Scheduled Appointments

We’ve had a multitude of patients come into the emergency department recently thinking or expecting that by coming to the emergency department we will somehow be able to connect them to a specialist because of an appointment that they’ve had that they decided not to keep. The irony is is that they’ve opted not to go to the primary care doctor or the specialist out of fear of COVID-19 (the novel coronavirus) only to come to the emergency department where the risk of exposure or transmission is actually significantly greater.

If you have scheduled appointments that were scheduled long before the COVID-19 pandemic became a problem in the community, talk with your doctor or the office and let them guide you on what the next step is. Many doctor’s offices now are implementing virtual care platforms that will allow you to keep those appointments in the privacy of your own home. Many of them are also constructing mechanisms to limit the number of patients in the waiting room but still honor appointments. For example, you might have a scheduled appointment with a specialist and they may guide you to come to the office and wait in your car until you are called to come to the office because they want to limit the number of patients in the waiting room.

Regardless of the situation, it is not a wise idea to come to the emergency department for care that your specialists have been coordinating and have been managing. It’s in your best interest to call those doctors with whom you have an established relationship and get guidance from them about what the next step should be.

COVID-19 Overview

I get a lot of questions from patients and their family members about just what is COVID-19 and where did it come from? Well, COVID-19 is the abbreviate name for the Coronavirus and the number 19 refers to the year that it was first identified in human beings.

Coronavirus describes what the virus looks like under a microscope and the Coronavirus family has been around for thousands of years in many different mammal species including humans. This specific strain of Coronavirus is different because it appears to have jumped from one mammal species – bats – to another – humans – in December, 2019. Because the human immune system had never been previously exposed to this specific strain of the virus, the body wasn’t able to mount an immune response to COVID-19 and therefore it made us sick. It’s a respiratory virus that’s carried from place to place in respiratory droplets, which are those small microscopic pieces of saliva that come out of our mouths when we walk and when we talk and breathe and cough and sneeze. It can be deposited onto door handles and other inanimate objects and survive there for up to four days. It can spread rapidly from person to person and make people sick.

It’s estimated that one infected person can infect at least two other people and that the number of COVID-19 cases in any given community can double about every four to five days. COVID-19 has an average incubation period of five days, but some can develop symptoms and therefore be infectious up to 14 days or more after initial exposure.

Although it produces very mild symptoms in about 85% of patients, it can be spread easily from person to person even when you don’t feel sick. Unfortunately, in high risk groups such as individuals over the age of 70, people with complicated preexisting medical conditions and compromised immune systems, it can sometimes produce a unique and potentially deadly form of pneumonia or severe acute respiratory syndrome.

Right now, there is no specific cure for COVID-19 which is why it’s important for us to both limit our exposure as well as our risk of transmitting COVID-19 to other people working together. We can help to stem the tide and weather the storm of the COVID-19 pandemic.

COVID-19 Symptoms

Full emergency departments all over the world demonstrate that people need to know and want to know how long it takes before COVID-19 (the novel coronavirus) makes them sick. Well, the answer is if you’ve been infected, then you’re sick and therefore you’re able to transmit the virus to other people. But the real question should be how long does it take for someone to show symptoms? And this is another aspect of this virus that makes COVID-19 so hard to isolate and treat. Up to 85% of infected people will have very mild symptoms like cough and fever and some may have symptoms that are so subtle that they might not even notice. On average, however, an infected person will likely begin to show symptoms within five days. However, there are many reports around the world of patients not showing symptoms until 14 days or more. For this reason, any patient who is suspected to have been exposed to COVID-19 should self isolate and quarantine themselves for at least 14 days. If you begin to feel sick, do not go to the emergency department, but contact your primary care physician first. If you can’t contact your primary care doctor, then contact your local public health officials for guidance. By putting yourself at risk in the emergency department, if you’re not sick or infected with COVID-19, you may be exposing yourself to those who are. So for that reason, we’re recommending that if you feel sick, contact someone before you go to the emergency department and follow that advice.

COVID-19 Test Results

I received a text message from a family friend who was recently tested in a community outside of Pittsburgh and wanted to know what the results mean and I suspect that there are many people out there who are either being tested, have been tested or are thinking about being tested and want to know exactly what the results actually mean.

So now I’ve gone through the process. I’ve had my test, I’ve stayed isolated while waiting for the results and now I get the call and I need to know just what to do with the results. Well, if I’m sick – meaning I had symptoms and my test was positive – it means that your symptoms were almost certainly due to COVID-19 (the novel coronavirus.) If you’re young and healthy and have no symptoms of chest pressure or respiratory distress, you can simply treat your symptoms at home, stay hydrated, and avoid contact with others for at least 14 days. Your results have already been communicated to your local public health officials and they will follow up with you.

If you’re positive and you’re part of a high risk group – you’re over 70 you have complicated preexisting conditions or immune compromised – but you have no symptoms, you can contact your primary care physician and monitor your symptoms closely with them and remain isolated for up to 14 days. If you’re positive, regardless of your risk factors for severe disease, but you’re experiencing breathing difficulty, chest pressure or pain or change in mental status, you should seek medical care promptly.

If you must call 911, please notify the dispatcher of your positive test result and the symptoms you’re experiencing. If you’re coming by private vehicle, as soon as you reach the registration area, you should let them know of your positive test result.

If you’re sick and you have a negative result, then your current symptoms are due to something other than COVID-19 but here’s the catch: because there’s not a lot known about this disease and how it progresses, it could be that your negative test result means that you have early disease, but the test just isn’t detecting the presence of the virus. So even in those cases, it’s best to probably keep yourself self isolated for up to 14 days. You should remain in self isolation for that period of time and it may require repeat testing, particularly if your symptoms get worse.

It’s important to know that it is currently unclear whether or not a COVID-19 positive patient can become reinfected during the same pandemic season. So that’s why it’s important regardless of your test result to practice social distancing. That’s why it’s important to keep your hands clean, to keep them away from your face and to keep the surfaces that you touch with your hands as clean as possible. That’s why it’s important that even after a positive test result and weeks and weeks have passed, if you begin to feel sick again, that you isolate yourself and go through the process all over again because the more we learn about this disease, the more we realize that there are things that we still may need to put into practice that we don’t yet clearly understand.

COVID-19 Testing

With the number of COVID-19 (the novel coronavirus) cases increasing daily in communities all over the world and with the increased availability of COVID-19 testing within communities, I’m getting quite a few questions from individuals about testing. One question is, should I even get tested?

The current guidance is that it will likely require both a high clinical suspicion on your part and on the part of your doctor and a written prescription from that doctor. So if you believe that you are sick and that you need to be tested, the first thing that you need to do is to not come to the emergency department, but contact your primary care physician first.

Call your doctor and if your doctor is unavailable, then call your local health department hotline for guidance, because simply wanting to be tested is not currently enough to guarantee that you will be tested. If you feel that you need to be tested and you have a doctor’s prescription and the local public health agency disagrees and your doctor still feels that you should be tested, they can refer you with that same prescription to a private third party lab for testing. Regardless of where you’re tested, the results currently take at least 24 hours, during which time the patient should be self isolated because if you thought that you were sick enough to be tested for COVID-19, then you should be separating yourself from those who may not be infected.

Once you get those results, then you need to follow the guidance of those who give you the test results and what your public health officials are telling you to do. But in general, most people (85% or so) will recover with only mild symptoms and therefore self isolation is all that’s required.

COVID-19 Treatment

With the number of positive cases increasing by the day, we’re receiving more and more phone calls in the emergency department from patients who are at home in quarantine with a positive test result and they want to know about treatment.

Well, for up to 85% of patients are known to be positive for COVID-19 (the novel coronavirus) their symptoms will be no more serious than a common cold or a mild case of flu. In those cases, the remedy is rest, hydration specific symptom relievers as directed by your primary care doctor and self isolation for up to 14 days. For the 15% or so of patients who are at higher risk – patients over the age of 70, patients with complicated preexisting medical conditions such as hypertension, diabetes, chronic lung disease, asthma, COPD, emphysema, chronic bronchitis, patients with compromised immune systems like patients receiving immunotherapy or chemotherapy. These patients are more likely to require hospitalization because they are at higher risk of developing the most serious complications of COVID-19 – those are the dangerous viral pneumonia and severe acute respiratory syndrome or SARS. These patients can suddenly and rapidly deteriorate and require care in the intensive care unit and may even require being placed on a mechanical ventilator.

It’s important to note that any patient with COVID-19 who develops chest pressure or pain or difficulty breathing or changes in mental status should seek care promptly and if possible, they should alert the EMS personnel or the emergency department prior to their arrival of their positive test result and their symptoms. I’m sure you’re seeing on the internet that there are a number of strategies that are being proposed in terms of using combinations of antiviral medications and other antimicrobial agents but currently none of these remedies has been approved or vetted and is being used in any case or trial to treat these diseases.

So it’s your best bet that if you have a positive test result that you communicate with your primary care doctor or your public health officials for the most up to date guidance on how to get healthy and stay safe.

Cure or Vaccine?

Earlier this week I heard a press conference from the white house where President Trump said that he believes that we will have a vaccine for COVID-19 (the novel coronavirus) very soon. As much as we would all want to that to be the case, that’s unfortunately not how vaccine development works.

There’s several steps involved in developing any vaccine that makes it to the marketplace: sequencing or determining the genetic makeup of the virus, creating a way of getting the immune system to respond to the virus without producing full blown symptoms or in other ways making the body sick, there are animal trials, then there are limited human trials, and all of this takes time. That’s why conservative estimates put the time for an expected vaccine to reach the marketplace at somewhere between 12 and 18 months and that’s why while we’re waiting, there are still things that we can do in order to limit the transmission and decrease our risk of personally becoming sick.

Our best defense is to put these strategies into practice: practicing good and consistent hygiene, practicing social distancing and appropriate hand-washing, using a hand sanitizer with at least 60% alcohol or using soap and warm water and washing our hands for at least 20 seconds, practicing social distance and keeping ourselves beyond six feet of other people, and continuing to self isolate when we feel sick. When we do these things and put them into practice, we can limit the exposure risk as well as the transmission with risk while we all anxiously await the arrival of a vaccine and perhaps even a treatment or a cure.

Emergency Room Risk

Many emergency departments like ours here in Pittsburgh have added additional staff because we are fielding a multitude of phone calls asking the question, should I come in to be checked? And the answer is absolutely not, for a number of reasons.

Number one, if you think you’re infected with COVID-19 (the novel coronavirus), most emergency departments are not readily capable of testing all suspected patients. We will test patients that are going to be admitted to the hospital and those who meet certain world health organization or CDC or local health department guideline recommendations for testing. In other words, if you come to the emergency department expecting to be tested just because you’re concerned, you’re likely going to be turned away and referred to a local testing facility or site.

The second reason is: the average length of stay in an emergency department in the United States borders on four or five hours, during which time you are in close contact with a multitude of people with a multitude of other medical conditions, some of which may in fact be infected with COVID-19. So while you’re waiting to be seen, you’re in a waiting room filled with people, and while you’re in the emergency department, even though the emergency department staff will do its due diligence to keep you as safe and quarantined as possible, you are still surrounded by pathogens and things that can make you sick. If you feel you need to be tested for COVID-19, contact your primary care physician. Your primary care physician, using the guidance of your local health department, will give you instructions about what to do next.

Now, if you feel that your medical condition is life threatening, whether it’d be something like chest pain or a suspected stroke, or you think you have COVID-19 and are in a higher risk group, or you’re feeling shortness of breath, discomfort in your chest or altered mental status, then you need to come to the emergency department. But you should still expect that you will be subject to rigorous screening before you are seen in the clinical area.

Prescription Medications

We field a lot of calls about a lot of issues in the emergency department and now that the COVID-19 (the novel coronavirus) pandemic is among us and upon us, we find ourselves fielding a lot of questions about medications. Patients with preexisting medical conditions, whether it puts them in a high risk category or not, are calling us because now that they have remained inside, now that they are practicing social distancing, they’re finding it challenging because they look at their pill bottles and their prescriptions are running low. They have prescription refills on file, some do not, but the question is how do I deal with my chronic medications when the prescriptions are running low in the house? Well, here are some simple recommendations.

Number one, you may be able to find someone who is in a lower risk category than yourself and you can ask them to go pick up your prescriptions for you. You may also call the pharmacy to see if they have a mechanism of home pharmacy delivery. Many pharmacies even that did not have this service have now implemented this service during this pandemic experience. You can also talk with your primary care physician to make sure that you have authorized refills so that you don’t have to go to places to get a prescription filled.

Patients who have medications that are controlled substances that require a physician’s handwritten prescription – it’s important for you to communicate with your doctor so that they can make arrangements in the safest way possible to get you the prescription that you need. In the end, you need to continue to take those medications because they were prescribed for you for a reason. It is not a wise idea to ration your prescriptions. For example, if you’re taking a prescription as prescribed every day and now that you’re running low, you have decided to take the medication every other day or every third day, you run the risk of complications that could make your chronic condition even worse.

Instead, your best bet is to follow up with your primary care physician by telephone or virtual care experience and get guidance from there. If you come to the emergency department, again you will be waiting in a long line of patients waiting to be seen, often only to be told that we cannot refill your prescription. But now having exposed yourself to a multitude of patients who are potentially sick, some of which may in fact be infected with COVID-19. Instead, use your primary care resources and let them help guide you on what the right next step is.

Prognosis Curve

What does it mean to flatten the COVID-19 (the novel coronavirus) curve? Earlier this week I began to see the hashtag #flattenthecurve, so I began to ask people and patients and families what they thought that hashtag meant. The number of answers I got made it clear that we need to have a better understanding of this concept. So in order to understand the concept of flattening the curve, we probably first need to talk about what the curve actually is.

The curve represents a graph that plots the total number of COVID-19 cases in a given city or state or country over time. If you recall from middle school math class, the X or horizontal axis represents time and the Y or vertical axis represents the total number of cases. The plot or curve for COVID-19 like most other viral illnesses has a bell shape, meaning that the number of cases increases over time, then it reaches a peak before finally decreasing. The total number of cases is the height of the curve and the length of time that people are infected is again the horizontal or X axis and both of them are dependent upon the number of infected people and the ease with which the infection is transmitted from person to person.

Flattening the curve simply means decreasing the height of the curve (meaning the total number of cases) and/or decreasing the number of new infections, which means that by controlling the number of new infections, we can decrease the length of time that new infections are identified and decrease the number of people who could potentially transmit the infection to people who are currently healthy. Hand washing, social distancing, self isolation, quarantine of patients with known infections all help to decrease the number of new cases or flatten this curve.

Flattening the curve is the difference between 5 million cases or 500,000 cases. Flattening the curve is the difference between 500,000 deaths and 50,000 deaths, and flattening the curve is the difference between a pandemic that lasts 12 months and one that lasts for only six months. All of us can do our part to help flatten the curve, to decrease the number of infections, and to shorten the length of time that this pandemic affects our communities.

Reliable Information

Information about COVID-19 (the novel coronavirus) is literally coming at us at light speed and it can sometimes feel like trying to get a sip of water from a fire hose. Even people with the best of intentions can sometimes provide information that’s not only inaccurate but it could actually be dangerous. Be leery of the blogger with a degree from Medscape University or the podcast from someone who trained at WebMD College of Virtual Medicine because there are enough reputable and credible, reliable, and trusted sources of information out there that you can sift through in order to get the information that you need to keep you and those who matter to you healthy and safe.

The Centers for Disease Control and the World Health Organization have perhaps the most accurate and up to date information about all things Coronavirus. You might also seek community specific information from your local or state public health officials who will almost undoubtedly be referencing the CDC or the WHO. Remember, knowledge is not key, but only accurate knowledge is key. Get the facts from a reliable source, follow those instructions and increase your chances of staying safe in and through the COVID-19 pandemic.

Social Distancing

Let me first start by saying what social distancing absolutely is not. It is not large crowds of patients flooding emergency departments sitting in close proximity to one another while waiting to be seen. Social distancing describes a practice of maintaining a distance of at least six feet between you and someone else in order to significantly limit the risk of either transmitting the virus or becoming infected. In the last week in response to many who either did not understand or consciously chose to not observe social distancing, many state leaders have issued restrictions that make it much harder to not practice social distancing.

Remember, COVID-19 (the novel coronavirus) needs a living host to grow and replicate, meaning that the greater the distance is between infected people and uninfected people, the less likely it is that we’re going to transmit the virus. When we practice social distancing, when we keep ourselves away from others when we feel sick, it limits the ability of the virus to be transmitted to people who do not have it. And when we do those things, we can decrease the number of sick individuals and speed up the time when the number of cases begins to decrease in the community.

Transmission Risk

Many patients who come to the emergency department for any number of complaints like so many of us have COVID on the mind and they ask the question, who are these high risk patients and what makes them so high risk?

Well, the answers are not quite so simple because we still don’t quite understand all that we need to about how COVID-19 (the novel coronavirus) affects individuals and why some get sick and some don’t. But what we do understand is that it appears that there are certain high risk populations who are at risk, not just for COVID-19, but this is the same group of individuals who are at greater risk for influenza and a host of other viral respiratory infections.

Those individuals over the age of 70 seem to be at greater risk. They represent by far the largest group of individuals who have severe complications and they represent the greatest number of patients who have died when infected with COVID-19. Patients with complicated preexisting medical conditions, poorly controlled hypertension, uncontrolled diabetes, chronic obstructive lung disease, COPD, asthma, emphysema, and a host of other lung diseases, patients that smoke cigarettes who probably have an underlying lung disease and have not yet been diagnosed – all of those individuals are at greater risk. Additionally, patients who are under chemotherapeutic agents or immunotherapy for cancer or have some other reason to have a compromised immune system, those individuals are also at greatest risk and even though they represent a smaller percentage, the concern is that there are a large number of minimally symptomatic or even asymptomatic individuals who can unwittingly transmit the virus to those in the high risk group.

That’s why it’s important and incumbent upon all of us to make sure that we are practicing social distancing, we are washing our hands vigorously with either hand sanitizer with 60% or greater alcohol content, washing our hands with warm soap and water for 20 seconds or more, while we’re cleaning the surfaces that we touch with our hands, while we’re avoiding touching our faces as best we can, and while we’re keeping ourselves separated from those who may not be sick, when we ourselves feel sick. We want to try to keep the entire community safe. And while we may only have mild symptoms, there are those among us who are at greater risk for getting very sick if they contract this potentially deadly virus. Let’s all do our part to keep everybody healthy and safe while we ride this storm out during this pandemic.