On 3/2/2020 I posted this on Facebook and on Linkedin.
3/2/2020 “Listen . . . there may be damn good reason to be nervous about corona, and I know a bit about this stuff (including having testified in front of Congress on it). 14 million people in the US had the flu last year and 40,000 died. The mortality rate is about 0.1% for flu. The infectivity of corona is probably much higher (meaning more will get it) and we have no vaccine. The fatality rate for corona is clearly above 1–2% at the same rate of infectivity for flu; it’s not inconceivable we might see half a million deaths in the US. I left work today in a major metropolitan hospital and nearly every single ICU bed in our hospital was filled up. And we have ZERO active cases of coronavirus. We will have no capacity to surge even 50 patients needing ventilators let alone 500 or a thousand. This could wipe out entire nursing homes. I tell my patient don’t be nervous until I’m nervous . . . well guess what, folks. I’ve been practicing for 30 years and this is the first time I’m legitimately nervous. Don’t panic but don’t be dismissive about it either because none of us really knows where this is headed, and those of us in the trenches have loved ones that we want to get home to also. We can’t help you if we are Ill ourselves.
This was posted well before our ER saw our very first Covid-19 patient. At that time, New York had just announced their first case and the total known cases in the US stood at around 100. A little over two months later we have 1.3 million confirmed cases and nearly 80,000 dead.
I had written about the potential for a pan flu epidemic in 2014 in “What Scares Me More Than Ebola” and I had been paying close attention to what was happening in Italy. Because of that, I was able to convince my kids to leave New York and come back to Indianapolis well before everything went south in that city.
Since that time, two days into March, our ICUs filled up with Covid-19 patients. We have had some days operating at near-catastrophe mode in our ER with patient after patient in respiratory distress, often requiring us to place a tube in their windpipe and hooking them to a ventilator. Sadly many of them died right in front of us with a rapidity that can only be described as startling. Every shift it seemed we were on the phone with family members explaining,
“If we put your mom (or dad or grandparent) on a ventilator, chances are not only will they die but sadly they will die alone since we can’t have you there at their bedside due to the infection risk.” We repeated this same discussion over and over to family members who never discussed end-of-life issues with their elderly relatives, so we were doing it on the fly. So much of our mental energy was spent, not only with tending to the sick and dying, but in convincing family members to let their loved ones go, while at the same time wondering ourselves . . . Will this be the day I fall ill? Will this be the beginning of the end for me?
I experienced something like this in the dawn of my career as a medical student during the AIDS epidemic. This was the closest I had come to this degree of emotional despair, not only for the patients but for the doctors and nurses that cared for them.
On top of this, we were doing all our patient care duties while rationing personal protective equipment (PPEs) and life-saving drugs. At one time, we were so critically low on basic medications to simply sedate patients on the ventilators, we actually discussed the prospect of giving intravenous alcohol as a substitute. So that while all this attention was being paid to the lack of ventilators, the dirty little secret that nearly every hospital held was that they were running out of antibiotics, Ativan, Propofol, and Ketamine—drugs that were absolutely crucial to providing care and comfort for these critically ill patients. Every day it seemed we were met with new drug and equipment shortages—and trust me when I tell you that our institution was far ahead of others. The stories on the ER physician blogs were sobering. However, in the midst of these shortages, at our most vulnerable time, it brought to light a stark realization that we now have to face head-on. The pipeline for our masks, our antibiotics, our medical equipment, our drugs should never again be dependent on a country that is unwilling to answer the question,
It’s one of the reasons we have to reassess where these drugs and supplies are manufactured from this day forward and realize that the medical well-being of our citizens is a national security issue that can have no compromise. In the US we have the Strategic Petroleum Reserve that holds on to hundreds of millions of barrels of oil should our pipelines to production be compromised. We have to approach healthcare supply chains in the same way. However, we may need health care systems to purchase these products from the reserve instead of from manufacturers and third-party intermediaries. If we just keep replenishing the strategic health care reserves on the back end, this would decrease the chance of those products expiring, would allow for a better understanding of our national consumption and needs, and address shortfalls on a national level months before they happen.
I am blessed. Fortunately the system in which I work, and Governor Holcomb of our state of Indiana, anticipated much of this. Our fiscal and supply reserves were a bit better than other states. We were able to shift patients, create ICUs where ICUs didn’t exist, we were proactive in many areas, and were able to work almost seamlessly with our rural hospitals—some of which showed creative initiatives that are nothing short of miraculous. I have little doubt that if we did not do what we did to slow the transmission we would have seen a complete collapse of American health care.
But now what?
We know we are going to see a bump in cases as we open up society and commerce and we know you are scared. I am too, just not as much as I used to be and here are some reasons why:
We didn’t see that many TOTAL patients clinically ill and in need of medical attention as I would have expected. What we did see were a large number of CRITICALLY ill patients. There is a difference. During H1N1 and even during the peak of flu season it was not unusual for each doc in our group to see 20–30 patients a day sick with influenza—the pediatric section had just as many cases, oftentimes requiring extra staff to handle the surge. In this pandemic those areas stood empty. Some might say that the current pandemic numbers were low because of the fear the community had of coming to the ER, but I don’t think so . . . and here’s my reasoning . . .
Our doctors and nurses simply were not falling Ill from Covid-19. Oh certainly we had some who fell ill and some well-documented cases nationally who even died, but this also happens each year with flu. During flu season, even with the vaccines, nearly all our doctors fall ill to some degree and most end up missing a few shifts. The same happens with our nurses. But our call-in sick rate was surprisingly low these last two months. That tells me that the number of people left unable to work from Covid-19 is probably lower than the flu, and for the vast majority of Americans it truly is a mild, self-limiting disease. To be completely honest and transparent, I am fairly certain most of our ER docs and nurses will test positive for the Covid-19 antibody once large-scale testing is done . . . because that’s what doctors and nurses have in common with patients.
They go to the hospital when they don’t feel well, just some of us go there with scrubs and a stethoscope around our neck . . . we have to, there is nobody else.
In the larger scheme, very few of those admitted were young healthy people and hardly any were pediatric cases. I suspect that in even those aged 16–30 that became critically ill, some will later be found to have an underlying precondition possibly related to asthma or vaping or perhaps a clotting disorder or autoimmune disease. Sure, there will be a few outliers. But I feel better about letting young healthy people go out and do what young healthy people do . . . and that is create natural herd immunity. We just need them to stay away from at-risk people and more importantly, at-risk people to stay away from them.
We have a better idea about what works and what doesn't. For example, we now know we can let these patients go a bit longer without being placed on a vent and let them tolerate more periods of low oxygen saturations than we might have in the past for other illnesses. We know that by creative positioning of patients, flipping them on their stomachs, etc., we can often buy them time and not have to intubate some of them. We have discovered there may be some benefit to anticoagulants, we know hydroxychloroquine and other therapeutics probably don’t work and that remdesivir and plasma antibody therapy seem promising in reducing mortality. In addition, we are discovering countless pearls in regards to ventilator settings, pulmonary and blood pressure control, optimal fluid management strategies, and extracorporeal membrane oxygenation (ECMO), etc., that will be invaluable in reducing mortality—and we are literally learning more by the hour. In scientific terms, we have never witnessed such a massive influx of scientific thought, resource channeling, ingenuity, data acquisition, and crowdsourcing as we have seen these last two months. That is a testament to free countries sharing the free flow of ideas and free thought to unshackle us from the bonds of this barbecued bat or lab-born menace.
We now have tens of thousands of doctors and nurses that have practical experience caring for a condition that just a few months ago was completely unknown to us. Our level of anxiety is declining every day when it comes to caring for these patients. That is huge for those on the front lines. The unknown is terrifying.
We now know our resources should be focused on the elderly and the nursing homes. That is where this is doing the most damage. We now know we CAN protect the most frail while providing freedom to the capable. Our Covid-19 response should now be channeled there, where we may have the greatest impact on those at the greatest risk.
To the 80,000 of my fellow Americans who have died and the 1.3 million who have contracted an illness that was virtually unknown to the world just a few months ago and to the millions of Americans that have suffered through catastrophic financial and emotional burdens of this shutdown . . . I’m so sorry we could not have done more for you. But I can say with absolute honesty that I am comfortable with what we were able to do with the knowledge and the resources we had at the time. I know it doesn’t ease your pain, especially for those who saw loved ones die, but I know we did our best. I hope that provides some comfort.
There was a world pre-911 and one post-911. There will be a time of pre-Covid and one post-Covid. And just like 911 we look for heroes and we look for villains. It’s easier that way, I guess. It’s easier than facing the stark reality that we are so very mortal. It’s scary to know that there are just some things we can’t readily fix by public policy or money or press conferences. Sometimes we are at the mercy of biology and we have to let things unfold, expose the gaps, identify what we can fix and what we can’t, and hope that we can bide the time to figure it out before it crumbles to our feet.
America did this for health care—for the doctors and nurses and techs and countless others who showed up each day regardless of the threat to their own health.
They think we saved them.
But America . . . you saved us.
And for that, we thank you.
Dr. Louis M. Profeta is an emergency physician practicing in Indianapolis and a member of the Indianapolis Forensic Services Board. He is a national award-winning writer, public speaker and one of LinkedIn's Top Voices and the author of the critically acclaimed book, The Patient in Room Nine Says He's God. Feedback at firstname.lastname@example.org is welcomed. For other publications and for speaking dates, go to louisprofeta.com. For college speaking inquiries, contact email@example.com.
Cover Photo by Marcus Hendry MD.
Dr Louis M. Profeta is an emergency physician practicing in Indianapolis. He is one of LinkedIn's Top Voices and the author of the critically acclaimed book, The Patient in Room Nine Says He's God. Dr Louis holds a medical degree from the Indiana University Bloomington.