “supply chain disruption” of healthcare providers, what will happen to the care?
I am hopeful and anxiously awaiting the development of the COVID-19 blood test as that may offer more rapid (and perhaps more accurate testing) so we don’t create a new problem with our quarantines.
3/3/2020: I heard yesterday that the new COVID-19 testing kits are now available in Colorado. But, I have to admit that my heart sank just a little bit when I heard that the capacity is only 160 patients a day. But, I am hopeful that those capacities will increase over time. As the virus spreads across the country, we will quickly have to ramp up that capacity to meet the need for the patients being tested. The CDC “relaxed” the criteria for testing last week and allowed for clinical judgment and so, as a physician, I hope I can test anyone in whom I have clinical suspicion even if my patient doesn’t strictly meet the “criteria” for testing. In South Korea, where “drive-by” testing is an option, many more cases of COVID-19 are being detected. If we did that here and tested more widely, we too would pick up more cases with mild or no symptoms and would better understand the spread, the behavior and the mortality of the virus. If we only test the sickest patients, then the virus will appear much more deadly than it actually is. I do hope that our resources will increase
In addition, I want to know more about the test as a doctor. Despite being a physician, I don’t really have much of an idea of the performance of the test. Is it accurate? What percentage of cases does it miss? What percentage are falsely positive, if any? I am hoping the CDC continues to provide more guidance to physicians as they roll out the testing kits who are getting dozens of calls every day and requests for testing.
3/2/2020: I opened my eyes before the alarm rang this morning to a phone call from my brother, who lives in Manhattan, New York, New York. My adorable nephew is only 2 years old and my brother was worried about the risk to children. I told him that information is limited at this time in children, however, very few cases have been reported in children, which seems to suggest a lower exposure risk or relatively mild cases. Heightened immunity in children may also be possible but is less likely. And in a small study of 9 infants published in the Journal of the American Medical Association, there were no deaths and no cases requiring mechanical ventilation (“ventilator”) support. But, I did take this as an opportunity to educate him about washing my nephew’s hands, wiping down his toys every day and being really careful about taking him on crowded NYC subways!
3/1/2020: I was very saddened to hear about the second United States death in the state of Washington. A new article from The New England Journal of Medicine, published on February 28, 2020, the mortality rate was reported to be 1.4% with Dr. Fauci and co-authors commenting in the editorial accompanying the article that the actual rate may be <1%. This was heartening to me. We may have overestimated how deadly this virus is and the risk is actually turning out to be lower than what we thought.
2/29/2020: 10 am: Today is leap day, which is a rare gift of valuable time that only comes once every 4 years. However, we will remember Leap Day 2020 for another reason… because it marks an important turn in the events from COVID-19. I was very saddened to hear about the first U.S. death from the coronavirus in King County, Washington today. This death has definitely made all the talk about the virus coming to our community so much more “real”. And, as a doctor, I want to ask several questions: How old was this patient? Did he/she have other illnesses that may have contributed? Did his/her clinical course teach the medical community any important lessons? I am anxiously awaiting more details in the press conference at 1 PM today for more details. More to come soon….
1:00 pm: After listening to the President and reading the reports, it appears the first U.S. patient who died today in Washington state was a man in his 50s (not a woman, as was accidentally said during the press briefing) and had multiple other medical problems. Although he is substantially younger than the typical demographic that has a high mortality rate from the coronavirus, it appears he may have had other medical problems that predisposed him to a higher risk of complications. Still… as a doctor, I do wish we had a slightly better understanding of what types of patients were succumbing to this illness as we have seen some deaths in younger patients, especially in China.
So, after the press conference, I decided to turn my attention back to the medical meeting I was attending in San Francisco. While having lunch, my colleague and I discussed the patient in California who presented to the hospital but did not meet “criteria” for being tested for COVID-19. We both agreed that the challenge remains of who to test and how much. If the criteria are too lenient, it can cause over-testing and strain on the availability of resources to test for the virus. But, if the criteria are too strict, we could miss cases, like this one. We weren’t sure whether the U.S. should do what some other countries are doing, which is to test anyone who is displaying any respiratory symptoms to increase the rate of detection. Because the illness is mild in most people (81%), it is probably being under-detected as everyone is not presenting to get medical care.
2/28/2020: As I get ready to head out to San Francisco for a medical meeting, I can’t help but feel slightly anxious about the state of emergency that has been declared in the city due to the coronavirus. As a hub for international travel to China and Asia, San Francisco is especially prone to having visitors from countries where the infection is rampant. For a moment, I wonder if I should cancel my trip altogether. However, the panic only lasts for a split-second and then the logical side of my brain kicks in. I realize that there are still only a handful of cases in the U.S. and the CDC has not yet issued any travel advisories for travel within the United States so the threat of this virus should not change my way of life today. I realize that fear is such a powerful emotion that it clouds our other emotions, like reason. I talk myself down from the ledge, finish my packing, pack plenty of hand sanitizer and Clorox wipes and head out to DIA. City by the Bay, here I come!
9Health expert Dr. Payal Kohli will continue to add to this blog as the coronavirus situation develops and changes.
There is a lot of information out there about the coronavirus, and it can be overwhelming. Dr. Kohli said the best things you can do to protect yourself are to stay informed and practice good hygiene. Don't panic, don't start canceling your plans, and no need to start stockpiling supplies just yet.
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