Covid – by Galaxy Jane
As a medical provider (PA-C with ten years of practice and a focus in Adult Primary Care and Occupational Medicine) who was recently the poster child for physically fit, middle-aged adult with zero co-morbidities hospitalized with a severe COVID-19 infection, I’ve been given an unusual perspective on the disease process from the inside with lots of good colleague conversation and education from the doctors, respiratory therapists, nurses and others that have been on the front lines of the pandemic during the course of my stay. I came out of it with a strong desire to counteract the constant media fear-mongering by demystifying a highly-predictable disease process and help people understand what they may experience if they fall ill and some of the progress we’re making with treatments.
I’d also like to offer some practical tips that can help you make the best recovery possible. We are almost certainly going to be living with this disease for a while and I think greater understanding can help us be appropriately cautious but less fearful as we go about our lives during this outbreak.
Nothing said herein should substitute for medical advice and care from your primary care provider or other medical specialist. I would also note that treatment protocols will continue to change as more data comes in, so any comments about current treatments is a snapshot in time reflecting practices in a specific East Coast hospital in mid-July 2020. All remain in stage 3 clinical trials, so are being implemented under experimental/compassionate use.
COVID-19 is a three-stage disease, following a predictable pattern and course over time. Each stage lasts approximately one week. Most people will not experience all three stages.
The first stage is the Viral Stage. These are your asymptomatic and mildly symptomatic people, who may never realize they had COVID-19. Symptoms are generally non-specific and include sore throat, low grade fever, post nasal drip, generalized aches and pains, nausea or diarrhea. The symptoms of this stage that are most specifically associated with COVID-19 are a fever higher than 100.3 F (38 C), and profound loss of the sense of smell and taste. Approximately 80% of those infected will not progress beyond this stage and will recover in approximately one week without further health issues.
The second stage is the Respiratory Stage. This is when cough develops, usually after about a week of non-specific illness, although it can be the initial symptom noted. The cough is usually dry and hacking, but can sometimes be productive. For most people who enter this stage, this is as far as the disease will progress and cough will remain mild. Mild disease simply means that you have good oxygen exchange on room air (i.e. without supplemental oxygen) and can range anywhere from a slight dry cough through mild viral pneumonia without respiratory compromise. So you can be quite uncomfortable while still being “mildly ill”. Most people who enter this stage will continue to be able to care for themselves at home and will make a full recovery without lasting side-effects.
The important thing about this stage is that this is where things may take a bad turn and if they do it will most typically happen around day 8-10 from the original onset of symptoms. This is the time to be extra scrupulous about monitoring your symptoms for worsening shortness of breath, chest pain, and to use a home pulse oximetry device (a small tool that clips to the end of your finger and measures the percentage of oxygen in your blood) if you have access to one. Worsening symptoms or a sudden drop in oxygen levels should prompt you to seek immediate care through your local hospital emergency room.
If you require admission to the hospital during this stage, you may be treated with a steroid called dexamethasone that has been shown in European trials to significantly reduce the risk of death and may also prevent future complications by reducing inflammation in the body. If the latter is borne out over time, this is going to be the real game changer. Preventing deaths is important, but preventing lung, heart, and other organ damage in the survivors will affect more lives long-term. Fortunately, dexamethasone is also cheap as chips and readily available. If you are sick enough to require supplemental oxygen, you could also be treated with something called convalescent plasma, which is an antibody rich blood product from a recently recovered patient, that can help directly fight the virus.
The respiratory stage also lasts approximately one week and most people who enter this stage will recover about day 14 without any additional care. This is what they mean in the media when you hear that people with mild disease will fully recover by about 2 weeks.
The third stage is the inflammatory stage. Entering this stage is rare but very dangerous. This is the stage where inflammatory markers rapidly increase causing blood clots in small vessels throughout the body and other sorts of lung, heart, blood vessel and other organ damage if not controlled. This is also the stage where patients develop ARDS (Acute Respiratory Distress Syndrome) due to damage to small vessels and alveoli in the lungs and may require intubation and ventilatory support. If this becomes necessary, outcomes are generally poor with both high mortality and lung damage in survivors.
If you enter this stage you may be treated with an anti-viral drug called remdesivir if it was not started earlier for decompensation (worsening ability to for the lungs to take in oxygen) during the respiratory phase. In an ideal world, we would start this medication even earlier, even before dexamethasone, but high cost and limited availability means that it is currently being reserved here for the sickest patients. It is given IV over five days (sometimes extended to ten), so if you are put on this medication you will have to stay in the hospital for the full course of treatment.
This stage also usually lasts about one week and is what is meant in the media when they say that severe cases usually resolve in a total of three weeks (although recovery in critically ill patients may be protracted). Even here most folks will recover, albeit possibly not without high level medical care and long-term health effects.
My own illness followed this pattern slavishly. For the first eight days, I still felt perfectly well and healthy, despite some mild aches and pains, nausea and the inability to smell or taste (which both sucks and is really, really, weird). Day nine, I developed a pertussis like cough which worsened rapidly over the next two days, but as my oxygen levels remained normal I continued to care for myself at home. Day twelve, I woke up feeling “not right” although not short of breath per se and when I used my pulse oximeter, discovered that my oxygen levels had dropped quite low overnight (normal is 95% or greater, mine was 88%), prompting an immediate trip to the local ER from where I was admitted.
According to my in-hospital pulmonologist, I presented right on the line between the second and third stages. I was developing respiratory decompensation, but while my inflammatory markers were high and rising, I was not yet to the point of irreversible inflammatory cascade. I received my first dose of dexamethasone upon admission and within twelve hours my markers were trending back towards normal. While my respiratory status did continue to worsen and my oxygen requirements increased steadily over the first 36 hours of my hospitalization, the second night saw the beginning of rapid improvement in lung function and I was able to be released home without oxygen on hospital day four (day sixteen of my illness) to complete my dexamethasone treatment there while I recovered. By day twenty-one my cough had resolved and my lung capacity had returned to near-normal although I was still somewhat short of breath and extremely fatigued (also crazy from the steroids).
I’m now five weeks from my first symptoms, my chest x-ray has returned to normal and I started running and weight training again last week. While it will be a little longer before I am all the way back to my previous fitness level, I can say with some confidence that I am fully recovered and my PCP has no worries about long-term health effects because I turned the corner before I showed any signs of organ damage.
Very few COVID-19 patients are requiring ICU treatment here in East Coast City now, because slowing things down back in March and April not only succeeded in keeping the system from ever being overwhelmed, but it has allowed time for treatments to be developed and deployed so local patients are now pretty evenly spread between the Medical/Surgical ward (this is a general hospital ward, basically where you go for observation to ensure you are stable), the Intermediate care or Step-Down unit (so called because it is a “step down” from the ICU and is for people like me who need closer monitoring and telemetry, but do not require critical care nursing) and the ICU/CCU (An Intensive Care or Critical Care Unit, for patients who require close round the clock monitoring. This is also where any ventilator patients will be).
About 2/3 of those admitted here now are not getting sick enough to reach the need for ICU/CCU. They are also admitting patients now for observation that would have been sent home to care for themselves earlier in the pandemic, when we were worried about overwhelming hospital resources. While the hospital ICU was fairly full during my admission, I have it directly from staff that very few patients were there for COVID-19, it was simply full of the normal ICU things that ICUs are typically full of this time of year.
I am not going to talk about things we can do to keep from catching COVID-19 as I feel we are all well aware of risk mitigation at this point. The constant drumbeat of the last five months has been, “don’t catch it, don’t catch it, don’t catch it”. But with sustained community spread, it is important that we have get comfortable with the idea that eventually a lot of us are going to be infected, no matter what precautions we take. So what practical things are within our power to reduce our chances of a bad outcome? And hopefully also reduce our stress about the parts we can’t control.
Start exercising today. Just a walk around the block if that’s where you are. Then add a bit every day. I know a lot of us went into lockdown thinking it was going to be a few weeks at home baking sourdough and drinking wine (no judgement from me!) and now it’s 5 months gone and we haven’t set foot outside the house except to work or get groceries. That’s OK, start where you are. The better condition your heart and lungs are in, the faster you will be able to recover. And better lung health will better enable you to withstand the respiratory symptoms of the second stage of disease. I do believe that going into this with a high level of aerobic fitness contributed to my rapid and complete recovery.
Exercise, fresh air and sunshine also naturally boost immune response, making you more resistant to becoming ill and hopefully helping you throw off disease more easily. And let’s face it, outdoors is probably the safest place you can spend time right now, no grotty surfaces or enclosed air circulation to spread the virus around, and viruses don’t like sunshine. Take advantage while the weather is still good, because colder days will be around the corner before you know it.
Corollary to the above. Other than age, the greatest risk factor for a bad outcome with COVID-19 is diabetes, the next greatest is obesity. These outweigh even chronic lung conditions such as COPD and asthma. While exercise alone will not necessarily help you lose weight, it will help keep your blood sugars in a safe and healthy range. Blood sugars spike uncontrollably even in some otherwise healthy people during the course of illness and this is associated with significantly worse outcomes. Make sure all of your diabetes medications are optimized and that you are checking sugars daily to stay in the ideal range, this is not the time for poor blood sugar control.
Lose weight if you can. I know we always say that when you come in the office, but this time instead of it being an abstract thing that may lengthen your life ten or twenty years down the road, during this pandemic it may make a difference next month. No crash diets right now, but a steady controlled weight reduction program with the knowledge of your primary care provider is a really good choice. I’m agnostic about how you choose to lose it, the best diet is the one that works for you.
Make sure you have all your chronic conditions under the best possible control. Diabetes, Blood Pressure, Heart Disease, Asthma, COPD, etc. Make sure you are staying in close contact with your PCP, even if this is telephonic or virtual, and ensure all your medications are up to date, you have any refills you need and that all your dosages are optimized for best overall health. Any co-morbidities need to be managed aggressively before you become ill.
As far as supplementation goes, if you do get sick, the supportive care regimen from the local ER for patients who can care for themselves at home is Tylenol for aches and pains, plus 500 mg Vitamin C and 220 mg Zinc Sulfate both taken 3 times a day for 10 days. I also was prescribed these during my admission and upon discharge. These supplements may have properties that slow viral replication and they are both readily available and unlikely to cause harm, so it’s not a bad idea to have them on hand to start taking if you become ill.
There is also growing evidence that low Vitamin D levels are associated with adverse outcomes. Most Americans are Vitamin D deficient, so in addition to daily walks in the sunshine I suggest supplementation with 2000 IUs Vitamin D3 daily. This is in addition to any you may be getting from a standard multivitamin. This you need to start now, and not after you are sick as it will likely take 8 weeks or more to get levels close to normal if you are currently deficient (and you probably are).
If you get sick with anything you believe could be COVID-19, no matter how vague and non-specific, STAY HOME, even if you choose not to be tested. CDC guidance for patients with symptoms is to stay home for a total of 10 days from onset of illness. At the end of that period if respiratory symptoms have improved (they do not have to be completely resolved) and you have had no fever during the last 3 days of your quarantine, you can return to work or school. This may seem obvious, but I was surprised how few people know the guidelines. Staying home if you are sick is the single most important thing any of us can do to slow the spread of this virus.
I do advise going ahead and getting tested if you develop symptoms, even if you are fully able to take care of yourself at home. This is both to give yourself peace of mind and because I suspect that in the next few months there are going to be situations where proving you have already been infected will just make your life easier. No, I’m not talking about “immunity certificates” per se, just that if my choice is between showing some business (say, an airline representative, or a conference organizer) a copy of my positive test result, rather than having a swab shoved halfway into my brainpan again 48 hours before some event, I know which I’d prefer. I would also get tested if a family member or close contact becomes ill, even if you remain asymptomatic. This can keep you from spreading the virus unknowingly and may actually allow you back in society more quickly if you test positive than if you don’t. The Virginia Department of Health guidelines for those exposed, but not symptomatic can be found here https://www.vdh.virginia.gov/coronavirus/local-exposure/ I think this breaks it down better than the CDC page and I include it here as the guidelines for asymptomatic contacts are actually more complicated than for those who get sick.
Testing options are going to vary by geographic location. Locally, we have one pharmacy chain that will test anyone, usually within the hour and another which is still using criteria from back in April and turning down most of those who ask. If you have kids, be aware that many of the drugstore chains are unable to test under 18s and they may require a trip to the local Urgent Care instead. The best advice I have is to check websites or call ahead about requirements and see if you need to make an appointment wherever you plan to be tested.
Also be aware that, again depending on location, results may be coming back really slow right now. Mine took eight days (by which time I was already hospitalized) and I understand that the average in my state recently reached ten days, which is not super practical from a contact tracing perspective. It is still valuable information to have for yourself. As contact tracing cannot function when tests are this untimely, I urge you to do the right thing, and if you have any suspicion you may be infected, reach anyone you came in close contact with (defined as within 6 feet for more than 15 minutes) in the 48 hours before you developed symptoms. The faster you do it, the faster they can take precautions, and waiting for your local health department to be notified of a positive result may mean it’s two weeks before they have any clue they were exposed. You are most infectious in the 48 hours before and the 72 hours after developing symptoms.
If you become ill, and particularly if you enter the respiratory phase of illness, a home pulse oximeter (pulse ox) is a really useful tool for knowing if your cough is just annoying or becoming something dangerous. Always listen to your body first. If you are short of breath or having chest pain, go straight to the ER, even if the numbers look fine. Don’t be afraid of wasting their time, that’s what they are there for.
A normal oxygen saturation level (the percentage of oxygen dissolved in the blood, also referred to as sat) is between 95-100%. If your levels are in this range you are most likely safe to care for yourself at home, but should keep in touch with your PCP so they can help you stay on top of your symptoms. They may also be able to prescribe medications to keep you more comfortable while recovering at home.
If you are between 93-94%, reach out your PCP, Urgent Care, or your local ER (who should have a COVID hotline) right away to let them know of the change and see what steps they want you to take next. If there is no response, go to your local ER for further care.
If your sats are 92% or lower, go straight to the ER. One of many weird things about this disease is that oxygen levels sometimes drop dangerously low without subjective symptoms of shortness of breath, so this may be the only early warning sign you get that things are going bad. In my own case, this was how I knew it was time to go to the hospital and upon admission, I was told that I had come at exactly the right time. A day sooner and they’d have sent me home, a day later and I would likely have been much further down the path of inflammatory cascade.
A very important part of this, is that you need to get the pulse oximeter before you get sick, and learn both how to use it correctly and what your normal is, in order to use it effectively when the time comes. Some important things to note are that nail polish or artificial nails can interfere with getting a good reading, your hands should be warm before you apply the device and you should give 30-60 seconds for the reading to settle before taking the result. But they cost around 20 dollars on Amazon or at your local pharmacy and should be sitting right next to your thermometer in your medical toolbag.
I don’t want to underplay that COVID-19 can be a severe disease with serious consequences. I am living proof that even the lowest risk can have an unpredictably bad course and there is very little we understand about why that happens. But I think the overall picture is encouraging and looking better by the day as we learn more about how this thing works. If I had been ill even a few weeks sooner, I would have had a far more protracted recovery, and possibly long-term health issues as dexamethasone was not yet being widely used outside of a handful of academic medical centers nationwide.
Getting as sick as I did was pure bad luck, rather like being struck by lightning, but my ferocious recovery was not accidental. It was the work of really good doctors and medical care team members who knew how to treat me, and the fact that I knew when to seek care instead of waiting to get sicker. And probably a little bit because I was in really good shape prior to my illness.
My hope is to give some knowledge and tools to aid in understanding what COVID-19 is, how it typically presents, the latest in treatments, and what steps you can take to ensure the best possible outcome if you get sick. It’s time to move from a place of fear to a place of cautious confidence. There is still a lot we don’t know, but we really are making progress.