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In This Week’s Podcast
For the week ending March 20, 2020 John Mandrola, MD comments on the following news and features stories.
Are We Hitting a Plateau?
Last Friday, there were a quarter million cases in the US. Today there are nearly half a million. The rate of rise—doubling—is less than the week previously which saw a three-fold rise. But testing greatly affects the case count. So, let’s look at deaths: Last week there were roughly 6,000 deaths in the US. Today there are about 16,600 deaths. The death rate increase of 2.7 is way less than last weeks’ 5-fold increase.
While the models are all super complicated the big question at hand is simple: How many people have this disease and how many get super sick and die from it? One thing is for sure: there is a tremendous variability. For example, Prof Noopur Raje, wife of electrophysiologist Prof Jag Singh, both from Mass General, put out a Twitter thread on their experience with COVID-19.
She described how sick her husband became with coronavirus. But throughout this whole thing, caring for her husband, working in the same hospital and city, she tested positive but never got sick—at all. Even after 14 days she has remained totally asymptomatic. A doc at our place tested positive and literally had zero symptoms. If you have only a tiny bit of curiosity this boggles the mind.
Caveats on epidemiology
A preprint (link below) looks at ILI surveillance and estimates that millions of people have this disease (link below), but you also have reports from NY that suggest recent surges of people dying at home. As reports of the cardiac manifestations of coronavirus become known it’s hardly implausible that sudden death from COVID myocarditis may be relevant. There is a nice news recap of a study from Columbia University researchers on theheart.org | Medscape Cardiology.
Second caveat: There is a clear distinction in how this virus sickens and kills people. Professor John Ioannidis published an analysis in a preprint looking at deaths in hotspot cities and countries. He and his authors dichotomized death rates above and below age 65. That’s always a lightning rod.
And I just saw a report from Ontario (thanks Swapnil Hiremath) showing that over 50% of COVID deaths there were from long term care and retirement homes. This predilection to older and sicker people soon will have to play into mitigation strategies.
References
Telehealth
After a full week of doing only telehealth I am even more convinced that this will stick after the crisis passes. My gosh, patients love it.
Kardia and Apple watch recordings are not the same as a 12-lead but it is something. Many patients have BP and heart rate recordings, and most patients an electrophysiologist sees has an ECHO. So let me ask: if a person can tell a good story, I can see her general appearance on video, and I know she has good vitals and a normal echo, why is an in-person exam that important?
Possible Iatrogenesis
Dr John Whyte interviewed the young and thoughtful intensivist, Dr Cameron Kyle-Siddell, who after working on the front lines of Maimonides Medical Center in Brooklyn sounded an alarm that the approach to intubation and ventilator management in patients with COVID-19 needed rethinking.
Andrew Foy, a cardiologist from Penn State alerted me to the notion that one reason COVID-19 mortality once on the vent is so bad may be due to the iatrogenesis of 1) early intubation and 2) strict adherence to established ARDSnet protocols. Some have advocated for early intubation because it reduces aerosols and that is not unimportant—especially in the setting of dubious PPE.
Dr. Kyle-Siddell and many colleagues, were drawn by their observations to pay attention to the thoughts of Italian pulmonologist Luciano Gattioni who, among others, penned an editorial in the Journal of Intensive Care Medicine. They feel that respiratory failure from coronavirus is not a uniform type of disease. Many of these doctors think the evidence from ARDS trials does not apply to most COVID-19 patients, at least early on. Many of these patients’ present with hypoxemia that seems way out of proportion to how the patient looks. Normally, the practice is to intubate with O2 sats this low. But this group believes using other strategies to deliver oxygen is best.
Here is the problem: these young caregivers have only their experience, common sense, and plausibility. But I was drawn to academic family medicine doctor Raj Mehta’s Tweet that noted that following protocols based on evidence with uncertain generalizability to COVID-19 and without taking into consideration of clinical factors is not evidence based medicine.
Reference
A Note on Humanity
My wife Staci Tweeted yesterday a story on how she had to use a baby monitor to tell a dying patient that his family loved him. I am going out a limb and will say the no-visitor policy for dying patients is wrong. Super wrong.
Many news stories chronicle the fact that hospital systems are cutting healthcare workers salaries. I get it. Revenues are down. Cardiologists like me ought to accept the cuts without debate. But across the board cuts are crazy. Those doctors, nurses, therapists, and anyone working with or around COVID patients ought to see hefty increases in pay. It is only just.
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Any views expressed above are the author's own and do not necessarily reflect the views of WebMD or Medscape.
Cite this: Apr 10, 2020 This Week in Cardiology Podcast - Medscape - Apr 10, 2020.
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