Dr. Jessica Nave: “Some of our sickest patients have been in their late 20s to late 30s. We don’t know why.”

For our 21st Century Plague project, we spoke with 17 Georgians about the toll of COVID-19.

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For our 21st Century Plague project, we spoke with 17 Georgians about the toll of COVID-19. Below, Dr. Jessica Nave—hospital medicine at Emory University Hospital—describes how her hospital is treating COVID-19 patients and the precautions she takes at home to protect her family. (Nave was interviewed on March 26.)

I am in internal medicine but work only in the hospital. If you get admitted, but not to the ICU, then I’m your doctor.

It started out with two to three patients, and it seems like every 48 hours that number almost doubles. We have 30 COVID-19-positive patients now [as of March 26].

When they come in to the ER, they’re screened up front the second they hit the door. If they have anything that sounds remotely like COVID-19, they go to a separate triage waiting room. Once the ER sees them and thinks the person needs to be admitted, then they call me. We have a discussion over the phone, I look at their charts, then I come to the ER and actually see the patient, interview them, take their medical history, and then initiate their care plan. If they need antibiotics, breathing treatments, whatever, I put all those orders in.

We’re seeing fevers and a dry cough. People are also having some shortness of breath. Some confusion, especially in the elderly. We’ve also seen more diarrhea, muscle aches, overall feeling crummy.

They’re cohorted into certain units. We’re trying to isolate them and keep them separate from noninfectious people. A lot of them aren’t that sick, or aren’t sick enough to go into the hospital, so we’re sending them home. The COVID-19 testing still takes 12-24 hours for our in-house test that we developed. For a lot of patients we’re not even running the test; we rule out flu or RSV and tell them to go home and self-quarantine.

What they’re dying from is acute respiratory failure. It’s happening late in the disease course. Normal flu hits you and hits you hard, and you feel terrible for three to five days, and you start to come out of it. With COVID-19, we see symptoms grow gradually and between seven and 10 days [after symptoms begin], we’re seeing them go downhill quick.

It’s scary. I feel like with most disease processes you can predict who’s really sick and who’s going to do well and not do well. You can predict that based on their medical history and demographics and some of their features when they initially present. It’s harder with this one because you might can have an idea at the beginning of the disease and that can change quickly. With the flu, people feel terrible but we tell them to go home. With COVID-19, there’s an unease with sending them home because we’re not sure how to predict [how they’ll do].

Sometimes illness is difficult to define by objective measures. We’ll get a call from the ER physician saying, “I think this patient needs to get admitted.” I’m looking at their chart and saying, “Well, they’re not hypoxic, they’re fine.” They’ll say, “Just come and lay your eyes on them.” So, I do, and it’s, “Oh yeah, this person is not going to do well.” They have a look about them. Their breathing pattern is abnormal. They’re using more accessory muscles.

We don’t have a great guideline of who should be admitted and who shouldn’t. Normally we don’t mind oxygen saturations unless it falls below 91 percent. But we have a higher cutoff for [COVID-19 patients]. If they’re 93 percent or below we’re a little more concerned about that patient. A lot of them are getting troponins, an enzyme that gets spilled into the bloodstream when your heart muscle is damaged. Some of these COVID-19 patients are dying from cardiomyopathies—the virus is either directly or indirectly affecting their heart, and we think they’re dying from a process related to that, if it’s not a primarily respiratorial process. Their heart will go into an abnormal rhythm, vfib or vtach, or they’ll go into a cardiogenic shock. You put them in the ICU, you put them on a ventilator, we have different drug therapies, we have ways to treat it. But that’s only if they’re in the hospital. A lot of these patients the worry is you don’t admit them, we don’t know who’s going to develop a cardiac myopathy. Luckily it’s rare, but it’s one of the thing that’s harder to predict.

[With COVID-19] there’s still a predominance toward the elderly. But some of our sickest patients have been in their late 20s to late 30s and otherwise healthy. We don’t know why.

I was hoping that, by early April, we’d peak. But now, my projection is we’ll peak at the end of April. And that’s still optimistic. It’s just the numbers. If you look at Seattle and New York, they’re still going. We didn’t start getting cases until the second week of March. We have to have a solid month of getting hit really hard before we peak.

I feel like it’s bound to happen [that a colleague will get infected with COVID-19]. We have coworkers who are getting Airbnbs so they can completely isolate from their family. We don’t have that luxury. We don’t have family close by that our kids can stay with. We’re both doctors and we both have to work. This is what we do: You come home from a shift after you’ve been exceptionally careful at work. You leave your shoes in the garage, you go immediately to the laundry room, take your work clothes off, put them in the washing machine, then you go shower. Then you can interact with family members.

We’ve started rationing our personal protective equipment. We’re trying to be very, very smart about when to use it and on which patients. It’s kept under lock and key because there’s panic even in the healthcare system when something like this hits. People start hoarding. Right now our hospital capacity is okay, because people who would otherwise be coming in for mild illnesses, they’re not even coming. They’re afraid to go to the ERs.

Primary care doctors are working insanely hard to try to manage everybody that sometimes they would send to the ER to get quicker management. So our whole capacity is fine, but we are worried about ICU availability.

Italy had so many cases that all presented at once that it overwhelmed their entire system, and they’re having to choose who’s going to live and who’s going to die. They’re looking at two patients who are actively dying and there’s one ventilator, and they’re saying “You get it.” That’s probably the most horrific experience for a physician. I can’t even imagine. That’s what we don’t want. In Italy, they don’t put anyone on a ventilator who’s over 60. Sixty is so young.

I think we did lose an opportunity [to get out ahead of the disease]. At the same time the school systems were shutting down it should have been an obligatory quarantine across the board for nonessential things. But I get it. I have a lot of friends who are small business owners. That’s the one saving grace in my profession. I’m dealing with all the stress of work: Am I going to get my own family sick? And if I happen to catch it not only do I risk my family’s health and my health, but how many patients did I spread it to before I realized I was sick? How many coworkers did I spread it to? And then the coworkers who would have to cover my shifts? It’s this domino effect. There’s this weird guilt associated with everything. You can’t take risks or you really will hurt a lot of people. But the one thing I don’t have to worry about is my income. For people who do have to worry about that, I can’t even imagine. It’s too much.

I call the family members [of COVID-19 patients]. The family members are terrified. To have a policy where you cannot go in and see your loved one heightens the anxiety. That extra efforts you put in to keeping the family informed, making sure they talk to the loved one, and letting them know their loved one is doing okay, is huge right now.

I don’t leave my house a lot [when I’m not at the hospital]. We have gone to the grocery store. We do not bring our children. I keep hand sanitizer in my purse. The second I get in my car, I sanitize my hands again. We bring all the groceries in, unload then, and immediately wipe every single food item down: boxes, milk jugs, whatever. Then, we take a wipe and retrace our entire steps from the time we entered the house—every doorknob, every baby gate, every counter.

This is a different infectious agent than we have ever seen in most of our lifetimes. This truly is unprecedented. I was at Emory when we dealt with Ebola. Ebola’s mortality is way worse than this, and it’s very infectious—but not as infectious as this. This is crazy: You start with one city in China, and now, the whole world has it because we’re so interconnected. This is such an unprecedented infectious agent that we have to be more diligent and cautious, even at the cost of some of the economics of this country. Because how do you put value on a life?

Is there going to be another wave of this come flu and viral season next year? Is this going to stick around and be something we have to worry about year after year? I don’t think anybody knows. We hope it’ll die off in the summer months. It should die off in the summer months. But we just don’t know.

Interview edited for length and clarity.

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