I just finished a 10 day working 12-14 hour days in my hospital's COVID ICU. I couldn't go one day without intubating someone. I couldn't go one day without asking my nurses and respiratory therapists to prone a patient to try and get them to breathe. I couldn't go one day without having a heart-and-soul wrenching video conference with a family, telling them their loved one was going to die despite everything we were doing. Every night I would walk out of the hospital, sit in my car, stare at my steering wheel, and sob. And then, after all of that, I see people all around me who still have the audacity to downplay, underestimate, and trivialize a pandemic that continues to spread illness, suffering, and death throughout the country. And doing so with no insight that the very ability to minimize or outright deny this is happening is a luxury that neither I, my fellow physicians, nurses, respiratory therapists, pharmacists, physical therapists, and most importantly the 151,077 (and counting) Americans who have died from this, get to have.
For those of you that point out a declining mortality rate is reason to disregard it, all I can say is, of course it's going down. After the entire world has seen over 17 million confirmed cases (again, and counting) over the past 6 months, my medical brothers and sisters and I have had no choice but to rapidly evolve and get better at managing this disease under the most dire of circumstances. Calculating a mortality rate is an incredibly complicated thing to do, and is continuously affected by countless things: our understanding of medical management like timing of intubation for respiratory failure, prone positioning, using medications that have actually shown benefit in prospective randomized controlled trials and avoiding medications that have not passed this standard, population behaviors like staying away from large crowds and properly wearing masks (yes, just putting a mask on doesn't mean you're doing it right), regional hospital bed availability and capacity to take new patients, availability of rapid testing, to name just a few off the top of my head. In fact, if the mortality rate was not going down that would be absolutely terrifying. That would mean that no matter what we've learned or what we try, our efforts have been completely ineffective and this disease is going to kill the same percentage of people no matter what we do. But that is the beauty of modern medicine; when done properly we have the capacity to learn, improve, and save lives that otherwise would be lost.
I think it is also important to point out what a mortality rate doesn't take into account. It doesn't take into account the morbidity and mortality of other diseases and conditions that are affected when a medical system becomes strained. Every other condition that leads to critical illness and death is still happening and needs care. It's not like hospitals are trading other ICU patients for COVID patients. We are having to taking care of heart attacks, strokes, septic shock, kidney failure, liver failure, traumatic injuries, and everything else an ICU does PLUS the added number of COVID patients. So having a 60 bed ICU doesn't mean you have room for 60 critically ill COVID patients. In fact, most major ICU's in this country run at 80-90% capacity ALL THE TIME. So even if elective surgeries and procedures get cancelled in an area, it's important to understand that there is not a lot of capacity to handle a surge of patients. And when that capacity gets overwhelmed, you can reliably expect that not only will your COVID-related mortality go up, but every other condition that requires critical care will as well.
While we're on the subject of percentages, let's make a few clarifications. In our everyday lives, I understand that 1-5% seems really small. But PLEASE understand that what counts as a large percentage in medicine is completely different. Medicine is not everyday life. It is exquisitely complex. Seasonal influenza usually has a quoted mortality rate of 0.1%. So even at the lowest estimated mortality rates right now, a group of COVID patients is dying at 10 times the amount a similar group of influenza patients does. It is also important to ask, what is the absolute number that the percentage is being applied to? 1% of 100 people is 1 person. 1% of 1 million people is 10,000 people. 1% of 370 million people (roughly the US population) is 3.7 MILLION PEOPLE. And to anyone who doesn't think that could happen, all is can say is, what evidence do you have? This virus has done nothing but spread to any place it has available to it. It spread from a single Chinese province to every single major metropolitan area in the world in less than 2 months. The US continues to post 60,000-70,000 new cases per day. There is not a single shred of evidence to suggest that will change unless we make it change. Everyone needs to understand that this virus will continue to infect until it has nowhere to go, either because it has infected everyone (see the above scenario to see how that will work out), it is cut off from a supply of new hosts (distancing and masks), or everyone it comes in contact with is immune (immunizations, which as yet do not exist for COVID and in the best case are still months to years away).
When it comes to properly interpreting studies, data, claims by people on TV, I get that there is an enormous amount of data circulating and that it is overwhelming to try and figure out what is true and what isn't. I would be wary of anyone claiming to have “absolute knowledge” or “found a cure” or “this works in their personal experience.” This pandemic continues to humble me over and over again, and I've spent 4 years of college, 4 years of medical school, 3 years of Internal Medicine Residency, 1 year as chief resident, and 2 years of Critical Care Medicine Fellowship (roughly 35,000 hours of study, training, and clinical practice) to try and be ready for something like this. For anyone that doesn't have a similar background, I wish I could make this simpler, but I can't. This is complicated. Being able to have a truly informed conversation about this requires knowledge of concepts like Ro (R-naught), ID50, Absolute mortality, number needed to treat, number needed to harm, sensitivity, specificity, positive predictive value, negative predictive value, droplet vs airborne transmission, pharmacokinectics, drug clearance in renal and liver failure, why prospective blinded placebo controlled trials are the Gold Standard and why retrospective studies are so limited to the point that they by definition cannot establish a cause-and-effect relationship, the difference between a statistically significant and clinically significant result, identifying clinically relevant endpoints in a study (mortality or time to clinical improvement, as opposed to viral clearance with no regard for patient clinical status), basic and advanced respiratory mechanics, identifying impending respiratory failure and properly timing intubation/mechanical ventilation, pathophysiology of exudative vs fibroproliferative phases in ARDS, calculation of ventilator tidal volumes based on Ideal Body Weight to prevent ventilator-induced lung injury, proper titration of PEEP, limiting ventilator pressures and understanding the difference between peak pressure and plateau pressure, permissive hypercapnia, preventing hyperoxia, appropriate use of neuromuscular blockade to prevent ventilator dyssynchrony, the benefit of prone positioning and understanding how long to leave someone prone, preventing complications of critical illness in particular venous thromboembolism and choosing appropriate anticoagulation agents, recognizing secondary bacterial infections and treating with appropriate antibiotics, managing volume status and diuresing appropriately, performing adequate spontaneous-breathing trials and extubating patients appropriately to prevent deconditioning... This and more. And while I don't expect people to have this knowledge if you don't do this for a living, if you feel like you “know” this disease without understanding the above concepts, then let me be the one to tell you that you are not an expert. If you are making decisions based purely on your own thoughts and opinions because you “don't trust the experts” but either have never heard of or don't understand everything I just mentioned above, then I hope you will see this and see that you are wrong to do so. What I listed above is the bare minimum needed to even approach understanding this disease at an expert level. So for anyone who doesn't, but feels confident that they have it all figured out, I would suggest some caution and humility, because likely the trained experts are taking things into consideration you have no idea even exist. Medical professionals who have devoted their entire lives to things like this are still grinding away and learning more. And while we may not always get it right, we're always getting better, and the expertise we've attained has been earned over years and decades. It is not something you can spend an afternoon or a weekend reading about. And I would encourage you to hold medical professionals to the same standard. If they spend too much time talking about “their experience and what they know works” and don't attempt to mention a single prospective, randomized controlled trial to support their thoughts, then you are right to not listen to them. Because they are in fact not an expert, they are someone in a white coat pretending to be. I'm not a farmer, I would never in a million years think that I could read a couple memes and youtube videos and walk away thinking I could just go out and plant crops and raise livestock, much less tell an actual farmer what to do.
If you read this, and nothing I've said resonates with you, nothing I've said convinces you, then at the very least think about me, how you know me. If the data, the math, the scientific jargon sounds hollow, then hopefully you can look at the person it's coming from and find a reason to believe. To you, maybe I'm the little boy your kids played with growing up. Maybe I'm the kid you sat next to in high school. Maybe I'm the young man you saw nervously running through the hospital as a medical student. Maybe I'm someone you consider a friend. Maybe I'm the doctor who helped you or your loved one when all seemed lost. Maybe I'm the doctor who sat with you when your loved one was dying and I wished I could do more. Regardless, I hope that you can see me as one person trying to help others and do the best I can in the face of an absolutely overwhelming enemy in COVID. I'm one doctor, working alongside the bravest nurses, NP's, PA's, RT's, PT's, OT's, Pharmacists, Nurse's Aides, Cleaning staff, Kitchen staff imaginable. Together, despite our very best efforts, we've lost many patients to COVID-19, and we face it knowing we are going to lose more. I'm not a conspiracy, I'm not tyranny, I'm not an assault on freedom, I'm not the enemy. And if you can believe that, then I am pleading with you to take this as seriously as you possibly can. Limit the number of people you are around as best you can, wear the masks, listen to the experts about which medications work (Remdesivir and Dexamethasone) and which ones don't (Hydroxychloroquine and Azithromycin) because they are the ones with the technical knowledge to properly figure it out. And if a safe, effective vaccine comes out, I beg you to get it. Because even if you don't know someone who had died from COVID-19, those of us who work in medicine have known them ALL. And if we don't work together to beat this, eventually you will too.
this post was originally written by Jon on facebook and is being shared here with his permission