There are so many
stories about the coronavirus pandemic — some inspiring, some tragic, and
all-too-many frustrating. In the world’s supposedly most advanced
economy, we’ve struggled to produce enough ventilators, tests, even swabs, for
I can’t stop thinking
about infrastructure, especially unemployment systems.
We’d never purposely shut down our economy; no nation had. Each state is trying to figure out the best course between limiting exposure to COVID-19 and keeping food on people’s tables. Those workers deemed “essential” still show up for work, others may be able to work from home, but many have suddenly become unemployed.
The U.S. is seeing
unemployment levels not seen since the Great Depression, and occuring in a matter
of a couple months, not several years. As of this writing, there
are over 22 million unemployed; no one believes that is a complete count (not
everyone qualifies for unemployment), and few believe that will be the peak.
systems could not manage the flood of applications.
As a psychiatrist, my role in COVID-19 has included that of a therapist for my colleagues. I helped start Physician Support Line, a peer-to-peer hotline for physicians staffed by more than 500 volunteer psychiatrists. Through the hotline and social media, physicians are revealing their emotional fatigue. One doctor shared her sense of powerlessness when she couldn’t provide comfort but instead had to watch her young patient with COVID-19 die alone from behind a glass window. Another shared his sorrow after his 72-year-old patient died by suicide. She was socially isolated and didn’t want to be a burden on anyone if she contracted COVID-19. An internist felt deep distress and alarm that her hospital was quickly running out of ventilators and had 12 codes in 24 hours.
Through a brief survey I
conducted across the U.S., 269 physicians reported moderate to severe symptoms
of anxiety (53%), depression (43%), and insomnia (16%). About 46% wanted to see
or would consider seeing a mental health clinician for severe anxiety (30%),
not feeling like themselves (27%), or being unhappy (21%). These are all similar statistics to
the front line health care workers in Wuhan.
We have seen and heard about the classic symptoms of
COVID-19 at UCSF Medical Center, where I work as a cardiologist. Patients keep
coming in with pulmonary distress, pneumonia, and ultimately, Acute Respiratory
Distress Syndrome (ARDS) – the life-and-death situation that requires
However, I’m beginning to learn about other symptoms that some
doctors are noticing. There are numerous reports of other complications, especially
in advanced disease.
Elevation in D-Dimer, (a biomarker of coagulation system activation) has been associated with dramatically increased risk of death from COVID-19. This has led some to speculate that empiric treatment with anticoagulants might improve outcomes in these critically ill patients. Indeed, there was this recent publication of a retrospective analysis of anticoagulation with heparin or low molecular weight heparin showing an association with improved outcomes in COVID-19 patients in China.
COVID-19 testing in grocery store parking lots. Clinicians crossing state lines to practice in hard-hit hospitals miles away from their health system. ICU doctors made to shore up shortages of ventilators by adapting medical equipment from its intended purpose. Are these just medical malpractice suits waiting to happen?
Margaret Nekic, CEO of Inspirien, a hospital-and-physician-owned medical malpractice and worker’s comp insurance company, reveals what’s happening behind-the-scenes as professional liability carriers hurry to adapt to the changing circumstances of a healthcare system thrown into crisis-mode.
While new legislation is emerging to somewhat safeguard healthcare workers from bearing the risk of some of the pandemic’s unprecedented circumstances, what happens when the immediate surge has passed? Will costs for medmal insurance go up? And, what happens from a worker’s comp standpoint if a healthcare worker becomes infected with COVID-19?
As healthcare delivery in hospitals continues to change — and, at the same time, more and more care extends outside the traditional doctor’s office by way of an uptick in use of digital health and telehealth options among non-COVID patients — it seems the pandemic might ultimately also accelerate changes in the way healthcare organizations think about risk management and their insurance coverage for it.
COVID is here. A little strand of RNA that
used to live in bats has a new host. And
that strand is clearly not the flu. New
York is overrun, with more than half of the nation’s new cases per day, and
refrigerated 18-wheelers parked outside hospitals serve as makeshift
morgues. Detroit, New Orleans, Miami,
and Philadelphia await an inevitable surge of their own with bated breath. America’s health care workers are scrambling
to hold the line against a deluge of sick patients arriving hourly at a rate
that’s hard to fathom.
I pause here to attest to the heroic response
of the medical community and the countless more working to support them. At the
time of this writing, despite 368,000 confirmed cases in the United States,
11,000 deaths have been reported. A
horrid number, but still a far cry from Italy with 130,000 cases, and 16,523
deaths, and Spain with 14,000 deaths amidst 140,000 cases. Italy and Spain may be a few weeks ahead of
the United States, but at the moment, Italy and Spain have case fatality rates
(12.5%, 10%) that are multiples of the United States (2.5%). If this rate does
stand, it will be a testament to the tenacity of medical workers toiling under
With the scale of the tragedy now obvious, the
take from some very smart people is that the people who should have been paying
attention were asleep at the wheel. The
easy target is the bombastic New York real estate developer and current
President of the United States who repeatedly assured raucous campaign crowds
and the nation that the virus was under control before it wasn’t.
The charge is made that the President ignored
warnings and painted a rosy picture of an unfolding crisis in a short-sighted
attempt to preserve the economy and a beloved stock market. He may be guilty of the latter charge, but
the real question relates to ignored warnings.
Where were the warnings? Who was sounding the alarm that was ultimately
To be honest, the United States blew it on the mask front. From a public health, caregiver and patient safety, as well as community transmission standpoint, we are at least 3 months late to game. Anytime a brand new virus that humanity does not have any immunity to makes an appearance, is highly contagious, starts rapidly infecting people as well as the doctors and nurses caring for them, hospitalizing, and killing them in concerning numbers across the globe, we should enable every proactive safety measure at our disposal.
The first confirmed case of COVID-19 in the US was on January 20, 2020. The general public and the millions of people who are considered at high-risk for complications from COVID-19 were advised that wearing masks in public was unnecessary. Many individuals were shamed and called out for wearing masks in public, being directly blamed for personal protective equipment (PPE) shortages on the front-lines. Meanwhile, hundreds of millions of masks and PPE are exported out of the country by brokers daily. People out in public have been mocked for a spectrum of reasons, being criticized as to why masks were being worn, used to run errands, and for removing them incorrectly. On April 4, 2020, the Centers for Disease Control (CDC) recommended that the general public wear cloth face masks in public where social distancing may be difficult, such as at the grocery store or pharmacy, especially in areas where cases of the infection are high for active transmission.
There has been extensive media coverage of PPE shortages at
hospitals on the front-lines of this pandemic. Protecting our doctors, nurses,
and all caregivers and first-responders is of utmost priority as we work to
fight against COVID-19. As a patient advocate, patient, and carepartner to 2
disabled adults, with multiple family members in the high-risk population, was
the call-to-action for the public to wear masks delayed so as to not risk
further depleting PPE needed for those directly caring for patients sick with
One harsh Chicago winter, I remember calling a patient to cancel his appointment because we had deemed it too risky for patients to come in for routine visits—a major snowstorm made us rethink all non-essential appointments. Mr. Z was scheduled for his 3-month follow-up for an aggressive brain lymphoma that was diagnosed the prior year, during which he endured several rounds of intense chemotherapy. His discontent in hearing that his appointment was canceled was palpable; he confessed that he was very much looking forward to the visit so that he could greet the nurses, front-desk staff, and ask me how I was doing. My carefully crafted script explaining that his visit was “non-essential” and “postponable” fell on deaf ears. I was unprepared to hear Mr. Z question: if this is his care, shouldn’t he be the one to decide what’s essential and what’s not?
This is a question we are all grappling with in the face of the COVID-19 pandemic. The healthcare industry is struggling to decide how to handle patient visits to doctor’s offices, hospitals, and imaging centers, among others. Elective surgeries are being canceled and advocates are arguing that non-essential outpatient and ER visits should be stopped. Ideas are flying left and right on how best to triage patients in need. Everyone has an opinion, including those who ironically consider themselves non-opinionated.
an oncologist, these various views, sentiments, tweets, and posts give me
pause. I understand the rationale to minimize patients’ exposure and thus prevent
transmission. However, reconsidering what we should deem “essential” has made
me reflect broadly on our method of providing care. Suddenly, physicians are
becoming less concerned about (and constrained by) guidelines and requirements.
Learning how to practice “essential oncology” may leave lasting changes in our
By CHITRA CHHABRA KOHLI MD, AJAY KOHLI MD, and VINAY KOHLI MD, MBA
With a doubling time of cases estimated between 3 days within the U.S. and about 6 days globally (at the time of this writing) COVID-19 is demonstrating its terrifying virulence as it spreads across the world.
What’s perhaps equally terrifying, if not more, is the absence of a known cure or treatment plan for COVID-19. While there has been a lot of attention focused on Hydroxychloroquine and Azithromycin, there has been debate on the scientific validity of these treatment options, either as therapy or as prophylaxis. The impact of a solution certainly has far reaching potential, the scope of the challenge is overwhelmingly large. The editor-in-chief of Science recently wrote that the efforts to find a cure are not just ”fixing a plane while it’s flying — it’s fixing a plane that’s flying while its blueprints are still being drawn.”
There is a promising therapy that may help us weather the COVID-19 storm and, perhaps, flatten the curve. It’s based around science that defines immunology and has already been used in many different diseases, going as far back as the 1918 flu pandemic. This potential treatment is convalescent plasma therapy — using antibodies from patients who have recovered from COVID-19 and then transfusing them into patients who are currently mounting an immune response against the rapidly rising viral loads of COVID-19.
In a physician WhatsApp group, a doctor posted he had fever of 101° F and muscle ache, gently confessing that it felt like his typical “man flu” which heals with rest and scotch. Nevertheless, he worried that he had coronavirus. When the reverse transcription polymerase chain reaction (RT-PCR) for the virus on his nasal swab came back negative, he jubilantly announced his relief.
Like Twitter, in WhatsApp emotions quickly outstrip facts. After he received a flurry of cheerful emojis, I ruined the party, advising that despite the negative test he assume he’s infected and quarantine for two weeks, with a bottle of scotch.
It’s conventional wisdom that the secret sauce to fighting the pandemic is testing for the virus. To gauge the breadth of the response against the pandemic we must know who and how many are infected. The depth of the response will be different if 25% of the population is infected than 1%. Testing is the third way, rejecting the false choice between death and economic depression. Without testing, strategy is faith-based.
Our reliance on testing has clinical precedence – scarcely any decision in medicine is made without laboratory tests or imaging. Testing is as ingrained in medicine as the GPS is in driving. We use it even when we know our way home. But tests impose a question – what’ll you do differently if the test is negative?
That depends on the test’s performance and the consequences of being wrong. Though coronavirus damages the lungs with reckless abandon, it’s oddly a shy virus. In many patients, it takes three to four swabs to get a positive RT-PCR. The Chinese ophthalmologist, Li Wenliang, who originally sounded the alarm about coronavirus, had several negative tests. He died from the infection.
“It’s fair to say that, in Italy, we are doing 10 years of digital health evolution in 10 days.”
Our “man-on-the-street” in Italy (well, man-sheltered-in-place in Italy) Roberto Ascione, CEO of Healthware, reports in on the Covid-19 outbreak and what’s happening with digital health startups, health system partners, and hospitals as Italians continue battling at the forefront of the coronavirus outbreak.
A few weeks ahead of the U.S., there are many things to learn about Covid-19 testing, treatment, outcomes, and timing from the experience in Italy, including some foresight on how pathways for telehealth and digital health continue to evolve as conditions become more serious and the outbreak progresses. (For all you Gretzky fans, this is “skating to where the puck will be” kind of stuff…)
Some navigational guidance on this chat which took place March 26, 2020:
Update on Italian Covid-19 outbreak from health industry insider
10:25 minute mark: Digital Health startup case study, Paginemediche, self-triage chatbot data from 70K Italians, data sharing with Italian government & WHO, telehealth model flipping to give overwhelmed physicians opportunity to triage and “invite” patients based on needs
19:10 mark: How to work with Italian digital health startups to advance Covid-19 work