Turns out we may know what works to keep healthcare workers and the public safe after all.
A live update, March 23 2020.
Here’s that New Yorker piece I reference in the show. And here’s the Google Doc with updated recommendations on COVID-19 treatment and management aimed at hospitalists.
All our COVID-19 coverage is here.
Hey, guys, it’s Dr. Z. All right, it’s our nightly COVID-19 update. And I’m gonna start calling this “The Voice of Calm and Reason” broadcast because that’s really what we’re doing here. Because you know what, things are actually not looking as bleak as everyone would have you think, which means we can take a deep breath, we can prepare, we can understand the science of this pandemic, look at what’s happening in other countries, look at what we’re doing in our own country, and actually come up with reasonable strategies that do not destroy the fabric of society and make us run in a panic for scarce PPE that we don’t have when we can actually be quite targeted and quite effective.
So the good news today, it’s, what is today, March 20-something, third? I better find that out. It’s March 23rd! So it’s March 23rd, as of March 23rd, what we’re seeing in Italy is the increasing numbers of cases are slowing their increase. Meaning rather than going exponentially faster, which is what you would expect if you believe some of the direst predictions without any mitigation strategy or with mitigation that doesn’t work well, you would see a continual exponential rise in cases. Instead we’re seeing a slowing in the increase. In Italy for the first time. It already happened early in China, early in the epidemic.
And it happened in Singapore and Hong Kong relatively rapidly. So what we’re gonna do today is we’re gonna look at what’s going on in those countries, particularly the successful ones, that we can apply to the U.S. So Atul Gawande put out a piece in “The New Yorker” the other day that I shared here on Facebook. You can see it from yesterday. And it is excellently done, if that’s an adverb. What Atul talked about is he looked at those countries and said, okay, here in the U.S. and in Italy, et cetera, everyone’s panicked that the health care system is, A, gonna be overrun. B, everyone in it’s gonna get sick. C, we’re gonna quarantine people that we are concerned could get sick, and that’s gonna lead to staffing problems. D, we don’t have enough PPE. And by PPE, they’re specifically talking about N95 masks which are used in airborne transmission, right, so they’re airtight, you’re fitted.
There’re very small micron holes that don’t allow viral particles through, et cetera. So we don’t have enough of that, so our workforce is gonna get devastated, we’re gonna get exponential rise and collapse of the system, despite everything we’re doing to destroy the economy in the process by keeping young people home from school and from work and shutting down the economy. Now, this is pretty devastating. And then they have the audacity to say that we may have to do this for 18 months straight with a few breaks because that’s the nature of these viral dynamics. Then you look at these other countries, and you go, now, wait a minute, and there are scientists now that are saying, look, look at the stats here. Look what’s happening. China has slowed the internal rate. And let’s go through a little history here. Initially when this broke out in Wuhan, hospitals were the amplifiers of the pandemic.
So hospital staff were getting infected left and right, and then were taking it out into the community. And so about 1,300 or so hospital staff were infected very rapidly to the point where, and then they were quarantining everyone else, to the point where they ran out of providers, doctors and nurses and everybody. I hate the P-word. And then what ended up happening is they had import a bunch of clinicians, and what they found then is they went super draconian. So shut down the city, intense travel restrictions. And the doctors were wearing full-on hazmat suits with the pappers and everything. They had sort of scaled up hospital capacity very rapidly. Had housed doctors and nurses separately from their families so that they wouldn’t reintegrate back in the community and be amplifier vectors of the disease. And what they found is, oh, that actually worked. So those draconian measures worked.
Well, that could never happen in the U.S., ’cause A, we don’t have the stuff. B, we can’t just take a bunch of doctors from one place, move ’em to another. People would say it’s un-American. They just won’t be able to do it. You need a infrastructure like China’s to be able to pull that off. So despair, right, we’re doomed. We can’t do it, what are we gonna do? Well, we could look at what happened in Singapore and Hong Kong for example. And Atul points this out in his article. In Singapore and Hong Kong they started getting cases, which makes sense, because there’s a lot of travel, it’s proximal to China, there’s a lot of trade routes, et cetera. And what they found was that if they did certain things, their health care workers didn’t get sick. And believe it or not, those things weren’t draconian. They were actually quite simple. Let’s go through them. What they found is that if people washed their damn hands, religiously, basically if people did what you’re supposed to do in the hospital anyways, which is aggressive hand hygiene, wash your hand before and after every patient. At least use gel, but more often, wash properly. Right? That’s step one. We don’t even do that in this country.
If you do an audit of a general hospital, people aren’t washing their hands, period. So already we’re behind, right? Like culturally we’re behind. We don’t typically do that, but we can. That’s not hard to do. You know what’s hard to do, shutting down the damn country. Shutting down the schools. Shutting down people’s businesses that put them out of business, that turn them from basically barely making it to not making it, which is a health crisis in itself in the making, destroying the retirement accounts of people living on the margins, destroying college savings accounts of children that are getting ready to go to college. It’s much easier to wash your damn hands.
So what they found in these hospitals, right, is that if you washed your hands and, and wear a basic surgical mask, not an N95 necessarily, but a surgical mask when you’re seeing most patients. So just that basic barrier with gloves when you’re seeing most patients, aggressive hand hygiene, and sterilizing the surfaces in between visits. So using an approved cleaner, whether the doctors or the nurses did it, or environmental services did it, or whoever did it, cleaning things down. Why, because the damn thing is spread not just by droplets, but by fecal/oral transmission and surfaces. So it can live on surfaces for a while. So sterilize the surfaces, wash your damn hands, don’t touch your eyes. The next thing they did in the hospitals, and by the way, so they reserved N95 masks and gowns and all the heavy-duty stuff for patients who were having respiratory procedures that were gonna aerosolize virus, which we’ve talked about. Or patients that had known or highly suspect COVID-19. So really typical respiratory symptoms. By doing that, they were able to preserve their PPE because they had shortages as well. They were able to preserve their PPE, and almost no transmission within the health care sector.
Okay, according to Atul’s data, and he talked to people there, looked at their public records. So unless we’re missing something, unless the Singaporeans and the Hong Kongers are hiding something, this is effective. Now, the other thing they did in hospitals, and very important, actual social distancing within the hospital. So you know that bullshit meeting that you have to go to with a bunch of ding-dongs where you sit there and like, “Well, our RVUs are down.” Or, “What are we gonna do to get patient satisfaction up? “Should we not wear masks so that we don’t “scare ’em in the hospital?” Which by the way, we’ve been getting messages that some hospitals are telling their nurses and staff not to wear PPE so that they don’t frighten the patients and lower their patient satisfaction scores. If that’s true, and again, it may apocryphal, but I’m hearing messages in my inbox from people working in these institutions. Anyways, so what they do is they social distance within hospitals. It means get rid of unnecessary meetings. Do them virtually. Stop seeing patients for stuff that doesn’t need to be seen in person. And guess what, you know what we’re learning now during this pandemic?
Most of the stuff we do doesn’t need you to be face to face with a patient. Oh, surprise! Most of it doesn’t even need a doctor. Just needs someone who can listen who has empathy. That’s what we’re learning. We knew that in our clinic at Turntable. I was screaming it to the world for years. You know what, a health coach is probably better for 70% of what we do than an overtrained physician who’s very good at that skillset, but you’re not needed for all the other stuff. Telehealth, phone, Skype, email, whatever it takes. So social distancing within hospitals, meaning keeping patients out if they don’t need to be there. And then separating wards. So for respiratory patients of any kind, they would start respiratory wards. And that would keep those patients with a different team in a different part of the hospital. And we’re seeing that start now in the U.S. There are institutions that are doing this. It’s very, very, very encouraging. So the other thing they did is in waiting rooms they would put the chairs like six feet apart, if you have the space, so that patients aren’t close to each other. Simple droplet social distancing. Everybody washing their hands, being absolutely religious about it, and they did amazing.
Now, on top of that, what they’re doing, so what happens when, and I’m hearing this all the time now in messages that are sent to me by Facebook. Caregivers all around the country. “I was exposed to a COVID patient briefly. “They were in the room, I didn’t have a mask, “and now I am in 14 days of quarantine.” Okay, if you want a surefire way to understaff our hospitals at the time they’re most needed, do something dumb like that. So what they did abroad is they said, wait, if you have a known case, in other words one of your staff tests positive, remove that staff and put them in quarantine and watch them to make sure they don’t get sick, et cetera. So that’s one thing. Trace the contacts of that person as best you can. And that takes some work, but it’s doable. Anybody who was exposed for a significant amount of time at closer than six feet without a mask or gloves, those are the people that you quarantine and watch. And what that means is in Hong Kong, that was 15 minutes of direct exposure. In Singapore, it was 30 minutes of direct exposure before they said that’s significant enough that you need to be quarantined. And they had like no nosocomial transmission. Like minimal compared to what you’re seeing in Italy and what you saw early on in China and what we’re probably gonna see in the U.S. if we don’t get this right. How encouraging is that? So then what they did is they said, okay, let’s say you were transiently exposed to someone.
You should wear a surgical mask, a surgical mask, not an N95, with all patients, just like you do if you refuse the flu shot, they make you wear the mask of shame, same thing. Wear the surgical mask, hand hygiene, check your temperature twice a day. That’s it. And so close surveillance. And then they actually were really telling people, any health care professional who’s coming in, before you come into work and after work, check your temperature, make sure. And if you have symptoms concerning, that’s when you either stay home or you’re wearing a mask or whatever it is they decide in each specific instance. And combined with basic social distancing practices in the public, right, telling people, teaching people about hand hygiene, again, wiping down and disinfecting surfaces, coughing in the elbow. If you’re sick, wearing a surgical mask and staying home. Combined with that, and testing strategically. So they were able to turn the tide in just a couple, three weeks. And if you look at the numbers globally, that’s what we’re gonna start seeing happen ’cause it’s happening. So instead of running around throwing feces like we’ve been doing, maybe we should learn what’s working and try to apply it within our particular paradigm, set of resources, and cultural environment. Because I’ll tell you, we don’t have a culture of hand washing here in this country. You’re called OCD if you wash your hands a lot, right? So we have to first of all start addressing that.
Now, the other thing that they learned from even the Diamond Princess cruise experiment, so let’s say you test and like 600 people of that cruise got ultimately tested positive for coronavirus. At the time they were tested, many of them had no symptoms. So that was screening an asymptomatic population. So at the time they were tested, nobody had, a lot of people didn’t have symptoms. But it turns out many of them later actually did develop classic symptoms. So what that tells you is the rate in the Diamond Princess population of asymptomatic patients who tested positive but never developed symptoms was about 18% screening a population that was at really high risk, because pretty much everyone on that boat was exposed at some point in a closed, unventilated system with no PPE, poor hand hygiene. I mean, how many norovirus outbreaks do you see on cruises? They’re festering basically Petri dishes of human feces. That’s what a cruise is, right, floating on the sea. Now I’m gonna get all this hate from the cruise industry. I don’t care, it’s gross. And so because people aren’t washing their hands. We’re not doing precautions.
So it tells you that typically, if you have symptoms, that’s a good indication to test, quarantine, trace contacts, do rational control and rational social distancing across the population that makes sense. Quickly get it under control. Now, it bears, and so again, the idea that our health care workers are then protected, right, if we take those precautions, separate wards, hand washing, surgical mask, scale up to N95 if you have a respiratory exposure from aerosolized procedures or true positive COVID, et cetera. And then you save the resources, train people appropriately to do this, right, social distancing within hospitals. How many of you guys are in a hospital right now where nobody’s social distancing at all? They’re all jammed into the break room sharing fricken utensils, shitting on themselves, and then touching everything. And then you wonder why people get stomach flu all over the place. It’s the same transmission, guys. It’s easy to prevent with hand washing and mindfulness of what you’re doing with your damn hands. That’s why, you know, you talk about meditation and people are like, oh, it’s all woo woo. Meditation is learning to be mindful of what you’re doing. Oh, look what I’m doing with my hands, I’m about to touch my eyes, I just noticed that. I’m gonna stop that, I’m gonna wash my hands, gel, use some gel and wears gloves in the next room and make sure to make it like almost a ritual, like a mantra going into a room, okay?
Clean, glove, surgical mask, in you go, right? So this is something that we can do in health care. This is a cultural thing, all right? Put a little distance between you and the case manager. Put a little distance between you and the ER doc that’s giving you the report. It’s not that hard to do, all right? We don’t really like these people anyways. It’s better to have them at a distance. I’m joking. And if we do those things, what we will start to see is an inflection, all right? Right now we’re on the upswing in the U.S., man. Hospitals are gonna get slammed, it’s gonna be real busy. And we have a choice, we can get overwhelmed like the north of Italy, or we can turn the tide. And part of that means that even young people have to, right now, if people are saying there’s a period where we’re doing aggressive mitigation and social distancing, we have to do it because it’s gonna buy our hospitals time. And if our hospitals screw up, you know, there’s all this discrimination against nurses and doctors going out in scrubs ’cause people are afraid they’re vectors. Well, if you behave like a jackass in the hospital, don’t wash your hands and don’t do the right thing, then you are a vector. So let’s be honest with ourselves. They can do it, we can do it. The pandemic’s global, the lessons are global too, even though all health care is local and how we institute it is up to us. All right, guys, this is so crucial and so important to understand that we are empowered to do this. I know so many of us feel helpless right now.
We’re not, we’re empowered to do this. This is something we can take control of right now, whether we’re a patient out there doing social distancing, making sure if we have symptoms we’re staying home, not showing up to the doctor if you don’t need to, calling ahead, all those other things. Very, very, very important. And then on the medical side, we just talked about it. So do this, share this video, leave a comment. Thank you to the 10,000 stars that we got to raise money to make all this stuff work. We’ve linked previously to Project N95 that is working on getting more PPE for health care professionals. For the supporters, the people who subscribe to the show on Facebook, understand this. I am gonna be posting in the Supporter Tribe closed discussion group right after this a link to a Google Doc developed by some hospitals in California that is everything you need to know about managing and discharging COVID patients that we know so far. It’s a really good doc, it’s always evolving and organic. And I think it’s gonna be a great resource. I’m gonna send it to you guys first, Supporters, because I want you to share it strategically. I don’t wanna put it on the main page and have a bunch of people bombarding it with edits and stuff. So I’m gonna put it out and then you guys can strategically share it. It’s very important that we share best practices right now. And with that, I’m gonna glove up. And put on my surgical mask, which is minimal, really minimal PPE. It is absolutely the bare minimum. People ask me, ZDogg, are you Vader, and I say no, I’m Vader, me, me. This is an N105 right here. And these patients are always trying to take it off my head. They’re like, “Bro, I need that, because you know, COVID.” And I’m like, “Bro, I need that because I’d die “without it, all right?” Anyways, ZDogg says share the video. And he says something like, I don’t know, fam, we’re out, whatever. He’s stuck in the ’90s. All right, bye-bye.
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