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Thursday, 30 April 2020

New York City ER Doc: ‘Never Seen The Amount Of Patients Crash From The Flu As We’ve Seen From COVID’

COVID-19, which originated in China’s Hubei province, has infected more than 3.17 million people worldwide, leading to more than 224,700 deaths, according to data from the Johns Hopkins Center for Systems Science and Engineering (CSSE) Global Cases map. Roughly 957,500 people have recovered.
In the United States, more than one million people have been sickened by the virus, leading to 59,392 deaths and counting.
The Daily Wire recently spoke with Dr. Michael Nickas, DO, fifth-year Emergency Medicine and Internal Medicine resident physician working at St. Barnabas Hospital in The Bronx, New York City, the heart of the COVID-19 pandemic in the United States.
In the interview below, Dr. Nickas speaks about how COVID-19 cases differ from severe flu cases, and explains a very specific reason why it’s been more difficult to accommodate COVID-19 as opposed to the seasonal flu.
[NOTE: The observations/opinions expressed below are that of one doctor in one hospital, and while indicative of what this physician is seeing on the ground in the hospital in which he works, nothing in this interview should be taken as necessarily representative of the experiences of other doctors in other hospitals in New York City and throughout the nation.]
DW: How has treating COVID-19 patients differed from treating hospitalized flu patients?
NICKAS: They’re generally a lot sicker, but it actually varies. Sometimes they come in at death’s door, and you’re scrambling trying to get all your equipment ready because occasionally we do need to intubate them right away. Other times, they come with only slight shortness of breath. Prior to the pandemic, many of the COVID patients would have probably been intubated as soon as they got to the emergency department, but we’re actually sitting on them a lot longer and trying to see if they can maintain their own breathing.
We were initially avoiding what’s called BiPAP or CPAP machines – those are the masks that are placed on the face that force in air – and the initial reasoning for that was because there was concern that the pressure would aerosolize the virus and spread it into the environment. That hasn’t necessarily been disproven, but since then, everyone in our department wears full equipment the entire shift, so it’s of slightly lesser concern, and it’s been shown that it’s probably better for the patient to try to breathe on their own and have this machine help provide extra pressure. Eventually, the patients have trouble sustaining that for too long, and often we’re still intubating them in the end.
Overall, the initial management in the emergency department is the same. It’s about supporting the airway.
DW: But there’s still a chance that they might not be intubated with this different technique?
NICKAS: Yes. The purpose of the positive pressure with masks is to possibly decrease the duration of a patient’s time on the ventilator if they’re later intubated. If you can give them that positive pressure mask for an extra 24 hours or a day and a half, that might decrease the overall duration of time spent on a ventilator, which also decreases a whole bunch of extra complications from being on a ventilator.
When they’re on the BiPAP or CPAP machine, they’re able to move on their own and work with you; you can do small trials of them off of the machine – so they can maybe take a sip of water or eat something – but once they’re intubated, you lose a lot of those benefits.
Also, when they’re intubated, they require multiple medications to keep them sedated. But what we’ve also been seeing a lot is, after we intubate them, some of them are requiring vasopressors, which are used for their blood pressure. A lot of the time with these COVID patients, their blood pressure just wants to bottom out. They go very low, so we have to place a central line and then give vasopressors to sustain their blood pressure. When they’re on the BiPAP machine, we very rarely, if ever, need to do any of those additional things.
DW: So how would one treat a hospitalized severe flu patient?
NICKAS: Severe flu would be pretty much treated very similarly. The main difference would be adding Tamiflu to their medication regimen. Last year was pretty bad, but I’ve never seen the amount of patients crash from the flu as we’ve seen from COVID. Throughout the whole flu season last year, I saw only a handful of patients come in like I’ve seen the COVID patients come in. So, it’s just more of the quantity of COVID that’s concerning.
Severe flu can present almost identically, but the one thing I’ve seen with coronavirus is how fast the patients are decompensating. Families are having a hard time understanding how severe COVID can be. When the family called EMS, the patient may have only been a little short of breath and not looked too bad. In fact, there are occasions EMS has told the family that the patient was going to be okay and do fine.
I’ve had this exact scenario where the patient got brought in, initially was doing fine, but over the course of 12 to 24 hours, they severely decompensated. We had them on high-flow oxygen through a mask, then had to upgrade to the BiPAP machine. Then there came a point where the patient couldn’t breathe on their own anymore, even with the BiPAP machine, so we had to intubate them. The patient subsequently died. So the families were having a hard time grasping how quickly their relatives could succumb to this. Anecdotally, it seems that patients with the flu tend to develop severe symptoms over a longer period of time.
I think another reason for families having a tough time with this is that they can’t come into the hospital. They aren’t seeing how bad their family members are getting over time. This is obviously another major difference from the social aspect of how COVID is being managed differently than flu. It is unfortunate, but extremely necessary at this time.
DW: I’m seeing some people say that the death rates from COVID-19 are comparable to a bad flu season, but they don’t seem to realize that all these COVID deaths are stacked on top of the regular flu season. Can you talk about that?
NICKAS: Initially, I was having a hard time understanding this as well, and throughout watching multiple podcasts and other things, it kind of made more sense. The way it was explained to me was that the flu season is just that, a season. So it begins in, say, September/October and then lasts until as late as May. So you have those cases, but they’re spread out over months.
COVID happened over the course of weeks, and you have practically the same number of patients crammed into those few weeks, which just rampages the health care system in the sense that you can’t handle that volume.
Also, they can occur together. The literature in the beginning, I think, quoted around 2%, and then it eventually went to 6%, and then some were even higher, closer to 20%, of having coinfection – flu and COVID at the same time. I don’t know if the literature supports it, but theoretically those patients would do even worse. We still do not know all of the ins and outs about COVID because the research is still in its infancy.
DW: What would you say to those dismissive of COVID because they themselves are young and healthy?
NICKAS: It’s not about you, it’s about everyone else you can help protect. It’s about your family members. It’s about your loved ones. There are cases where it has killed children as young as one or two – not many, but they’re out there. We’ve seen multiple cases of it affecting other young people. 18-year-olds or 19-year-olds, we’ve intubated plenty of those patients. We’ve intubated patients in their 20s, 30s, and 40s. The virus doesn’t care how old you are. So statistically, yeah, it might affect and kill older people, but it does affect everybody. Wearing a face covering can go a long way in slowing the spread of the virus.
Regarding herd immunity, the whole purpose of herd immunity is for you to be vaccinated (obviously not yet available) or exposed, and eventually be able to be immune from it. That protects people who might not be able to get a vaccine when it arrives – patients who are allergic to the ingredients in the vaccine or who cannot get it for some other reason. Herd immunity also decreases the chances of the virus being passed on to at-risk populations, such as cancer patients who are on immunosuppressive therapies, diabetics, hemodialysis patients, or patients with lung disease.
So, it affects everybody. You have to think of the global picture.

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