Humbled By A Virus - A Clinician's Perspective From the Ongoing Fight Against Covid-19Thoughts from the Moment of Covid-19
For the past four months, medical care in the United States, and for that matter, in the entire world, has been transformed by the Coronavirus pandemic.
In New York, the health system was almost overwhelmed, intensive care units were full, and refrigerated trailers parked outside hospitals served as temporary morgues.
In Guayaquil, Ecuador, hospitals were full, and patients died at home, with their families leaving the plastic-wrapped corpses of the deceased on the sidewalk for eventual retrieval and burial.
The disease seemed to enter an area randomly and then to explode, growing exponentially. The virus hit the elderly disproportionately, as it also hit people with obesity and with diabetes.
Media reported death rates by age groups and by the presence of preexisting conditions. The origin of the virus in China led to acts of racism and bigotry against Chinese-Americans in the United States. In Russia, Africans were blamed for spreading the virus.
Americans became experts in personal protective equipment (PPE), scrambling madly to find respirators, face shields, and gowns. The Centers for Disease Control issued guidance for reuse of respirators and even suggested the use of cloth face coverings in times of scarcity.
Hospitals and business tycoons dispatched jets to China and brought back KN95, N95, and other masks, sometimes counterfeit.
Hobbyists across America used their 3-D printers to make ventilator parts and face shields. People got their sewing machines out and started producing cloth face masks.
People fiercely debated the nuances of aerosol versus droplet transmission of the virus and argued over which activities led to virus aerosolization.
Early data suggested widespread transmission by fomites, and people cleared out the disinfectant section of their supermarkets.
Overnight, it seemed, we stopped going to school, to work, and to social and sporting events. Usually-busy streets and highways were empty, and pollution decreased.
The newly homebound population discovered baking and outdoor exercise. Parents struggled to work from home while also trying to make sure that children kept up with schoolwork. The federal government struggled to deal with the pandemic.
The government did provide emergency funds to millions of Americans and suspended evictions, student loan payments, and mortgage payments for those with no income. Many businesses, particularly in the restaurant and hospitality sectors, struggled to avoid bankruptcy.
Hospitals across the country braced for a surge of Covid19 patients and stopped routine surgeries. Physician and dentist offices closed.
Patients stopped coming to emergency departments, even for illnesses like heart attack and stroke.
Hospital revenues plummeted, and some hospitals, already in precarious financial shape, closed.
Early in the pandemic, first in China, and then in Italy, physicians tried therapies that seemed to make sense, using pathophysiological reasoning.
Physicians tried using the combination of lopinavir and ritonavir, usually used in HIV. Systemic steroids were tried, seemed to make things worse, and abandoned.
Politicians, physicians, and some media personalities touted hydroxychloroquine, causing a rush of prescriptions, making the drug difficult to find for patients with proven indications such as autoimmune disease. Dead ends.
The medications that were tried early in the pandemic did not seem to work, despite physicians’ fervent hopes, and the mortality of patients who needed mechanical ventilation was a fearsome sixty to eighty percent.
Finally, remdesivir, an experimental antiviral, available only in limited quantities, was shown to reduce mortality in the most severely ill, but not by a lot. We're hopeful. We're searching - fighting this thing - together (ugh, mostly) - daily.
Before Coronavirus, our medical-industrial complex churned out advanced treatment for heart disease, cancer, and infection. We were prolonging life and creating targeted therapies that modified the course and morbidity of many diseases.
Television advertisements urged patients to ‘talk to your dermatologist’ or to ‘talk to your oncologist’ about the latest breakthrough drug, often costing tens of thousands of dollars per year.
Hospital executives were building orthopaedic, neurosurgical, and cardiac programs, eager for the high reimbursements in those areas, while primary care mostly languished. Race and class disparities in health and access to healthcare were rarely discussed.
Coronavirus humbled us.
The virus did not respond to our treatment efforts, which were nothing more than ‘supportive care,’ and we were reduced to describing the course of the illness rather than modifying or halting it. We were not able to predict which patients would get very ill and which patients would have few, if any, symptoms.
For physicians, nurses, and other healthcare personnel, going to work was no longer a routine affair, where the patient was the one with the problem. We were at risk daily, and some of us became ill, and some of us died.
In cities, the public clapped or banged on pots and pans in appreciation of the healthcare workforce. They knew that we didn’t have this virus beat, but they appreciated our efforts and our caring.
We, in healthcare, were suddenly teleported back in time to the world of our predecessors, when treatments were few and contagions were frequent.
In New York, in the typhus epidemic of the 1840s, physicians had no cure and struggled to understand how the infection was even transmitted.
Eventually, germ theory, antisepsis, antibiotics, vaccination, and recognition of social determinants of health allowed cities to thrive, for a time, with little fear for epidemics.
Now, in the era of Coronavirus and Covid19, we’ll need a new combination of science and social reform to get us to our next iteration of society. We need to be learning and remembering everything. And we need a way to teach what's known about Covid-19 quickly.
History doesn’t repeat itself, but it rhymes.
Continue to fight. We're fighters. And we've won before.
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