Why I'm Afraid

This post will answer these questions:

1. What is so terrifying about COVID-19?
2. Why should I care?
3. How could this affect me or my loved ones?

I am grateful to be convalescing well from my infection. The cough overnight was still a nuisance, but the cough syrup allows me to sleep. My aches and chills are almost gone and I haven’t had a fever in 2 days. This is all good news. The reality is that I was never so terribly ill nor was I afraid for my health at any time. I was the first of my friends, family, and coworkers to be officially diagnosed with COVID-19 and was their first one degree connection to this disease, I received a truly heartwarming show of encouragement and support which I appreciated then and now greatly. It is so nice to know people care and are thinking of you.

At the same time, it was strange for me. There was a disconnect between my optimism over my prospects for recovery and the tone of the well wishes I was receiving. In my head there was no concern for my own health, but the messages I heard from others were as if I was suffering from a condition with a high mortality. I wasn’t exactly sure how to respond. I have thought a lot about it (I have more time to think than I have space to move here in the basement). I believe the problem stems from the fact that people are not receiving a clear and concise message as to why this pandemic is so frightening. They are receiving little snippets of information from many sources of variable quality and reliability, and they are receiving them in a disorganized, disjointed, and disconnected way.

This is compounded because the news media makes their money by stimulating subconscious fears to get your views and clicks. Meanwhile, the official and government websites are a repository of clear and accurate information, but present that information in a sterile and impersonal way. This makes it very difficult to relate to. It’s amazing how a government website can give you the online feeling of waiting in line at the DMV.

All of this combines, I think, to create a general sense of anxiety which is unfocused. This, of course, makes the anxiety worse. I think people have a hard time (unless, of course, they have a loved one who is critically ill with the virus) internalizing how real the situation is.

So when people heard that I had COVID-19 they knew that it was scary, they just didn’t know why. They did what any caring human being would do under the circumstances; they worried about me and tried to help by offering well wishes and advice for my own health and recovery. While I certainly appreciated this, I wasn’t personally afraid.

I wasn’t afraid until yesterday.

Then I saw an Instagram video from Peter Attia who is a physician with expertise in the science of longevity. That background gives him a good understanding of epidemiology and statistics. He also has a staff that can analyze data and he analyzed the data of the pandemic in New York, the epicenter of the pandemic in the United States. It is likely that other locations will follow although where and to what extent is not clear. To summarize the salient points as clearly as I can:

• There are about 1000 ICU beds in New York City. You could repurpose other beds in the hospitals (e.g. surgical or pediatric ICU beds, step down units, and post op areas) but you can never fully empty those beds. Lets assume you can get the number of COVID ICU beds up to between 1500 and 2000.
• The question is will the rate of COVID ICU patients be greater than the number of COVID ICU beds. All models are pointing to an emphatic yes.
• On Friday 3/20 there were about 150 ICU cases in New York.
• On Saturday 3/21 in the morning there were between 300 and 330.
• On Sunday night 3/22 there were about 450.
• On Monday 3/23 there were about 621.
• Those numbers speak for themselves.

Dr. Attia worked out the numbers to imagine the things that must happen for the healthcare system in New York to not become overwhelmed. For that to be the case the following has to happen:

1. As of Monday night 3/23 not a single new person in New York can get a new infection. This means there can be no contact between a non infected person and an infected person or an infected surface (have you been to New York!?!)
2. There can be no more than 3 times as many cases as there are reported positive tests. Remember, we’re not testing everyone (see my previous post on why not everyone can be tested). Since we’re not testing everyone it is not entirely clear how many people are infected relative to the numbers that are being tallied. It is quite probable than far more than 3 times as many people are infected as have tested positive. Also, remember from prior posts, it takes between 2 and 7 days from infection before people get symptoms and a few more days before they get need ICU. This means that there are thousands of people who are currently infected and do not know yet.
3. No more than 3-3.5% of infected patients will require ICU (currently about 5% of New Yorkers with COVID-19) are requiring the ICU

Of course, none of this is possible. What this all means is

New York will most likely become overwhelmed with COVID ICU patients, its only a question of when (other cities may be soon to follow).

Just like all things COVID-19 that is a difficult thing to put your head around. It sounds scary but the fear does not always seem tangible. The following is an account from a physician in Italy who is in the middle of the crisis. It was forwarded on a Whatsapp physician group I follow but unfortunately it did not include his name so I cannot give him proper reference (I have made some grammatical and spelling corrections to make it more readable. I added in parentheses some explanations of jargon and bolded things that caught my attention). It speaks for itself.

I spend most of my time in ER and “critical care” units that are the hospital wards we converted into “COVID wards” to better treat these patients. I am writing from Milan which is actually the most affected city in Italy. To be honest, the situation is dramatic. We had to create 4 new intensive care units to treat intubated patients and their p/f is never more than 120 (a measure of their oxygen levels – that number is extremely low). Our biggest trouble is that we are now noticing that even patients 40 years old or younger are developing very bad pneumonia.

Until now we were testing all patients who arrived in the Emergency department with respiratory failure. The first problem is that these patients have no symptoms until they become really sick. Now we have a lot of trouble taking care of new cases. Our “911 service” cannot take care of all the respiratory patients, they are dying in their house with no care. Our triage rules are to treat in ICU only “young” people (less than 60 yrs old) with ‘light’ comorbidities. Active cancer patients are the most challenging choices. I believe 3-6% mortality is real.

The other problem, all the intubated patient don’t improve quickly. Our ICUs are full of ventilated patients in their 40s and they don’t improve.

When we have to stay nearby a COVID patient we always wear a single-use cap, a single-use coat, shoe-covers, double gloves and goggles or face shield with a N100 mask. Despite all these, my first anesthesiology tutor is now intubated and mechanically ventilated in the ICU (she is a 36 year old female).

BE SAFE! Minimally symptomatic people are everywhere. Avoid crowded places, wash frequently your hands, neck and face.

We thought it would be “nothing more than common flu” and now all italian ICUs are full of COVID patients.

You can see that the Italian experience is horrifying. They are now seeing younger patients with a high mortality and their system is completely overwhelmed. It seems quite likely that something similar will happen in New York – how similar-I don’t know, but I’m afraid to find out.

Other issues to consider are the downstream effects.

1. Hospitals are not empty. There are patients who are critically ill for other reasons, what is going to become of them? What will be for all the heart attack, stroke, and pneumonia patients we see on a regular basis?
2. The more patients a physician has to see the harder it is for them to provide quality care.
3. This is in addition to the problem of the doctors and nurses themselves are getting sick.

These two new pieces of information have changed how I view this crisis. I received wonderful displays of support from people who were concerned but their concern was for my health. The concern should be more for the entire community and the country. We must strictly adhere to the government restrictions on movement at all cost. It will undoubtedly save lives. Remember that the best case scenario in New York is likely an impossibility. That is where you can impact this pandemic. If you think that since you’re young like me you won’t be affected, look to the Italian physician who was seeing younger and younger patients as the pandemic progressed. It may be that the demographics are shifting. We have to assume and prepare for the worst, while hoping and praying that we are all wrong.

The news media is too nebulous and sensationalist. The government is too sterile and impersonal. The pandemic has not been real for people but it just got real for me. For this reason, I am going to implore you to forward this message to everyone you know. Send it to friends, family, and strangers. Post it on every social media platform as any times as you can. Shout it from the rooftops. You can play a vital role which could save countless lives. Let’s get to work!

More reading:

Coronavirus Plea From Johns Hopkins. Baltimore Sun 3/24/20