Friday night update from the ER in Arlington, VA—Happy New Year.
I am certainly happy to welcome in 2021. This week marks the 1-year anniversary of the first reported cases on Coronavirus pneumonia in Wuhan, China. I believe I became aware of the virus in early January and started to get very concerned by late January when we had a handful of cases in America and I heard/saw they were building a hospital in China over days specifically for these patients. Building a hospital in days seemed like an extreme measure so I figured it was much worse than we were being told. We’ve come an extraordinarily long way since then but with tremendous costs. Approximately 345,000 Americans have died from COVID and more than 2900 healthcare workers (HCW) have died this year (according to Kaiser Health News) and we are still far from putting this behind us. Early on, I remember hearing that pandemics like this are expected to last 18-24 month, so perhaps we are ahead of the game with the vaccine.
Based on TSA and AAA reports, it sounds like a lot of people traveled over the Christmas holiday. I certainly realize people have traditions, want vacations, and expect to spend time with family during the holiday season. The risk may be low to each individual, nonetheless, there is an additional risk associated with traveling and of course, expanding your contacts. The CDC and other experts warned that we would see the results of Thanksgiving several weeks afterwards and our data shows that to be true. I expect another spike a month from now as we see the impact of the holidays and family and friend gatherings. There are definitely areas of the country that are in very bad shape. Healthcare wise bad shape is defined as running out of ICU beds, running out of ventilators, and not having enough space and staff to take care of all the patients coming into the hospital. Mortality rates increase as hospitals are overwhelmed. We saw this in New York with COVID in the spring and we have seen this time and time again in hospital settings in different areas of the country. As hospital capacity increases, it becomes increasingly challenging to care for all the patients. Across the country, this is compounded by having hospital staff out with COVID or as a result of COVID exposure, primarily through community spread. While the vaccine will likely decrease the number of healthcare workers (HCW) who get sick with COVID over the next couple of months, it won’t keep healthcare workers from missing work if they have high risk exposures (remember, we don’t yet know if the vaccine prevents asymptomatic carriers/transmission).
Let us look at the impact of Thanksgiving. In the weeks leading up to Thanksgiving, our ED was seeing about 200 patients a week who required our COVID isolation procedure. In October and November, about 30 to 40% of these patients ended up staying overnight in the hospital (admission or observation). As we look in later December, were seeing closer to 265 patients a week, and now about 40 to 50% of these patients require staying overnight in the hospital. On the inpatient side, in November we generally had about 40 hospitalized COVID patients. A month later, that number is in the 90 range. Our peak in April was about 120 COVID patients in house. We are certainly on a steady upward trajectory to hit or exceed that. Currently, we’re able to care for patients with enough bed availability, ICU care, and ventilators. But I certainly have my concerns on what the healthcare system will look like in a month based on what we’re seeing in other parts of the country.
When I watch the news each night, reports provide how many patients are hospitalized in Maryland (I watch Baltimore news). I’ll often hear reporters comment that 3 more people were hospitalized accounting for the bump in the number compared to the previous day. Only 3 new admissions doesn’t sound so bad but remember the daily changes represent the net between the admissions and discharges. About 10% of hospitalized patients die, another 10% get transferred to nursing homes or rehab, while most of the rest, fortunately, get discharged home. At our peak in the spring, we briefly had about 110-120 COVID patients in the hospital. At our low point during the summer, we had numbers in the 20s. If you go back and look at my posts from the summer and fall, you will note that I never talked about our inpatient numbers going up 50 to 100%, when we went from 20 to 30 or 20 to 40 inpatients at a time. That would have sounded really bad but it wasn’t a stretch to our system and I didn’t think it was appropriate to frame it that way. COVID patients are sick and as we close in on 100 patients in the hospital, our teams do feel it and start to get stretched. About half the patients I saw on my last shift had COVID. I admitted a little more than half of the patients I saw. In the pre-COVID days, our ER admitted about 20% of all patients. Now, we’re at 30%.
There’s a great website my wife came across this week that lists individual hospital capacity and what percent of the hospitalized patients have COVID. I’ll post the link in the comments or you can google “NPR Hospitalization Tracking Project.” Looking at the VHC data, it doesn’t link up perfectly, but it’s close enough to have a sense as to what’s going on in your community and around the country. What I’m always surprised by when I see hospital occupancy rates is that rarely are hospitals listed as 100% for adult beds., Every ER doc around the country will tell you that we are keeping admitted patients in the ER for hours (or longer) because there are not beds available in the hospital. This is referred to as “ER boarding” and something we track and try to improve on a regular basis. Boarding issues have been around for my entire career and they’re always worse in the winter. But hospital bed availability is much worse now and truly in crisis in certain parts of the country due to COVID. And many ICUs are overflowing.
From the testing perspective, in the weeks leading up to Thanksgiving, our overall percent positive rate in the ER was 8-12% depending on the week. Now, we’re exceeding 20%. Our symptomatic patients were testing around a 25% positive rate and now it’s about 45%. These are real increases in the amount of COVID in the community. How many COVID positive patients are running around our communities? I don’t know. Early on, I used to estimate 1-2% of the population was likely positive. Then I estimated based on the data we’re seeing from screening that it was up to 5%. The CDC reports that Maryland and Virginia have 37 and 43 new cases each week per 100,000 population, respectively. That’s fascinating to me since my ER sits in a county with about 250,000 (though our catchment area is bigger) and we diagnose 80-90 patients a week with COVID. We also treat about 50 more patients a week who come to us knowing they have COVID and now are sicker. I spoke to the owner of a local pharmacy in Arlington, VA, and he told me they’re doing over 1000 tests a week. Even if he has a 5% positive rate, that’s another 50 cases a week into the totals. And there are numerous outpatient testing options near the hospital who also diagnose people each week. I think in the immediate area around my hospital, we are above the state average. Johns Hopkins published a study recently looking at antibody data from autopsy patients from the Office of the Chief Medical Examiner in Maryland. I’ve spoken to the OCME’s office too many times to count as an ER doc working in Maryland as almost all ER deaths get reported. But the OCME generally only takes patients who died from trauma, drugs, homicide, or suicide. They do not take patients who appear to die of natural causes. From this patient population of 500 people in June, 10% had antibodies to COVID. This is higher than would have been expected that early in the pandemic. Hispanic men were four times more likely than whites to have antibodies. People dying in car accidents had similar rates to those who died of natural causes. Those dying of accidental overdose had a much lower rate of antibodies. I’ve reached out to the study’s lead author to confirm that the OCME did not change the cause of death based on the presence of COVID antibodies.
There have been new strains of virus identified in the UK and South Africa causing minor changes to the spike protein. The UK virus has led to lockdowns in Europe. The mutations appear to increase transmission/spread (remember the early discussions about RO) leading to more cases (which translates to more ER visits, hospital admissions, and death) but does not appear to be more dangerous or result in more severe illness (we do not expect a higher percentage of patients to require hospitalization or die). We believe the vaccine will protect against this strain as the protein the vaccine is built around is still relatively intact. All viruses mutate over time and getting control over the virus as quickly as possible is in our best interest to preventing more mutations. The first case reported in the US was in Colorado earlier this week and other cases are surfacing. It’s likely the virus has been in America for some time.
A paper came out in the British Medical Journal this week comparing hospitalized patients with COVID to those who were hospitalized with the flu (over the last several years). While doctors have been saying COVID isn’t the flu since the spring, I know there’s people who still see the 1% mortality number that’s thrown around and say it’s not a big deal. But when you look at the data, COVID is clearly not the flu. COVID patients have significantly more complications related to blood clots, kidney failure, heart problems, ventilatory and ICU needs, septic shock, and death when looking at hospitalized patients. It’s not even close to flu for those of us who treat patients.
There have been a handful of severe allergic reactions with the Pfizer vaccine. The risk of death is certainly higher if you contract COVID compared to having an allergic reaction. The CDC has released very clear guidelines about people who should avoid the vaccine due to allergy concerns. In the NEJM this week, the Moderna Vaccine data was published with a 94.1 effectiveness rate in preventing symptomatic COVID. And perhaps more importantly, there were no severe COVID infections among those vaccinated. The AstraZeneca-Oxford vaccine was approved in the UK this week. This was one of the first vaccines I started following last summer. It’s not a mRNA vaccine like Pfizer and Moderna and uses a genetically altered common cold virus (adenovirus) (that won’t reproduce or make us sick), carrying the gene that makes the spike protein, which then instructs our cells to make the spike protein so our immune system can learn how to react to it. It’s a two-dose vaccine that is believed to be about 70% effective but scientists believe that rate can increase to 90% by adjusting the dose.
While the vaccine rollout has started, we’re far behind from the goal of 20 million dosages injected by yesterday. There’s a lot of work to do getting vaccination programs up and running. Former Baltimore City Health Director and current GW emergency physician, Dr Leana Wen, had a great tweet that put the vaccination progress into perspective. “Here’s the math: If the goal is to reach 80% of Americans vaccinated with a 2-dose COVID19 vaccine, it will take 10 years at or current pace. We are at 1 million vaccinations a week. To get to herd immunity by June 2021, we need to be at 3.5 million vaccinations a day.”
Science matters. Wear a mask. Practice physical distancing.
PS: Happy New Year’s. I hope everyone had a quiet, safe, and bubble oriented holiday. Besides the holidays this week, we celebrated our wedding anniversary and a kid’s birthday (all socially distanced). Attached is a family selfie as a little proof that I do take a little time for family and to get out. Thanks for all of the support, well wishes, and reminders to do just that over the past 9 months.