One of the most distressing things I am seeing is conspiracy-minded conservatives in the US doubting the mortality numbers from the COVID pandemic. I really get upset as these people try to gas light the nation and convince people that COVID wasn’t that bad. And that people are just inflating the numbers for political gain.
I round at a number of dialysis units. At one unit, I cover the first shift. First shifts are popular. Lots of people want to do their dialysis first thing in the morning and have the rest of their day to themselves. I have 20 odd patients on that shift and every couple of months I’ll get a new patient when a chair opens up. This happens when a patient moves, transfers to another unit, gets transplanted, or unfortunately, passes away. Openings on the first shift are rare and they don’t stay open for long.
I distinctly remember going to round at this unit in late May and almost immediately seeing a new face. So I started my routine, new dialysis patient, spiel, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
And then a few chairs down, I saw another new face, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
And then a bit later, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
And once again, “Hello, my name is Joel Topf and I’m going to be your doctor here…”
I met as many new patients on that one day as I typically get on that shift in a whole year. Each of those new faces represented a patient lost to COVID.
We are not lying about the disease.
We are not exaggerating the dead for political gain.
I lost momentum on the COVID diaries, but today as some people are gas lighting the severity of the COVID-19 pandemic I want to finally publish a couple of posts that I started but never published.
As COVID-19 was raging through Italy one of the storylines that made it back to our shores was the number of docs that were getting sick. The number of doctors who were dying. A scary thought entered my head, in the form of a Twitter poll (it is strange how many of my thoughts are arraigned as tweets)
How many doctors at your hospital will die before you start thinking about heading for the hills?
A. Zero. I’m thinking about bugging out now
B. 4
C. 18
D. Infinity. I ain’t no coward.
I asked the question in a group chat but never on open twitter as it felt too inflammatory. My feeling was that it was less the number and more who got sick. The closer you were to the poor doc on the vent in the ICU the more terrifying it would be. Thankfully Ascension St John didn’t lose any doctors, nurses, or employees. But we did have people get sick. A lot of them.
Early in the epidemic we had an outbreak in the cardiology department. At least 8 of the cardiologists got sick and two of them were hospitalized. I don’t know how the ‘Rona spread through their department, but that gave a sense of how fast the disease could spread without precautions.
The housestaff (residents and interns) were also hit hard. Fully twenty-five percent of the internal medicine residents missed work because of COVID-19.
One in four
Thankfully none of them had to be hospitalized.
Probably another dozen doctors in the department of medicine got sick. A number of them were hospitalized, but no one died. Not because we were good, but because we were lucky.
My father is an oral surgeon and the program director of the oral surgery residency at St John and Beaumont Hospitals. His chief resident got COVID-19 and perished. I was on-call in a hospital full of Covid-19 patients when my dad called to tell me. It was startling and focused the mind. After that I found my self calling old friends just to say “hi.” Kind of getting my personal affairs in order, you know, just in case.
Looking back at the docs that got infected, it is noteworthy that the vast majority of infections were early in the epidemic. They were all in late March and early April. The time when we didn’t know what we were doing. I remember seeing videos on how to take off and safely store your mask between COVID patients.
Those halcion days when we thought we could label patients as COVID and NOT COVID. As soon as that lunacy went away and we just started wearing our mask all the time the infections among the staff melted away. It was a stark before and after experiment, but to my eyes masks worked.
When it became apparent that COVID-19 would not just be a medical event that happened over there but was going to affect everything I started jotting some notes. They have remained in Drafts for over a month, but now I am going to start publishing these diary entries mostly just to document the strangest, most unexpected experiences of my medical career.
I have lost a lot of patients. We all have. A lot of them were people I never knew. Consults in the ICU with a patient intubated and sedated in kidney failure. You don’t get to know these patients. The ICU discouraged going into the room to examine the patient unless it was absolutely necessary both to protect us from infection, and to minimize consumption of personal protective equipment. There was no family at the bedside. No visitors in the waiting room. I have never had thinner connections to my patients. We worked hard to save them. Most of them died. I can only remember a few of them.
But there are patients I do remember.
The first patient that I Iost was a dialysis patient. She was an older lady that had been taking care of for a few years. I remember the last time I saw her. I was rounding in the dialysis unit and she was sitting in her chair, mask on, and I told her that I was seeing patients with COVID and that it was really bad. I told her not to believe Fox News telling people it was just like the flu. She nodded her head. She was in total agreement. he last thing she told me was to be careful. She lived in a nursing home. Nursing homes are COVID tinder boxes. A week later she was gone. 😥
Another dialysis patient was a young (my current definition for young is anyone born after 1969) man. He was a rabid Michigan fan. Every time I saw him he would be hot about the latest U of M athletics story. Satellite camps, Louisville forfeiting the championship over Michigan, trips to the Vatican, sleep overs in tree houses, Beilein leaving for the NBA, it didn’t matter how minor the issue he would get completely worked about it. I loved his passion. He was one of only a handful of my patients that still worked and he was an essential worker at a grocery store. And then one day…he stopped coming to dialysis. We sent the police to his house and he was gone. 😥
Not all of the hospital patients were so isolated. I remember an older gentleman who came in because he fell. He was tested in the ER because we are testing everybody. He tested positive. He had just a small oxygen requirement but he was otherwise nearly asymptomatic. I saw him the day after admission for some mild acute kidney injury. After my evaluation I asked him he needed anything and he asked if I could get him some grapes. One of the strangest asks I have received. I couldn’t. The next day he was moved to the ICU for intubation and a week later he was gone. 😥
I lost a few patients from my advanced CKD clinic. These are patients that I see every four weeks to fight for every milliliter of clearance as we try to hold off on dialysis. The mantra of that clinic comes from the first season of Game of Thrones, paraphrased.
What do we say to the God of Dialysis? Not today.
One that I lost was a patient I had been working with for years. I helped him lose weight after learning about weight loss medications on The Curbsiders. I think it was the first time I consciously changed my practice based on a podcast.
He used to come to clinic with his wife and sometimes with his school-aged kid. He was kind and gentle. A good guy taken too soon. 😥
Last week I lost one of my favorite patients to COVID. He was a sweet man with severe CKD 5. He’d come to clinic every month where we would fight for every ml of clearance. He’d often come with his lovely wife and sometimes his 6 yr old son Now a widow. Now fatherless.#FuckCOVID
Another long time patient was a woman who would come to clinic with her sister. I always saw them together. In my clinic. I the hospital. Always together. She had terrible heart disease and we were forever adjusting her anti-angina medications and diuretics. Sometimes winning, sometimes losing. She had tough disease but she was a fighter.
One of my favorite memories of her was she used to wear an iPod nano as a wrist watch for years before finally getting an Apple Watch. loved that look.
Another one taken too soon. 😥
Another patient was not a clinic patient, or a dialysis patient, but a patient with pretty bad CKD that our group knew from frequent admissions. He would repeatedly come in with decompensated CKD and we would nurse him back to health and not see him for a few months until he came in again. Then he came in with COVID-19. 😥
Then there was the man who was shot in the bely. We see too much of that in Detroit. He required all the resources of St John’s trauma center. He was going to make it. He was recovering , still sick, but recovering. Then COVID was everywhere. And he no longer was recovering. Nothing feels more like a failure than a lethal nosocomial infection. 😥
The transplant patient who came to the ER because they thought they had COVID. They didn’t. Sent home. Patient returns days later convinced they had COVID. They didn’t. Sent home. Returns a third time convinced they had COVID. This time they did. I don’t know where they got infected, but I think the ER waiting room was a possibility. Another lethal nosocomial infection. 😥
I already wrote about patients that we thought were wins but we ended up losing. Those hurt. 😥
Don't turn your back after extubation. I have lost more than one after getting them through ARDS and transfer from the ICU and on to the wards for recovery and placement. COVID is a bastard.
Then there was another long-term patient of mine. Another one in the advanced CKD clinic. One we were fighting for every milliliter of clearance. Like Al Pacino in Any Given Sunday fighting for every inch.
https://www.youtube.com/watch?v=_b7bgtu2O4E
That patient was admitted with a viral illness at the end of February. The swab was positive for influenza. We didn’t have much capacity to test for COVID-19 and the protocol said that a positive influenza test meant no test for COVID. But I wonder. I haven’t lost a patient to influenza for years. I know it happens, but I wonder if this patient was actually the first patient I lost to COVID-19. 😥
There have been others. Too many other. The numbers are still piling up. Just last week I lost six patients. Six patients. One week.
As the US death toll spirals past the total from Vietnam, I keep thinking about how my medschool roommate, Tim Lamb, described the Vietnam memorial
You start walking and there are just a few names and as you walk, step by step, the names pile up until you are surrounded by names. Drowning in death.
When it became apparent that COVID-19 would not just be a medical event that happened over there but was going to affect everything I started jotting some notes. They have remained in Drafts for over a month, but now I am going to start publishing these diary entries mostly just to document the strangest, most unexpected experience of my medical career.
After the second week of peak COVID; a week where I had my own COVID scare, worked har, lost patients, and had a Quarantine Zoom Seder; I was relaxing on twitter, feeling pretty good when the NEJM dropped the first data on Remdesivir. It was a report on the compassionate use program. One of our patients at St Johns had been part of the program. The data looked promising and it was being published in the highest journal of the land. I had seen the article after reading about it from one of the top doctors on Twitter, Eric Topol.
Big for #COVID19 therapy: the compassionate use results for remdesivir in 53 patients looks very encouraging, especially in very sick patients on mechanical ventilation with 18% fatality (only, expect > 50%) and overall 68% improvement https://t.co/oP8eDK6jYL@NEJMpic.twitter.com/9kisPxy1un
It may not be my most populat tweet but it is certainly in the top 10.
It may have been popular but mostly at my expense. I was not ratioed, but it sure felt like it. Comments were about 10:1 opposed to my enthusiasm. Here are a few of the best:
That’s not a good tweet Joel
— Swapnil Hiremath @hswapnil@bsky.social (@hswapnil) April 11, 2020
You thinking about running for president @kidney_boy??? It’s a cohort study with no control group and 13% loss to follow up of 61 patients. Not even a historical control??? How did it get into the @NEJM???
My Tweet was the lead in coverage over the reaction to the study by WebMD. No, they didn’t reach out to me for comment.
So now it seems like I own remdesivir. See Waitzman’s comment when the Executive Deputy Editor of NEJM presented Grand Rounds at Beth Israel.
Dr. Hamel, when asked about @kidney_boy's favorite remdesivir trial: -We are publishing more case series and case reports than we used to. -But publishing "good enough" research faster may be more useful and save more lives than "perfect" work.https://t.co/jpQyrUqbtm
And this week, the study, and my tweet were part of The Curbsiders
And I was Exhibit A in the ID Journal Club Chat (#IDClub)
Previously, there had only been a case series of 53 patients treated with RDV under compassionate access. 2/3 pts had some clinical improvement but pt selection was unclear & there was no comparator. The response on #MedTwitter was divided. Was the criticism warranted? #IDJClubpic.twitter.com/JquctIEORC
I think it was an unfortunate tweet made too quickly in the evening. I was hoodwinked by the authority of the NEJM and Topol. It probably dropped my credibly as a science communicator. But the importance of this moment is quickly approaching zero as placebo controlled remdesivir data (both positive and negative) begins to emerge. Live and learn. Tweet and move on.
When it became apparent that COVID-19 would not just be a medical event that happened over there but was going to affect everything I started jotting some notes. They have remained in Drafts for over a month, but now I am going to start publishing these diary entries mostly just to document the strangest, most unexpected experiences of my medical career.
After my first week in COVID land I was on-call and we adapted to the new crisis. That Saturday while on call I was very tired. This is not so unusual, call is tiring. But that night I went to bed at 9:30, that is unusual. I never go to bed that early. By the next afternoon I had a scratchy throat and I started to wonder if I had the ‘Rona. Monday morning I woke up with a headache, body aches and a sore throat. I definitely was having a viral syndrome. No fever though.
I texted one of my favorite ID docs, Miriam Levine, explained my symptoms and she suggest I take the day off and see how things develop. I should also get tested. I called employee health and they took my information and told me they would set up a test and call me back. No time though, just a vague promise that they would call me back. I decided to take matters into my own and get tested through the Detroit Health Department. They were running a drive through testing program at the State Fair Grounds. All you needed was a doctors order and through the magic of self prescribing I got myself an appointment for Tuesday.
The following day, I remained afebrile, the myalgias and sore throat had resolved. I went through the state fair grounds but when I arrived I realized I hadn’t actually written out the prescription for the test. I scrambled around my car and found a script pad but no pen. I tore off the top page and put the black script on the dashboard and hoped no one looked too carefully. Amazingly it worked and I got the brain biopsy, err nasal swab without a hitch. Later that day St John called me and gave me an appointment for testing the next day. That afternoon I did Telehealth visits for my CKD patients.
I also updated Dr. Levine, and she said that if I remained afebrile tomorrow I could return to work. So Wednesday, I went to the St John testing facility on my way to work. While the Detroit Public Health was a wham bam thank you ma’am test, St John had a much more traditional doctor experience, I came in, filled out forms, had an MA take a full set of vitals. Then a doctor came in and did a full history and physical culminating with an influenza swab as well as the desired COVID swab. Later that afternoon I got this text:
I have never returned a page so fast in my life. I was positive for Influenza A. I had previously been immunized so I had a really mild case without fever. The fatigue and viral syndrome I felt on over the week-end bleeding into Monday were real, but they weren’t the COVID. Fake COVID, FauxVID.
And if you are a doctor reading this, don’t send out texts like that.
PS On thursday my COVID came back negative and a week later the Department of Public Health called and told me I was COVID negative.
COVID19 is the only thing on people’s minds. Everywhere you turn organizations are trying to create policies to address the crisis and inevitably they are turning to the CDC for reliable recommendations. Unfortunately, the CDC seems to be making scientifically questionable and politically motivated recommendations. News reports keep filing stories of scientists being muzzled so that they only voice the administration’s position. Dr. Paul Sufka was as frustrated as I was about this and wanted my advice about sending a letter to state officials asking for more aggressive measures to be taken to stave off the pandemic. I thought it was a great idea and suggested a joint letter. Later that day he added me to a DM group of physicians working on such a letter. The mission of the letter mutated over the next 72 hours from a plea to government to an informational post for patients.
The final result is now up at Kevin MD and Howard Luks website. Howard was really the driver of the letter. It felt like a productive project to work on as we wait for the disease to wash over our hospital. On Thursday (3/12/20) I was editing an early outline and documented there were 1,200 people in the US with confirmed cases of Corona. Then when re-editing on Friday, that number was up to 1,600. Today it was 2,100. In three days the number almost doubled.
This is going to get rough.
Let’s be careful out there.
Update. Howard Luks’ website is getting hammered. This post is really catching fire. He is asking that people look at the Medium post for now.
Update 2: the post went viral and was read by approximately 8 million people. 5 million on Howard’s site, 2+ million on KevinMD, and 1.5 million on Medium. This is the most reach I have ever been a part of. It speaks to the tremendous hunger people had for unbiased, science-based information in a time when everything seems to be politicized.
