COVID-19 Resource Center

COVID-19 Resource Center

Issue: April 2020
Disclosures: Romeo reports he receives royalties, is on the speakers bureau, is a consultant and does contracted research for Arthrex; receives institutional grants from MLB; and receives institutional research support from Arthrex and Paragen Technologies.
April 07, 2020
9 min read
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COVID-19: Learn, innovate and inspire the next generation to be prepared

Issue: April 2020
Disclosures: Romeo reports he receives royalties, is on the speakers bureau, is a consultant and does contracted research for Arthrex; receives institutional grants from MLB; and receives institutional research support from Arthrex and Paragen Technologies.
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Anthony A. Romeo

Thursday night was date night with my wife. We had a reservation at a lower Manhattan restaurant that takes months in advance to get a reservation. The night was a special evening for us. The multicourse meal was filled with amazing dishes with fantastic flavors and great scents and an amazing wine to complement the chef’s selections of contemporary Asian cuisine. This would be the last meal my wife and I would taste or smell for more than 2 weeks.

On Friday morning, I awoke before my alarm and went to prepare for my early morning session at the gym. I had been going to the gym sparingly during the previous 2 weeks due to the growing concern of the viral infection spreading in New York. The viral infection was due to COVID-19, a novel coronavirus that originated in China, but was quickly spreading around the world. We had just heard about a man who had returned from Italy and unknowingly transmitted the virus to others in the town next to ours.

Every time I went to the gym, I wiped down each machine or bar before and after every use, washed my hands frequently, including the liberal use of hand sanitizer at the end, and did not touch my face. I also stayed away from anyone who was coughing or sneezing. As soon as I got home, I showered then had a light breakfast.

COVID-19 diagnosis

Earlier in the week, I went to an occupational health clinic to get my updated tDap vaccination and a blood test for tuberculosis – a normal part of the re-credentialing process. I was also tested for the proper fitting of an N95 mask in the event it was necessary to use one due to potential exposure to COVID-19, officially known as SARS-CoV-2. Otherwise, it was a normal week of 2 days seeing patients in the office, 2 days in the OR and the fifth day adjusted based on clinical or surgical needs. I had a great day in the OR on Thursday. I finished a little early and was ready for a special night out with my wife.

Something happened in the less than 6 hours from the time I went to bed to when I woke up Friday morning. As I walked toward the closet, I realized I could not take a deep breath. In fact, it was uncomfortable. When I tried to take a deeper breath, I started coughing. It was a dry cough, but it was accompanied by the feeling that somehow cement had been poured into my lungs and it had collected in the lower half of my chest. There was no sore throat, runny nose or headache. I continued to change into my gym clothes. I then realized my muscles seemed fatigued and a little sore. Without being able to take a deep breath and with my muscles feeling like I would not be able to give a good effort at the gym, I went to my home office to get a few administrative tasks completed. The longer I sat there, the worse I felt. In fact, I felt warmer, too.

With breakfast, I added some extra-strength Tylenol. Still feeling worse, I realized I may have COVID-19. At that time, less than 600 people had tested positive in New York, and I was unsure of the restrictions and guidelines for going to work as a health care provider. I decided to go to the ED.

I qualified for COVID-19 testing due to my symptoms – an elevated temperature, status as a health care provider, negative influenza and respiratory syncytial virus tests. I received recommendations for treating symptoms and was told to go home and isolate myself from my family, pets and anyone outside my home. My COVID-19 test came back positive the next day. I was not surprised as my symptoms were worse with more difficulty breathing, dyspnea, consistent dry cough and muscle fatigue with myalgias. In hindsight, I realize I could not smell or taste food and I did not have much of an appetite.

Later that day and into Sunday, my wife started having symptoms, too. The labored breathing was similar, but she also had a significant persistent headache and a constant feeling of nausea. On Monday, I received a letter from the New York State Department of Health confirming I was COVID-19 positive, and I had contracted a highly transmissible disease and therefore was confined to my home for isolation with the potential for criminal prosecution if I violated the terms of the commissioner’s orders. I was told I would need two COVID-19 tests to have negative results before I was released from isolation and allowed back into the public. None of these parameters exist anymore.

Two-week blur

The next 2 weeks were a blur. As is typical, the symptoms gradually worsened at times with the primary concern related to breathing. Other symptoms also worsened to varying degrees. Fever is common with COVID-19 infection and we both had one at times. However, less than 50% of patients present with fever, yet almost 90% will experience a temperature above 100.4° F as was our experience. We tried over-the-counter cold medications, acetaminophen, high doses of vitamin C and other multivitamins, zinc and a healthy diet. Since we were quarantined at home, we both had more sleep than usual. The symptoms responded partially, yet we were miserable for some or most of the day at times during the first week.

The infection was tenacious, constantly present and uncomfortable for longer than we had ever experienced. By day 8, it was frustrating to wake up and feel the same or worse with breathing. In fact, I was able to obtain a home pulse oximeter, which was helpful because my wife’s breathing for 2 nights in a row was severely affected. The infection did not significantly lower her O2 saturation to dangerous levels requiring hospitalization, so we stayed home. Every day the ED physician who tested me at the beginning called to check on us. Other members of our group did, too. Neighbors helped with the shopping. We stayed home.

I had time to research what was being done in China, South Korea, Italy and France. I also have good friends and colleagues there, so I contacted them to learn more about what was happening in their communities. They said physical isolation was critical and, of course, they also confirmed the importance of washing hands frequently, staying 6 feet apart from others and washing surfaces touched by others. In addition, they all recommended wearing a mask when around other people, even my wife, to reduce viral load.

They emphasized this viral infection was unique in that it is transmitted by people who have no symptoms. When the virus gets to a community, you behave as if everyone has it. Otherwise, a large part of the population will get it. Their experiences in Asia with SARS-CoV-1 and MERS had taught them that SARS-CoV-2 was more difficult to contain because of asymptomatic carriers. They also reported health care workers who consistently went into an environment with incomplete protection were getting sick and some dying, even though they were younger than 60 years old.

In harm’s way

My wife and I are part of the first 1,000 recovered cases in New York, the U.S. epicenter of this infection, at least for now. Other metropolitan areas are rapidly increasing their detection of COVID-19. From social media and other resources, it appears each community waits until the virus reaches a certain level of prevalence in the region before politicians and health care leaders react and establish guidelines and restrictions, as if they were waiting to see if their experience would be the same as other regions. This is similar to the actions in New York despite knowing what was happening in Europe.

By the time leaders act, the exponential growth of the respiratory virus that infects many people silently and without warning is endemic in their community, with the more advanced cases bringing attention to its presence through the consequences of the pathologic immune response, excessive inflammation and severe respiratory distress. This can lead to decreased oxygen saturation, other organ involvement, and, in a small percentage of patients, loss of the ability to re-establish respiration often with cardiac compromise and death. This overwhelms the health care system’s ability to respond to the surge of sick patients due to the expanded need of health care workers, hospital beds, life-saving respirators and medications.

Unfortunately, due to the bureaucratic inertia of large organizations, the WHO and CDC guidelines crafted with the previous viral pandemics were incomplete, ineffective and dangerous to health care workers. COVID-19 was first detected in the United States in late January. More than 2 months later, the CDC and WHO are still modifying the guidelines to match what our Asian colleagues told us regarding personal protective equipment (PPE), especially the liberal use of wearing a mask. It not only prevents you from being infected by droplets and microdroplets, but also protects others from being infected from asymptomatic carriers. A recent study on orthopedic surgeons from Wuhan, China confirmed the value of wearing an N95 mask to reduce the incidence of infection and transmission of the virus to others, including family members.

The most significant failures of our infection management health care system led by the CDC, FDA and HHS included the lack of preparation to have a sufficient amount of tests available for surveillance and management of the pandemic; the lack of a strong recommendation for physical isolation early in the viral spread; and the lack of recommendations and provisions for PPE for health care workers and the affected public. All of this is coming together now, but more than 8 weeks since the first diagnosis in the United States on January 20.

Health care workers have been placed in harm’s way without proper PPE and necessary resources to care for every patient, and they soon may have to make decisions regarding who lives and who dies. No one can convince me that this is an acceptable consequence of a pandemic in a first-world country like the United States.

One country that was prepared, organized, innovative and immediately responsive was South Korea. Their experience with the pandemic should have provided strong clues to our government and health care leadership on what was necessary to avoid the estimated more than 100,000 to 200,000 lives that will be lost in the United States. South Korea has 51 million people and has lost less than 200 lives, as of press time. Sadly, in New York state with more than 20 million residents, as of press time, we have already lost more than 4,000 lives to COVID-19 infection. This is significantly more than was lost on 9/11. The first documented patient with COVID-19 in the U.S. and in South Korea was on the same day, January 20.

Future ahead

Information and research about COVID-19 is evolving and being applied every day. We know the genetic code. Vaccines are being developed. Medications are being carefully studied. Treatment protocols are being shared and refined worldwide. One amazing component to this pandemic is the incredible focus and collaboration of the world’s community of scientists and health care workers, supported by industry and philanthropy, which crosses all lines of separation among nations without concern of political leadership.

I look forward to learning about whether my recovery is associated with immunity and whether that immunity is lifelong. I also hope the investigational medications I used, including hydroxychloroquine and azithromycin, will be shown to be safe and valuable to others. I want to know why children seem to be exempt from the severe manifestations of this infection, while older adults are particularly vulnerable. I want every health care worker to be provided with proper PPE, including masks.

The CDC and WHO should have been more proactive in their efforts so health care administrators could not hide behind their recommendations and send their valuable health care providers to fight a battle without proper equipment. We may have other methods to reduce infection in the future, including vaccinations, as well as medications to take early in the disease process to prevent the virus from causing immune systems to destroy important cells in lungs. I hope our current experience will allow us to be prepared like South Korea and have rapid tests available from our private business sector to get results in minutes, not days or weeks.

Feedback from orthopedics

The COVID-19 pandemic is a crisis of a lifetime. I have mostly positive reviews from orthopedics. Many orthopedic departments, multispecialty groups and private practices have developed plans to repurpose surgeons and staff to help their medical colleagues, especially during the surge of patients admitted to the hospital and ICUs. The management of musculoskeletal problems in the ED or urgent care centers, restricting surgical care to emergencies with a limited list of urgent procedures, and even working as hospitalists on the non-COVID-19 floors demonstrates a commitment to the community and colleagues outside orthopedics.

However, a few reports have suggested some groups are prioritizing practice volume with the continuation of elective cases and nonemergent procedures. When the virus is endemic in the community, physical interaction with patients in the office or OR risks transmission of the virus to the patients and their families, as well as health care workers and their families. Some may argue it is a small risk because fatalities are concentrated in elderly and medically compromised patients. However, if that death is in your family, there is no amount of revenue to justify the decision to do one more elective procedure, injection or office evaluation. It should be the same toward staff and their families. People are our most valuable resource and should be the priority with all leadership decisions.

The COVID-19 pandemic will pass. We will have tragedies to report. However, we will also learn, innovate and inspire the next generation to be prepared, to execute the proper plan, to protect our health care workers and to prioritize humanity over commerce.

 

Reference:

Guo X, et al. JBJS Express. 2020;doi:10.2106/JBJS.20.00417.

 

For more information:

Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Road, Thorofare, NJ 08086; email: orthopedics@healio.com.

 

Disclosure: Romeo reports he receives royalties, is on the speakers bureau, is a consultant and does contracted research for Arthrex; receives institutional grants from MLB; and receives institutional research support from Arthrex and Paragen Technologies.