An Anniversary to...

A year ago, today, I was a 56-year-old, experienced, well-read Infectious Diseases physician, confident in my understanding of the available knowledge on the presentation, diagnosis, treatment, and prevention of all known infections. I had worked hard to reach this point in my career. That work had paid off. I was prepared for all clinical situations and had not seen a disease I didn’t understand in many years.

Covid-19 had reached Seattle in early March and a couple of weeks later, reached NYC and a few days later Holy Name Hospital in Teaneck, just across the Bridge (in our vernacular, the Bridge means the George Washington Bridge). Seattle is blessed to have the University of Washington or UW, which went to work on Covid in all sorts of ways. I read everything they published. I read the other publications from China and Italy. When Covid hit Holy Name, where my brother works, I started to get anxious. The reports from colleagues there were terrifying.

In mid-March, my wife and I attempted to escape for a few days to Jamaica, an island we know pretty well, where my Dad’s cousin, Billy, lives. But there was no respite. Calls, texts, reading, I couldn’t escape the coming wave. We came home a few days early after my partner, younger than I, asked me to, even though we had seen a Covid pt yet.

While away, my buddy, Craig texted me and asked me if there was anything to take prophylactically. I started texting my ID friends. One, Dan, suggested HCQ might work. I said “Hydroxychloroquine?!? You gotta be kidding.” I knew HCQ was a lupus drug, a malaria drug, but come on. I did some reading. HCQ had been shown to have antiviral properties year before in tissue culture, meaning on cells grown in a Petri dish. The more I read, the more I thought, well maybe. From Jamaica, a few days before Pres. Trump announced that HCQ “may be a game changer” and before Dr. Raoult had published his first paper on HCQ, I electronically prescribed HCQ to my siblings (unbeknownst to them) and to Craig. No pharmacist questioned the prescriptions, the cost of each was $5.

My wife and I came home that Sunday or March 15th. When I heard the President’s announcement about HCQ that night, I went onto my computer and prescribed HCQ to several friends in town and elsewhere. I knew the next morning there would a run on the bank, so to speak. I didn’t see my first Covid pt until that Wednesday, the 18th. Dr. Lejla Mujic, an excellent and very brave ER doc, called me directly. She had a Covid pt or so she suspected in the ER for us. I wasn’t on call that day, but I took the call and then decided to go see the pt myself. I couldn’t have been more prepared. I took to two tablets of HCQ and headed to the hospital, albeit with some trepidation. But in the ER, those fears went away. I donned the blue gown and surgical mask and then a nurse asked me if I wanted an N95, which UW had reported wasn’t necessary. I said “Sure, why not?”.

I went to the pt’s room. He was in his mid-40’s, obese, Haitian with no known medical problems. I had seen his labs and chest CT scan. I knew he was very sick. I asked him how long he had been ill. “3 weeks”, he said. I said to myself “Huh? What does he mean 3 weeks? Respiratory viruses don’t cause 3 week, progressively worsening illnesses. They DON’T. I know this to be true.” I questioned him on the duration of his symptoms. He was very confident that he first got sick 3 weeks earlier and slowly gotten worse.

The pt was very hypoxic, meaning he had low oxygen level in his blood. His CT scan show diffuse pneumonia. Yet, the only thing he complained about was severe fatigue. He denied being short of breath or having cough. He had had cough for a few days, but that went away. After examining him, I went out and talked to Dr. Mujic. Before I said anything about his complaints, Lejla said “You know, funny thing, these Covid pts…there main complaint is fatigue.” I finished doing the consult, during which I diagnosed my pt with diabetes. Making the diagnosis of diabetes in an obese pt is not particularly rare, but this pt’s blood sugars were pretty high and I started him on insulin as well. Also, I had already ordered him HCQ with AZM (azithromycin). As this was my first Covid pt (his test result wouldn’t come back for a week) and he had symptoms for 3 weeks, I also sent tests to rule out fungal diseases and even considered TB (tuberculosis). Now, when I read my consult, I get a chuckle. How naïve I was. How stupid I was.

I then went to see our second Covid pt. He had been in the hospital for 3 days already. His Covid test was still pending. He had unrelenting fever. I went into his room and his eyes were shut. The pt was 48 yo, had no medical history and was very fit. I asked him why his eyes were shut, I feared we had missed meningitis in our zeal to diagnose and isolate Covid pts. Once isolated, pts do not receive nearly the same attention as they do outside of isolation. This second pt said he had no headache; he was just very tired. I examined him head-to-toe. I asked him to sit up. The pt started to raise the bed. I explained “No, I need to you sit up away from the bed, so I can listen to the back of your chest”. He said he couldn’t. Now, I am getting very concerned. This guy averaged 200 sit-ups per day and had the 6-pack abs as proof. Eventually, he did sit up and I listened to his chest. Like the first pt, his lung sounds weren’t bad at all, although in both pts, the lung sounds were not as loud as they should have been.

In one hour, I went from that experienced ID doc, who knew the limits of diseases, to a confused spectator. I knew I knew little about this disease. I started this pt on HCQ as well.

That night, the first pt coded and had to be intubated on the floor. The prognosis of someone intubated on the floor for respiratory disease is terrible. 3 days later, the pt was extubated. 7 days later, he went home off of oxygen. That simply never happens. The first pt’s fever broke the day after he was started on HCQ and we sent him home a day after that.

That was March 18th. We had 2 pts. Both confused and baffled me. The things that I saw in these pts were in none of the publications. I wouldn’t put the diabetes and obesity thing together for another few days because I knew diabetes and obesity weren’t really a risk factors for serious respiratory viral infections. Diabetes is a bad risk factor for bacterial infections and some fungal infections, but not respiratory viruses. I knew that. Obesity had been seen as somewhat of a risk factor during the 2009 flu pandemic, but it was not that big of risk factor. For ordinary flu, obesity isn’t much of a risk factor. By that evening, I knew I knew little about this disease. Although at one level fascinated that some disease could be so different, I was also very worried.

So, 2 pts by March 18th. By the end of March, we had seen over 100 Covid pts. By March 23rd or so, I had made the diabetes and obesity connection with severe Covid. And we all made the Haitian connection, as over 25% of our Covid pts were Haitian or of Haitian descent. In late March, we tried to publish our findings on diabetes and obesity. I couldn’t. Editors told me they just didn’t believe me. I asked “What’s to believe? These data are extracted from each pt’s chart. They are not experimental data.” Still, editors wouldn’t listen, because they too KNEW diabetes and obesity could not be so tightly linked with severe Covid. I even offered to remove the Discussion section of the paper and ONLY publish the clinical, chart-derived data. Unlike me, these editors stuck by their incorrect knowledge. While doctors need to be confident, arrogance has no place in Medicine. Now, everyone, including these editors, accepts and acknowledges that diabetes and obesity, along with age, are the biggest risk factors for severe Covid.

By the end of April, we had seen almost 200 inpts and I had seen a bunch of outpts in my jury-rigged garage turned examination room. I remember friends and colleagues suggesting that I was waiting or preparing for this my whole career or something to that effect. I quickly corrected them. I hated this disease to my core. I wanted it gone and wished I had never seen a case. Seeing people die slowly is no fun and we literally saw them unlike many doctors.

To my team’s credit, they went into these pts’ rooms. Many doctors stopped coming to the hospital. Many, who did, called the pts from the nurses’ station and talked to them via the phone. Not my team, Julie, Enrique, Ramon, Kathy, Daniel, and I, we went into the pts’ rooms, where almost every pt thanked us. That was another first.

Oh, btw, a day or so after seeing my first Covid pt, I stopped using N95’s as the hospital was running low. I remember when I stopped, I said to myself “UW had better be right about not needing them”. Fortunately, they were. I also continued HCQ until I got the vaccine.

Covid was strange and awful enough. A year ago, I had no idea that I would become controversial by prescribing a drug based on the only, available clinical data. The failings, the missteps, the mistakes and the misguided views of politicians and administrators made it much worse. More on that, maybe later. For now, it’s time to process the year of Covid and the death and suffering this disease caused. There will be time later to point out what could have been done differently and the impact those moves could have made. However, I am not sure anyone will much care to hear how politicians and administrators made this outbreak much worse. So maybe, we won’t get into that.