The COVID Wars: At What Point do you Not Answer “YES” ?

Editor’s Note:

This is January 27, 2021. A year ago news stories were talking about the Wuhan virus in China, and few of us really took note although it to catch my attention. I think perhaps the American response to all of this was dampened by the political morass that we were embroiled in, and that the veracity of anything coming from the media whether from the left or right was in doubt, suspect, and always overshadowed and overwhelmed by new cycles spanning the next emerging 72 hours.

It is those recurring whirlpools of 72 hour News cycles  that in my opinion became an open door policy for a virus that might otherwise not have been able to be disseminated so opportunistically, but in this case somehow managed to crawl into our society hidden and cloaked by misinformation and lack of trust.

Clearly this virus has affected every aspect of humanity- so I share my perspective of the cardiovascular perfusionist impacted by this virus on a multitude of levels.

Level I: The economic impact of COVID cannot be overstated in terms of how it has affected people of all walks of life.  While we are designated first responders- and clearly when we engage in cardiopulmonary bypass or ECMO for COVID patients, we become a rare yet expensive sidenote to perfusion contract companies that are otherwise crippled due to a cataclysmic decline in their normal cardiac surgery caseload volumes.  This, resulting in a two fold dilemma:  We have lost 80% of our revenue- yet we still need to provide backup cardiac surgery services to our client hospitals or organizations;  That caseload volume in and of itself cannot sustain the salaries of those employed to deliver these crucial front line resources or interventions that hospitals require to save patient lives.

Hence- I found myself furloughed, to watch helplessly on the sidelines as COVID became a 24/7 Spectre on every media platform.

Level II:  What is readily evident is that the advanced nature of the respiratory cardiopulmonary support that ECMO delivers-becomes self-limiting in terms of availability for multiple reasons: It is so highly complex and costly-that there are few institutions that have the supplies, the personnel, or the hardware and disposables to offer this bail-out option to more than 2 or 3 patients at a time.  Considering the incredible volume of patients, this rare option becomes the unicorn of hope for all but the incredibly rich or the amazingly lucky.

Assuming that a hospital can place a patient on VV or VA ECMO, the next question to be addressed is how long can they sustain that patient, and at what point do they transfer that patient to a more skilled facility, or grapple with the next decision of withdrawing care when millions have already been spent to keep this patient in a suspended limbo between death or survival in terms of man hours, resources, and medical therapy?

Going on ECMO under these conditions is like being bitten by a Great White Shark- living or dying ends up being a crapshoot on whether or not there is an evacuation option, a medical option, or a life guard that witnessed the event to begin with- and activated advanced EMS recovery algorithms.

The sheer patient numbers are staggering, and advanced options become incredibly ineffective because of the fact that getting clearance or making a forward decision to actually deploy them is undone by the time delay to patients that are actually offered them- and at that point it is far too late.

Social Darwinism is not a factor here.  Institutional money, available resources, or qualified personnel  to actually manage the ECMO are the primary road blocks to be contended with.  That, and the fact that it has become very clear that this advanced modality should be restricted to institutions that do employ this technology on a routine basis- and have research and protocols that are based on success.

From my observation, we were lucky to have a 50% survival rate once a patient with COVID was placed on ECMO/

Level III:  Our Screening Process is a joke, and at the same time- a two-edged sword.

The AMA prerequisite screening questions are as follows

• Have you or anyone in your household had any of the following symptoms in the last 21 days: sore throat, cough, chills, body aches for unknown reasons, shortness of breath for unknown reasons, loss of smell, loss of taste, fever at or greater than 100 degrees Fahrenheit?
• Have you or anyone in your household been tested for COVID-19?
• Have you or anyone in your household visited or received treatment in a hospital, nursing home, long-term care, or other health care facility in the past 30 days?
• Have you or anyone in your household traveled in the U.S. in the past 21 days?
• Have you or anyone in your household traveled on a cruise ship in the last 21 days?
• Are you or anyone in your household a health care provider or emergency responder?
• Have you or anyone in your household cared for an individual who is in quarantine or is a presumptive positive or has tested positive for COVID-19?
• Do you have any reason to believe you or anyone in your household has been exposed to or acquired COVID-19?
• To the best of your knowledge have you been in close proximity to any individual who tested positive for COVID-19?

As perfusionists- we would have multiple “YES” answers to this particular list, and the next question then becomes: what happens if and when you do say “YES”?

In my case, the “YES” answer was to a 24 hour fever of > 101 F.  That automatically funnels you to a COVID screening test, which either requires a physician order (if you are asymptomatic), or you enter into a State mediated testing site which if you are lucky, will give you a definitive result in 24-72 hours.

This of course removes you from the clinical setting and into an economic limbo where it may end up costing you a significant amount of lost income as a result of clinical and corporate prudence.

My “YES” ended up being an FUO (Fever of Unknown Origen) and a negative COVID result.  For that I am grateful, but then realize that the next time I have a fever- or don’t feel well, of have a cold, or body aches, or any of the myriad symptoms that hover around people during flu season, I would be less inclined to share that information with a screener. 

In a world where we are all just a stumble away from financial ruin – why would anyone want to answer that question with a “YES” ?

On the topic of screening, in my opinion the temperature tests that we take here in the northern Midwest area- as we enter a hospital are tragically flawed because it is a forehead temp, taken after you have just walked through freezing cold weather as you made your way through the parking lot. 

Lately I have noticed that my temps always come in at a low 96’s – as the screener asks the requisite questions while looking down at a sheet of paper, promptly gives me a visitor’s badge, seemingly clueless that I was standing there with my scrubs on and my employee ID in plain sight.  And this guys was a screener that knew me by face and by first name!

My guess is that a lot of those 96 temps are normal 98.6 results, which then makes you worry what a 98 or 99 temperature may really be?

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Be Safe out there…

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Pump Strong

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Frank