COVID-19: Thoughts from A Primary Care Provider

Eden Family Practice opened only a few weeks before #COVID19 hit the dirt here in the United States, so my clientele is still very small. During the months of the pandemic, I saw no new clients and only maintained the care already established with those who demonstrated necessity, essentially all via telemedicine. I've been seeing entire families rather than just individual clients so I am working with men and women of all ages, and their children. Within that time, I've had three families in which all members were believed to have had COVID-19. The first two had moderate symptoms back when testing was only available to hospitalized patients and the third family was able to get free screening at a drive-up testing site. Ironically, as the primary care provider ordering the screening, never did I receive results or receive any contact by the Indiana State Department of Health even though the client received a text indicating they had positive results. When I called to follow-up and began asking questions, I was repeatedly told, "I don't know, but that's a great question." The state was far less prepared to handle positive results than I ever imagined even weeks into this pandemic.

Each client suffering symptoms within my practice had very similar courses and similar fears. Among my non-infected clients, their concerns have been largely how they might optimize their ability to not suffer the consequences of this virus and they've sought intellectual discussion on the many controversial issues surrounding COVID-19, including the potential risks associated with wearing #masks and potential mandating of the COVID vaccine into the future. These issues are complex and where data is available, often this only muddies the waters further, inviting more questions than clarity.

Certainly if you are a client of mine, we've already had lengthy discussions and I am more than happy to discuss any further concerns with members one-on-one. However, here, I do want to provide some resources and a few thoughts from the more recent data coming across my desk and of course, I'd also like to discuss some of the more controversial points.

Understanding SARS-CoV-2

Briefly, severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) mainly causes acute respiratory disease, but it can also cause multiple organ failure. While autopsies were avoided in the early months of the outbreak to protect clinicians, as these have resumed, pathologists are reporting a much broader impact throughout the body than what was previously anticipated. Research has identified that up to 76% of COVID-19 patients have abnormal liver function tests and these patients are those more likely to progress towards severe pneumonia.

Several mechanisms have been suggested as the underlying pathology of COVID-19, one being direct liver toxicity through angiotensin-converting enzyme 2 (ACE-2) receptors and sepsis which promotes cytokine storm or more specifically, that interleukin-6 production which regulates hepatic homeostasis and liver regeneration ultimately leading to COVID-19 specific drugs inducing resulting liver injury. Patients with abnormal liver tests on admission seem to be independent predictive risk factors for poor outcome to SARS-CoV-2 viral load. This data is specific to patients in China however, and there is no real data on European populations, with exception of France.

However, another theory offers strong support for bradykinin storm rather than cytokine storm and this hypothesis does answer some of the questions surrounding the more bizarre symptoms. A supercomputer crunched data on more than 40,000 genes from 17,000 genetic samples to identify this as the potential underlying pathology which also provides more than ten potential treatments, some of which are already FDA approved.

According to this later theory, COVID-19 generally enters the body through ACE2 receptors which is why those who over produce these receptors are at greater risk of disease. These receptors are quite abundant in the nose and from here, they enter the body and spread to the intestines, kidneys, and heart which helps explain the cardiac and GI symptoms associated with COVID-19. Although high expression of ACE2 receptors seems to make people more vulnerable to disease, this doesn't explain the severity of their suffering as the virus can trick the body into up-regulating ACE2 receptors in places where they usually aren't even expressed to any significant degree, such as in the lungs. As bradykinin builds up in the body, it dramatically increases vascular permeability which explains why COVID-19 seems to be more a vascular disease. One in five COVID-19 patients have damage to their hearts and half suffer neurological symptoms such as dizziness, seizures, delirium, and stroke. Bradykinin can also lead to a breakdown of the blood-brain barrier which an otherwise tightly regulated environment to become vulnerable to toxins and pathogens.

A recent study published in Pediatrics supports the role of ACE2 receptors as increasing susceptibility, but not playing significant role in the severity of the disease. Literature published within Circulation speaks more to the coagulopathy which occurs. Each of these studies really demonstrate how very little we know about COVID-19. What we know about preventing its spread is likely even Iess.

Here is a map of the Coronavirus spread and here is a tool for calculating your COVID risk.

For those more interested in management, here is a clinical guideline developed by the Infectious Diseases Society of America (IDSA) for COVID-19. Hydroxychloroquine is only recommended within the context of a clinical trial and IDSA currently recommends against corticosteroids unless the client also suffers ARDS. Convalescent plasma is also only recommended within the context of a clinical trial. However, the IDSA also recommends patients be recruited into clinical trials to evaluate the efficacy and safety of potential therapies.

A consensus statement is offered for utilization of imaging for patients with risk factors for COVID-19 progression and either positive testing or moderate-to-high pre-test probability in the absence of COVID testing. Currently, imaging is not indicated in asymptomatic patients or those with suspected COVID-19 and mild clinical features unless they are at risk for disease progression. It is however, indicated in COVID-19 patients with worsening respiratory status as it helps provide a baseline for pulmonary status and identifies underlying cardiopulmonary abnormalities that may facilitate risk stratification for clinical worsening. Imaging is also appropriate in patients with functional impairment and/or hypoxemia after recovery from COVID-19.

Maternity management has also been some of the more frequent questions I have been asked. The American Academy of Pediatrics (AAP) released an initial clinical practice guideline on the management of infants born to mothers with confirmed or suspected COVID-19. Keep in mind, this is just one organization and all professional organizations have blindspots, agendas, and their main objective is to represent their members, not their consumers. Currently the Academy recommends separating newborns from mothers with known COVID-19 infection; however, if the family opts to keep the infant in the room, they should be educated on the potential risk of COVID-19 for the newborn. Certainly many facilities will not allow mothers to make these decisions. To date, SARS-CoV-2 has not been found in breastmilk. After discharge, it is recommended that she maintain six feet from her newborn or wear a mask when closer, until she is 72 hours without fever and at least 7 days have passed since the initial appearance of symptoms.

Mindset About COVID-19 & Altruistic Providers

The shortage of personal protective gear for healthcare workers who have martyred themselves during this pandemic is one of my greatest concerns as it speaks volumes about the priorities of our country's leadership and puts into question the real motivating factor behind their various mandates, such as the wearing of cloth masks. I'll speak more on that in a moment, but healthcare workers committed to service without reassurance their own healthcare expenses would be covered. They worked without protection for their families as they returned home each evening, many offering the ultimate sacrifice. However, our police were immediately donned in full military gear when facing riots and were armed with weaponry against the masses.

Most of my readers are of the mindset that healthcare in the United States is not about practicing evidence-based medicine; its about risk-based care. That is, the risk posing the clinician, not the inherent risk the client faces. The Patient Bill of Rights has no value in American healthcare. Clinicians don't educate. They don't empower. They strategize based on liability claims. Their risk calculators evaluate for risks not in alignment with the risks of individual consumers. When we include public health risks into these equations, individual freedoms are granted even less priority.

Humor me one moment and consider this. If health really was a priority, why was McDonald's allowed to stay open and serve the public, but gyms were required to close and many remain so today? If #breastfeeding has clear advantages to our babies, why doesn't the government promote, protect, and support women in doing so especially during a national crisis (maybe because large corporations for which the government holds costly contracts would lose profit)? Why has prevention or early management of COVID-19 not been a real priority beyond the recommendation to #quarantine yourself while eating McDonald's and to wear a cotton mask while shopping for your favorite snack foods? Early victims of COVID-19 were told to stay home, essentially until they faced respiratory failure. They were provided warning signs, not a plan for optimizing their outcomes.

In response to the "all hands on deck" mentality that initiated during the initial onset of the pandemic, state health departments began reaching out to their advanced practice nurses, knowing that many are highly skilled in critical care, emergency department management, and in-patient care. I was contacted as well, and having had experience in all these areas, including experience in emergency response. I responded with willingness to volunteer wherever there might be need until it occurred to me that I lacked healthcare coverage myself. If I were to become sick or suffer long-term consequence of my volunteer efforts, I would have no financial means to pay for my own treatment. This was never offered to me by the professional agencies seeking my volunteer efforts, nor was assistance at home offered to care for my children if I were to be exposed or become sick with COVID-19. I am a single mother of three young children but my country asked me to martyr myself knowing that nurses are ultimately very altruistic. Throughout my entire career I have repeated the sentiment that what is asked of us as healthcare providers is great, and what is offered us is little more than hostility and moral injury. Consider too, that during the pandemic, nurse-practitioners and nurse-midwives no longer required #collaboration with a physician because the profession well understands this doesn't improve client outcomes. These requirements only restrict our ability to practice. It only minimizes competition for the physicians, which during a pandemic probably isn't wise. Post-pandemic however, these restrictions will return.

It seems if we work in the healthcare field it is assumed we will endure risks without sufficient protection. This is not dissimilar from when nurses are assaulted by patients yet officers refuse to file charges and judges refuse to award damages because the opinion is that this is part of the role we accept. Ironically this isn't the case for police. In fact, assault an officer and your consequences advance exponentially. Not providing protective equipment to healthcare professionals during a pandemic is the epitome of proof to support the utter apathy of our government towards our healthcare infrastructure and its providers.

Offering police immunity but allowing unprecedented legal claims on healthcare providers to the point that the profession now prioritizes minimizing liability to improving patient outcomes. This shortage of personal protective equipment and basic medical supplies is anticipated to persist for years without strategic government intervention. The American Medical Association offered a "deal" to clinicians in Indiana for obtaining protective equipment, none of which were approved for healthcare providers. Were we being deceived or was the AMA's leadership ignorant to the lack of protection these "deals" offered healthcare providers?

There isn't even a long-term strategic plan for the manufacture, acquisition, and distribution of PPE for the immediate future, or into the future for preparing for our next pandemic. The supply chain needs to be strengthened dramatically if there is a real concern for the health of the masses and certainly, its clinicians. Not only has the need within healthcare increased, but distributors are also being called upon to meet the needs of first responders, schools, clinics, and even retail businesses.

A study conducted at Penn University by researchers at the Perelman School of Medicine reported that more than half of the reported deaths among healthcare workers globally were physicians. Notably, family physicians appeared to be affected more often than frontline, hospital-based physicians. This outcome is thought to be based on the fact that frontline providers had better access to personal protective equipment such as #masks, face shields, and gloves. This smaller study seems to support that when PPE is available, it is safe and improves outcomes, but sadly, a significant number of clinicians and support staff were denied protection.

As of May 13th, 2020, an online database of healthcare deaths worldwide, requiring confirming documentation, found 1,004 deaths and nearly 55% of the COVID-19 deaths were physicians. The average age among physicians who suffered demise was 62 years, and among non-physicians, the average age was 52 years. Twenty-seven percent were general practitioners, or family practice doctors in primary care. Front-line physicians, such as critical care specialists, anesthesiologists, and emergency room physicians represented only 7.4% of deaths within this cohort.

General practitioners are more likely to see clients with more early-stage symptoms, even asymptomatic, but still thought to be contagious and of course, they often donned no personal protective equipment. Males seemed to be more impacted than female providers. Certainly this is a single cohort which creates some weaknesses in the study, but the data identifying the bradykinin storm supports the gender preference of COVID-19 towards males.

There are significantly more deaths globally within healthcare than these 1004, as more than 600 nurses alone have demised of COVID-19. Reporting deaths and assigning cause of deaths differs from country to country and case to case. If you are aware of deaths within the healthcare profession from COVID-19, Medscape is