I hope you are all hanging in there doing social isolation at home. For this weekend update, I want to emphasize one message: Stay home, stay home, for the love of all things good and merciful, STAY HOME, please. There have been a lot of changes this week and it’s been a bit of a whirlwind. I’ll try to clarify some points for you.
I’m hearing that many of you now cannot get pulse oximeters from Amazon, Walmart, etc. There is an app that so far looks like it works well. It is available in the App Store on iPhones (not available on Android). It costs $4.99, and I have a picture of it on the Priority Care Facebook page. If you aren’t following it already, it’s a good way for me to get information to you as some information is better in chart or picture form which I can’t email easily. You could also interact with the posts if you have any questions.
Back to the Pulse Oximeter App, I’ve tested it against my personal pulse oximeter and it matches. Takes some time to get heart rate, but the pulse ox is the measure that’s important. People with COVID-19 may not feel short of breath or like they are having problems breathing, but things can go downhill fast. The pulse ox lets us keep tabs on where you are clinically. It can help with knowing whether or not your symptoms warrant going to the ER. Normal oxygen saturations are between 95-100%. Call me if your measurement gets below 95% and critical value would be ~92%. Knowing where you are at baseline (normal healthy) will also help to know when something is abnormal. This app, like all things right now, isn’t perfect, but it’s the best alternative that DPC doctors are seeing if you can’t get a pulse oximeter.
Some data: Currently there are ~1,200,000 cases of COVID-19 worldwide. ~250,000 cases have recovered. The U.S. now leads the world in the estimated positive COVID-19 cases at 310,000, with 8,700 deaths. The situation is critical in New York with 113,700 + cases that we know of and 4,000 deaths that we know of. Healthcare workers in New York still face a shortage of PPE (personal protective equipment) and the only word that I know that adequately describes the situation there is chaos. There are shortages of equipment, beds, ventilators and medicine. New Jersey, Michigan, and Illinois (specifically Chicago) are beginning to show critical strain on our healthcare infrastructure. This is due in part to a lack of being prepared, lack of adequate social distancing, and underestimating the severity and insidiousness of the COVID-19 infection. Please help healthcare workers from the ICU and ER doctors, PAs and NPs, nurses, respiratory therapists, lab personnel, hospital maintenance staff, etc. stay protected by staying home so we can possibly prevent a similar situation in NC. Washington State, one of the first states effected, has been able to achieve some slowing down of the spread by utilizing stay at home orders. It really can be done.
In NC, there is a big effort to try to be as prepared for a surge in cases as possible. We only received about 17% of the requested PPE from the federal government that was requested. Our hospitals are trying to conserve resources as best they can by trying to utilize the least amount of masks, gowns, and gloves while still protecting the health care workers and patients. It’s not an ideal situation, but they truly are trying to do the best with what they have. Our projected surge is late April. We want to be sure we have ICU beds for as many patients as possible and are in the process of converting some of the UNC Charlotte campus into makeshift hospitals, retraining doctors in critical care and emergency medicine so they can serve where most needed, and stopping all nonessential procedures and visits to make room for the increase in medical care needs that are possible.
We still have the time and ability to minimize the loss of life in our state if we make a huge concerted effort to stay home and try to prevent the spread of this coronavirus. Because the virus is so easily transmitted and a person not showing any symptoms could be contagious (this is different than what we reported initially), staying home and not co-mingling with neighbors and friends is necessary. When someone has to be admitted to the hospital for treatment for COVID-19, they are not permitted visitors and staff has to minimize the time in the room with the patient. It’s a cruel virus in that the very ill are made to fight the virus alone. Doctors and nurses are trying creative ways to help patients communicate with their families by using iPads, Facetime on phones, and phone calls, but in person visitation is simply not allowable. Please stay home so that someone’s loved one doesn’t have to suffer this way.
As for testing, there is good news to report in that the hospitals are able to run more than a thousand tests a day. They are using the Roche platform with PCR as a backup (for those that want to research). The tests have a high sensitivity and specificity rate, but this can be dependent on how the sample is taken. It’s a bit uncomfortable to swab the nose as deep as needed for an adequate sample. This explains why you are probably hearing the reports that the testing is only 70% accurate, as there are various factors to consider. Testing is still reserved mostly for those that are admitted to the hospital, so staying home, resting and pushing fluids while monitoring is still recommended. Again, call or text me if you have questions about whether to seek care or not. If you have a thermometer and a pulse oximeter (or the app), then this will help me guide you.
Some of you have asked about treatment options. There are many clinical trials going on in different states in the U.S. and in other countries. Hydroxychloroquine (Plaquenil) and chloroquine which is used in treating rheumatoid arthritis and lupus as well as a prophylactic medication for malaria acts as an ionophore, or simply a way to get zinc into the cells infected with COVID-19. Once zinc is inside the cell it can disrupt the process of viral replication and give the infected patient’s immune system time to respond. If it is given early enough, the theory is that the virus will not replicate as fast and the immune system will respond without “over responding” and producing too many of the cells that our body uses to fight infection. The term “cytokine storm” is used to describe one of the ways that the immune system can over respond and start attacking healthy cells as well as infected cells. So, there are currently trials that are studying if giving hydroxychloroquine along with zinc to health care workers with repeated exposures, helps prevent them from getting very ill with COVID-19. Azithromycin is added to this regimen to treat a possible secondary bacterial infection as many of these patients do have significant pneumonia and lung disease. According to the U.S. Department of Health and Human Services (HHS), 30 million doses of hydroxychloroquine have been donated by Sandoz, the Novartis generics and biosimilars division, and one million doses of chloroquine have been donated by Bayer Pharmaceuticals, for possible use in treating patients hospitalized with COVID-19 or in clinical trials. These and other companies may donate additional doses, and companies have ramped up production to provide additional supplies of the medication to the commercial market and pharmacies that we all use.
In order to prevent a shortage of hydroxychloroquine and other potential treatment, many states’ medical boards have issued statements to prescribing physicians about not prescribing these medications for COVID-19. One could argue that maybe they should limit the “amount” of medications prescribed for COVID-19 to prevent hoarding and limiting prescribing 90 days’ worth of medication to only 30 days’ worth for those with rheumatoid arthritis or lupus. Physicians could then judiciously decide which patients might benefit from these medications and prescribe accordingly. I’m going to assume there is more that I don’t know and thus a reason for these restrictions as production is ramped up. But I’ll be following along closely to see if the recommendations for treatment changes. There are clinical trials going for Remdesivir, an antiviral medication and the use of plasma from a person infected with COVID-19 and recovered (term is convalescence serum), and other treatments, but the time frame for these are expected to take longer and involve a more complicated course than we have resources for at this time. A vaccine is still hoped for within 18 months or so.
To summarize, there isn’t any outpatient treatment that I can prescribe in North Carolina at this time, so our best defense to prevent the spread of the COVID-19 infection is social distancing and staying home.
Finally, there has been a change on the recommendation of the use of masks in public. The recommendation that we did not need to wear masks in public was driven by the supply chain and lack of enough supplies for health care workers. Because it is now accepted that someone who is not showing any signs and symptoms of having a COVID-19 infection can be positive and contagious, it is advised to wear a homemade mask (video on Priority Care, PC Facebook page of how to make one with a washcloth and 2 rubber bands or hair ties) when going out in public and maintaining a distance of 6 feet between people may be difficult. So, now we are saying, that yes, you should wear a mask to the grocery store or if you are one of the essential employees that needs to leave your home. We need to conserve surgical and N95 masks for health care workers, therefore, making your own is advised. I’m not really seeing this recommendation being utilized yet, but it is new from the CDC so I wanted you to be aware of it.
Remember, we are dealing with a highly contagious viral infection. Also highly contagious is kindness, patience, love, enthusiasm, and a positive attitude! And one of the best ways to show kindness and love right now? You got it—staying home and practicing social distancing!
We will get through this together, call or text as needed.