This question finds me pretty often now. I’m not a public health guru and I only have a small sliver of a 2 dimensional view of this 12 dimensional elephant named COVID. While the party line seems to be “test, test and more test,” to me, the devil’s in the details. I do think it’s safe to say the approach for any disease probably needs to vary based on its prevalence, as well as its capacity to maim or kill people, or destroy an economy.
In the case of rhinovirus, its prevalence is high, but most people muddle through with their runny noses and keep on working. So we don’t chase it down with much testing.
Flu is worse, but seasonal. Plus we have Tamiflu, which lies somewhere between wonder drug and placebo. So our testing is variable. If it’s a busy shift and all over town, we “treat and street.”
On the other extreme lies ebola. Its prevalence is extremely low. But when it appears it’s horrendous. Even a single case can close a hospital and shut down a community. Many of you will remember that outbreak a few years back. In some parts of the world it’s still wreaking havoc. There’s plenty of good reason to chase down every case of ebola that’s out there with vigorous testing and contact tracing.
COVID resides somewhere between flu and ebola. In the ER we say a few versions of “well is easy, and sick is easy. The middle patients are hard.” COVID’s in the middle, but on a macro scale. It injures and kills many. It unemploys many too. But far more survive and grind their teeth about loosing their livelihoods and freedoms.
When it comes to testing for COVID, it makes sense to me to test like crazy when cases are localized and actually countable. Contain, and hope it flames out like SARS, MERS, Zika and others. However, when the whole population is infected, massive testing and contact tracing efforts will no longer be feasible. So my question today is, where’s the inflection point? When fighting a fire there’s a time to pour water on the flames directly, and there’s also a point where fire fighters start cutting lines in the dirt instead to limit spread. When do we start that for COVID? That will likely differ by community and even within communities. Other countries have already done that… with us.
Another analogy came to me during my last shift. I majored in math and physics, and have forgotten most of both. But for some reason the Heisenberg Uncertainty Principle still flickers. I’ll have a quick whack at it here. (To proper physicists please forgive me.) When studying tiny fast moving particles, we can’t precisely determine velocity and position of a particle at any precise moment in time. The act of measuring velocity impacts position and vice versa. (That’s the shortest version of the “HUP” out there.) Strangely, that shapes my take on COVID testing today.
On my recent ER shift, the number of COVID anxious patients far exceeded the number of truly sick patients. “My grampa tested positive and I want to get checked.” “My boss sent all of us here to get the test.” “I have a scratchy throat and I plan to go camping this weekend. So I want to do the responsible thing.” “My 18 month old was pulling at her ear and she was playing with a kid whose uncle may have been exposed.” “I tested positive a couple weeks ago. I feel fine, but I’m told I need to have a negative test to come back to work.”
I’ve heard of employers sending buses of employees to get tested all at once upon learning about one positive within their companies. I get it, and I don’t blame the employers. Everyone wants to do what’s right… or what’s perceived to be right. And nobody wants to be the next Smithfield.
EMTALA prevents me from saying: “Please stay home, or find a drive through somewhere that will swab through your window and call you for free.” So instead, on my recent shift I had throngs of patients on separated chairs outside with masks awaiting vital signs, swabs and discharge papers. I know versions of this scene have been playing out across the country, with far more craziness and actual sickness. So while I do see the benefits of testing, I also fear that testing itself can amplify spread.
I actually wonder sometimes if our problem isn’t so much COVID, but rather PCR (the method used to test for COVID). I don’t know. Picture a world without the rapid testing option or the word “COVID” for that matter. We’d probably be more scared. Maybe more of us would be dead. Or would we? Maybe more of us would willingly wear masks in public. Those of us who could hunker down would probably do so. Those of us who couldn’t afford it would fearfully keep going to work. I wonder if the mortality rate would resemble that of the Spanish flu 100 years ago or if we’d be smarter. I wonder if we’d be treating each other with more kindness.
Here’s another consideration. Many hospitals and ERs are actually quite happy to receive the incoming wave of worried well to make up for so much lost revenue when curves got flattened a few months back. Who would ever have predicted the industry, that cost taxpayers trillions preCOVID to buy number 27th (+/-) on the world’s healthiest countries list, could be crushed so quickly by a tiny little virus and so much curve flattening… only to be rescued a few short weeks later by that same little virus?
I don’t know. Despite the obstacles and general confusion, I guess I’ll/we’ll just keep trying to take the edge off of suffering. Let’s be nice to each other and keep on keeping on.
