I worked clinically in the ER the evenings of Tuesday and Wednesday this week. Those days were interesting because of the planned demonstrations in DC. Many DC hospitals were on ambulance bypass so we received extra patients. This happens from time to time and adds a little complexity as our electronic medical record doesn’t link up with GW or MedStar (we do link up with INOVA and Kaiser) so reviewing old records becomes very difficult. This can impact the evaluation and treatment of these patients. (reminder—you’re generally better off going to the ER where they know you and have your records than thinking you’ll try a new place, particularly if you’re medically complicated or have had recent surgeries/procedures). With that said, I personally saw a handful of patients that had been at the rallies. Everyone had a little different story and they all needed to be there for medical reasons. One was surprised to find out they were COVID positive, which means the group they drove to DC with, in a car without masks on, will all likely become positive as well. None were injured or gassed or had anything related to the event. Historically, about 10-15% of our patients are tourists and this patient population is part of what makes my job fun and interesting. I will also add that through the years, I’ve taken care of my share of patients who are openly anti-semitic and/or racist, as well as violent criminals, and other people that I would not interact with if I had a choice. But as an ER doc, even had any of these people stormed the Capitol and were considered domestic terrorists, I put that aside, do my job as a professional, and focus on the reason they’re at the ER. Wednesday afternoon was definitely more stressful. As the demonstrations escalated, we didn’t know what to expect. Would we be seeing dozens of injured people or would someone come in with weapons and shoot up the ER? That added some real stress that increased a bit as we heard about how crowded the Metro was as people came back to their hotels in Arlington. But by 8pm as the curfews were in place and we were hearing from colleagues who came in for their shifts and the police that the streets were quiet, there was considerable relief.
Before I go on, I want to acknowledge that there are parts of the country where hospitals are so overwhelmed with COVID patients, that EMS is not transferring patients that meet certain criteria or where there are no critical care beds for patients within hours of the ER they’re in. I see posts on social media of ER docs requesting help getting critically ill patients transferred to available ICU beds or ECMO treatment. One doc in a rural area said they had contacted over 100 hospitals looking for a bed for a patient. That’s just unheard of in American healthcare. Many cities, counties, and states have reached the level where the healthcare systems are overwhelmed, which is what we were so concerned about last spring.
This is a long post, but I think you’ll like it, so please don’t get overwhelmed at the length. The second half of the post has a great guest writer. Let’s get into the data.
The good news is that the hospital has a handful less COVID inpatients today than it did a week ago. That number fluctuates a little bit from day-to-day but I will take any good news I can find. To temper the good news, however, is that we are continuing to see a steady increase in the number of patients who require our COVID isolation procedure. Over the past week, we had the third highest number of patients requiring COVID isolation since I started tracking data in early March. Last week was our fifth week in a row of a steady increase and we’re basically seeing double to triple the amount of patients requiring COVID isolation the we saw in September and October. The number of patients we put in COVID isolation is an important data point because many of these patients are coming to us with a positive COVID test and therefore do not get reflected in the number of COVID diagnoses we make by testing each week (I will report on that data in a second) and are not reflected in our positivity rate. About 40-50% of the COVID isolation patients require admission to the hospital. This number has been fairly consistent since Thanksgiving week and is just a touch below our peak in the spring. Regarding testing, our percent positive rate among our symptomatic patients remains fairly constant at about 40%. We have had a fairly steady number of positive tests among our symptomatic patients over the last month or so. However, when we look at all patients tested in the emergency department, last week was the highest number of patients we diagnosed with COVID. We had about 100 positive tests in the emergency department last week, which is about double the amount of positive tests we had in the spring and quadruple the amount of positive tests we had in the summer. We also had a small uptick in the percent positivity rate among all comers to the emergency department, representing the highest positivity rate we have had since I started tracking data in April. I am not sure where all of the numbers will peak, but I suspect we won\’t see a peak for 4 to 6 weeks.
I received the second dose of my vaccine at 2pm Wednesday. I went on and worked the evening shift and felt fine. I took some OTC meds before I left around midnight. My arm was a little sore overnight and I was tired Thursday, but I think that had more to do with going to bed at 2am. You’ve probably seen a lot of pictures of docs and other frontline healthcare workers posting pics online of them getting their vaccine. Hopefully you realize we do this to make you aware that educated people who have seen too much death from COVID are appreciative of the science and safety of the vaccine process and are not missing their chance to get vaccinated. We hope it will reassure you that the vaccine is safe and encourage you to get it when your time comes.
I got a lot of questions about vaccines last week. I don’t have all the answers but here’s what I know. There is a clear disconnect between the Feds delivering vaccine to the states and the states infrastructure to deliver it. About 21 million doses have been delivered nationally with only about 6 million vaccinations given. It’s been just over 3 weeks since hospitals received their first shipment of vaccines so now they’re providing the second round. That will increase the doses administered but still leaves at least 10 million that are in storage. Because decision making was handed over to the state without the necessary budget, it’s very complicated. Furthermore, throughout each state, each county may be doing things a little differently. Sending vaccine to hospitals made sense and was fairly easy to get doses administered. Getting them to nursing homes is more challenging but things are moving along. Some of you may have seen the article in Forbes showing data that hospitals were only vaccinating about 40% of employees. We’re doing much better than that but certainly not at 100%. As I’ve talked to some of our younger staff who were reluctant to get it a few weeks ago, they now are changing their minds as they have seen so many of us safely get our vaccine and not grow tails yet (yes, that’s kind of a joke). My understanding is that the state and county are still developing their plans but I do anticipate an increased vaccination rate at nursing homes in the immediate future and then a rollout to pharmacies in the near future. And if the Virginia Governor hasn’t announced plans to move to phase 1B by the time you read this, I hear rumors that move is imminent. My hospital is already planning on opening outpatient vaccination clinics (more info to come when it’s official). Currently, there are some counties where, if you qualify, you can call and schedule an appointment.
The Virginia Department of Health is looking for evidence of the mutant Coronavirus variant. The state analyzes a percentage of positive of cases from the reference labs (LabCorp and Quest) as well as the tests they perform, though they are not requesting samples from hospitals. They have not yet identified any cases in Virginia with the UK mutation. The CDC reports that there are at least 52 cases of the UK variant Coronavirus that have been found in the US as of Wednesday. There have been 26 cases in California, 22 cases in Florida, 2 cases in Colorado, and one case each in NY and Georgia. No doubt there are other cases in the US but these are the cases that have been identified through analyzing positive samples.
Guest writer………I’m really excited to share with everyone the perspective of Dr Anthony Casolaro who is the Washington Football Team’s chief physician. I am honestly somewhat amazed that we got in an entire football season. I didn’t think it was possible. As we head into the playoffs this weekend, below are his words on how COVID impacted the NFL.
“In February 2020 I was honored to be elected president of the NFL Physician Society (NFLPS), the medical society comprised of the 32 NFL teams’ physicians. I have been the Head Team Physician/Internist of the Washington Football Team for over 20 years and have been a strong advocate for health and safety for athletes.
Typically, the job of president of the NFLPS requires several hours per month preparing for the NFL Combine medical exams for the draftees and participating in NFL meetings such as the NFL Head Neck and Spine Committee and working with the National Football Players Association (NFLPA) on issues of health and safety.
That all changed with the COVID-19 pandemic in March. This part-time position became another full-time job working closely with the NFL and others to navigate a path forward for NFL athletes and for a country in need of something else to focus on than nightly case counts and mortality projections.
As an internal medicine and pulmonary/critical care physician for over 40 years, I have had decades of experience evaluating and treating respiratory disorders. In addition, I was fortunate to spend several years at the National Institutes of Health, working with Dr. Anthony Fauci, whom I greatly respect.
With that background, and in keeping with the recommendations of a group that included the NFL, the NFLPS, Professional Football Athletic Trainers (PFATs) and the NFLPA, the NFL teams severely limited their activity in their facilities and eventually closed them to in person activity. In April, we also recommended that the usual in-person evaluations of athletes be suspended. Under the incredible leadership of Dr. Allen Sills, the Chief Medical Officer for the NFL, we spent the next three months divided up into six separate groups of eight to 12 professionals, each comprised of infectious disease specialists, NFL team physicians, epidemiologists, athletic trainers, NFLPA representatives, laboratory medicine directors, attorneys and NFL representatives. We would meet virtually several times weekly and each of the six sub-groups had a chairperson that reported to the NFL COVID steering committee.
Our mission was clear: Establish guidelines that would enable the safe performance of the sport for the athletes, staff and fans. Each week we reviewed new research and recommendations with regards to COVID-19 diagnosis, progression and management. We had already quickly learned that testing is not a substitute for being careful, practicing proper hygiene, and observing distancing and always wearing masks.
By early July we had proposed a regimen of remote/Zoom team meetings, social distancing, masks, and testing to allow the sport to proceed with the goal of an NFL season. We spent considerable time educating players, coaches and staff with up-to-date information about COVID-19 and trying to recognize and respond to concerns and questions.
We ultimately recommended a program of daily testing, strict social distancing, and hygiene protocols while allowing players and key staff to maintain in their home residence near the teams’ training facility. Once at the team facility, we all wore a Kinexon device that monitored one’s proximity to another person and time of exposure to that individual so that we could track exposure. If one were closer than six feet to another person a red light blinked continually on the device.
There were no traditional “training camps” for any team. A number of players came into the facilities in early August having had COVID or having recently been exposed. They were separated/quarantined for 10 days and did have to undergo cardiac evaluation prior to returning to activity (as there were concerns that there could be cardiac manifestations of COVID-19 that we did not want to miss).
We have worked with IQVIA, a well-respected data company, that among other things, has superb epidemiologists that worked with us to track any illnesses and to perform contact tracing that developed throughout the league. We continued to meet weekly reviewing our dashboard of COVID-19 cases and close contacts. We continually evaluated the strategy of testing including the addition of rapid testing as a supplement as the science evolved. We needed to adjust our recommendations as we evolved with the science. Once a case was identified with a team, we required that all in person activities/ meetings etc. cease at the team facilities other than actual practice which is typically two hours – three to four days a week. Athletes were required to wear masks when they were not actively involved. Even with all these of athletes and staff were wholeheartedly behind the task.
We expected and anticipated that there would be outbreaks of COVID-19 that would need to be managed with the safety of the athletes, staff and their families, as well as the greater community, the top priority. We learned that the majority of primary cases came from exposures outside the team facility. There was no evidence that player-to-player transmission had occurred during practice or games. Most of us were also grateful for the normalcy that NFL games brought back to our living rooms — even if one game was played on a Tuesday. This has been an extraordinarily difficult year for sports and, more importantly, for our country and the world. We are immensely grateful to the healthcare teams and frontline workers who were able to help us all over the last nine months and in the months to follow.
The work that the NFL has done including testing, results, contact tracing including using proximity devices and recovery will ultimately prove very useful to other sports leagues as well as the population as a whole. We are planning to publish our findings from the results of the research data from the last six months. We are hopeful this data will help us manage the pandemic both now and in the future.
Sports has always played a central role in American life. Even during World War II baseball and football remained a welcome relief. We are proud to have gotten this far in the season and hope it’s brought some sort of normalcy to a time where nothing is normal.”
Science matters. Wear a mask. Practice physical distancing.