Case 37: Swab-Worthy (COVID-19, I)

In a 1995 episode of the popular sitcom Seinfeld, Elaine Benes learns that her preferred method of contraception, the Today Sponge, has been taken off the market. As many people are doing with toilet paper these days, she hoards as many boxes of the sponge as she can find, then, uses her limited supply sparingly, deciding whether or not her partners are “sponge-worthy” or not.

Russell Greaves is a smart kid. He’s twenty, he speaks well, tells me exactly what I need to know, and he’s wearing the sweatshirt of my Alma Mater. He was here two days ago with the same symptoms he has today.  It’s Thursday, March 12, 2020, day four of his illness. It started with a sore throat and a dry cough. No fever. At his first visit, he was asked if he’d traveled anywhere. He had. In late February, he’d been to a beach resort, but the country he’d visited wasn’t on the list. So, like today, he was given a surgical mask and directed into the main department, unlike those who have been waiting in their cars, cellphone in hand, for hours.

For the last decade, our busy Emergency Room, thirty minutes north of Toronto, has been at (or near) the top of the list of shortest provincial wait times. It’s a well-oiled machine: when patient volumes surge, or wait times creep toward sixty minutes, we call in another physician so that sick patients can be seen quickly. We also have the best nurses anywhere and they’re dedicated to making sure our patients get great care as quickly as possible. But today, at the top of our tracking board, there are patients who have been waiting hours just to come inside our department. But this is no ordinary day. I’ve heard many strange things between patients: my kids will be out of school for the next three weeks; all major sports leagues have put their seasons on hold; patients have been caught stealing masks and toilet paper from the ER.

Russell’s vital signs are good. He hasn’t had a fever through this illness and doesn’t have one now. His heart rate is 88 beats per minute and his breaths are slow and even. He smiles when he chats with me, he’s animated and he calls me “doctor,” when he answers my questions. His ears are clear as is his chest, but when I look inside his throat, it’s inflamed, and his right tonsil is streaked with a faint white film. “I had a strep test,” he says, “a swab of my throat – but it came back negative.” The first doctor I saw said it might even be mono.

“Have you been coughing?”

“Yes,” he says, “but the worst part is my throat. It’s getting worse.”

His throat does look sore. I tell him that it looks viral, and that it could possibly be Mono, but it doesn’t seem like it. He doesn’t have any fatigue, or fever, and he looks well. “We can do a blood test for mono,” I say, “but even if it’s negative, that doesn’t mean you don’t have it. Also, Mono is viral, which means it’s just rest, fluids, and symptom control, which I’m happy to offer you right now.”

Russell’s mother is with him. She’s well dressed, has a kind manner, and has been smiling throughout their visit with me. She asks if we can do the blood test. I tell her sure, and offer to let them escape once the blood is drawn. “If it’s positive, I’ll call you, but either way, treatment doesn’t change.” I write a prescription for codeine and tell Russell he can take ibuprofen along with it.

He and his mother look to each other. She speaks. “Okay,” she says hesitantly. “So, can you tell me for sure, that I don’t have Coronavirus?”

I know they’ve been thinking this. I’ve thought about it too. I’ve been asked this question a hundred times in the last two weeks.

“No,” I say. “Of course not. For all I know, you’ve got it.”

“So, shouldn’t I be tested?”

The guidelines, I tell them, are like a moving target. “Currently, we’re only testing people in negative pressure rooms, and we only have two of these rooms in our department.” Negative Pressure rooms, now more commonly known as Airborne Infection Isolation Rooms (AIIRs) are single occupancy patient care rooms used to isolate patients with a confirmed or suspected airborne illness. An AIIR, according to the Centers for Disease Control, provides:

a) negative pressure in the room (so that air flows under the door gap, into the room)

b) an air flow rate of 6-12 ACH (I have no idea what this means)

c) direct exhaust of air from the room to the outside of the building or re-circulation of air through a HEPA filter before returning to circulation (HEPA = high efficiency particulate air)

At this point, 9pm, there are still people waiting in cars to come in for COVID testing. Once a patient is tested in one of our two negative pressure rooms, it has to be cleaned thoroughly. Some patients have been sent in by Public Health, some have been sent in by their doctor’s office, and some just want to be tested. When a room becomes available, a nurse yells out “clear the hall,” to make way for these patients, and they are escorted into the room. Then, the doctor and nurse don hazmat suits – impermeable gowns, gloves, masks so tight that you can’t speak properly, and ugly shower caps – to assess the patient.

I rise from my chair and speak to Russell and his mother. “Right now, you don’t meet the criteria we’re using for testing. You don’t have a fever, and you haven’t traveled to an at risk country. You also haven’t had exposure to a suspected case.” Like most people, they understand. “We know now, though, that the virus is travels via droplet transmission, and not airborne transmission. So there’s a good chance we’ll be able to increase testing over the next few days by testing outside of negative pressure rooms.”

“So, what do you think we should do?”

I’ve been asked this question many times over the past few days. “First of all, I think the travel history is meaningless. We already know it’s in our community, so you can get it without having traveled to a so-called danger zone. If you’re having respiratory symptoms, you should quarantine yourself until you’re symptom free – at least fourteen days. Fortunately, we haven’t seen any really sick patients like those we’re hearing about in other countries. But, they’re coming. If you get a fever, then it may be worthwhile to come back to get tested.”

Friday, March 13, 2020. Russell’s Mono test is negative but I text him anyway. “As long as you’re not getting worse, or more short of breath,” I tell him, “you probably don’t need to be tested for COVID. Just stay home.”

Just this morning, our ER has just set up a drive-through assessment area for patients who are seeking COVID testing. I’m chatting with a couple of nurses at triage when a father brings his two young to the registration desk. “I just didn’t know what else to do, so I brought them for testing,” he says.  I’m not close enough to the trio to tell whether or not they have cold symptoms, or a fever, but the boys are active, and playful. They look perfectly well. All three are registered, and given charts, then sent back out to their cars to wait until they’re waved into our ambulance bay, like customers waiting to have an oil change.

I spend much of the day getting emails – from the hospital, from our provincial medical association – guideline after guideline. I’m told, by word of mouth, that we’re only to swab and test those with a fever, respiratory illness, and a ‘positive travel history,’ but I’ve read the documents over and over. The more I read them, the more I think that the travel history is meaningless – that we’re supposed to swab everyone with a cough and fever. Ontario Public Health, which for the last week has been sending patients to us, has sent out a document, suggesting that a “Probable Case” is any person with a fever (over 38 degrees Celcius) and/or onset of (or exacerbation of chronic) cough AND any of the following within 14 days prior to the onset of illness:

a) Travel to an impacted area*

b) Close contact with a confirmed or probable case of COVID-19 or

c) Close contact with a person with acute respiratory illness who has been to an impacted area*

The problem, however, is that the asterisk leads to point #9 on page two. And point #9 states: “impacted areas is based on current epidemiology and WHO situation report.” And, according to the WHO Situation Report #53 (the most current as of March 13, 2020), Canada is a country in which there is “local transmission.” So, as I’d told Russell and his mother, travel history is meaningless.

It’s Friday night, now, and my colleagues, like me, are looking for clarity. Emails are sent back and forth for hours. One of my colleagues described the patients he’d seen at a neighboring hospital looking for COVID testing. One was at a major conference where another person was confirmed to have COVID. Another came for testing because his family members had been tested (for no good reason). One said she’d been told to get checked because there was a confirmed case on her university campus. One was just demanding the test – screaming so hard through his surgical mask that my colleague had to step back.

He also said that there had been great variability between physicians. Some swabbed almost no one, some swabbed everyone. In the end, we decided to follow the guideline: swab anyone with a fever and cough. Travel history is meaningless. It’s already here.

Saturday, March 14, 2020. It’s the second day of testing in our drive through clinic. I’m working tomorrow, so I call my colleague who’s just finished the first shift, 9am to 3pm. He saw close to twenty patients, and stuck to the guideline as we’d discussed. The clinic ran smoothly, and people who weren’t tested were understanding.

An hour later, however, there was another email. We have a limited supply of testing swabs. If cases rise exponentially, as expected, it could only be days before we run out. So once again, my inbox is full and our physician group is trying to figure out who gets swabbed and who doesn’t. That being said, we’re set now set up to assess everyone who’s suspicious for COVID without bringing them into our ER where they might infect those who are most likely to suffer this new disease’s worse consequences. And we can assess them fairly quickly.  Those who are sick will be directed into the ER for further testing, and those who can manage their symptoms at home, will be counseled on how to decrease spread to others. Likely, until testing kits become more widely available, only those whose management will change with a swab result will be swabbed. And our approach to this pandemic will change quickly from day to day, as it has in the last seventy-two hours.

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  1. With your writing and observational skills you are a good chronicler of what the medical system is going through. I hope you can still manage it if or when the crunch comes in the next few weeks. It will be useful when it is time to assess what happened and what needs changing for next time.

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