By NIRAN AL-AGBA, MD
The Trojan Horse is a tale about subterfuge. After a decade of war, the Greeks had made little progress against the Trojans so they constructed a huge wooden horse and hid a select force of men inside. Believing the Greeks sailed away, the Trojans pulled the horse into their city as a victory trophy. That night the Greeks crept out of the horse and unlocked the gates for their fellow soldiers, who had sailed back secretly. The Greeks ended the war by destroying the City of Troy.
COVID-19 is our Trojan Horse. It has snuck inside the gates and attacked. How do we fight against an enemy we don’t entirely understand?
When the first presumptive positive case was reported in Kitsap County this week, my clinic began screening patients and their parents for fevers. As a result, not a single febrile person has stepped through my front door since last Monday, March 9. There is a temperature triage station set up under a Seattle Seahawks tent in front of my clinic. For the record, I am no fan of professional football, and I never imagined it would serve as a triage station.
If a patient has a fever, they are asked to return to their car for what is now called a “car visit.” During the measles outbreak, I did “car screenings” to make clear patients to come in to the clinic if they had a rash. Examining young children out in freezing temperatures while standing outside a car is a whole different thing entirely.
There is no precedent here.
For a “car visit,” I leave my office and walk into an empty building next door. In there, I put on a different jacket (in lieu of a gown, which I don’t have), safety glasses and an N-95 mask, pick up my leather doctor bag—which contains its own set of medical equipment, pen, prescription pad, and other essentials—and walk to the patient’s car, which is waiting in a makeshift “drive through” spot next to my clinic.
My worldview has changed. I am evaluating and diagnosing febrile patients in a way I never imagined. It is not perfect. I am just like every other doctor in Washington State, doing the best I can to navigate the unthinkable.
And this week, a child presented with a fever, cough and shortness of breath. They tested negative for influenza. So what next? We are not testing these cases. There are strict test criteria requiring an ‘exposure’ history. Studies from China reveal only 10% of patients who acquire Covid-19 through community-spread—meaning they were not exposed to the market—had an ‘exposure’ history. There is no scientific rationale for the testing criteria. We are essentially winging it.
Let’s say I wanted to test this child.
Unfortunately, there is not enough protective equipment available to safely obtain the nasal sample. When children have swabs placed in their nose, they cough. Usually in my face. I don’t worry when testing for RSV, other viral infections, or pertussis. But I do worry about how many I could infect if got infected myself. And still worse, even if I take the risk and collect a sample, there is nowhere to send it to be tested.
As of this writing, there are limitations on the number of tests that Washington State DOH can run in a single day. The lab must prioritize severely ill patients over the healthier ones which makes sense. The University of Washington Virology Lab is an alternative location to send swabs for testing, but they too, are overwhelmed with samples. They are no longer accepting submissions for testing from outside clinics around the region.
On the front line, diagnosing and treating patients with Covid-19 is no longer about being right or wrong. There are simply no answers and I have no idea how best to help my patients. These families have been coming to my office since before I was born. I must try to provide them with answers. We were not trained to fight infection blind, but this is the kind of battle every physician, nurse and other healthcare worker faces. I am armed only with fortitude and a desire to help save lives.
To that end, I have pored over studies done in China, Singapore and Korea in JAMA, New England Journal of Medicine, the British Medical Journal, the Lancet and others. There are a few laboratory tests that might be helpful in the absence of ideal options (like PCR testing.) About 60-70% have a low count of a certain kind of white blood cell (known as a lymphocyte) in their blood. Up to 90% have an increased C-reactive protein level. Some clinical review papers have suggested using low lymphocyte counts as an indicator for diagnosis.
Under normal circumstances, getting a chest x-ray would make sense as most have evidence of infection in both lungs, but the local radiology facility no longer does chest x-rays as of this week to avoid Covid exposure, so that option is not available either.
Finally, if I have a patient who I believe is ill from Covid-19, how do I treat them? The short answer is I don’t know. There are some promising results with various antiviral or anti-retroviral medications. Anything we use to fight this disease is experimental. There is a growing body of evidence that using anti-malarial medications like Chloroquine or Hydroxychloroquine is helpful. It is my understanding that these medications may slow viral replication and help with clearing this infection more quickly. There are no randomized controlled trials, there are no studies regarding safety, effectiveness, and mortality reduction.
Covid-19 has taken over our lives. There are no answers. Now we must do the best that we can. That will have to be enough.