Friday night update from the ER in Arlington, VA via FACEBOOK POST, Mike Silverman

Friday night update from the ER in Arlington, VA via FACEBOOK POST, Mike Silverman

When I think about our phases of COVID, I generally think in 2-3 month blocks. It started in March, ramped up with a peak volume in late April, and then took through May to feel noticeably better. June and July had less cases than the spring but more than August-October. As we’ve gotten into November, there is a definite uptick in patients who present with COVID like complaints. We see this in the number of patients that require isolation and in the subset of these patients who require admission. We’re now into the volume numbers that are consistent with June and July. By the end of my shift a few days ago, I felt “covid dirty” like I did during the spring. The big question is whether it will get worse and look like the spring (or worse) or can we get it back under control? Different states are implementing restrictions or introducing lockdowns again. COVID has not gone away.

About 20% of inpatients go to the ICU. This has remained consistent. When our ED volume goes up, hospitalizations go up, and the numbers in the ICU increase. As ICU admissions increase, we get more deaths. Last week I wrote that we had 100,000 new cases in the US in a day. This week, we’re over 140,000 daily new cases. That’s a huge increase which results in the subsequent downstream effects of ER visits, hospitalizations, ICU admissions, ventilators, and deaths. Everyone has to get on board with turning this around.

Let’s look closely at our numbers this week. In our symptomatic patient testing, we had an increased positivity rate. In fact, it was the highest number of positive cases and the highest positivity rate we’ve seen in months. When looking at our total testing, we probably test 35-40% of all patients seen in the ED. This includes our symptomatic patients plus our admissions, transfers, and other people who require testing. We’ve been testing similar numbers each week for about 6 weeks, but this is much more than we were testing through September. Last week was the most positive patients we’ve seen week over week since the spring, though we’re also testing much compared to the spring. Among my testing data, which really started in late April, we’re seeing the highest overall positivity rates since late May.

Each week as I start thinking about this post, I always wonder if there will be any interesting news. Some weeks are more newsworthy than others. This was a pretty big week. Pfizer released news earlier this week that their vaccine was 90% effective. This is extremely promising and gives some hope for all of us. Pfizer has about 43000 volunteers who got the 2 dose vaccine and they’ll run the study until that 164 patients will get COVID (statisticians look to achieve a critical number so the results can show statistical significance). These volunteers go about living their lives with likely a mix of masking, social distancing, eating out and then scientists assess the differences between groups that got the vaccine or got a placebo. Preliminary data reviewed by the data safety monitoring board after 94 symptomatic COVID cases, shows that 90% of the positives were in the placebo group and only 10% of positives were in the vaccine group. That’s great news. Even with the flu vaccine, some people still get the flu but it’s generally a milder version. Very little data has been released so far, so there’s still a lot of questions such as: what impact the vaccine will make on high risk groups of patients, do hospitalized patients who got the vaccine have a lower chance of dying than those who got placebo, and how long will the antibody response last for? We get a flu vaccine every year. How frequently will we need a COVID vaccine and will it be 2 doses in the future. Make no mistake, the preliminary results are very positive. We just need more information.

Last week I mentioned the Eli Lilly antibody cocktail as being better in the early stages than in hospitalized patients. The FDA has since granted an emergency use authorization for this medication to be given in certain circumstances. It will be a one-time dose, requiring a couple hours of the patient’s time. I don’t know how soon until hospitals will have access to it (though likely in the next few weeks on a very limited basis) We do know something about the target patient population, keeping in mind the drug is in very limited supply and it’s not for hospitalized patients. This medication is intended for high risk, non-hospitalized patients not on oxygen, within 10 days of symptom onset. Keep in mind that 80% of patients have very mild symptoms and it’s often not until day 5-7 when we start to see the sicker patients, so most patients do well without this treatment. However, getting the medication in earlier is likely better and it appears that the medication has been shown to reduce the risk of 28-day hospitalization or ER visit from 6% in the placebo group to 1-2% in the medication group. As we’ve talked about sample size before, it’s important to note that this was a small study, with the placebo group having 156 patients and the treatment group had 309 patients spread out over 3 dosages. These are really small numbers and I hope the results are reproduced in larger studies.

Data analytics are pretty amazing. The NFL has players and coaches wearing location monitors so they can contact trace. Maryland is advocating that people download an APP. In a recent study out of Nature, the authors analyzed millions of Americans tracked by their cell phones during the first wave, and it looks like new cases were spreading outside the home from restaurants, coffee shops, and gyms.

Thanksgiving is less than 2 weeks away. I’ve barely seen my parents or my brother’s family since March and Thanksgiving is always our big family holiday. But as our kids come back from college and we think about everyone’s risk, there’s no way I would recommend a traditional family get together. Along those same lines, I loved watching the outdoor dining pop up at my favorite restaurants over the summer. But as the tents have started to add siding, these now have the potential to be a non-ventilated space. Be careful going to your local outside tent and make sure the windows are open.

Whether getting together with family for Thanksgiving or going out to dinner: Stay outside. Wear a mask.

The CDC said that wearing a mask protects both the wearer and others from spreading coronavirus. In fact, it may reduce transmission by up to 70%. In the words of Maryland Governor Larry Hogan (R), “wear your damn mask.”

Science matters. Wear a mask. Practice physical distancing.

MikeFriday night update from the ER in Arlington, VA

When I think about our phases of COVID, I generally think in 2-3 month blocks. It started in March, ramped up with a peak volume in late April, and then took through May to feel noticeably better. June and July had less cases than the spring but more than August-October. As we’ve gotten into November, there is a definite uptick in patients who present with COVID like complaints. We see this in the number of patients that require isolation and in the subset of these patients who require admission. We’re now into the volume numbers that are consistent with June and July. By the end of my shift a few days ago, I felt “covid dirty” like I did during the spring. The big question is whether it will get worse and look like the spring (or worse) or can we get it back under control? Different states are implementing restrictions or introducing lockdowns again. COVID has not gone away.

About 20% of inpatients go to the ICU. This has remained consistent. When our ED volume goes up, hospitalizations go up, and the numbers in the ICU increase. As ICU admissions increase, we get more deaths. Last week I wrote that we had 100,000 new cases in the US in a day. This week, we’re over 140,000 daily new cases. That’s a huge increase which results in the subsequent downstream effects of ER visits, hospitalizations, ICU admissions, ventilators, and deaths. Everyone has to get on board with turning this around.

Let’s look closely at our numbers this week. In our symptomatic patient testing, we had an increased positivity rate. In fact, it was the highest number of positive cases and the highest positivity rate we’ve seen in months. When looking at our total testing, we probably test 35-40% of all patients seen in the ED. This includes our symptomatic patients plus our admissions, transfers, and other people who require testing. We’ve been testing similar numbers each week for about 6 weeks, but this is much more than we were testing through September. Last week was the most positive patients we’ve seen week over week since the spring, though we’re also testing much compared to the spring. Among my testing data, which really started in late April, we’re seeing the highest overall positivity rates since late May.

Each week as I start thinking about this post, I always wonder if there will be any interesting news. Some weeks are more newsworthy than others. This was a pretty big week. Pfizer released news earlier this week that their vaccine was 90% effective. This is extremely promising and gives some hope for all of us. Pfizer has about 43000 volunteers who got the 2 dose vaccine and they’ll run the study until that 164 patients will get COVID (statisticians look to achieve a critical number so the results can show statistical significance). These volunteers go about living their lives with likely a mix of masking, social distancing, eating out and then scientists assess the differences between groups that got the vaccine or got a placebo. Preliminary data reviewed by the data safety monitoring board after 94 symptomatic COVID cases, shows that 90% of the positives were in the placebo group and only 10% of positives were in the vaccine group. That’s great news. Even with the flu vaccine, some people still get the flu but it’s generally a milder version. Very little data has been released so far, so there’s still a lot of questions such as: what impact the vaccine will make on high risk groups of patients, do hospitalized patients who got the vaccine have a lower chance of dying than those who got placebo, and how long will the antibody response last for? We get a flu vaccine every year. How frequently will we need a COVID vaccine and will it be 2 doses in the future. Make no mistake, the preliminary results are very positive. We just need more information.

Last week I mentioned the Eli Lilly antibody cocktail as being better in the early stages than in hospitalized patients. The FDA has since granted an emergency use authorization for this medication to be given in certain circumstances. It will be a one-time dose, requiring a couple hours of the patient’s time. I don’t know how soon until hospitals will have access to it (though likely in the next few weeks on a very limited basis) We do know something about the target patient population, keeping in mind the drug is in very limited supply and it’s not for hospitalized patients. This medication is intended for high risk, non-hospitalized patients not on oxygen, within 10 days of symptom onset. Keep in mind that 80% of patients have very mild symptoms and it’s often not until day 5-7 when we start to see the sicker patients, so most patients do well without this treatment. However, getting the medication in earlier is likely better and it appears that the medication has been shown to reduce the risk of 28-day hospitalization or ER visit from 6% in the placebo group to 1-2% in the medication group. As we’ve talked about sample size before, it’s important to note that this was a small study, with the placebo group having 156 patients and the treatment group had 309 patients spread out over 3 dosages. These are really small numbers and I hope the results are reproduced in larger studies.

Data analytics are pretty amazing. The NFL has players and coaches wearing location monitors so they can contact trace. Maryland is advocating that people download an APP. In a recent study out of Nature, the authors analyzed millions of Americans tracked by their cell phones during the first wave, and it looks like new cases were spreading outside the home from restaurants, coffee shops, and gyms.

Thanksgiving is less than 2 weeks away. I’ve barely seen my parents or my brother’s family since March and Thanksgiving is always our big family holiday. But as our kids come back from college and we think about everyone’s risk, there’s no way I would recommend a traditional family get together. Along those same lines, I loved watching the outdoor dining pop up at my favorite restaurants over the summer. But as the tents have started to add siding, these now have the potential to be a non-ventilated space. Be careful going to your local outside tent and make sure the windows are open.

Whether getting together with family for Thanksgiving or going out to dinner: Stay outside. Wear a mask.

The CDC said that wearing a mask protects both the wearer and others from spreading coronavirus. In fact, it may reduce transmission by up to 70%. In the words of Maryland Governor Larry Hogan (R), “wear your damn mask.”

Science matters. Wear a mask. Practice physical distancing.

Mike

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