Flatten the COVID-19 Curve, Social Distancing, Hospital Capacities (Lecture 36)
Welcome to another MedCram covid-19 update. As you can see, this is now becoming a pandemic. This is validated with the numbers that are coming outside of China. If we go to the Worldometer site, you can see clearly we are in the acceleration phase here.
As a result of this, we are seeing some things that are very unusual, notwithstanding, of course, the stock market, which is taking a tumble at this point, but we’re also starting to see things that we’ve never really seen before.
We’re starting to see official statements made because of the fact that there are groups, there are fans, there are stadiums, where when you have people congregate together, it can spread disease. We’re seeing that from the NHL; we’re seeing that on the NBA website; we’re even seeing spring training Major League Baseball being postponed.
Governor Newsom of California is now able, through an executive order, to commandeer hotels and motels to house coronavirus patients. Patients in the state have already been moved to hotels. The Desert Sun reported that a 120-room hotel in San Carlos, which is near San Francisco, has already been tapped to house passengers from the Grand Princess cruise ship.
There was an executive order released on Thursday that includes the authority for Sacramento to take over hotels and motels for medical use for coronavirus patients in a move, he said, will help the state of 40 million to prepare for any widespread outbreak.
We’re also starting to see here at the municipal government level, Garcetti, who’s the mayor of Los Angeles, urging residents to take steps to protect themselves. But they also banned all events or conferences with more than 50 people. They called these common-sense measures. In San Bernardino County, which is the largest county in the United States, there’s not even a single confirmed case of covid-19.
This website here is very instructive, which I’ll put a link to in the description below. It has to do with this notion of “flattening the curve,” and that’s what I want to talk about today。
So here’s the curve. If you have everybody congregating together, of course, the virus is going to move fairly quickly it is thought. If you don’t have protective measures, that transmission is going to be very rapid. But then just as quickly because you have burned a large swath in the population of people, there’s going to be immunity that is built very quickly in the survivors, and then the curve is going to flatten out quickly as well. But there’s going to be so many patients so fast coming into the hospital that we’re not going to be able to take care of them. As it shows here, this is the healthcare system capacity way down here in terms of the daily number of cases.
If, however, we are able to distance ourselves and to shut down the transmission of the virus by spreading us out, so we’re not in close contact with each other, if we’re not congregating together in large masses, then the daily cases, it is thought, is going to come up slowly. Even if it’s the same number of people, we can spread those out so that the amount of cases that we’re seeing on a daily basis doesn’t exceed our ability to take care of those people.
We can kind of see that happened in the early phases of this epidemic in China. In the epicenter of this outbreak in Wuhan, the mortality rate was calculated to be higher than the mortality rate outside. Of course, this is not a case fatality rate because we don’t know exactly the toll, and we don’t know exactly the denominator and the numerator involved in that, but if you were to compare those two, you would see that the number of deaths divided by the number of confirmed cases was lower outside of Wuhan than it was inside of Wuhan.
Of course the reason for that was that the hospital capacity was just not there, and that was part of the reason why the Chinese felt it was necessary to build thousand-bed hospitals. It was to take care of this swell of daily number of cases.
Distancing is going to slow down the virus, but as it has turned out here from this not peer-reviewed paper that is ready for publication, they did extensive research to answer a question that I have been asked several times, and that is how long does this SARS-cov-2 last on surfaces and in the air?
The results are disconcerting. It showed here that the H-covid-19, or the SARS-COV-2, was investigated, and they showed the overall stability is very similar with the original SARS-COV-1 that was found back in 2002. They found that the viable virus could be detected into aerosols up to three hours post aerosolization. So this is when somebody sneezes, or if there is an isolation event, like if the patient is being intubated, or if they’re on a positive pressure mask.
This could be seen up to four hours on copper and up to 24 hours on cardboard and up to two to three days on plastics and stainless steel, which of course has real implications in hospitals and in operating rooms.
These two viruses, SARS-COV-1 and SARS-COV-2, exhibited similar half-lives in aerosols with meeting estimates around 2.7 hours. Both viruses show relatively long viability on stainless steel and polypropylene. The median Half-Life was around 13 hours on steel, and around 16 hours on propylene.
So basically they found that these viruses can remain viable and aerosols for multiple hours and on surfaces up two days, so you can see that the importance here of masks is there, but really the key is not touching things where this virus may exist, and making sure things get wiped down on a frequent basis, which may give you a question about exactly what could you use to make sure that SARS-COV-2 virus would be eliminated, and we’ll put a link in the description below to EPA website that lists that information.
Going back to this flattening of the curve. When we eliminate sporting events and meetings, things of that nature, we are able to drag this out. Even though the same number of people might become infected, we are able to better take care of them. I know exactly what it’s like being on the frontline and being in the Intensive Care Unit. How frustrating it is to have more cases than you can actually take care of.
It doesn’t happen often, and it might happen for just a short period of time. But imagine trying to take care of a very critically ill patient and have another patient becoming critically ill right at the same time, then as that’s happening, something else is happening downstairs in the emergency room that they need help with right away. You just can’t be in three places at once. Oftentimes, when this happens, I call in a backup physician who’s a colleague of mine who’s in clinic. He has to cancel clinic and come in and help me.
Instead of being an exception to the rule, could be the rule itself. Obviously nobody wants to have a loved one or be that patient in that situation because you want the attention of the doctor to be on you when this is happening. Of course that’s assuming that everything gets done correctly. What you don’t want to have is what’s described here in this medical staff update, and that is Distracted Doctoring and Patient Safety.
Imagine someone being interrupted. By their interruptions, it’s hard to put two thoughts together. You’re not dealing with computers when you go into the hospital even though there are many computers there. You’re dealing with physicians. Physicians who are human beings, who have to think and have to decide what needs to be done on a patient, and they need to take all those things into consideration. If they get interrupted because there’s such an influx of patients coming in, that’s when mistakes can also happen, and that’s what this article points out. I’ll put a link to this article as well.
An example of this point is a recent event. A physician was busy trying to complete progress and consult notes while waiting to get a call back on a page that he had placed. Realizing that there were orders that needed to be put on Patient A, the physician inadvertently placed a medication order into Patient B’s record, which was opened in EPIC. EPIC for those who don’t know is the medical record system.
The staff complied immediately with the order with Patient B, getting the medication intended for Patient A. Fortunately, Patient B did not get injured by the event. But the root cause of this error was the physicians’ momentary distraction while trying to do several routine things at once. That is the key and that is generally going to happen more often if this is the situation that we have versus this being the situation that we have. We just don’t have enough hospital beds, physicians, nurses, ancillary staff, respiratory therapists, to be able to deal with this in a safe way.
Pothof says that if everyone practices social distancing and practices good hygiene, it will help slow the spread of the virus so that everyone who will eventually need medical care can be properly treated. If that, what is happening in Italy and China doesn’t happen here. Even though in many parts of the country, where there are no cases, because we really don’t know how widespread this virus is because really we’ve under-tested.
So on this update, we took a little bit of a break from the molecular biology, but next week we’re going to be getting into a lot of the details of this ACE2 receptor. This is the receptor that is targeted by the virus itself. There are a lot of interesting things about this receptor not only from a vaccination and from an entry point, but this ACE2 protein is not in isolation, it does have a function, and that function may be modified by the binding of this virus. It’s interesting to talk about the implications of that modification. We’re also going to talk about practical things that you can do. And what does it mean to have immunity. Thanks for joining us.