Updates From the Socially Distant

My daughter donates blood at Cedars Sinai on March 24

[I’m writing this on Monday, March 30. Everything in this post might be false in a few days, and conditions might be different in places other than Los Angeles. Keep up to date by checking your local health department website.]

“Don’t stand so close to me.”
— The Police

As more and more patients are diagnosed with COVID-19 there’s a lot of discussion about home isolation, home quarantine, and social distancing. In this post I explain which of us should be in each group, and what precautions should be observed by each.

Home Isolation

Who should be in home isolation?

Anyone who has been diagnosed with COVID-19 but does not need to be hospitalized should isolate at home. Being diagnosed with COVID-19 does not necessarily mean having a positive test for COVID-19. (See my post about testing to understand why a test might come back negative even if you have COVID.) Your doctor might decide you have COVID-19 simply based on your symptoms, such as fever and cough. If your symptoms are mild, recovery at home is likely the best course.

What’s involved?

Someone in home isolation should stay home except to get medical care. You should not use public transportation. Getting groceries and medications should be left to someone else. If at all possible, the person in isolation should have his own room and bathroom at home. The isolated person should stay 6 feet away from other housemates. You should not prepare or serve food to others and should not share utensils, towels, or bedding with housemates. You should wear a mask when in the same room as housemates. Visitors to the home should not be allowed. There is much more detailed guidance in the LA County Dept of Health instructions.

You should also talk to your housemates, caregivers, intimate partners and anyone else who was within 6 feet of you for more than 10 minutes. Their exposure to you makes it possible that they will get COVID-19. They should home quarantine even if they have no symptoms. (See next section.)

When should you get medical attention?

If symptoms worsen or if serious symptoms occur such as shortness of breath, vomiting, or changes in metal status, then call your doctor immediately. If a visit to your doctor is planned, call ahead to make sure they understand that a patient with COVID is coming. Wear a mask.

Patients who are at high risk of severe illness – people 65 and older, pregnant women, and patients with chronic medical problems – can deteriorate rapidly. They should have a plan for frequent contact with their doctor (by phone, video or in person).

When does it end?

You should remain in isolation until at least 7 days after your symptoms started and 3 days after recovery. Recovery is the absence of fever without fever-reducing medications and improvement of respiratory symptoms. Then you get to join the rest of us in the social distancing group.

Home Quarantine

Who should be in home quarantine?

Anyone in close contact with someone who has COVID-19 (or presumed to have it) should quarantine at home. It can take 2 to 14 days after infection for symptoms to appear, so even without symptoms quarantine is important to prevent infecting others.

What’s involved?

The restrictions are identical to those for home isolation. The only difference is that there’s no reason to wear a mask since you don’t have any symptoms. It’s especially important to remember that you might be infectious and to avoid people who are at higher risk of serious illness – people who are 65 years and older, pregnant women, and people which chronic medical problems. The LA County Dept of Health has more detailed guidance here.

When should you get medical attention?

If you develop fever, cough, shortness of breath, shivering, body aches, or sore throat, call your doctor. Depending on your symptoms, age and medical problems, your doctor may decide to examine you or just presume you have COVID and ask you to home isolate (the group above).

When does it end?

Quarantine ends 14 days after exposure to the person with COVID-19. If you live with the person with COVID and despite their home isolation are unable to avoid close contact (for example, if you’re her caregiver), your quarantine ends 14 days after her home isolation ends. Then you move to the social distancing group, below.

If you develop symptoms and your doctor decides you are likely to have COVID, you shift to home isolation (above).

Social Distancing

Who should be practicing social distancing?

All of us. If you’re not in one of the above two groups. You should be practicing social distancing.

What’s involved?

Social distancing means staying home and avoiding non-essential trips out of the home. Essential trips out of the home include acquiring groceries and medicines. When out of the home, avoid crowds and stay at least 6 feet away from others whenever possible. Work from home if possible. Cancel routine non-essential healthcare appointments. Avoid public transportation, if possible. You can take walks outside, or bike or hike, as long as you stay 6 feet away from others. The detailed guidance from the Dept of Health is here.

When should you get medical attention?

If you are sick, call your doctor before visiting. She may offer a video or phone appointment.

When does it end?

I have no idea. We’re all waiting for the numbers of new cases in Los Angeles (or in California) to significantly decline day after day, but that hasn’t happened yet. (And such a sustained decline would suggest that we’re about halfway through, not done. We’re only done when there are almost no new daily cases.) Keeping the new cases as few as possible will be essential to making sure that everyone who needs a hospital bed gets one and everyone who needs a ventilator gets one. It would be a great comfort to know now when the social distancing will end, but there’s no way to predict how long it will take to decrease the number of new cases. My son is in Bellevue, King County, a suburb of Seattle, the first American city to have a significant number of COVID-19 cases. He’s been working from home for 3 weeks. The number of new daily cases there are hinting at a downtrend, but nothing is definitive, and there’s no known time yet that his lockdown will be over.

So we do the best we can and we wait. Not having a prespecified finish line makes it much harder. It would be less miserable if we knew now when this would be over, but we don’t. Anyone reading the news out of Italy and out of New York knows what we’re trying to prevent in Los Angeles. If we can’t prevent it, we must try to endure it with minimal loss of life.

My suggestion for all of us in this group is to find ways to support our local hospitals. Donate blood. If you have a stash of surgical face masks (not handmade ones) or N95 respirators, and the realization is dawning on you that ICU doctors and nurses don’t have them, donate them.

I sincerely hope that in a month or so I’ll be able to rewrite this post and describe a fourth group, those known to be immune. People whose immunity could be proven, either because they had a positive test for the coronavirus while they were sick, or because they had a positive antibody test after recovery, would be able to return to work and would be the safest healthcare workers to care for COVID patients. They could resuscitate the economy without spreading disease. As I wrote in my last post, a reliable antibody test is not yet available, but multiple labs are working on it.

Until then, stay inside and stay healthy.

Learn more:
Home Isolation Instructions for People with Coronavirus-2019 (COVID-19) Infection (LA County Dept of Public Health)
Home quarantine guidance for close contacts to Coronavirus Disease 2019 (COVID-19) (LA County Dept of Public Health)
Novel Coronavirus (COVID-19) Guidance for Social Distancing (Los Angeles County Dept of Public Health)
Blood Donor Services (Cedars Sinai)
Donate Supplies (Cedars Sinai)

My previous posts about the novel coronavirus:
Testing, Testing
Novel Coronavirus FAQ Part 2 – Pandemic Hullabaloo
Coronavirus Frequently Asked Questions
Community Transmission Of Novel Coronavirus In LA County
What You Need To Know About The Novel Coronavirus

More

Testing, Testing

Calvin Fuchs
Calvin Fuchs
I got tired of showing a picture of the coronavirus at the start of each post, so here’s Calvin, our dog. He loves having the kids home all day.

[I’m writing this on Thursday, March 26. Everything in this post might be false in a few days, and conditions might be different in places other than Los Angeles. Keep up to date by checking your local health department website.]

“Time I had some time alone”
— It’s the End of the World as We Know It (And I Feel Fine) by REM

The kerfuffle about coronavirus testing is causing much confusion and anxiety. I attempt below to summarize the situation, at least as it currently stands in Los Angeles.

How can I get tested for the novel coronavirus?

It’s no secret that tests for COVID-19 have been in very short supply. Here are the different ways to get tested, for now.

The City of Los Angeles is offering very limited testing to people in the following groups.

  • Those with symptoms who are 65 and older
  • Those with symptoms who have underlying chronic health conditions
  • Those who are subject to a mandatory 14 day quarantine period due to a confirmed COVID-19 exposure (with more than 7 days of quarantine remaining)

Testing is only available by appointment through the website (link above). There are reports that lines are long. The LA County Dept of Health is also offering tests but only for healthcare workers, first responders, and residents of congregate living settings, like assisted-living facilities or nursing homes.

Doctors’ offices, including ours, have a limited number of tests which are performed by private laboratories. Our tests are run by Quest Diagnostics. (But please read the rest of this article before you contact your doctor asking for one.) There are companies that promise home testing, but these are not yet available. Finally, some large hospitals have started running their own tests. Cedars-Sinai Medical Center just started running COVID-19 tests for their hospitalized patients and will be offering tests for outpatients and community doctors’ offices soon.

How is the test performed?

The test is done with a swab inserted in the nose to the back of the throat. Some tests also use a swab in the mouth to swab the back of the throat.

What are the problems with the test?

One problem with the private labs is the very long backlog, which is causing a long delay before results are available. One test sent from our office took longer than a week to result. Presumably this will improve as testing capacity ramps up, but the details are foggy.

The bigger problem is the test’s low sensitivity. Sensitivity is a precise term in testing jargon. It means the fraction of people who have the disease who will have an abnormal (positive) test result. The sensitivity of the current test is about 70%. That means that three out of ten people who really have COVID-19 will test negative. So, for people who are extremely likely to have COVID-19, for example people with classic symptoms and no other likely diagnosis, a negative test result is more likely to be a false negative than a true negative. Meaning, the test’s low sensitivity makes a negative result untrustworthy. So for cases in which a negative result must be reliable, for example in removing someone from quarantine, multiple sequential tests have to be used.

I feel fine but I’m worried. Can I get tested?

A negative test result won’t help you. You could still be exposed tomorrow or the day after that. And a positive result won’t change much since you should be staying away from people anyway. If you feel fine, assume you have it, stay home, and stay away from others.

I have a cough and a fever. Can I get tested?

Maybe. Call your doctor to report your symptoms. If you’re young and generally healthy, your doctor might simply assume you have COVID. If you can care for yourself at home, a test won’t help improve your care. I have a patient in his 50s who developed a fever and cough about two weeks ago. I saw him in the office. His symptoms were classic for COVID-19. A test would have taken a week and would not have changed his plan. We talked about it. He agreed with me that a test wouldn’t help him. He’s recovering at home and will be well soon. (And he gave me permission to write this.)

So what’s the point? If the test has such terrible characteristics, why did WHO weeks ago recommend widespread testing to member nations? Why do we hear of the success that China and Korea had with widespread testing?

Nations that used testing successfully used it as part of a massive public health effort, not as part of individual patient care. In these nations public health officials went door-to-door and tested tens of thousands of random people so that those who tested positive could be quarantined. Some jurisdictions had specific facilities to quarantine positive cases who didn’t need hospitalization. That allowed them to very quickly separate infected populations from uninfected populations.

We don’t currently have the testing capacity to do that. It’s unclear if we will have that capacity in time to execute the sort of massive public health effort that would help blunt the worst consequences of the pandemic. But I think a bigger barrier is cultural. Would most of us allow health officials to knock on our doors and test us involuntarily? I would, but I’m a doctor. Would we be content to see those who tested positive being housed at the neighborhood high school gym for two weeks against their will? Some nations have cultures of obedience and respect for authority. That’s the sort of culture that allows a massive compulsory intrusion for the public good. We, on the other hand, have a culture of individuality, tolerance of differences, and suspicion of authority. I suspect a massive intrusive compulsory public health effort here would be very challenging. I’m not making any judgments about either sort of culture. I’m just asserting that the reason that we can’t have a large-scale testing effort here isn’t just the lack of tests.

So how are we using tests here?

We’re trying to use tests (a) if the results will affect the care of the individual patient or (b) if the result would make a difference to how people are isolated or quarantined. So hospitalized patients are frequently being tested to confirm the diagnosis, since they may require experimental treatments. Sick people who live with high-risk household contacts are being tested to see if they need to be quarantined elsewhere. Sick people who were recently in a large group are being tested to see if everyone in that group needs to be tracked down. Ultimately this comes down to the judgement of individual physicians, and we’re trying to do the most good with each swab.

What all this about antibody testing?

An antibody test for COVID-19 would be a blood test that would be able to identify if a patient had COVID-19 in the past and recovered. Such a test should be able to identify those who are now immune. Some of the people who are now immune may not know that they were sick, since their symptoms may have been very mild. There is likely a very large group of people who are immune and don’t know it. Companies are gearing up to produce such a test now, but no one knows when it will be widely available.

I think widespread antibody testing would be much easier to implement, and, at this late stage, much more beneficial. (Please note that I’m not an epidemiologist. And if an epidemiologist disagrees with me, then I’m probably wrong.) People who are found to be immune could be allowed to return to work immediately, and healthcare providers who are found to be immune could preferentially be assigned to care for COVID patients. Identifying the immune population and placing them at the forefront of restarting the economy and at the forefront of patient care might be the kind of testing strategy that helps us out of the storm.

Until then, stay inside and stay healthy.

Learn more:
Schedule a COVID-19 Test (City of Los Angeles)
Long lines, big demand: Still-limited LA-area drive-through coronavirus testing inches ahead (Los Angeles Daily News)
Mass testing, alerts and big fines: the strategies used in Asia to slow coronavirus (The Guardian, March 11)
U.S. Communities Struggle to Deal With Coronavirus Testing Backlogs (Wall Street Journal)
Clinician Check List Evaluating Patients Who May Have COVID-19 (Los Angeles County Dept of Health)
COVID-19 testing (Wikipedia, cites an estimate of test sensitivity)

More

Novel Coronavirus FAQ Part 2 – Pandemic Hullabaloo

SARS-CoV-2
SARS-CoV-2
Transmission electron micrograph of SARS-CoV-2
Credit: National Institutes of Healt / flickr

[Author’s note: This post was written on the afternoon of Friday, March 20, 2020. The subject matter is rapidly changing, and the recommendations below may be out of date in a few days. Find the latest recommendations from the LA County Dept of Public Health and the Centers for Disease Control.]

In these turbulent times I’ve curated the most common questions and requests I’ve received and attempted to answer them.

This is totally unprecedented! Crazy times! I can’t believe it.

Yeah. It’s pretty disorienting. There’s nothing to compare this to.

Is your office closed?

No. We’re open. We’re seeing only urgent appointments in the office. We’re handling everything else by phone and video chat. We’re here.

You must be swamped!

Uh huh.

Am I supposed to stay inside?

Yes. Yesterday the Governor ordered the entire state to stay indoors except for essential activities. The details are here.

Can I go outside for a walk?

Sure. That’s a very good idea. Just stay at least 6 feet away from others. Daily exercise will help keep you fit. And during this stressful time it’ll be a terrific distraction.

I feel fine. But I heard that there are medicines that will help if I get sick. Can I have a prescription for hydroxychloroquine (or azithromycin, or remdesivir, or lopinavir-ritonavir)?

Hydroxychloroquine (Plaquenil) is used to treat lupus and malaria. There have been tantalizing anecdotes of people with COVID-19 improving very quickly on it. There are similar anecdotes of people taking Plaquenil plus the antibiotic azithromycin. Unfortunately, anecdotes don’t prove anything. There are currently trials testing these medicines in patients hospitalized with COVID-19. Plaquenil also has side effects and can cause dangerous EKG changes. Let’s be sure it’s effective before prescribing it.

But I’d like it now, in case the pharmacies run out.

There are rumors of doctors prescribing unproven medicines to asymptomatic patients. If these are true, the doctors should be exposed to public disgrace. Did they check an EKG on every patient prior to prescribing Plaquenil to assure that it will be safe? If one of my lupus patients has a hard time refilling her Plaquenil prescription because these bozos prescribed an entirely experimental medicine to people who were feeling fine, they should have to answer to her. Anyway, what were you going to do with the Plaquenil if you don’t get sick?

I was going to keep it right here next to the Cipro I didn’t take for anthrax.

Oh. I see. Well, as soon as it’s proven safe and effective for COVID, and as soon as you get COVID, I’ll be happy to prescribe it for you. Until then, let’s let the lupus patients have it.

I heard the President say…

NEXT!

What’s all this I’m reading about the dangers of ibuprofen and naproxen?

There were reports out of France that patients who were sick with COVID and took ibuprofen and other non-steroidal anti-inflammatory medicines (NSAIDs) had worse outcomes. That’s a problem, because for many patients who are sick with COVID and are not hospitalized, treating their fever and aches is about all we can do. NSAIDs are a mainstay of symptom control. First, this mini-controversy has nothing to do with what patients were taking before they got sick. So there’s no reason to avoid NSAIDs when you’re healthy. Second, US and UK experts challenged the data out of France and currently there seems to be no evidence that NSAIDs worsen COVID illness.

I’m washing my hands constantly. I’m staying home. I’m staying away from others. What else can I do?

Donate blood. Many blood drives have been cancelled, so donating at the medical center of your choice would help a lot. Call your elderly neighbor who lives alone. Ask if he needs anything. Make a trip to the grocery store for your friend who is going through chemotherapy (and leave her groceries on her doorstep). If you’re young and healthy you can do the critical errands for all the old and not-so-healthy people you know. Be that hero.

Hang in there. There’s no way to know for how long our lives will be like this. And there’s no way to know what the world will be like at the other end of this. But we’ll probably all remember this for a long time. So behave like the character in a story that you’ll want your children to tell. Stay healthy. I’ll try to write again soon.

Learn more:
California Orders Lockdown for State’s 40 Million Residents (Wall Street Journal)
Stay home except for essential needs (CA.gov)
A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19 (New England Journal of Medicine)
COVID-19: Could Hydroxychloroquine Really Be the Answer? (Medscape)
Are Warnings Against NSAIDs in COVID-19 Warranted? (Medscape)
Cedars Sinai Blood Donor Services

My previous coronavirus posts:
What You Need To Know About The Novel Coronavirus
Community Transmission Of Novel Coronavirus In LA County
Coronavirus Frequently Asked Questions

More

Video Chat Instructions

Instructions for having a video chat with your doctor

  1. For computer users:
    Please make sure you have a webcam.
    Please have the Chrome browser installed on your computer OR download the desktop “Intermedia AnyMeeting” app.

    For iPhone users:
    Please download the “Intermedia AnyMeeting” app.

    For Android users:
    Please download the “Intermedia AnyMeeting Videoconferencing” app.

  2. You will receive an email invitation to join the meeting online.
More

Coronavirus Frequently Asked Questions

SARS-CoV-2
SARS-CoV-2
Transmission electron micrograph of SARS-CoV-2
Credit: National Institutes of Healt / flickr

[Author’s note: This post was written on the afternoon of Friday, March 13, 2020. The subject matter is rapidly changing, and the recommendations below may be out of date in a few days. Find the latest recommendations from the LA County Dept of Public Health and the Centers for Disease Control.]

What has changed in LA County since Wednesday?

A total of forty cases have been identified in LA County, with a handful of cases having no identified source of exposure. Today’s press conference has updated guidance from the County Dept of Public Health including the following.

  • Avoid non-essential travel, public gatherings, and places where large groups of people congregate.
  • Event organizers postpone or cancel non-essential gatherings of 250 or more until at least the end of March.
  • Smaller events proceed only if the organizers can implement social distancing of 6 feet per person.
  • Limiting the gatherings of individuals who are at higher risk for severe illness from COVID-19 (people older than 65, pregnant women, and those with chronic illness) to no more than 10 people.
  • If you are mildly sick with a fever, stay home except to get medical care.
  • Individuals who are elderly, have underlying health conditions or pregnant should consider contacting their providers earlier when they are sick.

Note that the recommendation against non-essential travel was only for high-risk people earlier this week. Now it’s for everyone. (Read all the recommendations by following the link above.)

I’m young and healthy and have a trip / concert / public event planned. Should I go? Why not?

Probably not. Note the recommendation against non-essential travel above. If you were infected with COVID-19 you would very likely survive (though there are lots of stories of young healthy people surviving after being on a ventilator in an ICU for a couple of weeks). But the goal of having you avoid groups isn’t just about protecting you. It’s about protecting the older sicker people around you. And it’s also about slowing down how quickly the virus spreads. If everyone who is going to get sick gets it in March and April, there will not be enough ICU beds for everyone who needs one. If we can slow down the spread, the demand for critical care will stay below the supply. That’s what people mean when they talk about flattening the curve.

I’m young and healthy and just developed a fever and cough. I don’t feel too sick. Can I come to the office to get a test?

Tests are in pretty short supply. Definitely call your doctor to discuss your specific circumstances. But if you can take care of yourself at home and are not around people who might need hospitalization if they were sick, it’s unlikely that a test result will change your care or the care of your loved ones. Stay home. Follow your doctor’s instructions for self-quarantine. Call if you get worse.

Should I go to the ER if I need to be tested?

No. Go the ER if you have a medical emergency. In the case of coronavirus that means a fever and shortness of breath. Otherwise call or see your doctor.

Can I have Tamiflu to stockpile just in case? Can I have remdesivir to stockpile just in case?

Tamiflu works for influenza virus. It doesn’t work for coronavirus. Remdesivir is an investigational intravenous medicine that may work for coronavirus. It is being used through a compassionate use protocol in very sick hospitalized patients. It’s not available commercially. If you’re asking this from home, you can’t have it.

I got a fascinating email from Stanford Hospital with intriguing advice I haven’t heard before. It has zero links to the sources of the information. It was forwarded to me by a friend and so I’m sending it to you.

The ton of circulating misinformation is reaching more people than the coronavirus. Since we’re all obsessing about hand hygiene, now is a good time to remind ourselves about email hygiene. Don’t forward content in emails without links to sources. It’s always better to forward links to articles than the actual content. You and I don’t know enough to know if an email contains legit content or bogus content. So it doesn’t matter if you think the information seems reasonable. When you forward content without sources, you’re infecting other brains with misinformation. When you send links, people can judge for themselves if the source is reliable. The fact that the content of the email says it’s from a trusted expert doesn’t mean anything. Take a minute to find that expert’s website and send a link to that instead.

Aren’t we all overreacting?

I don’t think so. If in the next few months the ICUs don’t fill up, heart attack and stroke patients are treated promptly, and everyone that needs a hospital bed gets one, then we all did our part. To the people who give up going to the theater and skip their crowded exercise class and never get sick, to the people who aren’t counting COVID-19 cases and hospital beds every day, it might seem like we overreacted. But the alternative is the experience in Italy, where currently the number of patients exceed the capacity to care for them, care is being rationed, and doctors are burning out. If none of those things happen here, then we did it just right, even if lots of people think we overreacted.

I’m really scared.

I hear you. This is a big deal. And anxiety and the sense of helplessness can make it worse. The Wall Street Journal had a helpful article about managing anxiety about coronavirus. It has common sense advice like eat healthfully, get plenty of sleep, exercise, limit how frequently you check the news, and distract yourself with other activities. The Dept of Public Health also has some useful suggestions for coping with this. Talking to a psychologist or therapist might also help, and your doctor can refer you to one.

I’ve told you not to worry about anthrax and H1N1 and SARS. So I know you’ll believe me when I tell you that COVID-19 deserves to be taken seriously. But we’ll get through it.

Learn more:

News Release March 13, 2020 (County of Los Angeles Department of Public Health)
Flattening the Coronavirus Curve (New York Times, March 11)
Home Isolation Instructions for Novel Coronavirus-2019 (COVID-19) (Los Angeles County Dept of Public Health)
Remdesivir: A Possible Treatment for 2019 Novel Coronavirus (More@MedLetter, The Medical Letter blog)
That Widely Circulated List of COVID-19 Tips Is a Hoax (Los Angeles Times)
How to Manage Your Coronavirus Anxiety (Wall Street Journal)
Coping With Stress During Infectious Disease Outbreaks (LA Dept of Public Health)

More

Community Transmission of Novel Coronavirus in LA County

SARS-CoV-2
SARS-CoV-2
Transmission electron micrograph of SARS-CoV-2
Credit: National Institutes of Healt / flickr

[Author’s note: This post was written on the afternoon of Wednesday, March 11, 2020. The subject matter is rapidly changing, and the recommendations below may be out of date in a few days. Find the latest recommendations from the LA County Dept of Public Health and the Centers for Disease Control through the links below.]

I wrote about the novel coronavirus outbreak ten days ago. The situation in LA County has changed since then.

In their daily press conference on Monday, the LA County Dept of Public Health announced the first documented case of community transmission of COVID-19. That’s the first person in LA County documented to have COVID-19 who didn’t have a travel history and wasn’t in close contact with someone with a travel history. Community transmission means just that – people in LA County are infecting people in LA County. That development on Monday led the Public Health Dept to recommend that people at high risk of having severe disease stay home as much as possible, avoid public gatherings, and practice social distancing. Groups thought to be at high risk are people 65 and older, people with chronic medical problems, and pregnant women. There is more detailed advice in today’s Department of Public Health News Release and at the CDC’s page for people at risk for serious illness, including the following list.

If you are at higher risk of getting very sick from COVID-19, you should:

  • Stock up on supplies.
  • Take everyday precautions to keep space between yourself and others.
  • When you go out in public, keep away from others who are sick, limit close contact and wash your hands often.
  • Avoid crowds as much as possible.
  • Avoid cruise travel and non-essential travel.
  • During a COVID-19 outbreak in your community, stay home as much as possible to further reduce your risk of being exposed.

Today’s press conference (which I recommend you watch) reported the second case of documented community transmitted infection. It also reported the first death in LA County from COVID-19. The number of documented cases is still quite low, 27, but this is certain to be an undercount. First, there are thought to be many cases of mild illness that have not come to medical attention. Second, some cases have not yet been counted because of insufficient tests and delays in testing. Of course, it’s impossible to know what the actual number of cases are. They are still likely to represent a tiny fraction of the 10 million residents of LA County, but the numbers may increase quickly, and our data will lag behind the actual situation.

Some college campuses have cancelled classes and are moving to online instruction. Many large events (including the American College of Physicians annual meeting, scheduled in Los Angeles for April) have been cancelled.

Meanwhile, the previous recommendations still apply.

  • Stay home if you’re sick, even your symptoms are very mild.
  • If you are mildly sick with a fever, stay home until you have been fever-free for 72 hours, except to get medical care.
  • If you have a fever and cough or shortness of breath, call your doctor before arriving at your doctor’s office so that they can prepare to care for you while protecting themselves and their other patients.
  • Don’t go to the emergency room with mild symptoms. Go to the emergency room only if you’re short of breath or can’t care for yourself at home.
  • Wash your hands frequently.
  • Cover your cough with a tissue.
  • Don’t shake hands. (This recommendation is killing me, but I’m doing it. I’m the son of European immigrants. I was raised to always greet people with a handshake. I’ve been apologetically declining to do so since Monday, but it feels very impolite.)

For those not in the high-risk groups, some difficult decisions remain. Can we go to a movie theater? Should we? Should we all follow the guidelines for the high-risk groups? I have no evidence-based answers to these questions. I don’t even have guidance from health officials. But there are a few reasons that low-risk individuals might want to practice the precautions recommended for high-risk people. First, they might be the caregivers or household contacts of high-risk people. By protecting themselves, they protect their frailer loved ones. And second, even if they would get through the illness without complication, slowing the spread of the disease might make the difference between having plenty of ICU beds, ER beds, and test kits when the outbreak peaks and completely swamping our healthcare system. But obviously that has to be balanced with the fact that we don’t know how long this will last, staying inside for months might be miserable, and the risk (while unknown) might be low.

If you’re in a high-risk group, follow the recommendations. If you’re not, use your judgment. In either case, stay informed as this is likely to change over the next days and weeks.

Learn more:

People at Risk for Serious Illness from COVID-19 (Centers for Disease Control and Prevention)
Daily Novel Coronavirus Update with Public Health Officials 03-11-2020 (Los Angeles County Department of Public Health)
Los Angeles County Announces First Death Related to 2019 Novel Coronavirus (COVID-19)- Public Health Confirms First Death from COVID-19 and Six Additional Cases in Los Angeles County (Los Angeles County Department of Public Health)

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What You Need to Know about the Novel Coronavirus

SARS-CoV-2
SARS-CoV-2
Transmission electron micrograph of SARS-CoV-2
Credit: National Institutes of Health / flickr

Unless you’ve been strictly limiting your media consumption to reviews of the midseason finale of The Walking Dead, you’ve probably heard of a novel coronavirus that is causing a bit of bother among public health officials. In this post I’ll try to summarize and explain the evolving situation and highlight the current advice for the US public.

In December, a coronavirus that had never before been detected in humans began making people sick in Wuhan City, China. Since that time according to the World Health Organization, this novel virus has caused about 83,000 people to be sick and has caused 2,858 deaths. Almost all the deaths have been in China. The illness has now been identified in 52 countries. There have been 15 confirmed cases in the US, 12 of which related to international travel. The first death in the US was just reported.

This novel coronavirus (The virus’s official name is “SARS-CoV-2”, which is a terrible name. As soon as it turns 18 it should legally change its name to something simple, like Fred.) typically causes cough, fever and shortness of breath. But in some people these symptoms are very mild, and it’s likely that some infected people never develop any symptoms. (This is an important fact that we’ll return to.) The fatalities have been disproportionately older patients and patients with other medical problems. There have been virtually no children or young adults among the fatalities.

First, let’s take a step back to ask what’s the big deal? There are lots of existing viruses that cause fever, cough, and shortness of breath, like the influenza virus and all the viruses that cause colds. Influenza kills lots of people every year. Why the big fuss over the novel coronavirus / SARS-CoV-2 / Fred?

There are two answers. The first is that the novel virus might be more dangerous than other typical respiratory viruses. The CDC estimates that the US has tens of millions of influenza cases annually, causing tens of thousands of deaths. That works out to 1 to 2 deaths per thousand cases. So far, the fatality rate (the number of deaths divided by the total number of cases) for the illness caused by SARS-CoV-2 is about 3%. That’s about 20 times higher than the fatality rate of the flu. (By the way, the official name for the disease caused by this new virus is “coronavirus disease 2019” which is abbreviated COVID-19. The jargon might kill us before the pandemic.) That comparison very likely overestimates the severity of COVID-19, because it likely doesn’t count a very large number of cases that were asymptomatic and never came to medical attention. So the actual fatality rate of COVID-19 is likely smaller, but let’s assume that it’s higher than the flu.

The more important reason why new viruses in humans scare public health officials is because the entire human population is susceptible. Viruses (like flus and colds) that have been circulating for centuries constantly mutate to produce new strains, but lots of people recently infected with similar strains are partially immune. So as a new strain spreads through a population, it encounters some individuals who can’t get infected or who have only a very brief illness because they were recently infected by a close cousin of the current virus. That slows the virus’s rate of spread and limits the number of vulnerable people. An analogy is the effect of occasional brush fires in large forests. The brush fire might burn an acre or two, but it clears out lots of fuel and limits the damage that the next fire can do. Occasional small fires prevent any one fire from doing very much damage.

An entirely new (to humans) virus is faced with a worldwide vulnerable human population, since no one has immunity to it. That’s like a single match in a forest that hasn’t had a brush fire in a century. The major problem to public health isn’t that the new coronavirus might kill 3% of those it infects, it’s that it might make 10,000 people sick in LA during one week. Not only would this overwhelm our ability to care for coronavirus patients, but anyone with a stroke or heart attack that week would be unable to receive prompt care. Problems that grow exponentially swamp our resources. We can take care of tens of thousands of flu cases when they spread out over the whole flu season. We couldn’t do it if they all got sick at the same time.

So what should we do? Is it time to cower under our desks? Not yet. Is there a vaccine? Not yet. Is it time to take all the cipro you’ve been stockpiling since the 2001 anthrax scare? No. Antibiotics kill bacteria. They don’t affect viruses. Should we stockpile Tamiflu? Current antiviral medicines like Tamiflu don’t work on coronaviruses, unfortunately.

First, if you are planning to travel, keep an eye on the Centers for Disease Control Coronavirus Travel page. The global situation is evolving rapidly, and various regions have different levels of health notices to travelers. If the CDC recommends against travel somewhere, don’t go there.

Second, follow the CDC’s commonsense suggestions for avoiding getting sick. Wash your hands frequently. Stay home when you are sick. Cover your cough or sneeze with a tissue. And don’t bother stocking up on facemasks.

If you get sick with a fever and respiratory symptoms like cough or shortness of breath within 14 days of travel to an area with COVID-19, stay home other than to get medical care. Call your healthcare professional prior to arriving to let them know about your symptoms and travel history.

Finally, as of this writing there is NOT any community spread of COVID-19 in Southern California. But if in the future there is community spread of COVID-19 in Los Angeles, then be prepared for the possible cancellation of public gatherings, such as schools, non-essential work, and public events. You should have at least several days of food, water and any prescription medications on hand and be prepared to stay in your home. But that’s not a new suggestion, since we live in earthquake country.

So take a deep breath, wash your hands, and keep an eye on the CDC page. We’ll get through this.

Learn more:

Coronavirus disease 2019 (COVID-19) Situation Report – 39 (World Health Organization)
First Coronavirus Death Reported in U.S. (Wall Street Journal)
What We Know About the Coronavirus, From Symptoms to Who Is at Risk (Wall Street Journal)
Coronavirus Disease 2019 Information for Travel (Centers for Disease Control and Prevention)
Coronavirus Disease 2019 Prevention & Treatment (Centers for Disease Control and Prevention)
Coronavirus Disease 2019 What to Do if You are Sick (Centers for Disease Control and Prevention)
Emergency Supplies for Earthquake Preparedness (Centers for Disease Control and Prevention)

My previous posts on potentially apocalyptic pathogens:
Zika Virus Gains A Foothold In Florida
Swine Flu: Unlikely To End The World
Why Ebola Is Not A Major Threat In The US
Contagion: The Reality Behind The Movie

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What You Need to Know If You’re Taking Ranitidine

Some pills that are entirely unrelated to this story

Last week the Food and Drug Administration (FDA) made an announcement that generated scary headlines and resulted in lots of phone calls to me from worried patients. The announcement warned about a contaminant found in some tablets of ranitidine. Ranitidine is an antacid used to treat heartburn and ulcers. It is sometimes sold under the brand name Zantac and is also available generically. It is safe enough to have been available over the counter for years.

The contaminant found in the ranitidine tablets is N-nitrosodimethylamine (NDMA), a compound also found in grilled and cured meat. NDMA can form during the manufacturing of medications if the chemical reactions are not carefully monitored. NDMA has been shown to cause cancer in lab animals, and so is thought to be likely to cause cancer in people.

To put this warning in context, we should recall that since February NDMA was also found in some lots of losartan, valsartan and irbesartan, which are commonly prescribed blood pressure medications. The concentration of NDMA in these batches of medicine was high enough that many lots of medications were recalled, causing shortages and forcing many patients to switch to different medications.

The FDA so far hasn’t ordered any recalls of ranitidine. It said that the amounts of contaminant found in the tested ranitidine tablets “barely exceed amounts you might expect to find in common foods.” Some generic drug makers have voluntarily stopped distributing ranitidine while they investigate.

So, is this trace amount of NDMA dangerous? The alert states that “the FDA is evaluating whether the low levels of NDMA in ranitidine pose a risk to patients. FDA will post that information when it is available.” That’s not very helpful. “The FDA is not calling for individuals to stop taking ranitidine at this time; however, patients taking prescription ranitidine who wish to discontinue use should talk to their health care professional about other treatment options.” That’s also not very helpful. Patients should always talk to their doctor if they want to switch medicines, not their librarian or grocer. Understanding the magnitude of the risk would be more helpful. Is the increased cancer risk comparable to smoking 2 packs per day for 40 years, or is it closer to having one additional hot dog?

I’m glad you asked. An FDA report about the blood pressure medicine recalls states

We initially estimated that if 8,000 people took the highest valsartan dose (320 mg) containing N-Nitrosodimethylamine (NDMA) from the recalled batches daily for four years, there may be one additional case of cancer over the lifetimes of those 8,000 people.

This was their worst-case estimate for the most contaminated lots of valsartan. Using a lung cancer risk calculator I calculated the risk of smoking 1 pack of cigarettes per day for four years (compared to not smoking for those for years). It turns out that for every approximately 54 people who start smoking and smoke 1 pack per day for 4 years, there will be one additional case of lung cancer. So smoking 1 pack per day is 150 times more carcinogenic than taking the most contaminated recalled batch of losartan.

Given that ranitidine batches haven’t been recalled yet, I would guess that the risk of ranitidine is much smaller still. Does that mean that I know for sure that ranitidine is perfectly safe? No. And after all, we only think that that NDMA causes cancer in people by extrapolating from lab animals. To sort this out definitively we would have to conduct a randomized Give Me NDMA Or Placebo For A Decade study. No one is going to sign up for that.

We should also keep in mind how carcinogens work. They make changes (mutations) in cells that make the cells susceptible to other changes. It is these multiple changes over time, usually over decades, that lead to cancer. Smoking today doesn’t cause cancer today. It increases the risk of cancer decades from now. So when my 30 year-old patient calls with concerns about contaminated medicine, I worry that she might live long enough to suffer the consequences of any carcinogens she is ingesting now. When my 90 year-old patient calls, I reassure him that any current exposure is very unlikely to lead to cancer.

So for now, unless the FDA makes further worrisome discoveries or orders recalls, I’m reassuring most of my patients that ranitidine is probably still OK. If you are not reassured, there are alternative antacids that your doctor can recommend, at least until we find out that the alternatives are contaminated too.

Learn more:

Zantac Has Low Levels of a Cancer-Causing Chemical, the F.D.A. Says (New York Times)
Should You Keep Taking Zantac for Your Heartburn? (New York Times)
Statement alerting patients and health care professionals of NDMA found in samples of ranitidine (FDA)
Statement on the agency’s ongoing efforts to resolve safety issue with ARB medications (FDA)

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This Might Be a Great Time to Quit Vaping

Image credit: flickr / vaping360

People in North and South America have been smoking tobacco for millennia. The reason is simple. Tobacco contains nicotine, a highly addictive stimulant. So smoking tobacco feels good and is difficult to quit. After being introduced to Europe, smoking became very popular, because it feels good and is difficult to quit. It wasn’t until the 1950s that the association between smoking and lung cancer was confirmed.

Electronic cigarettes (also called e-cigarettes, vape pens) in contrast, have been available in the US for a little over a decade. They are designed to deliver nicotine without combustion, thereby sparing the user all the harmful components in tobacco smoke. E-cigarettes contain an electronic heating element that heats and vaporizes a solution of nicotine. The vapor is then inhaled. (Using e-cigarettes is called vaping.) E-cigarette fluid (e-liquid) is also available with THC, the psychoactive compound in marijuana, rather than nicotine. E-liquids are also available with various flavor additives.

Since their introduction in the US market, e-cigarettes have become very popular, because nicotine feels good and is difficult to quit. (Have I mentioned that?) Proponents of e-cigarettes claim that e-cigarettes provide a safer alternative to smoking. They offer a way for current smokers to switch to a safer nicotine delivery system until they quit. Critics of e-cigarettes note that they have never been proven to be effective for smoking cessation, and their long-term safety is unknown. They also note that the flavors of e-liquids are clearly intended to make them palatable to teens, not to current smokers.

And that’s where the debate stood until a few weeks ago when a few users of e-cigarettes started getting very sick. Last week the Centers for Disease Control and Prevention (CDC) released an alert that 215 patients in 25 states have developed a severe acute illness involving cough, shortness of breath and chest pain. Some of the patients have required hospitalization. One patient in Illinois died. The patients were generally young and otherwise healthy, without a history of lung disease. The specific cause of these illnesses is still unknown. Tests for infectious organisms have been consistently negative and antibiotics have not been effective. Health officials suspect that a contaminant or solvent in the e-liquids is causing acute lung injury.

The CDC is asking doctors to help identify patients with these symptoms and submit their vaping equipment for analysis. The CDC suggests that members of the public who are concerned “consider refraining from using e-cigarette products”, and that those who do use e-cigarettes “should not buy these products off the street … and should not modify e-cigarette products or add any substances to these products that are not intended by the manufacturer.” (See the full Recommendations for the Public in the CDC alert.) Some state health officials are not being so reserved and are asking everyone who uses e-cigarettes to stop vaping until the cause of the illness is identified.

Eventually the contaminant causing these illnesses will be identified. Then it will either be eliminated, or for some secondary reason it will continue to be distributed in e-liquid. (Heroin mixed with fentanyl, for example, is a major reason for deaths due to opioid overdoses. But fentanyl persists as an intentional contaminant in heroin because of its potency. So if the contaminant in e-liquid adds a pleasant kick to nicotine or THC, maybe illicit distributors will continue using it.)

But these acute illnesses should bring attention to the question of long-term safety. We have no way of discovering the effects of thirty years of vaping until enough people have been vaping for thirty years. We had no way of figuring out that smoking caused lung cancer until lots and lots of smokers developed lung cancer.

Ask yourself if you’d like to be in the guinea pig cohort for vaping. If not, please get your nicotine from gums, patches or lozenges. You can reconsider vaping in 2050 or so.

Learn more:

Severe Pulmonary Disease Associated with Using E-Cigarette Products (Centers for Disease Control and Prevention)
The Mysterious Vaping Illness That’s ‘Becoming an Epidemic’ (New York Times)
As vaping-related lung illnesses spike, investigators eye contaminants (Washington Post)
First death in US from lung illness linked to vaping reported in Illinois (CNN Health)

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Why I’m Not Burning Out

Photo credit: Hilary Clark, Pixabay

Physician burnout has been in the news for many years. (I wrote about it eleven years ago.) In the last two decades the practice of medicine has become more difficult and less rewarding for many doctors. Though I know that physician burnout is increasing, I still find it shocking. We’re paid better than most. We’re generally held in high esteem. Why don’t more of us love what we do?

This month Dr. Danielle Ofri, an internist at Bellevue Hospital in New York penned a New York Times opinion piece that sounds the alarm about physician discontent. Her accusation is summarized well by the piece’s headline – “The Business of Health Care Depends on Exploiting Doctors and Nurses”. (The rest of my post is a reaction to her article. You might want to read it first and then come back here. I’ll wait.)

I find her charges entirely credible, as I’ve heard them corroborated by many colleagues and friends who work for large medical groups. The consequences are deeply disturbing. Physicians and nurses – who would be expected to be most aware of mental illness warning signs and of mental health resources– commit suicide at higher rates than most other professions.

I think good luck much more than wisdom led me to escape the sources of stress and frustration listed by Dr. Ofri. Like most doctors in training, I looked forward to the practice of medicine and had no interest in (and no training in) running a business. I took my first job at the UCLA Medical Group thinking that if I left the hiring and firing of office staff, the billing, all the details of running the business to someone else, I could concentrate on doctoring.

But I quickly learned that running the business is integral to patient care. Hiring excellent staff, deciding on which insurance contracts to accept, making sure the appointments are long enough, and myriad other administrative details directly determine the care I deliver in the exam room. I became an employee under the assumption that these details would be executed well, and that the administrators’, doctors’ and patients’ interests all aligned. I quit my job and went into private practice when I saw that this wasn’t so. Administrators have a strong interest to maximize volume. Doctors and patients have an interest in maximizing the quality of each encounter. Administrators have an interest in enrolling their group in as many insurance contracts as possible. Doctors have an interest in limiting their patient panel so that they can deliver excellent care and availability to each patient.

Dr. Ofri bemoans the enormous increase of administrators per doctor. But that simply reflects the exploding complexity of medical billing and insurance contracts. Dr. Ofri is right that these administrators are not creating value for the patient, but they are clearly creating value for the large medical systems which employ them. “If we converted even half of those salary lines to additional nurses and doctors,” she suggests, “we might have enough clinical staff members to handle the work.” Who is “we”? Dr. Ofri is not hiring the administrators. Her bosses are. Sadly, she does not have the authority to convert anyone, and there are no incentives for her bosses to act against their interests and instead follow the advice of an excellent NYT Opinion piece.

Dr. Ofri offers no solutions for physicians, and instead looks to the administrators for help. “Those at the top need to think about the ramifications of their decisions. Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine.” I hope administrators heed her plea, but I suspect they won’t.

My suggestion is much simpler. Unhappy doctors and new trainees should go where the happy doctors are – into private practice. Our practice has three physicians, two employees and zero administrators. We three have chosen an EMR that we actually enjoy using (appropriately named Elation). We are in control of our own schedules. We balance our work and our lives. We are directly responsible to our patients.

If we want happy doctors, medical training should teach the rudiments of business management – how to hire and manage employees, how to select and lease office space, how to lead a team. As it is now, everything about medical education prepares physicians to be dedicated, brilliant, unhappy employees.

For a generation doctors have fled private practice and entered jobs as employees. They gave up risk and autonomy for job security and a steady paycheck. They gave up the responsibility and burden of running a business to focus on patient care. Now it turns out that the administrators to whom doctors ceded their authority are making decisions that doctors don’t like. Doctors shouldn’t be surprised by that.

Doctor’s owe their patients excellent care, and they owe themselves a life outside of medicine and reasonable compensation. If we have failed to keep that balance, we have no one to blame but ourselves. We should look to no one but ourselves for solutions.

Learn more:

The Business of Health Care Depends on Exploiting Doctors and Nurses (New York Times, Opinion)
What’s Doctor Burnout Costing America? (Shots, NPR health news)
Beyond the Economics of Burnout (Annals of Internal Medicine, Editorial)

My post in 2008 on the shortage and discontent of primary care doctors:
On Being Doc And Being Happy

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