It is mid-April and physicians and hospitals are already planning on how and when to re-institute normal operations, like flowers poking through snow after a cold winter. But it is pretty clear that the normal operations of the future will not be like the normal operations of the past. I’m using this post to speculate on how things may be different.
Hand sanitizer will become the new tabletop condiment
If you go to a breakfast restaurant, you’ll find pitchers of syrup and honey on the tables. At lunch and dinner, there will be bottles of ketchup, mustard, and hot sauce on the tables. In the future, look for bottles of hand sanitizer on your restaurant tables.
Obstetricians will be busy in January 2021
“Blizzard baby booms” are a debated phenomenon that lie somewhere between urban myth and obstetric reality. I am a member of the baby boom generation, a surge in babies born after soldiers returned to the U.S. after World War II and the Korean War. That baby boom was a reality but whether there is a mini-boom of babies born 9 months after hurricanes and blizzards keep people indoors for a period of time is more uncertain. A blizzard or hurricane keeps people cooped up together for just a few days but COVID-19 keeps couples isolating at home with little to do for weeks. Will the social isolation of March and April result in a lot of babies in December and January?
Infectious disease physicians will be hospital medical directors
In a war, Majors are promoted to Colonels and Colonels are promoted to Generals by demonstrated success in battle. Similarly, hospitals select their medical directors based on administrative success in leading individual hospital programs. Throughout the world, hospitals are having their COVID-19 response led by epidemiologists and infectious disease specialists. Those who successfully steer their hospital through the infection control and financial perils of the pandemic will find themselves in line for promotion to hospital leadership positions.
Surgical masks won’t just be for surgeons any longer
Wearing a surgical mask does help prevent one from becoming infected with respiratory viruses when an infected person coughs or sneezes in your face. But when everyone wears a mask, there are two other important infection control effects. First, if the person wearing the mask is unknowingly infected with a respiratory virus, it helps prevent that masked person from coughing or sneezing on others. Second, when a person is wearing a mask, it reduces the chance that the person will touch their nose, mouth, or eyes with hands that could have picked up respiratory viruses from fomites such as a door handle, shopping cart, or elevator button that harbored viruses. In the future, people may likely feel more safe when those around them are wearing masks and that may be doubly so for their doctors and nurses wearing masks. Look for future masks emblazed with people’s favorite NFL team, alma mater, or beer maker.
A COVID-19 PCR test will become a routine admission order
When most patients get admitted to the hospital through the emergency department, they get “routine admission labs” – generally a CBC and chemistry panel. Look for a COVID-19 test to be added to that list of routine tests. Right now, there is near-paranoia by many physicians that their patients will have asymptomatic and potentially contagious COVID-19 to the point that they will not do procedures unless their asymptomatic patients have a negative COVID-19 PCR test. Even then, many demand that they be allowed to wear an N-95 mask for patients with a negative test because of the theoretic possibility that the test is a false negative.
Public health nurses will have job security
Countries that have been successful in controlling the COVID-19 outbreak have had very strong case isolation and contact identification. This takes manpower – primarily public health nurses that can go out in the community to interview patients and do testing of contacts. Public health departments are often underfunded and understaffed. There will be increased demand for public health nurses for the foreseeable future.
Don’t expect your hospital to replace the old MRI machine
Although many U.S. hospitals have their ICUs full of COVID-19 patients, their overall medical/surgical census is generally low. That is because elective surgical procedures have all been postponed. Not only are surgeries not being done but neither are non-emergent diagnostic tests such as MRIs, CT scans, cardiac non-invasive tests, and pulmonary function tests. Hospitals don’t make much money off of medical admissions and depend on those surgeries and diagnostic tests to show a positive financial margin at the end of the year. Currently, hospitals are burning through their reserves (“days cash on hand”) with all of these surgeries and procedures not being done. With days cash on hand depleted, hospitals will be postponing large expenditures over the next couple of years.
The handshake will be a custom of the past
When a patient is infected with COVID-19, their hand becomes a fomite that can transmit the virus to everyone that they touch. Overnight, the handshake has changed from a greeting of politeness to a gesture of threat. Look for the handshake to disappear as an American social convention.
Telemedicine will come of age
Until March 2020, telemedicine was relegated to a few specific circumstances and primarily used in rural, sparsely populated areas of the nation. With the federal government relaxing rules for telemedicine, physicians all over the country are realizing that a lot of routine outpatient care can be done by telemedicine. Medical practices are adopting video telemedicine platforms through their electronic medical record or through separate commercial video applications. I have found that video telemedicine works very well for many of my patients, for both new and return visits. For patients who lack transportation or who live long distances from the office, the convenience of a video visit is a game-changer.
Anti-vaccine proponents will finally be quiet
One of the reasons that anti-vaxxers have flourished is that enough other people get vaccines so that devastating diseases such as polio, measles, and hepatitis B are uncommon enough that herd immunity protects the anti-vaxxers. If there were no influenza vaccines, then even influenza could periodically be as threatening as COVID-19. The current pandemic is a reminder of just how deadly infectious diseases can be and how much they can disrupt the economic structure of a community. An effective vaccine against COVID-19 will hopefully silence the anti-vaxxers since COVID-19 is unlikely to otherwise go away – it will just periodically die back and flare up as long as there are immunologically susceptible people for it to affect. The older the anti-vaxxers get, the more likely they are to become critically ill and die should they become infected and this will hopefully motivate them to forget their conspiracy theories and get a COVID shot.
It will be safe to go outside when your doctor has a beard
All of a sudden, most doctors and nurses in the United States became clean-shaven. That was because they needed to get fit-tested for N-95 face masks and a couple of years ago, OSHA made a rule that men with beards could not undergo fit-testing. Because I normally see patients in the hospital in airborne isolation (for example, those who are suspected of having tuberculosis), I have had an annual N-95 fit test for many years. And each year, I always passed my fit test, even though I had a beard. When OSHA came out with their rule, I was no longer permitted to wear an N-95 mask and had to switch to a PAPR hood but with PAPRs in short supply nationwide, men who provide inpatient healthcare had to shave and be fit tested. Just like robins are the first sign of spring, doctors with beards will be the first sign that the hospitals are no longer full of COVID-19 patients.
April 16, 2020
Coronavirus are transmitted the same way as other respiratory viruses are transmitted, by droplets of respiratory secretions. There are two ways that droplets can spread the virus. Either an infected person can cough or sneeze in another person’s face with the result that those respiratory droplets land on the second person’s nose, lips, or face. Or, the the infected person can get those respiratory droplets on their hands by coughing into their hand or touching their nose or mouth with their hand; when the infected person’s hand then touches a surface such as a door knob, light switch, keyboard, or television remote control, then those droplets get passed to those surfaces.
For example, 
In public, it is just the opposite; the infected person should wear the mask and not the average uninfected person. As long as you are maintaining social distancing by standing 6 feet from someone who is infected, even if that person coughs, those droplets are going to fall to the ground by gravity before they reach you. By having the infected person wear the mask, when they cough, they cough into the mask, thus substantially reducing the ability of those respiratory droplets to reach someone else. In fact, when healthy people wear masks when they are out in public, those masks get moist from the humidity of breath and most masks tend to get colonized with bacteria and fungus that can then make that previously healthy person sick.
If I could only have one thing to reduce the spread of COVID-19, it would not be a surgical mask or a face shield, or an N-95 mask. What I would want instead is soap and water.
Patients are told to drive to a specific location and look for innocuous colored signs with arrows labeled with non-specific wording so as to not attract people who just show up without being screened and registered over the phone. They pull their car up to the testing station and a nurse with proper personal protective equipment comes to their window, confirms their identity, performs a nasopharyngeal swab, and the patient drives off. Patients who appear ill are directed to go to the emergency department; others return to their homes.
The United States gets a lot of criticism about poor overall national health compared to other economically advantaged countries. However, our nation’s poor health really relates to lifestyle issues (obesity, high numbers of suicide by gun, etc.) and outpatient healthcare (high percentage of uninsured citizens, poor access to primary care, high cost of medications, etc.). American inpatient hospital care is actually among the absolute best in the world. Similarly, Canadien and European nation hospitals provide great inpatient care to the sickest patients. On the other hand, many countries, such as China, lack the same ability to care for critically ill patients in their acute care hospitals and particularly in their intensive care units. The greatest danger of COVID-19 is respiratory failure and to successfully manage a large number of patients with respiratory failure, there has to be a well-trained population of critical care physicians, critical care nurses, and respiratory therapists. In addition, there has to be a sufficient supply of mechanical ventilators, monitoring equipment, and inpatient infection control practices in place. With SARS and Ebola outbreaks, the highest mortality rates were in those countries with the least ability to manage critically ill patients; in more economically advantaged countries, the mortality rates were much lower.
To accurately determine the mortality rate of a disease, you have to be able to identify every person who gets that disease. It is becoming clear that many patients with COVID-19 have milder forms of the disease and likely have gone undetected in China. In other countries, there have been efforts to track down and test any contacts of persons with confirmed cases of COVID-19 and as a consequence, milder cases are more likely to be detected in these other countries. When more of these milder cases are diagnosed, the ratio of deaths to confirmed cases falls resulting in a lower mortality rate. It is likely that there have been many more than 77,262 cases of COVID-19 in China and if that true number was known, then the mortality rate would likely be much less than the currently reported 3.4%.
In China, the outbreak of COVID-19 has struck large metropolitan areas, such as Wuhan (a city of 11 million people). Like influenza, the people who are most likely to die from COVID-19 infection are the elderly, the very young, and those people with chronic medical conditions. In cities such as Wuhan, there are large numbers of these vulnerable people living in close proximity to each other with the result that many elderly and debilitated persons become infected. Until this week, most of the cases outside of China have involved persons traveling from China. International travelers tend to be young and middle aged adults. Newborns, the very elderly, and those suffering from chronic disease tend to not do as much international travel. Those infected international travelers are therefore a select population of people who are best able to survive COVID-19 infection. This may be changing soon, with large numbers of domestically-acquired cases of COVID-19 being recently reported in South Korea and Japan.
Here in the United States, the Centers for Disease Control has recommended a very high level of quarantine for patients with suspected COVID-19 infection including droplet, airborne, and contact isolation. This means gowns, gloves, negative airflow hospital rooms, and face shields. Many countries do not have the resources to provide this level of patient isolation. Indeed, persons suspected of having the infection are told to just stay home. In crowded, often multi-generational housing (such as exists in many Chinese communities), this quarantine practice can facilitate transmission to the vulnerable elderly, debilitated, and infants. In hospitals, sub-optimal isolation practices can facilitate transmission to other patients in that hospital and these patients with hospital-acquired COVID-19 are a select population of particularly vulnerable people who are more likely to die of the infection.
Death from COVID-19 does not occur instantly. There is first an incubation period of up to 14 days. Once a person develops symptoms, it takes several days to develop respiratory failure and die. The outbreak has been present in China for 2 months and so there has been sufficient time for those persons who get infected to develop symptoms and die of the infection. However, in other countries, patients with the infection have been identified and confirmed relatively early in their disease and in many cases, those people have not yet had time to develop respiratory failure and die.
Coronaviruses are common upper respiratory viruses that generally cause fairly mild infections. They account for about 5-10% of common colds and cause typical cold-like symptoms such as fever, cough, and sore throat. Like other upper respiratory viruses, they are spread by aerosolized droplets and primarily occur in the winter months. The regular coronaviruses are detected with the standard respiratory viral PCR panels that most hospitals use. These panels detect other common viruses such as influenza, rhinovirus, parainfluenza virus, and others. Treatment is supportive and there are no effective vaccines or anti-viral antibiotics. As with all respiratory viral infections, patients admitted to the hospital should be placed on droplet isolation.
From 2002 – 2004, an outbreak of a coronavirus resulted in SARS (Severe Acute Respiratory Syndrome). Overall, 8,098 people were known to become infected with 774 deaths, a 10% mortality rate. The natural host of the virus was the horseshoe bat and the outbreak was traced to a remote cave in Yunnan Province in China. From the bats in this cave, the SARS virus was spread to a masked palm civet, a cat-like wild animal in China that is often hunted for food. The civet was killed by a hunter and landed in a meat market in Guangdong, China in November 2002 where the virus then jumped to humans. Chinese health authorities were not forthcoming about the spreading Guangdong outbreak and did not report it to the World Health Organization (WHO) for several months, resulting in rapid spread of the infection due to a lack of public and healthcare worker awareness that it even existed. 
In February 2003, a businessman traveling from China became ill and was admitted to a hospital in Hanoi, Vietnam. An astute Italian physician working at the hospital, Dr. Carlo Urbani, recognized that the man’s infection was something different than regular influenza and notified the WHO. However, several healthcare workers at the hospital became infected; both the businessman and Dr. Urbani ultimately died of SARS. Meanwhile, a doctor from Guangdong unknowingly infected with SARS had traveled to Hong Kong where he stayed at the Metropole Hotel. He transmitted the virus to 16 international guests at the hotel who then traveled to Canada, Singapore, Viet Nam, and Taiwan, carrying the virus with them. On February 23, 2003, an elderly woman returning to Toronto from Hong Kong became ill with SARS and went to her local hospital. Canadien health authorities and healthcare workers did not have adequate infection control protocols in place and were unprepared for SARS and consequently within weeks, 257 people in Toronto were infected. In the United States, there were 27 cases and no deaths.
From 2012 – 2015, another coronavirus caused the Middle East Respiratory Syndrome. Overall, 1,227 people became infected with an average mortality rate of 37%. The natural host was the dromedary camel and the virus made the jump to humans in Saudi Arabia. There were two main outbreaks of MERS, the first in Saudi Arabia in 2014 when 402 people became infected. The second outbreak occurred in 2015 when a businessman traveled from the Arabian Peninsula to South Korea, unknowingly infected with the MERS virus. Ultimately, 150 Koreans became infected and the main locations that these people acquired their infections were hospitals and clinics that were not prepared to institute proper isolation precautions and infection control practices. 
Ultimately, the South Korean outbreak alone cost $8.5 billion. The main symptoms of MERS were cough, shortness of breath, and fever. Chest x-rays showed patchy pneumonia or ARDS patterns. There are several sessions to be learned from MERS:
Wuhan City is the 7th largest city in China with a population of 11 million. To put that in context, New York City has a population of 8.6 million, Los Angeles 4 million, and Chicago 2.7 million. Wuhan is a traditional manufacturing hub and the political, economic, and commercial center of Central China. Its location on the Yangtze River as well as its location at the intersection of several rail lines and highways makes it one of China’s main transportation hubs. The main rail station sees up to 80,000 people per day and the airport serves 20 million passengers per year with direct flights to Tokyo, Paris, London, San Francisco, and Chicago among other international destinations. In December, 2019, a new coronavirus called the “novel coronavirus” or 2019-nCoV appeared in Wuhan City and is believed to have originated at a Wuhan market where wild and domesticated animal meats are sold.
As with the SARS outbreak, Chinese health authorities were slow to recognize and report the emerging infection. The result was that the virus rapidly spread through Wuhan City and from there, to other towns and cities in China. Within weeks, the virus had spread to many other countries throughout the world, including the United States. Like other coronaviruses, the presenting symptoms are fever, cough, and shortness of breath. The incubation period is 1-14 days. In some people, the infection is rather mild but in others, it can result in severe illness. The mortality rate is about 3%.
When performing testing, 
All testing should be performed with the patient in proper isolation, including airborne precautions; testing should not be performed in regular emergency department rooms or clinic rooms that are not capable of negative airflow. There is no effective anti-viral for 2019-nCoV so treatment is primarily supportive. For those patients who develop respiratory failure and require mechanical ventilation, intubation should be performed in a negative airflow room with all isolation precautions and should be performed by the most experienced physician available (this is not a procedure for trainees). If a person believes that he/she might have 2019-nCoV, then they should call ahead to the emergency department so that their throughput can be expedited and avoid exposing other patients in the waiting area.
