John Awah, MD, CCD
No doubt, we are at war against a small virus, the Corona, besieged by a surprising storm. The frontier is moving. From Wuhan in China, across Europe. Surfacing in the United States and leaving behind a trail of dead people. Africa is just getting a whiff of it.
What we know is what we do not know. Luckily, in Africa, we have a small amount of time to make sense of it all. We can learn from the war field and prepare before it hits home with full impact.
My son is a Medical Resident, training to be an orthopedic surgeon, in a leading hospital in New York. April 1st, 2020 he was put in the front line, the Intensive Care ward of his hospital, in the fight against the common enemy, the Covid -19. He said it felt like he was drafted. He has no choice but to commit to his pledge to save life, one at a time.
He will be one of the many doctors whose stories I have put together about the reality of caring for Covid-19 patients. These are true stories from real doctors and their first hand experience of the reality on ground in hard hit areas in the first world.
With these stories, Africa, Ghana, can prepare to prevent the full impact of this virus. Some of the front line doctors sent their families away, to be alone. Others self-quarantine as soon as they get to their apparent safe haven, home. When not on duty these doctors are very isolated and literally so.
The first world, even, is overwhelmed, and do not have enough kits to test the front line doctors. The inadequacy of PPE’s to the front line medical staff is very apparent and shows how ill-prepared we are. As a result some of these doctors catch the virus, may pass it on unknowingly, and some succumbed.
The doctors gown the whole shift in the PPE, avoiding eating or drinking during this period, in an attempt to avoid touching their face with contaminated hands. When they get home they dispose their outer cloths outside the confines of their home.
The patients they see have a predictable clinical course. They typically present 2-11 days after apparent contact to the source of infection. The usual symptoms are fever, headache, dry cough, body pain, nausea, abdominal discomfort, diarrhea, fatigue, loss of taste, loss of smell and poor appetite.
Typically, about 81% of patients will have mild symptoms and will recover. 14 % will require hospital admission and 5 % will develop a very serious disease requiring an ICU bed. So, theoretically, in Ghana with a population of about 32 million people, assuming we all get infected at the same time, there will be the need of 1.6 million ICU beds or deaths.
About 5 days after presenting to a health facility, those with weak immunity will have increased shortness of breath, secondary to direct invasion of the tissue of both lungs by the virus. This is called viral interstitial pneumonia.
About day 10, they rapidly go into multiple organ failure including acute respiratory distress syndrome. This is due to a cytokine storm. The latter are a group of proteins released by the immune system in an attempt to control the infection. In an overwhelming infection like Covid-19, the cytokines continue to work even after overcoming the virus and misdirect their target to the lungs, liver, kidneys, heart and brain, leading to failure of these organs. This is serious and happens very quickly. Death occurs within hours unless drastic measures are taken including ventilation and ICU care. The Cytokine storm is measured by checking the blood for Interleukin-6 (IL6).
It is important to make sense of the laboratory tests. The oxygen content in blood is measured by the pulse oximeter and in Covid patients, this is usually less than 95% with or without symptoms of breathing difficulty. Chest x-ray is not reliable to make a diagnosis; it may show infiltration in one or both lungs or none at all. Our stethoscopes
are useless in this instance to pick up the usual signs of pneumonia. It is therefore, not a tool needed in these patients and can be a source of contamination to the next patient. If the doctor needs to use it to exclude other lung ailments, a glove must be put over it before using it and the glove is discarded after use.
There are additional clues in the blood test in the Covid-19 patient. Total white count is low, platelets count is low, lymphocytes count is low. A ratio of absolute neutrophil count to absolute lymphocyte greater than 3.5 is a highest predictor of a poor outcome.
There is elevation in the following tests: CRP, D-Dimer, LDH, AST, ALT, CPK, Alkaline Phosphatase…. Sorry for the non-medicals, I could not break it down any further.
The elevated D-Dimer and low pulse oximeter perfectly fits into the diagnosis of a Pulmonary Embolism. One will be tempted to do a CT-angiogram. This is a bad idea because the contrast that will be used for the angiogram will kill the already compromised kidneys very quickly.
So, simply put, for the Medics, if you have a patient with bilateral pneumonia, normal to low wbc, lymphopenia, elevated CRP and ferritin you have Covid-19 in your hands. Predictors of bad outcome are: Liver enzymes above 5x normal, low platelet counts, ratio of absolute neutrophil to absolute lymphocytes more than 3.5.
The treatment of Covid-19 in the hospital setting is usually supportive. Most patients will recover and can be discharged home with or without oxygen.
Worldwide 86% of Covid-19 patients who go on ventilator die. Therefore, it is a prayer that you do not get the cytokine storm which in our world, in Ghana, with limited resources, would almost certainly lead to death. There are many investigational medications in use at the moment. Due to the very poor outcome of patients on the ventilator their use should be started early before the cytokine storm hits.
These medications have not yet been shown to make a difference in the ICU patients. These medications include but are not limited to: Hydroxychloroquine, Chloroquine phosphate, Azythromycin, Tetracycline, Remdesivir and Favipiravir.
For the Medics, once you decide to put someone on the ventilator, the setting must be as you will use for Acute Respiratory Distress Syndrome patients ie, low volume, permissive hypercapnia but keep a high PEEP between 14 and 25.
Even though these patients are dehydrated, their lungs cannot take too much IV rehydration and they will quickly drown. Therefore it is advised to use fluid cautiously.
It has been observed that patient oxygenation is better when he or she lies on the
stomach rather than the back.
It has also been observed that following management modalities cause more harm and
must be avoided or used with caution.
- Steroid use has not been shown to make a significant difference; it has been reported that it makes the patient worse and must be avoided. In this acute setting one needs a high immunity to fight the infection and steroid use has the potential of lowering one’s immunity
- Bipap does not work well and should be avoided. It also aerosolizes the virus for many hours, especially after a cough or sneeze and poses a danger to staff and other patients.
- Nebulizers also pose the same problem like the Bipap. It is better to use inhalers for wheezing in Covid-19 patients. But if compelled to use it, keep the patient in a negative-pressure room, and let the patient turn on and off the machine him or herself. Do not be in the same room with nebulising patients.
By the time the Covid storm is over we would have known how to treat it and even prevent it. But that would be too late for many people.
We need to act fast and use the little knowledge we know to prevent more catastrophes. We will have more time to do retrospective studies but have limited time to do prospective ones. So far, in Ghana, we are doing all the right things, thanks to the leadership. We need to prepare a modality of treatment to prevent/reduce the number of patients requiring ICU treatment.
We have azithromycin and will soon have chloroquine phosphate and hydroxychloroquine. We must use these medications liberally on all Covid-19 patients with pre-existing conditions such as: hypertension, diabetes, kidney failure, sickle cell, liver disease, asthma, COPD, alcoholics and so on. It is obvious that the number needed to treat (NNT) to save one life may be high, but given the safety profile of these medications the harm they will cause will be very minuscule.
John Awah, MD, CCD
Internal Medicine & Osteoporosis