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Monday, June 1, 2020

Ten Lessons Learned

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Check out these 10 lessons learned in dealing with the Covid-19 pandemic

The scientific method encourages discovery. Science rechecks assumptions and logic as more information is available. It is how we learned a great deal about the COVID-19 virus and its impact over the last couple of months. What is important is to apply our knowledge as we make decisions as a country, state, community and individuals. Ultimately, each of us will make personal decisions about our individual definition of reasonable risk relative to this pandemic. To make good decisions, we need accurate information.

Advances in effective treatment of COVID-19 are being made. Remdesivir – an antiviral agent developed during other viral pandemics – has proven effective against COVID-19 in a large, double-blind, randomized clinical trial. Hydroxychloroquine has been used in treatment protocols in our local health systems and around the world. Trials with other promising drugs, plasma antibody infusions and nitric oxide are underway in our community and around the world. Antiviral drugs are being investigated with hope of developing a multidrug treatment for COVID-19.

Our expectations must be realistic. There is little to indicate this viral pandemic will disappear as fast it appeared. The virus is too easily transmitted.

This is important to understand now because unrealistic expectations can lead to disappointment, and this may lead to overreaction if minor increases in adverse outcomes occur in COVID-19 statistics. As stay-at-home interventions are loosened, we can expect transient increases in new cases. The reason for gradual reopening is to minimize the risk of a significant second wave of cases that overwhelm the health systems.

COVID-19 is a disease where complications occur predominantly in the elderly with chronic problems such as obesity, hypertension, diabetes, COPD and heart disease. A third of COVID-19 deaths are in nursing home patients. Our priorities in prevention are taking care of those at high risk, especially those in disadvantaged communities and nursing homes.

COVID-19 can impact all age groups. Until this pandemic resolves, everyone will still be at risk. The disease is generally milder, and there are fewer complications in the 18-50 age group but still 30% of hospitalizations for the virus are from this age group. Throughout the pandemic, serious complications have been very rare in children. Young and old and in between will need to continue to apply principles of social distancing, handwashing and face covering for some time.

The percentage of people who have this disease and die from the infection is much lower than initially forecasted. Large-scale testing studies indicate there are a significant number of people infected with the virus that have little or no symptoms. Because of these findings, mortality rate estimates are much lower than original projections – from previous projected rates of 3 to 4% to current estimates in the 0.3 to 1.0% range.

The COVID-19 virus will be with us much longer than we would like. We can flatten the curve, but we will still have a curve until we have effective therapy with multiple drugs, a vaccine or herd immunity of the population. Researchers are working on potential vaccines with the timeline estimate of 12 – 18 months. It is noteworthy a vaccine is not guaranteed. Researchers have not been universally successful in developing vaccines in recent epidemics of HIV, Ebola and SARS.

Social distancing worked in Northwest Louisiana and needs to continue. At least partly because of intense social distancing, the health systems in our region never experienced the surge expected in hospitalization and ventilator usage. The virus is highly transmissible from person to person, and the incidence of a disease in a community is very dependent on the density of people. It is important to support common sense social distancing practices in our community, especially as we enter the next traditional flu season.

Hospitalizations and ventilator use will give the best indications of whether we are adequately flattening the curve. We know that the number of new cases identified is going to be impacted by the number of tests. Following the number of new cases may be more dependent on our decision to test more people than due to a greater virus presence in the community.

COVID-19 hospitalizations and ventilator use are our best indicators of capacity in our health systems.

The unintended consequences of stay at home, shelter in place, and temporary business closures have been Great Depression-like unemployment and reports of a significant number of permanent business failures. Unemployment and business failures will lead to higher poverty levels with the associated negative health outcomes. We have always known public health depends on economic health. Due to the enormous social and economic cost, community lockdown will likely only be embraced in the future if health systems are truly overwhelmed.

Health consequences for people with health problems outside COVID-19 have been substantial. Strict lockdown strategies have led to greater concerns about domestic, drug and alcohol abuse as well as depression and suicide. People with heart disease and cancer have been especially negatively impacted. At Willis-Knighton, 27 life-threatening heart attacks requiring emergent care were noted in March and April of last year. This year, there were a total of three. People simply did not seek care because of fear of the COVID-19 epidemic. We are only beginning to see the consequences of people putting off care. The truth is Shreveport-Bossier ERs and hospitals have enacted very strict prevention protocols to limit the transmission of COVID-19 and separate the infected from the noninfected. Hospitals focus on safety.

We need to show the same degree of support for our local business owners as those of us in the health system received from the community during this pandemic. Work in our hospitals is important but so is the work to build strong businesses and put people back to work. With this dual health and economic crisis, there can be no trade-off between lives and livelihoods. In all cases, policy has to be designed considering both.

In our profession we are taught to treat the whole patient – not just the disease. When we treat our patients, we consider the context – age, other diseases, family and social history – and make decisions based on what we learn. If we get laser focused on just one thing, we don’t pay attention to other problems right before our eyes. Every public policy decision will have to consider both health and economic outcomes. The whole patient has to be considered every time.

We can’t ignore the health implications of COVID-19, but we also can’t indefinitely shut down the whole country because of the virus. We can continue to live our lives, work in our jobs and do our part. We can continue to learn so we can engage the virus pandemic more on our own terms.

Our greatest anxiety and fear is of the unknown. As we learn more, we can replace anxiety with confidence – a confidence based on knowledge and not false bravado and unrealistic expectations. Ultimately, we will all have to decide individually about what is reasonable risk for us, but it should be an informed choice based on both what we have learned and will learn.

Dr. Phillip Rozeman is a practicing cardiologist at Willis-Knighton Health System and former board chairman of the Greater Shreveport Chamber of Commerce; Dr. Todd Thoma is an emergency room physician at LSU-Ochsner and coroner of Caddo Parish; Dr. Steen Trawick is CEO and chief medical officer of Christus Health Shreveport - Bossier.

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