COVID-19 in California

by Margret smith


from Dr Rick Loftus, MD. update about Covid-19:

I'm in a hotspot hospital in a hotspot region (Coachella Valley, Inland Empire, CA). We just converted the entire second floor of our hospital to COVID-19 care yesterday, July 1. We have 65 inpatients with COVID-19 in a hospital with 368 beds. It is the same at our other 2 hospitals in the Valley. We spent yesterday deciding the ethical way to divide up limited remdesivir (30 patients' worth) for the hospital patients. My 20 incoming interns for our IM resident were exposed to COVID 2 weeks ago during their computer chart training; apparently 100% of our computer trainers had COVID19. One intern tested positive 7 days later and I insisted we re-test them all again, as there are almost certainly other cases with minimal symptoms. I raided my household and took my entire supply of face shields to the hospital for the residents to wear on their first day, and I paid $1000 of my own money to equip all of my residents with medical-grade face shields. I require all residents to wear a surgical mask or N95 with face shield if they are within 6 feet of another human, patient or coworker.

Roughly 20% of our inpatients die. Only 30% of our ventilated patients survive. (We try to avoid ventilation at all costs. Some people insist on being full code and decompensate despite high flow with face mask, proning, dexamethasone, antibiotics, and a cocktail of famotidine, zinc, Vitamin D, Vitamin C, NAC, and melatonin--we throw everything we can at each case, so long as it won't hurt them.)

My administrative assistant, who sits adjacent to the interns, just went home with COVID symptoms. Her test is pending.

In the Southwest, we are experiencing catastrophic exponential growth. I have had multiple families--siblings, parent-child, spouses--admitted with COVID-19. I had a 31 year old come in satting 78% on room air; he had been sequestering himself in his bedroom for a week to avoid infecting his elderly parents, with whom he lived. His sister, the only person he saw outside his immediate household in the 10 days prior to onset of fever, cough, and dyspnea, had also had fevers but had tested "negative" at our other large hospital so he thought it was safe to visit her. (Sigh. The Quest PCR test is about 80% sensitive, we think--it had emergency approval, so sensitivity data was not required. The Cepheid rapid COVID PCR test is 98.5% sensitive but is in short supply due to limited reagent availability.)

I'm glad some of you are sheltered from what unbridled COVID-19 looks like. It's a hell show. This is July. What do you think my hospital will look like in winter?...

This is real. Doctors in places with proper public health responses will see few cases in their hospitals--like UCSF--but let me tell you something: The laws of physics and biology don't change. If you're in an unaffected region, an introduction and poor governance and low use of physical distancing and masks will give you an exponential increase in no time flat (i.e. 2-4 weeks). That's pandemic math. And 20% of the population infected needs a hospital. You will run out of beds with an unbridled pandemic. There is almost ZERO pre-existing immunity to SARS-CoV-2. There may be some "priming" of T-cell responses due to exposure to other "benign" beta-coronaviruses, but we have no idea if that explains the 20-40% of people who seem to get minimal symptoms. Asymptomatic infected persons, however, can, and do, spread COVID to those who die from it.

By the way: I've seen scary looking CT scans of the lungs that look like terrible interstitial pneumonia in a patient who had ZERO symptoms and SaO2 94% on room air. She came in for palpitations and the intern overnight got a chest CT for cardiac reasons. We didn't know it was COVID until her test came back 36 hours later. So "asymptomatic" does NOT mean "no biological activity." The virus replicates furiously in people who feel fine. Kids can spread this as easily as grown ups, even if they feel okay.

Related: I've talked to two previously healthy patients ages 32 and 44 who are 3 and 4 months, respectively, post their acute COVID. They continue to have cough, nightsweats, fever, fatigue. How many survivors have "post-COVID syndrome"? We don't know. Less than 20% but we're not sure. I've asked my hospital to allow me to establish a post-COVID clinic to care for and study survivors. Both NIH and UW are planning similar efforts based on my dialogues with them.

Autopsies show anoxic brain injury in many patients who died of COVID, not to mention microthrombi throughout the lungs and megakaryocytes in massive infiltrations in their hearts and other organs. People get heart failure, lung fibrosis, and permanent kidney injury from COVID-19. This is a disease of the vascular systems, and it can affect any organ, with lungs and kidneys being especially at risk.

In early May, thanks to lockdown, our census of 55 came down to 10 COVID cases, and for a brief moment, I actually had hope that the worst nightmares I had about COVID, as a biohazard virology-trained hospitalist, would not come to pass. Then we re-opened, without test/trace/isolate systems anywhere close to adequate. Eight weeks ago my county decided to make masks "optional," despite 125 doctors begging them not to do that. Now we're worse than we were in April. And it's getting worse every day.

You wanna see if COVID is real? Come walk on my COVID ward with me. It's real. Hearing people talk about it as if it's an exaggeration is, well, rage-inducing, honestly. Denial is the most common reaction to a pandemic. Denial is how the US will wind up with 1.1 million deaths instead of 30,000. I saw AIDS denialists get killed by their belief that HIV "isn't real, it's a pharma conspiracy of the medical industrial complex." Yeah, right, if you say so. I watched patients with those beliefs die.

The hardest part about this is, every new case I treat exposes me. I have assiduous hot zone technique. But no technique is bulletproof. If you keep exposing me to case after case, eventually, the virus will get through my defenses. I'm a 50 year old hypertensive. I don't expect to do well if I get infected. For now, I keep going to work. I'm one of the few pushing forward on COVID clinical trials, basic science, public health messaging, and diagnostic studies at my hospital. I feel a responsibility to keep going. I wake up with nightmares every morning at 4am. But I'm going to keep going for now. I feel very alone a lot of the time. People are not taking this seriously, and it's costing lives. -R

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Margret smith

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