Dispatch #3: Dr. Shlain reporting from the front lines
We have 160,000 ventilators in the country. 1,000,000 coronavirus victims will need ventilators. Half of the people on ventilators die in the first week, survivors stay on the vent for about 4 weeks. We don’t have enough ventilators.
I am not panicking. I am genuinely concerned.
For clinical people, Here is a post from a doctor in Seattle, yesterday with a lot of medical data.
For everyone, the days of denial are over. The goal is to flatten the curve.
The time to act is now.
Fortunately, for most of us, the action to take is as simple as staying home. This needs to be a collective, coordinated shared action. This is not a social movement. This requires us all to take a huge deep breath and realize that we have some agency over our personal and collective fate. Stay home!
Social distancing is in full effect. Anyone can be vectors for the spread of disease.
The days of just no handshaking are over. Get inside your home and stay there with your family. Know who comes in and out.
Stay far away from people over 60. Sorry boomers, you’re going to be feeling isolated like never before, but it’s for your own protection. I’m recommending that people over 60 do not get near anyone younger than them for at least 20 days and it may be longer.
Try to channel political theorist - Hannah Arendt and take action.
We need to weigh the cost of being wrong against the chance of being wrong.
Can we afford to bear that risk? No!
The World Health Organization declared a full-blown pandemic. NBA cancelled, US tax day postponed, flights from US-Europe cancelled. We are on the cusp of a true black swan, a once-in-a-hundred year event. No one alive has ever been throughout a global pandemic of this scale. So, if someone tells you they know what’s going to happen next, recognize it as pure hubris.
The big question: Is this seasonal? Fingers crossed.
The scientific community is doing our level best to understand the biology and pathophysiology of this novel coronavirus. It may be worth, during your home quarantine, to watch this documentary of the Spanish Flu of 1917–1918
Read what I am about to tell you, and please read slowly.
We are in phase 5 in the United States and about to enter phase 6. I just received a heart-sinking memo from Seattle. They are running out of ventilators.
Let me take a brief moment to acknowledge that people are getting very anxious and feeling helpless. This is a normal response to great uncertainty. Altruism and resilience will be the key attributes to get us through this. We will be stronger on the other side.
Here is a must read good article from my dear friend Elissa Epel on how to deal with the stress and anxiety.
Remember. Be nice.
Every alternative to being nice has negative consequences.
And as I said before,
There is a ton of bullshit being disseminated. Please do not disseminate anything you can’t verify. Science must prevail.
There are already hackers making fake maps!
What you need to know
From UCSF Expert Group: whole post here
It appears one can be infectious before being symptomatic. We don’t know how infectious one is before symptomatic, but we do know that the highest level of virus prevalence coincides with symptoms. We currently think folks are infectious 2 days before through 14 days after onset of symptoms (T-2 to T+14 onset).
How long does the virus last?
- On surfaces, best guess is 4–20 hours depending on surface type (maybe a few days) but there is still no consensus on this.
- The virus is very susceptible to common antibacterial cleaning agents: bleach, hydrogen peroxide, alcohol-based.
What you can do
If you have hoarded masks (which will not help you), please give them to your local hospital. Please help ensure healthcare workers are safe.
We are the ones who are going to be taking care of you or your loved ones.
Basic hygiene — Hand washing, don’t touch your face. hand washing, If you have hand sanitizer, use it wisely. I know a bunch of people who have overused it and are out.
Take your temperature — It might be useful to understand everyone’s baseline body temperature. Wash it thoroughly after use unless you have disposable tips.
Open your windows — Keep air circulating.
Drinks lots of water. The proof of this will be how many more times you’re going to the bathroom each day.
Eat super healthy. Avoid processed sugars and junk food. No soda. Eat as plant-based as you can. (Note: This is more common sense than scientific.)
Put olive oil on everything. It’s been shown over and over again to be cardioprotectant. (This is speculative yet common sense)
Have enough of your prescription medicine. I’ve said this before, get a 90 day supply.
If you live in an elevator building, don’t touch elevator buttons with your fingers….use your knuckle and then immediately wash your hands.
Vitamins? I’ve never been much of a vitamin guy. There is some evidence that Vitamin D and Vitamin C may be helpful. I am going to make sure that I have Vitamin D and C in my diet and will supplement accordingly. I do realize I may just get expensive urine. The point is, I do not see any downside.
Cancel all non-essential medical procedures. I told a friend yesterday to have her 80-year-old father postpone his cancer radiation treatment. The risk of getting sick from this outweighs the benefit of one round of radiation treatment. Very difficult choices will have to be made. This is more personal than scientific.
Turn off your alarm clock. Wake up naturally. It’s quite amazing that humans are the only living species that interrupts a critical biological process that helps our immune system.
Tele-medicine. As I stated earlier, contact your insurance company and find out what you options for getting questions answered at home.
Good article from New England Journal of Medicine.
What if someone is sick
Stay home and socially isolate. There is very little a hospital can do that you can’t do at home. While most cases are mild, one has to be vigilant for a progression to shortness of breath.
If someone gets sick and is old or with known lung issues, head to the Emergency Room.
There is no treatment at the moment, yet there are many clinical trials either underway or about to be underway. The Whatsapp group I participate in is thinking of crowdsourcing what remedies people are trying at home to see what might work….a noble effort.
Hospitals can give oxygen, IV fluids, and supportive care.
What is the healthcare system doing
Every hospital worth their weight is gearing up for a flood of patients.
Hospitals are preparing by building tent hospitals in preparation for the wave of people who walk in short of breath. Seattle is very close to looking like Italy.
On Testing
Many epidemiologists may not like me here, but we’re past the point of testing contacts of people. Furthermore, the specificity of the polymerase chain reaction (PCR) tests being used by labs isn’t great. That means we could get false negatives (negative tests that are wrong). Commercial labs can do 1000 tests per day.
CT scans are much more reliable for diagnosing as discovered in China. However, here is a commentary from a doctor in Seattle:
China is CT’ing everyone, even outpatients, as a primarily diagnostic modality. However, in US/Europe, CT is rare, since findings are nonspecific, would not change management, and the ENTIRE scanner and room have to terminal-cleaned, which is just impossible in a busy hospital.
We should only be testing people who are symptomatic. If we don’t we will run out of protective gear for the healthcare people. What we really need is an antibody test to see who has already had it. We need to start understanding who is in the clear. If anyone is reading this and is an antibody scientist, please focus your energy on getting this test fired up!
Testing is the big conversation now. Soon everyone is going to be talking about ventilators. And for those who have asked me if they can buy a ventilator for their home, I say — save the $ and stay home. You can’t catch a highly transmissible disease if you stay away from the people who have it. Hubris and wealth cannot buy you privilege when the precious resource of human compassion is the raison d’être of the Hippocratic Oath. Please give to your local hospital.
We have 160,000 ventilators in the country. 1,000,000 coronavirus victims will need ventilators. Half of the people on ventilators die in the first week, survivors stay on the vent for about 4 weeks. We don’t have enough ventilators.
We don’t have enough medical personnel.
All the specialty doctors and nurses who see an empty schedule due to cancellations canceled, please reach out to your local public health department or hospital find ways to help volunteer.
To all the capitalists who have resources, please contact your local hospital and find your philanthropic soul. Step up and start helping, please. Donate to your local hospital, ask you medical clinic if they need money or resources. Most medical practices are small businesses that do not have financial buffers.
History will look back on this time ~ it will illuminate the cowards from the courageous.
More Numbers
If we don’t get our collective asses together, we will all suffer.
The blue line in this graph is us “doing business as usual.”
We need to get dead serious about the yellow line. 25% contact reduction. (yellow line)
Cancel all gatherings
What can our country do? Lock shit down. While mass containment may be too late, there is a shred of time for us to get real and make a dent in this beast.
We are projected to have 40–70% of the entire US population get this. It’s more a matter of when, than if.
Days behind Italy
On Treatments and Vaccinations
This is all conjecture below but there are a small army of scientists working on every angle to find a treatment. Experts believe that between 200,000-1,500,000 Americans could die if we don’t find a treatment — this compares to 50,000 in a normal flu season.
If someone gets sick who is high risk (e.g., is both old and has lung/cardio-vascular problems), you can try to get them enrolled for “compassionate use” of Remdesivir, a drug that is in clinical trial at San Francisco General and UCSF, and in China. For San Francisco folks — You need to find a doc at SF General or UCSF in order to ask to enroll.
As mentioned earlier, all of us in the healthcare field are working to find a cure.
For the science geeks out there
I’ll take the L-type.
Genetically, there are two variants of this virus. The L-type and the S-type.
On Mortality
The death rates are real and reports from Italy and Seattle confirm that even young, healthy 30 and 40 year old folks are succumbing. These numbers are moving targets. I do not recommend we dwell here. It’s all post-hoc. We need to pre hoc our avoidance strategies.
In closing
I regret to be the bearer of this sobering news. Only you can decide how to act and how to process this unprecedented time. I have long ralied that our healthcare system has relegated doctors to widgets in the medical industrial complex. Physician burn-out is at an all time high. We are often disrespected by the financial folks who run healthcare businesses. We are tools to increase profit margins and EBITA for shareholders. If anyone is interested, here is a talk I gave at CogX in London on a framework for a new Hippocratic Oath.
As for me, I was born an optimist. I embrace balance and I love people. I will continue to do everything and anything I can to convene my network to get answers that are science-based and actionable.
I will be posting on LinkedIn with breaking news, research and stats in between now and my next Tincture dispatch. Don’t forget to find small things that bring you joy. Talk to your friends on the phone. We have a moment to reconnect with our family and friends….get analog and have real voice conversations; they are amazing.
There could be a massive generational, moral, choices that are upon us. At a point in the not too distant future we could be faced with an existential Hobbesian choice — who do you save? Our kids + ourselves or our parents.
We could be bankrupting an entire generation of healthy people in our efforts to save the sick and elderly ~ no one wants to touch this stove…its a moral dissonance.
Please stay safe, stay at home and stay informed. We’re much stronger the more we cooperate. We’re in this together.
Until my next dispatch.
Sincerely yours,
Jordan Shlain, MD
Jordan is a practicing internist who manages a team of doctors and nurses in SF, Silicon Valley, NYC, and LA. linkedin twitter
