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Purpose of discussion
My goal here is to help the lay-person understand the current pandemic crisis, what steps could be taken to mitigate it, and provide a discussion of hypothetical future steps and/or opportunities for collective action. I want you to be informed, calm, and rational in the face of an emergent medical crisis just as I have been in my professional and personal life. Moreover, I want you to be capable of doing something productive and useful to others.
What is SARS-CoV 2 and why it matters
This is a novel (new) strain of coronavirus, so named because of the corona or “crown-like” morphology of the virus’s structure. “Full-genome sequencing and phylogenic analysis indicated that the coronavirus that causes COVID-19 is a betacoronavirus in the same subgenus as the severe acute respiratory syndrome (SARS) virus (as well as several bat coronaviruses), but in a different clade.” Basically this is a particularly nasty variation of the same group of bugs that causes certain colds and previous forms of SARS/MERS.
This strain seems to be especially deadly, and as of the date I write this on March 22nd over 13,000 people have died world-wide. To put this in perspective, during the SARS outbreak 774 people died. Mortality rate estimates according to the World Health Organization are 3.4 %, but these numbers vary wildly depending on location. By contrast, while influenza is certainly deadly (I have personal experience performing CPR on sepsis cases secondary to pneumonia infections brought about by seasonal flus) the over-all mortality rate is around 0.1 %. SARS-CoV2 also appears to be much more contagious with one infected person spreading it to 2.2 people on average compared to the 1.3 associated with seasonal flus. Once again, I’m writing this while the outbreak is ongoing and my sources may not be entirely accurate, but we can assume that this infection is deadlier and more contagious than influenza, a disease that already kills well over 30,000 people in the United States every year. Given the strain already placed on our healthcare system by seasonal viruses I think this is certainly cause for grave concern.
As would generally be expected, SARS-CoV2 presents a greater threat for vulnerable populations like the elderly, immunocompromised, respiratory compromised, pregnant, or extremely young. This is a serious problem for the human lungs and can create a variety of complications such as but not limited to acute bronchitis, pneumonia, ARDS, sepsis, or respiratory failure. The most commonly cited statistics as of this writing are that roughly 40 % of people will be sickened but relatively stable, another 40 % will develop “mild” pneumonia, 14 % will be acutely ill, and 5 % will be critically ill and require intubation and ventilator support. In other words, lots of people are going to get severely sick and many of these will require hospitalization.
SARS-CoV 2 appears to mostly be transmitted by direct contact with infected people. An infected person coughs or sneezes resulting in a spray of small droplets containing sufficient viral load to create a new infection when it enters the nose or mouth of an uninfected person or is inhaled into the upper respiratory system. It is also possible to contract diseases via touching a contaminated object (called a fomite) but this is not thought to be the primary means of transmission. There is some indication that simply breathing or talking maybe enough to transmit viruses from person to person within enclosed spaces.
This is a potentially contentious topic due to the general public receiving recommendations inconsistent with what healthcare providers would typically observe to prevent disease transmission. Healthcare providers practice Body Substance Isolation (BSI) via the use of Personal Protective Equipment (PPE). This is typically broken into two levels, Standard Precautions, which include gloves and handwashing, or Airborne Precautions which include both of the aforementioned steps but also adds a properly fitted respirator and possibly goggles.
The CDC is recommending airborne precautions to healthcare workers, but is telling the general public not to wear surgical masks or respirators. There’s a couple of considerations to take into account. First of all, the CDC is definitely considering the impact of widespread demand on availability of N95s to healthcare workers and is attempting to maintain supplies. Secondly healthcare workers are both trained on how to use PPE and have a higher exposure to infected persons.
Ultimately the final decision on implementing standard and/or airborne precautions rests with the individual and their own perception of the threat. If you’re going to these lengths then you must use PPE correctly as simply buying boxes of gloves and a respirator does not by itself confer any protection if you don’t know how to use these items appropriately. Once you don a pair of gloves and come in contact with a potentially contaminated surface or person, you MUST treat the outside of that glove as a fomite capable of spreading infection to whatever you touch, including your face. You MUST remove the gloves in such a fashion that you do not make contact with unexposed skin and wash your hands immediately afterwards. Respirators MUST fit your face tightly and create a mechanical seal around it, otherwise any gaps will allow unfiltered air to infiltrate into the interior of the mask itself. As anyone that’s used a bag valve mask can tell you, it’s difficult to get a good seal around someone’s mouth and nose, which is why the approved N95 respirators are often very uncomfortable due to the amount of pressure they apply to your face.
Finally, if you decide to master Body Substance Isolation, you are still left with the challenge of what to do with a potentially contaminated respirator, clothing, and other items exposed to infection. Most likely this would entail setting aside at minimum some sort of decon area or quarantine room and developing a procedure for safely removing your PPE and outer layers of clothing. With limited resources and a crisis this severe it may be necessary to simply isolate the items for a specific period of time, upwards of 72 hours. Cold items could be placed inside plastic bags before being put into a freezer or refrigerator. To my knowledge viral load on surfaces has a half-life like anything else and with SARS-CoV 2 the amount of viable infectious material decays rapidly over time.
Opportunities for community action and reducing strain on the healthcare system
This is the most hypothetical component of my article and addresses purely theoretical options. If this turns into a major pandemic event that overwhelms the medical system, some creative measures might be necessary to preserve human life, particularly among vulnerable populations. There is reason to suspect the United States simply does not have the healthcare resources to adequately deal with a major pandemic, especially given the outcomes witnessed in Italy.
Given strategies like “shelter in place”, “social distancing”, and essentially wide spread limitations on human movement are rapidly being adopted on a global scale, we should be thinking about how to integrate these measures in practical terms. I think this is potentially where protocols like Standard Precautions and Respiratory Precautions could be used by a designated layperson to minimize disease transfer to vulnerable populations. One possible tactic would be to train a given volunteer on using gloves properly with a respirator (preferably one with no exhaust valve to minimize potential exposure via exhalations) to serve as a personal shopper for the elderly and establish a quarantine zone for the items at each individual residence. Just by eliminating the social contact among this vulnerable group and concentrating PPE resources on a small unit of designated providers it may be likely that the spread of SARS-COV 2 could be slowed.
This is a relatively practical measure that could be standard practice with a modicum of training.
Should healthcare systems be overrun, it’s likely that the acute cases I mentioned previously will be either placed into large scale temporary hospitals or else just sent home to weather out the virus. I think that caring for and monitoring patients discharged back to their residence may become a necessity. In such a scenario it’s possible laypeople could be recruited and trained to perform basic skills related to patient care and taking vitals. Replacing trips to doctor’s offices and hospitals for routine medical and minor trauma scenarios with community medicine might also be viable avenue to explore.
About the author
I’m Alex McNabb, a currently certified Advanced Emergency Medical Technician in the state of Virginia. I do not consider my completely meager medical credentials to be any source of medical authority, rather, I believe my combination of life experiences and slightly above average writing abilities provide me with a unique opportunity to produce something of value in a time of crisis. My professional experience consists of roughly 7 years of service as an EMT for volunteer, private medical transport, ER, and paid rural 911 services. While I could cite many of my former coworkers who would give me glowing recommendations, post a copy of redacted patient care reports, or wax poetic about my experiences writing up a prehospital sepsis screening protocol, I think I could best paint a picture of who I’ve been as medical provider with three examples:
1. My experience as an AEMT in an underserved rural system meant I was accustomed to being the Attending In Charge and making critical decisions regarding patient care with often extremely limited resources and personnel. Our emergency room was so understaffed I had actual triage authority, a rare responsibility for an EMT.
2. I was the first emergency services worker on scene at my own mother’s suicide, and no, I did not miss my next two work shifts which both required emergency responses to older female patients in cardiac arrest.
3. I delivered my own son under midwife supervision.
While I think this establishes I’m if nothing else a very level-headed veteran EMT, the most important thing you can know about me is that I put on skintight spandex and ride a spindly carbon fiber bicycle for distances exceeding 100 miles in 90 + degree weather. Just think of what implacable, inhuman force of will must drive a man to shave his legs and hop on a road bike for hours at a time on public roads where anyone can see how ridiculous he looks!