On March 11, 2020, The World Health Organization (WHO) declared COVID-19 a pandemic. At this point, over 110,000 cases were reported in over 100 countries around the world. The disease was first reported in the Hubei Province in China. There were a cluster of pneumonia cases that were all connected to exposure at the Huanan Seafood Wholesale Market in Wuhan. The first case in the United States was a 35- year old man that presented to an urgent care clinic in Snohomish County, Washington – my hometown. This man had returned to the States on January 15th after visiting family in Wuhan. The patient had dyslipidemia but otherwise had a nonsignificant medical history. Upon exam at the urgent care, he was afebrile, normotensive, mildly tachycardic, with adequate oxygen saturation on room air. Lung auscultation was positive for rhonchi and CXR was unrevealing. A nasopharyngeal nucleic acid amplification test (NAAT) for influenza and respiratory viral panel were sent off – all came back negative within 48 hours. The center of disease control (CDC) was notified of this person-under-investigation. This patient had no reported contacts with ill people during his trip and was not present at the seafood market. The CDC tested the patient’s nasopharyngeal swab with real-time-reverse-transcriptase-polymerase-chain-reaction (rRT-PCR) which was positive for the 2019-novel coronavirus. The patient was admitted to an airborne isolation room at Providence Regional Medical Center. During this patient’s hospitalization, his course was closely monitored. He initially presented with dry cough, gastrointestinal symptoms including loose bowel movements, and low-grade intermittent fevers. He then presented like an atypical pneumonia and required 2 L supplemental oxygen. He was trialed on empiric antibiotics and an experimental drug Remdesivir without noticeable side-effects. The patient clinically recovered and was relatively asymptomatic besides the cough at 2 weeks from onset of symptoms. The takeaway from this patient’s presentation is that the first signs of this novel coronavirus is indistinguishable from other common viral illnesses such as influenza and the common cold. The patient also had no direct contact to the seafood market where the initial exposure occurred, which tells us that he likely contracted the illness in the community likely via the respiratory route. When evaluating patients with flu-like symptoms, travel history is important to flag high-risk individuals who may be infected with the virus, however due to the possibility of community-spread, anyone with these non-specific symptoms should be considered a person-under-investigation. While this all is happening, I’m witnessing the events unfold from Philadelphia. I’m midway through my surgical internship. As more information is released about this virus, we are growing more concerned about the limited resources that we will experience if this contagion spreads. Our healthcare system is already stressed as it is and seeing the protracted course covid-19 can take, critically-ill patients afflicted by this may need to be on a ventilator for weeks on end. Severe cases will require extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support and will need hemodialysis for acute kidney injury. One-by-one, states are announcing a mandatory lock-down which supports social distancing and decrease the unnecessary exposure of the public to potentially infected individuals. I see #FlattenTheCurve, #StayHome, #StaySafe all over social media. On March 18, 2020, the city of Philadelphia was placed on lock-down. Nonessential business in Philadelphia closed. Restaurants were takeout only and the lines to get into grocery stores wrapped around the block. The next several weeks, the city streets were eerily empty as I made my commute to the hospital. Day-to-day operations changed at the hospital as well. We were required to wear masks in all patient care areas. Due to the impending “covid surge,” each clinician was allotted one isolation mask per day. The majority of elective surgeries were canceled. Our surgical patient census dropped precipitously as we witnessed our internal medicine colleagues grow their numbers for covid-positive patients. The surgical residents were reassigned to alternating week-on, and week-off schedules with no cross-over between these two teams to prevent cross-infection. During this, we see in the news that hospitals hit the hardest by the covid surge have already started running out of supplies, most notably in NYC. Hospitals that had supplies en-route were getting their shipments seized by the federal government for redistribution. Supply coordinators have gone to great lengths to prevent the seizure of these needed medical supplies by masquerading the supplies in food service vehicles with the shipment split into multiple routes to their hospital to decrease the likelihood of having their bounty snatched away. The federal government had refused to provide information on where the supplies were going and the logic to some shipments being seizure and not others. Healthcare workers are succumbing to this illness. Lack of gowns, masks, and face shields is commonplace. Resident physicians that were relatively without medical comorbidities at various stages of their training had died from complications of this virus. Included in this is Dr. Chris Firlit, a senior OMFS resident and 2 residents in NYC whom identities had not yet been released. Healthcare workers at other institutions are announcing that their pay is being cut while they are expected to put themselves in harm’s way and work increasing hours under conditions where they cannot even be supplied with the basic personal protective equipment (PPE) to keep themselves safe. There have been reports about hospitals giving their staff a single mask to use an entire week and with staff being fired for reporting on social media the atrotious conditions they are working in. Fast forward to mid April 2020, there are now protests in the street. The protestors are congregating all over the country –many without face masks and without regard to the social distancing guidelines—are calling for an end to the covid-19 lockdown. In some states, the number of new cases of covid have plateaued with the strict social distancing mandates, however the fear is that is the country were to open up too quickly without adequate measures in place, a second wave of infections could potentially be deadlier than the first. Georgia was one of the last states of close down and the first to open up. We will see soon if the fears come to fruition. How has my daily routine been changed by covid? For the last month, I’ve been working every other week which has been a nice change from my normal surgical training schedule of sometime upwards of 80 hours per week. The days I have off, I am on stand-by call if my presence is needed in the hospital. Educational conferences and all meetings occur over the internet. We have been using Microsoft Teams and it surprisingly has been working fairly well. I’ve found that more surgical residents can be in attendance of the conference and there can still be a productive, interactive component. There are few people on the street. When we leave the house to walk the dog or to get groceries, we always wear a facemask. We pay special attention to avoid touching our faces. Hand sanitizer is kept close by. In the grocery stores that are still open, there is usually at least one dedicated staff member that is in charge of sanitizing carts and check out counters. There are lines to get into grocery stores with lines on the ground demarcating 6 feet between customers. The parks are empty. I haven’t seen family or friends in weeks. I’m taking extra precautions when I approach someone that may be immunocompromised. I am a high-risk individual that may be an asymptomatic carrier. The self-isolation has been taking a mental toll on some of my family, especially my grandmother. She lives in an independent apartment building with residents over 65 years in age. She hasn’t left her apartment in over a month. Her only contact being her son – my father– who meticulously does her grocery shopping and cleans off any supplies that enter her home. He wears a mask and gloves when in contact with her. My grandmother also has hepatocellular carcinoma. She had a bland embolization of her liver and has routine imaging follow-up studies every few months to monitor the tumor progression. Due to the COVID crisis, her and many cancer patients who have a compromised immune system are delaying routine follow-ups and treatment. Some centers have stopped offering any cancer therapies during the pandemic. The negative impact this will make on these patients will be nothing short of disastrous for some.
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