We are on the back slope of the epidemic, according to University of Massachusetts Dartmouth Professor of Biology Erin S. Bromage, Ph.D. He explains what to expect and where not to go in an article this week which was cited in the New York Times: The Risks-Know Them-Avoid Them. The bad news is that the back slope can have as many deaths as the upslope.
The good news is that you don’t get COVID outdoors, as long as you are not standing close to someone who might have the virus for a period of time, perhaps over ten minutes. Bromage reviews a series of epidemiologic studies tracing the spread of the disease in situations including standing outside talking to someone (one case), church choir practice (45 of 60 infected, 2 died), indoor sports, specifically a curling tournament in Canada where 24 of 72 attendees became ill, birthday parties and funerals (high rate of infection and many deaths related to hugging, kissing and sharing food), grocery stores (safe for shoppers but employees get infected), and restaurants (50% infection rate after sharing a meal with nine at the table). He also reported details about the spread of disease at meat packing plants, a call center and a medical conference.
The risk of infection increases with exposure to a larger number of virus particles over a longer period of time in a smaller space with poor air flow. This is why shopping and outdoor activities are not likely to be dangerous. Breathing releases a small number of virus, between 50-5000 droplets per breath. Talking expels more and singing is definitely a means of spreading virus. A single cough releases 3000 droplets traveling 50 miles per hour, mostly falling rapidly to the ground. In contrast a sneeze may release 30,000 droplets at 200 MPH, many of which are smaller and stay in the air longer.
Dr. Bromage writes that 44% of infections come from people who have no symptoms at the time. The virus can be shed up to five days before a person becomes ill. Most people contract COVID from a family member who brings it home. Children are three times less likely to become ill but three times more likely to spread the virus.
I wondered if the lower barometric pressure at altitude could cause viral particles to be less compact. I called Peter Hackett, MD of the Hypoxia Institute in Telluride and he agreed that theoretically the less dense air would not carry as many particles. We also discussed antibody tests, which are still experimental, not recommended and difficult to interpret. The population screened in Telluride showed a 0.5% positive rate, but when a disease has a low prevalence there are more false positives. They did blood tests on some 5,000 people early in the outbreak. They were not able to repeat the serology due to staffing problems at the lab where many technicians contracted the illness.
My advice is to wear masks anytime you are out of the house, except if you are biking, hiking, running where the viral particles will be dissipated rapidly. Wearing a mask during these activities is still a kind gesture to reduce the anxiety of others. Continue with frequent hand washing, avoid touching your face, practice social distancing, and when the churches reopen we should hum instead of sing.
Today, I am going to share news gleaned from meetings and publications that address the importance of preventive care, returning to daycare, pulse oximetry as a screening tool for COVID, and the Accordion Theory.
Every Thursday the Children’s Hospital of Colorado presents a panel of experts with updates and answers to questions.
“Your offices are the safest place in the country,” they proclaimed. With social distancing many parents and patients are delaying routine care which has led to the largest drop in vaccination rates in 50 years. This could result in outbreaks of measles, whooping cough, pneumococcal and other infections. With the loss of revenue, small clinics may go out of business, and large clinics and hospitals are laying off workers by the hundreds. If there is a large outbreak of preventable disease, on top of a resurgence of COVID, there could be a devastating shortage of providers to care for the victims. Now is the time to call your clinic and set up appointments for check ups and vaccines. If you don’t feel safe yet you can do a Telehealth visit initially and schedule the vaccines and hands-on portion of the exam in a month.
Another reason not to delay preventive care is the increase in stress, isolation, and anxiety which can cause serious depression. We had a tragic teen suicide in the county this month. Students from middle school through college should be seen annually for mental and physical health screening as well as vaccines. One mother told me that the depression screening done at our office “saved my daughter’s life.”
More daycares are opening soon. Parents are asking me whether to send their child back. These facilities follow strict public health guidelines to prevent infection. Children are not likely to be affected by COVID. Any child with symptoms should be tested. Enrollment should be diminished due to parents preferring to keep their child at home. However, if there is a high risk family member, I advise not to return to daycare yet.
School age children should be limited to playing with friends and family members who have been part of their social circle during the last two months. To borrow a slogan from the AIDS campaign, “KNOW YOUR NETWORK”. This is not the time to expand friendships. There will be no team sports this summer. Children should play outside and not share toys or balls.
An emergency physician in New York, Richard Levitan, published an editorial in the NY Times on April 20 advocating the use of pulse oximeters to screen for COVID. Citing the many patients with low oxygen levels and abnormal x-rays who did not complain of trouble breathing, the delay in obtaining results and inaccuracy of the COVID testing, he sees the simple pulse oximeter as a source of immediate information as to who needs medical attention. I’ve been speaking and writing about this for weeks.
Finally, one of the panelists at Children’s mentioned the accordion phenomenon. As we reduce social distancing restrictions and open commerce and travel, there will inevitably be more cases of COVID. It is likely that restrictions will be imposed again, and this may occur in cycles during the next year(s). We may be able to decrease future shutdowns by wearing masks and gloves when we go out, using hand sanitizer, soap and water, not touching our face, covering our coughs and sneezes, and limiting exposure to large groups of people. I hope all these will be permanent behavior changes except the masks and the large groups (I love the Lake Dillon Amphitheater and the BBQ challenge).
Take care, stay engaged, and have another safe week!
A panel of experts at the University of Colorado School of Medicine had some good news this morning: we may have passed our peak here in Colorado.
Of the 8,675 cases there are 374 deaths. Less than 2% of those with the illness are under age 18, compared to the population of 22% children. This week there are only 4 children admitted to Children’s hospital with COVID-19, two in the ICU. There is a leveling-off of patients presenting to the hospitals and less ICU admissions.
So social distancing has flattened the curve and no hospitals were overextended or lacked ventilators. The initial R naught (the number of people infected from one individual) of each infected person spreading to 4 is now down to 1.5. A study from Singapore showed that 7% of cases came from presymptomatic persons. The infection can be transmitted 2 to 3 days before symptoms show. Of 121 healthcare workers exposed 35% developed symptoms but only 2.5% tested positive.
Our own experience with testing has been equally frustrating. The virus can be present for weeks but usually rapidly declines after 7 days. The PCR test (polymerase chain reaction test – the standard nasal swab being conducted to test for Corona virus) is said to be 75% accurate in detecting viral RNA. Even patients we’ve tested during the first 4 days of typical symptoms have been negative. Other viruses identified at Children’s Hospital in the last month include rhinovirus, adenovirus, enterovirus and human metapneumovirus, which can all cause fevers and respiratory illnesses.
However, many people we are treating have the unusual symptoms and course that seems unique to COVID. Not all have fever. They experience chills, fatigue, sore throat, then improve. A day later they are having chest tightness, trouble breathing, making it difficult to talk or walk, and upper abdominal pain. They feel worse at night and better in the morning. Symptoms can last for weeks. Lung specialists describe several different effects the virus can have. ARDS (adult respiratory distress syndrome) is a diffuse loss of protective protein that causes the air sacs to collapse. The pulmonary disease in the second week is described as a cytokine storm, where the immune system overreacts and damages the lungs.
Testing is less accurate when the prevalence of a disease is low. In Colorado 1.4% have been affected, in comparison with Wuhan where 5-10% were. Experts and individuals are waiting for antibody testing to see if they are immune and if so for how long. Immunity in similar infections has been shown to last anywhere between 3 weeks and 3 months, as opposed to diseases like measles and chickenpox which confer lifelong immunity.
Pediatricians are seeing few patients in the office these days, which raises the concern for a future epidemic of preventable diseases from a delay in vaccinations. Most clinics, like Ebert Family Clinic, are only seeing healthy patients or those with noninfectious complaints such as eczema and lacerations. Anyone with respiratory symptoms or fever is seen by Telehealth. This is effective because COVID, like most illnesses in the community, is usually mild and self-limited. Antibiotics are rarely indicated. A recent study showed that of several hundred children diagnosed with community-acquired pneumonia, those given antibiotics had the same outcomes at those who were not treated, with 4% of each group needing hospitalization for worsening symptoms.
Telehealth does not allow for auscultation of the heart and lungs (listening with a stethoscope), but the vital signs including oxygen saturation, heart rate and temperature along with the patient’s history usually give the provider enough information to make treatment and testing decisions. A face-to-face video interaction is ideal, protecting the patient and provider from exposure to infection. The expanded use of Telehealth is one of the good outcomes of this pandemic, especially in states like Colorado with far flung rural populations.
The University of Colorado is doing 3000 telehealth visits daily. Specialists at Children’s are ramping up their services online while accepting the sickest patients in the state for inpatient care. They have the largest number of doctors in Colorado, many of whom are in research and can transfer to frontline and ICU duties. The University does 500 million dollars of sponsored research every year, with over 1000 studies. Many of these are on hold now, but with the capacity to initiate new trials within a week and laboratories adjacent to clinical care sites, CU has been tapped for many COVID-related studies. They are testing several antiviral drugs, including the new product from Gilead laboratories Remdesivir. There are also studies on disease modifying treatments such as steroids to prevent future problems caused by the infection. Other trials focus on sample collecting and processing. Some studies may show results within weeks but others take months or years to determine effect.
The University was one of the first centers to use convalescent plasma to treat COVID. The hope is that antibodies from previously-infected and recovered individuals can be lifesaving for severe cases, although the best timing of such treatment, originally used one hundred years ago in the influenza epidemic, is not yet determined. Plasma donations can be arranged by visiting the UC Health website. Since most people will not need hospitalization, instructions for home care can be found on the CDC website.
Vaccine development will proceed over the next 12 months. Until then, lifting of current social restrictions will depend upon having adequate and accurate testing to find cases early enough to quarantine patients and public health workers to trace contacts. Antibody testing must be done and repeated over months and years to determine susceptibility. Continued use of masks in public and the prohibition of large gatherings may continue for a year.
Another Spring season in Colorado. The ski resorts have closed early per the COVID-19 protocol, along with most other establishments. Even on the normal schedule, most ski resorts would have been closed for the season by now, bringing more people to the backcountry. But this year seems to have seen an upswing in backcountry activity, where many people are going to stay active while limiting exposure to others. Just over a week ago, a team of 20 search and rescue volunteers rescued a 26-year-old man who had fallen hiking on steep terrain around St. Mary’s Glacier, Colorado. Last year, a total of 10 snowmobilers were killed in the backcountry in avalanche slides. Only one was wearing a beacon.
Backcountry and Avalanche Safety resources, thankfully, are growing more plentiful and accessible, and last winter, we published an article on the basics. Earlier this winter, I spoke with backcountry athlete and web development colleague Dan Beerman, whose experience in the backcountry really broadened as a backpacking guide in New Mexico during the summers 12 years ago, followed by a position as a climbing instructor.
Dan Beerman on the Pacific Crest Trail
When I was a backpacking guide, I was on the search and rescue if I didn’t have a crew … We had a radio, so we were the point of contact for finding and doing extraction. That’s when I learned the most and was exposed to the most. I took my Wilderness First Responder course in 2014, and that was through the Wilderness Medical Institute.
Dan’s also a fellow hut tripper, and we’ve been talking about doing one together (when we’re on the other side of the current pandemic). He’s spent the last two New Year’s in huts, backcountry skiing or snowshoeing tours. This past year, he skied Buffalo Mountain’s Silver Couloir, in the Gore Range, and made an attempt at a couloir on Mt. Torrey’s. And there have got to be some good “couloir” puns out there.
Beerman on Buffalo, Summit County, CO.
I have aspirations to do the Colorado trail quickly, but I don’t know if I wanna do that in a competitive way or just recreationally backpack it. It’s hard to balance summer objectives, or climbing objectives vs. winter backcountry goals vs. alpine mountaineering objectives.
And he makes a great point:
In Colorado, your recreation is so close to becoming high-consequence all of the time! If the weather changes from the trailhead, that could be a really big problem.
I’m familiar. Nothing really teaches you as much or as quickly as getting caught in Colorado’s extreme weather patterns.
Avalanche Safety
Dan took an Avalanche Awareness and Safety class through Colorado Mountain School, held up in Rocky Mountain National Park over two field days after two nights of class in Boulder. His main takeaway:
Check an avalanche conditions snow report daily. Observing the snowpack over the seasonis going to make your confidence on the day of your excursion a lot higher. I’d had no context for why avalanches were happening, where and why it’s dangerous. Having that lens through which to view weather events in terms of avalanche conditions is so valuable. It’s an intuitive thing about paying attention to the weather.
This is my first season getting out at Copper, for example, and they all have that double-black diamond terrain in the back bowls that are labeled ‘EX’ on it. There’s a sign that says, ‘Ski with a partner,’ and I just thought, ‘Oh, shit, that sign should probably be much bigger!’
Beacon, shovel, probe are the mandatory avalanche terrain items — you’re putting other people at risk if you don’t have [them], because even if you observe a slide, you can’t do anything about it. Additionally, if you don’t have a beacon in a slide, others can’t find you. You’re not contributing to a rescue, nor can you be rescued. In Colorado, there’s an increasing awareness for that. I typically will bring that with me all the time, it’s just always in my ski bag. Having some snacks, having some water, those are the kinds of things: you should never not have them.
Beerman in his beacon.
Training
I’ll take the goals of the expedition and plan accordingly. If I’m doing a ski trip, I’ll wanna get out and do hikes with weight or runs where I’m doing elevation several times. I like to do six weeks out, of four weeks of training and two weeks of tapering down.
Nutrition
I tend to be in a constant attempt to gain weight. On the Pacific Crest Trail I tried to gain weight prior, eating a lot of fatty foods, that kind of thing. Jonathan and I came up with this metric: calorie-per-dollar-per-ounce. Lightweight food that’s affordable, easy to ingest, easy to prepare, and you aren’t having to burn a lot to carry that with you to the backcountry.
[On the trail], peanut butter is always a winner. Olive oil is one of the highest calorie-per-ounce [food]. I have literally drank it before, but just add it to everything. I do eat a lot of standard trailmix, it’s easy and accessible. I’m a big fan of pumpkin seed mix or stuff with chocolate in it. I like CLIF bars. I do not like Luna bars because I’ve eaten so many of them. I can’t eat pop tarts anymore because they used to be in the meals that were issued when I was a guide. Snickers bars are a great calorie-per-dollar-per-ounce deal. I eat a Snickers bar or two before bed when I’m sleeping at altitude so my body has calories to stay warm.
I’ll make these mass-gainer complex food supplements. It’s like protein powder, but it also has carbs, like a workout and performance powder. And I would add that to water with coffee, and that would be a breakfast while hiking. There’s a lot of different kinds of powders and mixes you can add, but when you’re in calorie-burning mode, I do recommend this. If you’re hiking 20+ miles in a day or 4000+ feet of elevation in a day, you’re burning greater than 4000 calories, so you really have to eat more than you think you can.
Acclimatization
I wouldn’t say that I had HAPE (high altitude pulmonary edema) or HACE(high altitude cerebral edema) … Definitely, especially when I was younger … I would travel from 4000′ to 10,000′ in a 24-hour period. I’ve actually had search and rescues where someone was having night-terrors or hallucinations [due to HAPE or HACE]. I was a backountry professional for the Boy Scouts at a camp at 10,800′ (one of the first backcountry camps, in New Mexico). I’ve experienced dizziness, nausea, insomnia, weakness of the knees, elevated heart rate … and I’m a runner, I’m in decent shape. But you should acclimatize before setting out on a trip.
Skiing down the Silver Couloir.
One last piece of advice,
Learn the Leave No Trace principles. We live in a state where impact is so concentrated that the more that everybody knows, the more likely it will be there for the next generation.
Dan and his backpacking, backcountry cohorts keep a blog full of breathtaking landscapes and telling captions on CaptainsofUs.com.
There will be plenty of time to escape to the backcountry again after the risks of COVID-19 have subsided. The current time is a good time to start preparing mentally. Know before you go.
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
Dr. Chris with Dr. Eric Swenson from the University of Washington
An article published yesterday, April 13, 2020 in the Journal of High Altitude Medicine and Biology clarifies misconceptions in the media comparing high altitude pulmonary edema (HAPE)and COVID lung injury. The six authors include two critical care pulmonologists from the University of Washington: Andrew Luk MD and Eric Swenson MD, as well as Peter Hackett MD of the Hypoxia Institute in Telluride and the University of Colorado Altitude Research Center. Dr. Swenson is the editor of the journal and has given presentations in Summit County on altitude. Both Dr. Hackett and Dr. Swenson personally communicated with Dr. Chris yesterday.
Dr. Chris with Dr. Peter Hackett of the Hypoxia Institute in Telluride, CO
Severe viral pneumonia, as seen in COVID-19, can cause Adult Respiratory Distress Syndrome (ARDS) leading to respiratory failure and the need for ventilator support. As with HAPE, this is a form of non-cardiogenic pulmonary edema, where the air sacs in the lung fill with fluid due to conditions not related to heart failure, the most common cause of pulmonary edema. Other causes include bacterial pneumonia, near-drowning, nervous system conditions, re-expansion, and negative pressure edema. Radiographic findings are similar in all these cases with diffuse bilateral densities in the lungs. All these patients have severe hypoxia.
At altitude, hypoxia can lead to uneven pulmonary vascular constriction, (hypoxic pulmonary vasoconstriction or HPV). In the areas with the highest pressure, fluid leaks from capillaries into the alveoli. With COVID, alveolar inflammation reduces the protein surfactant that maintains expansion of the alveoli. The alveolar collapse causes hypoxemia, low blood oxygen. Severe viral and bacterial infections also cause inflammation in other organs, such as the liver, kidneys, and brain, which is not seen with HAPE.
Medications used to treat HAPE are not likely to be useful in treating COVID pneumonia and may have harmful effects such as increasing perfusion to damaged areas of the lung that are not oxygenated.
Both these conditions likely have large numbers of patients with mild symptoms who recover without seeing a medical provider. However, both HAPE and COVID can cause a sudden, rapid deterioration with severe hypoxia and death.
ACCESS TO A PULSE OXIMETER TO TRACK OXYGEN SATURATION IS VITAL.
Oxygen levels below 90% merit medical attention. Pulse oximeters can be purchased online, at drug stores, or at Ebert Family Clinic.
A good friend in Hawaii recently sent me a YouTube video referencing Dr. Cameron Kyle-Sidell, a critical care and emergency room physician at Maimonides Medical Center in NYC. Dr. Kyle-Sidell was discussing his findings while working with COVID-19 patients in NYC and compared those findings to altitude sickness. I did a search and found he had posted several videos on social media comparing Acute Respiratory Distress Syndrome (ARDS) in COVID-19 patients to altitude sickness and reconsidering how these patients are treated. Altitude sickness is something I see and treat frequently here in Summit County. Based on the similarities between the two conditions, the same treatment for altitude sickness and high altitude pulmonary edema (HAPE)[1] may be beneficial to COVID-19 patients.
In an interview with Dr. John Whyte, Dr. Kyle-Sidell described the acute ARDS he is seeing in COVID-19 patients as atypical and not responsive to standard treatment, specifically in regards to ventilator use and settings. He describes some of his patients as alert, talking in full sentences, and not complaining of shortness of breath but have oxygen saturation levels in the 70s (John Whyte & Cameron Kyle-Sidell, 2020). Normally, that is not the case when a person has an O2 saturation[2] in the 70s and is in respiratory distress. However, this is not abnormal in patients with altitude sickness and HAPE. There are certain protocols in hospitals regarding when to intubate a person and to put them on a ventilator. According to Dr. Kyle-Sidell, these protocols apparently aren’t always helpful for COVID-19 patients with ARDS, and can at times be harmful.
The similarities between findings with COVID-19 and HAPE are remarkable. These similarities include: hypoxia (low oxygen levels), low CO2 (carbon dioxide) levels, tachypnea (rapid respiratory rate), patchy infiltrates seen on chest x-ray, bilateral ground glass appearing opacities on chest CT, fibrinogen levels/fibrin formation, aveolar compromise[3], decreased Pao2:FiO2 ratios[4], and ARDS in severe disease (Solaimanzadeh, 2020). Noting these similarities may be helpful when approaching treatments for COVID-19. Acetazolamide (Diamox), Nifedipine (Procardia) and Phosphodiesterase inhibitors (Viagra, Cialis etc.) have been used in treating HAPE and could possibly be beneficial in treating COVID-19. For example, Acetazolamide potently decreases the constriction of small vessels in the lungs that contribute to fluid build up (edema) seen in both HAPE and COVID-19 patients (Solaimanzadeh, 2020).
In our house call practice, we treat quite a bit of altitude sickness due to our elevation here in Summit County. During the ski season, we may see 3-4 patients per month that develop HAPE. The majority of the time, these patients can be safely treated and monitored in their residence or hotel room. Treatment for both altitude sickness and HAPE consists of oxygen, usually 2-5 L/min via nasal cannula continuously while sleeping or resting. We also treat our patients with an injection of a steroid, Dexamethasone. We closely monitor them and may repeat the dose of Dexamethasone or prescribe an oral steroid. These patients usually see some improvement by the next day and significant improvement when they descend in altitude. I have read recommendations for and against steroid use with COVID-19. More studies need to be done, which I will be following closely as future recommendations may change how I treat HAPE when there is also a suspicion of COVID-19.
The key to treatment is oxygen! We’ve seen patients with O2 saturation levels in the 40s and 50s and lungs that sound like a “washing machine”, as Dr. Gray, has described it (in a previous Doc Talk article). If we can get their oxygen saturation up into the mid 80s or 90s on 5L/min (of O2) or less via nasal cannula, typically, they can avoid an ambulance ride and emergency room visit. As Dr. Kyle-Sidell notes, many of the COVID-19 patients he sees are talking coherently and not in severe respiratory distress. A friend who is an EMT in New York described a man he recently transported to the hospital, in his 50’s, with presumed COVID-19. He had no respiratory distress, walking and talking coherently, no chronic medical problems but his oxygen saturation was in the 60s. He said they took him to the emergency room and he was intubated and placed on a ventilator. Apparently, this is a common occurrence from what he has seen. I am still amazed when a patient calls, gives me their address and directions to where they are staying and when I arrive, their oxygen levels are in the 40s. It is a very rare occurrence that I need to send a patient to the hospital, which they always appreciate. We monitor our patients very closely until their departure and have them call anytime, day or night, with any changes in condition.
Dr. David Gray, who started our business, has been treating these patients for over 18 years. He states that in a few of the HAPE patients that he has treated, including his own 13-year-old son, he has seen O2 saturations in the 30’s & 40’s. In these few patients, he was only able to get their O2 saturation up to high 60’s, low 70’s, on 5 liters. They were so much improved, clinically, that he accepted those levels. A large dose of Dexamethasone & 12 hours of rest, on nasal oxygen, resulted in marked improvement by the next day, every single time. His rule, as in patients with DKA, is “if the pathology didn’t happen rapidly, you don’t necessarily have to reverse it rapidly.”
Dr. Kyle-Sidell suggests not putting COVID-19 patients on ventilators based solely on numbers (John Whyte & Cameron Kyle-Sidell, 2020). Treating these patients with prone positioning, oxygen via nasal cannula, high flow on a non-rebreather mask or CPAP[5] along with careful monitoring and a little patience may be preferable to a ventilator (John Whyte et al, 2020). If a ventilator is needed, using less pressure to reduce lung damage and higher oxygen levels may prove to increase the likelihood of a better outcome (John Whyte et al, 2020). There is so much to learn about COVID-19 and how to treat it. Treating it as you would with HAPE is certainly something to consider. I appreciate providers who are sharing their personal experiences in treating these patients. As healthcare providers gain more experience treating this virus and share their experiences, protocols will change and I suspect ventilator use as well as the death rate will decrease.
[1] A complication of altitude sickness in where the lungs fill with fluid and small amounts of blood
Danielle Shook MSN, NP-C is a board-certified Family Nurse Practitioner. She has been in nursing for over 27 years. She earned her Master’s Degree at University of Colorado, Colorado Springs through Beth El School of Nursing. Her nursing experience includes 10 years in Obstetrics and 7 years in Hospice home care. She has over 9 years experience as an NP which includes Family Practice at the Air Force Academy, Urgent Care, Acute and after hours care with the Army Premier Clinic as well as house calls.
References
John Whyte, Cameron Kyle-Sidell. Do COVID-19 Vent Protocols Need a Second Look? – Medscape – Apr 06, 2020.
Solaimanzadeh I (March 20, 2020) Acetazolamide, Nifedipine and Phosphodiesterase Inhibitors: Rationale for Their Utilization as Adjunctive Countermeasures in the Treatment of Coronavirus Disease 2019 (COVID-19). Cureus 12(3): e7343. doi:10.7759/cureus.7343
April 1 is traditionally celebrated in Colorado’s mountain resort communities as “Gaper Day.” Locals dress in their finest 70’s and 80’s outdoor fashions and commemorate the tourists who stop in the middle of the mountain to stare at the beauty that surrounds us. This year travel is discouraged, so the tourists are gone. Here are some local updates on the pandemic to reinforce these directives from Governor Jared Polis.
One day this week, several residents were intubated and transferred to intensive care in Denver. Physicians at St. Anthony Summit Medical Center have access to an ICU and ventilators, but patients with severe respiratory symptoms and hypoxia have a better chance at lower altitude. Let’s hope the day doesn’t come when the Denver hospitals are full, leaving us no choice but to provide this care locally in our low-oxygen environment.
As of April 3, 29 people in have been hospitalized with COVID illnesses, ranging in ages from 20’s to 60’s. There have been 43 confirmed cases in Summit County, according to the Summit Daily News. It’s here, it’s real, it’s dangerous to all.
Follow the footprints of the fox.
EVERYONE LIVING AT ALTITUDE SHOULD HAVE ACCESS TO A PULSE OXIMETER. You can buy this simple instrument at the pharmacies or call Ebert Family Clinic. You don’t need to go to the hospital if you are breathing normally and your oxygen is above 88%. You can call your doctor or the Ebert Family Clinic for a Telehealth assessment and advice. Our nurse practitioner Tara Taylor will be available 7 days a week between 9 am and 5 pm and Dr. Chris will answer calls and texts for parents and children 24/7. We all know to keep washing our hands: the Corona virus hates soap. Don’t touch your face.
And now I’m going to endorse recommendations from New York and other hard-hit locations: wear a mask and gloves when you go shopping. A bandana, ski mask, surgical mask, anything that reduces the spray of droplets from your mouth and the chance you will inhale these from others. We are all wearing gloves to keep our hands warm this time of year anyways.
For your mental and physical health, get outside every day. Walk around your neighborhood. Exercise stimulates the immune system. Sunlight helps prevent depression. Look up at the mountains. Gaze at the stars. Let us all be gapers.
It has everything to do with how well the body functions at increasing elevation. In Summit County, Colorado, we live at an average elevation of 9000′ (2743 m). Most bodies start a significant physiological response to 8000′ (2438 m). Even healthy athletes experience shortness of breath during certain activities that wouldn’t be noticeable at lower elevations. The body compensates by circulating more oxygen-carrying red blood cells, because there isn’t as much oxygen packed into each breath you take. Heart rate increases, you take quicker breaths, speeding up your ventilation. You are hyperventilating. If you manage well enough for a couple weeks, your body will eventually start creating more red blood cells to circulate more oxygen throughout your body at all times. This process will peak at about three months.
We often get questions about the canisters of oxygen sold at convenience stores, souvenir shops and gas stations across Colorado and whether or not they make any difference. There is a 100% consensus among every physician, athlete, EMT and ski patroller we have ever interviewed that they do not.
Why not? Dr. Chris has been practicing medicine at 9000′ for 20 years in Frisco, CO, so I asked her a couple of the questions that have come up at our clinic and on our blog recently and frequently.
How much oxygen is needed to actually mitigate symptoms of altitude sickness?
For someone with low blood oxygen saturation, our target would be 90% . They should be put on a concentrator or a large tank [of oxygen]. The adult dose is 2 to 4 liters per minute, the pediatric dose can be between 1/4 L per minute and 1 L per minute, 24 hours a day, for up to a week, or until their oxygen saturation can maintain at 90%. Less than that, and usually, it will drop again after 10 minutes off oxygen; and it’ll often be lower when you sleep, too.
What if I bought ten of these canisters of oxygen available at the gas station and breathed all of them in, one after the other. Would that make a difference?
You might get three hours worth of oxygen if you bought ten of those store-bought cans, which might help an altitude sickness-induced headache. But again, your oxygen would likely drop shortly thereafter, and you would be experiencing the same symptoms.
What happens if someone struggling with acclimatization also contracts COVID-19 or another disease with associated respiratory complications?
We don’t know. Their oxygen requirement might be higher. All of us at altitude might be at greater risk than someone living at sea level.
When do you make the decision to send someone to a lower elevation? How low?
If they are having trouble breathing in spite of being on 4 L of oxygen per minute. If they need more than that, we would send them to a lower elevation. Most people are fine going to Denver. By Georgetown (8530’/2600 m, a town between Summit County and Denver), they’ll experience an improvement. It’s above 2500 m where altitude issues become problematic.
Research in recent years, including our own, is revealing many other different variables that may affect an individual’s ability to acclimatize to high elevations, including different hormones, genetics, and muscle mass. We continue to advise anyone traveling to the Colorado mountain region above 7000′ from lower elevations to stay hydrated and well-rested, and time a slow ascent, planning to spend at least 24 hours in Denver, or another comparable lower elevation, before arriving at your final destination.
Roberto Santos is from the remote island of Saipan, in the Commonwealth of the Northern Mariana Islands. He has since lived in Japan and the Hawaiian Islands, and has made Colorado his current home, where he is a web developer, musician, avid outdoorsman and prolific reader. When he is not developing applications and graphics, you can find him performing with the Denver Philharmonic Orchestra, snowboarding Vail or Keystone, soaking in hot springs, or reading non-fiction at a brewery.
This is a Corona virus update from Children’s Hospital of Colorado and Ebert Family Clinic as of March 27, 2020.
Dr. Chris attended the weekly Children’s Hospital providers update webinar last night. The good news is that the number of admissions and outpatient visits for children with respiratory illness is down by 50% compared to this time in previous years.
Another
hopeful report about COVID transmission is that only 10% of family members
develop symptoms when someone in the household becomes ill.
Testing priority update:
Hospitalized patients and health care workers with symptoms;
People in long term care and/or over age 65 with underlying health conditions, first responders and those working with seniors AND symptoms;
Others with milder symptoms.
Testing involves inserting a swab deep into the nasopharynx. This requires having the swabs, tubes, protective equipment for the care provider, test kits and coordinated delivery of the specimens. There are shortages in all these areas, along with the risk to the health care worker. Thus, in Colorado at Children’s Hospital and in Summit County there are very limited controlled locations where respiratory specimens are collected. Currently, this is at the Summit County Community Care Clinic at a station behind the medical office building.
Anyone needing a test or face-to-face exam for respiratory symptoms must call ahead to any of these locations providing care: 970-668-4040.
Both the American Academy of Pediatrics and the Center for Disease Control recommend we continue providing well child care to those under age 2 in order to maintain vaccination rates at a level that will reduce the risk of another outbreak, such as measles or pertussis. If the child or any family member has respiratory symptoms, the visit should be rescheduled.
Telehealth visits for everyone with mild or moderate respiratory illness are being offered at Ebert Family Clinic and most other facilities. Because the illness can rapidly worsen, even after five days, IT IS CRITICAL THAT YOU HAVE A PULSE OXIMETER TO MONITOR YOUR OXYGEN. Blood oxygen saturation level is a critical vital sign that greatly aids in medical assessment. You can obtain a pulse oximeter at any pharmacy or at Ebert Family Clinic: (970) 668-1616.
Most patients can be treated at home with oxygen if they have saturation readings in the 80’s or high 70’s, but a rapid increase in oxygen requirement, shortness of breath, and readings below 75% merit an evaluation in the Emergency Room. CALL BEFORE YOU GO! (970) 668-8123.
Health care providers in the mountains can evaluate your breathing effort by phone and video, and order oxygen to be delivered to your home.
Ibuprofen is safe (barring allergy), and along with acetaminophen, are the only medications recommended to treat the fever and pain (headache, backache, earache) of COVID-19, according to the infectious disease experts at Children’s Hospital. Other medications mentioned in the news are experimental, used on very ill patients in the hospital, and could possibly make an individual’s condition worse.
I am here at the Ebert Family Clinic waiting for the Public Health nurse to arrive for our staff training. Our plan is to set up an outdoor facility to screen individuals for COVID-19, Influenza, Strep, and Respiratory Syncytial Virus, when symptoms indicate to do so. The guidelines are ever-changing, but we are staying updated on the daily, even hourly changes. We are following guidelines published March 15:
If you have mild respiratory symptoms – stay home!
If you have a fever over 100.4° with respiratory symptoms (cough), but no shortness of breath or trouble breathing – stay home! Testing for COVID-19 is reserved for health care workers or senior services at this moment.
If you have a fever, respiratory symptoms and trouble breathing – call the Emergency Room to set up a time to be screened and examined. If symptoms are severe – call 911.
EVERYONE AT ALTITUDE MUST HAVE ACCESS TO A PULSE OXIMETER!
Pulse oximeters are available at pharmacies and most stores. If you are unable to find one, please let us know. Your oxygen saturation is the key to assessing the severity of your illness.
Respiratory infections (such as influenza or COVID-19) puts high altitude residents at higher risk for pulmonary edema. Symptoms of pulmonary edema are cough, shortness of breath, and an oxygen saturation below 89%. Supplemental oxygen is the treatment, but it must be ordered by a physician.
Resources such as laboratory testing, x-rays, antibiotics and inhalers may be limited during this pandemic. As a physician, I use clinical judgement when sending patients for additional testing and treatment. I will take extra caution when sending stable patients to the hospital if they can be treated without an x-ray or lab test, or when no treatment is available. I am conservative in prescribing inhalers to people without a clear indication in order to conserve these for patients with definite reactive airways disease that respond to these treatments (i.e. asthma). These individuals should make sure that they have their medications on hand.
Viral pneumonia and pulmonary edema look the same on an x-ray, and clinical standards of care do not require an x-ray for diagnosis. The health care provider will prescribe antibiotics based on clinical suspicion and risk factors since chest x-rays do not always indicate whether someone has pneumonia.
Eagle County has 50 confirmed cases, so far, and several who were severely ill had to be transferred to Denver. As Governor Polis stated, the small mountain hospitals will be quickly overwhelmed as cases increase. There will also be a time when the hospitals in Denver are full and cannot accept transfers.
Ebert Family Clinic will continue seeing patients for preventive care. Wellness visits are scheduled in the morning and sick visits in the afternoon. Patients are not left to mingle in the waiting room as they are taken immediately back into a room. If they wish, they may also stay in their car or outside until we are ready for them to be roomed. Specific rooms are reserved for well visits. Deep cleaning and sanitization is performed after all visits and at the end of the day. We ask that you also take preventative measures, like covering your cough, staying at home, and washing your hands.
Dr. Christine Ebert-Santos and an MA assess a patient and test a sample for COVID-19 in the parking lot in front of Ebert Family Clinic, Frisco, CO.
Influenza vaccines are important and available. There are cases of combined COVID-19 and Influenza, both of which attack the respiratory system, which is serious. Other vaccines that also prevent respiratory illnesses, such as pneumococcal, pertussis and HIB, can be LIFE-SAVING! These important vaccinations are administered at 2 months, 4 months, 6 months, and 1 year of age. Adults over 50 should receive the pneumococcal and flu vaccines. Children under 18 years have not had severe cases of COVID-19, but they are very contagious, even when they have no symptoms.
If you or your child are otherwise well and do not need vaccines, it is reasonable to postpone contact with the medical system and to reschedule routine checkups.
Dr. Chris is always available on her cell outside clinic
hours for advice and treatment to continue her epic and ongoing efforts to keep
patients healthy and out of the emergency room.
Please monitor our Facebook site for updates from our viewpoint. Read our blog for a wealth of information on living in a low-oxygen environment, including interviews with local physicians practicing here for 20-30 years.
