It is now roughly 5 weeks since the spread of the novel coronavirus forced us to shut down the vast majority of our commerce and personal interaction. It’s been a long period with a very unnatural but necessary restriction of our freedoms. At this point, enough time has passed that we are starting to see the trajectory of this pandemic.

In most places, even in New York, the number of new diagnoses, as well as deaths, have either plateaued or are on the downslope. This is not to say that the numbers are small. As I write this, it appears that another 20 people died in my county in the last 24 hours (50 deaths of 1800 total cases).

By all accounts, outside of New York City, hospital systems have not been overwhelmed. Our facility continues to see sporadic cases, none of them particularly severe. Many of these people come from nursing facilities. An emerging problem is the understandable reluctance of those facilities to receive these residents back once they no longer require hospitalization.

I want to discuss several topics related to COVID 19. The first is the topic of ventilators. When the pandemic started there was enough hype to suggest that these devices were going to be essential for the survival of the species. We all watched the great efforts that were made to procure large numbers in anticipation of a respiratory disaster.

There was also talk in the popular press that severely compromised patients should be kept on a ventilator for at least 14 days prior to “weaning” them. I looked around the pulmonary literature but could find no support for this. Still, I kept seeing this in medical chat rooms and the like. My partner, who is also very experienced in critical care, was equally befuddled.

Roughly a week ago I began to hear a different theme. Suddenly, there arose the theory that ventilators are actually the problem, and that mechanical ventilation is causing damage to the patient’s lungs. Therefore, only oxygen should be given.

Given my career in critical care, none of this has any bearing on reality. Ventilators are used in situations where either the patient’s oxygenation cannot be maintained by the lesser means, and/or when the patient’s own respiratory system can no longer maintain ventilation without fatigue and ultimately respiratory arrest. Beyond this, there is no therapeutic benefit. Actual harm to the lungs can result if ventilator settings are inappropriate. We do think we have learned over the years how to minimize this problem.

We also have intermediate modalities, including oxygen supplementation, “high flow oxygen” and “noninvasive ventilation as “that are delivered by mask, and generally offered long before intubation is considered.

The problem is, these less invasive respiratory modalities have a bad tendency to create aerosols of the patient’s secretions, which, in a small ICU room, puts the staff at risk.  

Also, the actual act of intubation (placing the breathing tube in the trachea) exposes the operator to a high risk of infection. This is even more true when done emergently. Thus, I think there has been a general sense that when the patient is deteriorating, that “securing the airway” in a deliberate fashion, before the crisis, is safer for all concerned than intubating a “crashing” patient.

In ventilated patients, once there is no other factor to prevent it, patients are tested daily to see whether they can breathe on their own once again. If so they are extubated. This is important as endotracheal tubes provide a significant risk of secondary infection, and the enforced inactivity in ventilated patients creates other complications.

The sooner you can get them extubated, out of bed and ambulatory, the better they do. So far as I can tell, other than some interesting nuances about the patient’s lung physiology, there is nothing really truly different about ventilating these patients versus those with other similar critical illnesses.

On other fronts, as antibody testing proceeds, we are started to get a sense that many more in the population have been infected then we ever expected. In some ways, this is good news as it suggests there may be many more recovered people about, and we are closer to herd immunity. it also drops the case fatality rate, perhaps significantly.

Unfortunately, this is a little comfort to the roughly 47,000 people have died. Even if the death rate approaches that of the flu, the denominator for the flu is always based on symptomatic patients, who are the only people we test. There is little sense in the literature that influenza, unlike coronavirus, can be asymptomatic.

There is evidence that in the first quarter of 2020 the overall death rate in the United States is not particularly high. This is curious. Some of this may be due to the “cause of death substitution”. It may also be due to decreased opportunities for auto accidents and other trauma, given the social isolation.

I don’t think however it diminishes the extraordinary number of deaths in unique situations like New York City where reliance on public transportation and population density seems to have affected them exponentially. I have no desire to downplay the severity of this pandemic.

Nonetheless, I continue to believe if we are to prevent a severe economic recession if not depression, we need to adapt to current reality, and reopen commerce in a thoughtful way. I look at vast states like Wyoming and Montana where there are less than a quarter of the cases than in my little county. Is it fair to ask them to remain “locked down”?

 There is probably no way to do this without some risk, and we have to know that some degree of increased spread will occur. We need to steel ourselves for this and not panic when it happens.

This can only occur if the political factions in this country stop attacking each other for political gain, every time there is bad news. That must stop. This is too serious now.

I hope you and your loved ones, are safe and well.

Let’s see what this next week brings