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Dr. Mark E. Esterle, MD

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The Hardest Part is Yet to Come. Stay the Course!



I have not blogged about anything in a while because it seems that all that is worth talking about is the Coronavirus pandemic. As the Intensivist that takes care of the sickest COVID-19 patients in the ICU, I do feel that I am an expert on the subject, but as anyone who is worth anything in the medical community can tell you, this is an evolving understanding of the disease process and treatment that we are experiencing. Anyone who says they are the authority and have all the answers is full of themselves and are usually just looking for their fifteen minutes of fame, or they are trying to downplay the issue for their own financial gain. Some have even touted questionable, to say the least, if not downright, flat out fake therapies like the olden day snake oil salesman of the past. This is an ongoing learning process and our understanding of what is a therapy of real benefit is evolving. For this reason, I have steered clear of making any recommendation on therapies. But I am seeing a concerning attitude develop in the community, online and in the news, and I am afraid we are about to make the mistakes of the past again as they did in the 1918 pandemic.


Regarding current therapies, clearly, Hydroxychloroquine has failed to meet the standard and a more recent paper suggests that the convalescent plasma from donors of COVID-19 survivors also does not show survival benefit. Decadron for more severe cases seems to help and Remdesivir I can say from firsthand use with my patients has true benefit. The therapy Regeneron that works by blocking the virus from entering normal cells theoretically should be a real contender for treatment and if President Trump’s response to his treatment can be attributed strongly to Regeneron then I am hopeful for others to be able to get that as an option for treatment as well soon. To date, however, only study candidates have been given this outside of Mr. Trump and it is not available for the general public. With all the trials that are ongoing for therapies and the vaccine trials well on the way I am hopeful that meaningful treatment and prevention is coming. With that in mind however, I feel the hardest part is yet to come.


I am concerned about the fatigue that is clearly setting in. People are showing signs of fatigue simply due to the length of the pandemic and with that, becoming lax in their social distancing, protective strategies of mask wearing and hand washing. With that fatigue they look to leadership for guidance and getting mixed messages seeing the President mocking these strategies and making claims that the virus will miraculously just disappear one day. He is not wrong, it will abate one day, but he says that out of our knowledge and experience with other pandemics. What he does not say, is that day is quite a long way off. The pandemic of 1918 took three years to pass. They made huge mistakes trying to keep commerce open and even threw a parade that clearly caused the pandemic to stretch out longer than necessary. If they had not tried to argue it was a Hoax and did what was necessary, that three years likely would have been significantly shorter. There are many similarities between how that pandemic was handled and how this one is being handled, including the fact that the President at the time, Woodrow Wilson, downplayed the virus, said it would last a very short while and there was nothing to worry about, and he himself ended up contracting the disease, just as Trump has. With a vaccine that time frame could be shorter but even with a vaccine it is quite a way off. In the defense of the previous pandemic response however, they did not have the luxury of understanding what a virus was at the time. True knowledge of what is a virus and how they work did not come about until 1931 when the electron microscope was invented.


Vaccines help the body recognize a virus and respond more quickly, but a vaccine does not prevent you from catching the virus to begin with. When vaccine is available and we start administering it to the population, it is unlikely that the rate of positive cases will change for this reason. Hopefully we will be able to clearly see a lower acuity of illness in those that do contract the virus after receiving the vaccine, reducing morbidity and mortality. Hopefully, the hospitalization rate will drastically change converting this to a virus that is more like a common cold as most other Coronaviruses are. Time will tell.


The next few months are going to be a real test of character. We will be moving to more of an indoor lifestyle as it gets colder and thereby be in closer proximity for longer periods of time. This will only increase risk of transmission. With public fatigue, lack of leadership and clarity of message, I fear growing negative attitudes will further embolden those that want to believe this a hoax to push against the needed distancing and thereby lead to even more cases.


Recently I was asked why it was so important to come up with a vaccine and continue social distancing for something that for the majority of people that contract the disease will only have the consequence of mild illness with shortness of breath, cough, fever and fatigue that doesn’t require hospitalization unless you are one of the unlucky that get severely ill. They argued to me, “Why can’t I do me and you do you? Why should I limit my lifestyle if I don’t have any risk factors for severe illness and why don’t we do this level of distancing for things like other Coronavirus’, rhinovirus, RSV or Influenza?” It is a reasonable question and essentially the question that has led so many to not take this as seriously as is needed. The answer is related to the level of infectiousness of the virus. This is something a lot of people do not understand. They think that it’s a virus like the flu, so they understand the infectiousness thinking they’ve had the flu before and remember how it felt.

It comes down to something epidemiologists refer to as R naught designated R0. It is the mathematical term indicating how contagious a disease is. R0 is determined by the infectious period, mode of transmission and contact rate. In plain language, it is the number of people an infected person will spread the disease to. R0 of COVID-19 is somewhere between 3-4 it appears. R0 for influenza in 2018 was 1.4. The most infectious virus R0 was measles at 18. Ebola as one of the deadliest diseases has an R0 of 1.5 only. So, what does that mean? Look at the context. Ebola is extremely deadly, but the virus is not transmitted until the person infected is already showing symptoms. Therefore, it is easier to control the rate of transmission to close to that of the Flu. With Influenza people start to show symptoms within 24-48 hours of transmission. Therefore, even though they are infectious before symptoms start, that time frame is quite short. COVID-19 has a long asymptomatic period in which the infected person is sheading virus to others. For this reason, the R0 is significantly higher than that of Influeza or Ebola, etc. So, the next time you say to yourself, it’s okay if we aren’t following the social distancing rules to the letter because none of us feel sick, remember this point. With a vaccine we can hope for reduced length of disease and severity of symptoms. This will hopefully be able to reduce the effective contagiousness of the virus. Reduce the R0 to an effective R0 less than one and then there is a real chance for making a case to safely open commerce.


As the vaccine and other treatment options become available in the course, hopefully, over the next 6 months, I suspect the medical guidance is still going to be a recommendation for social distancing, masks, and hand hygiene. I suspect fatigue with the pandemic will further grow because of this and those that were once calling medical workers heroes will start blaming the medical community for the message. I am already seeing some of this and I can assure you that it weighs heavily on the staff, nurses especially. Those workers are frustrated with people getting sick because they are not following guidance. They are really getting fatigued with the feeling that there is a lack of support from hospital administration and more and more nurses are leaving because of it. In at risk COVID-19 wards, nursing turnover is becoming a real problem, especially in critical care wards where there already was a significant nursing shortage. These people are selflessly taking care of the critically ill COVID-19 patients at significant risk to themselves. They feel underappreciated. I do not blame them. They have more patients to care for with higher levels of acuity and needing evermore close attention every day. For years, the administration to the hospital they work for have kept their salaries essentially the same and bonuses seem nonexistent. Locally the nursing staff used to get a cash bonus at the Christmas holiday season which was changed to a free ham or turkey several years ago and most recently that changed to a coupon for a percentage off of the cost of said ham/turkey. I for one think that these nursing heroes, who put themselves through school often via loans, deserve a bit more and am hopeful that legislation will include some level of loan forgiveness for service rendered regarding COVID-19.


Stress levels are extremely high with the pandemic and with the general election politics. So, everyone I think should just take the time to take a breath. As they say, it is always darkest just before the dawn and I think the next few months especially are going to be an even greater challenge for America. Truth of character is only truly measured when challenged. We will get through this and someday be able to put away the masks, but I do think the hardest part is yet to come. We need to stay the course.


This is how I see it. Stay safe,


Mark

"Well done is better than well said"

Benjamin Franklin

Dr. Mark Esterle, MD

Louisville Pulmonary Care, PLLC

(502) 899-7377

4003 Kresge Way #312, Louisville, KY 40207, USA

©2018 by Dr. Mark E. Esterle, MD.