Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 128

Grand rounds today: tinyurl.com/y3vyakjs. I thought it would be great to hear reports from healthcare leaders in cities w/ surges: @CarlosdelRio7 @EmoryMedicine in ATL, Tanira Ferreira @UMiamiHealth & Rich Robbins from Houston Methodist.

2/ ... and Adrienne Green, @UCSFHospitals CMO. While @UCSF is having a bump, it's benign compared w/ ATL, MIA, & HOU. 30 Covid pts @ucsfhospitals, 9 on vents (Fig). Test positivity down a bit; asymptomatic rate – was 0.3% for mths – had risen to 1.1%, but now 0.68%–hopeful trend.

3/ SF numbers also fairly stable, w/ cases down a bit (Fig on L; though might be testing or reporting lag. But at least it’s not surging & might be improving.) SF hospitalizations flat, ~100 (Fig R). Bay Area continues to outperform rest of CA; things are much hotter in SoCal.

4/ To Grand Rounds. George Rutherford on CA situation (@ 13:00), noting new headline: CA now w/ more Covid cases than NY. Though pretty awful, it’s a bit misleading since we have twice the population. We’re still 23rd in U.S. in cases/capita, & 27th in total deaths per capita.

5/ @ 5:30, George gives a vivid and sad statistic about the overall situation in U.S: yesterday, our country had 70,000 cases (our total now exceeds 4M). 70,000 is more cases than the entire outbreak in Wuhan, China (!) In other words, says George, “we’re having one Wuhan a day.”

6/ @ 51:00 (skipping around a bit), Adrienne describes @UCSF's surge planning. Difference betwn March & now: now we're trying hard to stay open for other pts while caring for Covid pts. So far, we’re doing OK: our volumes are nearly back to normal (vs. half empty in March/April).

7/ @ 55:30, issues that keep Adrienne awake (Fig): while supply issues are still real (new PPE, reagent shortages arising), the biggest concern is that the workforce is burning out. On top of all the stressors, the schools add another huge hit for many. The other speakers agreed.

8/ Adds @CarlosdelRio7 @ 1:07:00, re: clinicians. “They’re exhausted, frustrated, saying this shouldn’t have happened. We focus a lot on stuff & not a lot of staff.” While Emory has had Covid cases in nurses/MDs, most from outside the hospital. Little nosocomial transmission.

9/ @ 8:00, George shows figure from @nytimes, which elegantly depicts surges in hospitalizations, including in Miami & Houston. Georgia’s surge is real but doesn't reach FL & TX levels; it actually matches the hospital numbers in Los Angeles.

10/ First report from the front, from @CarlosdelRio7. @ 27:00: What happened in GA, I ask? “The governor closed the state late and opened it early.” Carlos has been having a public “debate” w/ Gov. Brian Kemp, who is suing Atlanta mayor over mask-wearing ordinance. Sheer lunacy.

11/ @ 28:00 Carlos says that GA opened up because they misinterpreted an epi curve ("falling cases" was actually a reporting lag). Later skewered in @mluckovichajc cartoon. “Giving epidemiology to people who don’t know how to use it leads to problems,” Carlos says of GA leaders.

12/ @ 34:00, Tanira Ferriera: @UMiamiHealth was prepared for surge, but not this big. “4 wks ago, we had 5 Covid pts in [450 bed] hospital. Today, we have 156…38 are in the ICU & 30 are intubated.” So 1/3 of the hospital is filled w/ Covid pts. Not quite NYC in April, but wow.

13/ @ 35:00: In Miami, "people simply didn’t adhere, there wasn’t a unified force to speak to the right thing to do…” They are not yet seeing a surge in mortality @UMiamiHealth, but she is very worried that it will start going up soon. W/ 30 intubated patients, seems inevitable.

14/ @ 38:00, Rich Robbins, chair of medicine at Houston Methodist. Here, we see massive surge in cases, w/ ICU cases lagging behind – a general theme. Not clear if ICU trend is due to younger patients in the hospital, improved therapies, or a time lag. Likely all of the above.

15/ @ 40:20, Rich overlays Houston/TX policy timeline. It’s clear that the surges began around Memorial Day, and the state was late to enforce mask wearing and to shut high-risk places back down. Harris County (Houston) acted more quickly than the state, but not quickly enough.

16/ @ 43:10, Rich describes their Covid demographics. Their main hospital has 900 beds; it now has 250 Covid pts (similar proportion as Miami). Sharp uptick in mortality in pts > age 70. Surprisingly, not seeing racial disparities; cases/mortality similar in Caucasian/Black pts.

17/ @48:00: I asked Adrienne to react to FL, GA, & TX numbers. “It’s scary… while we have been watching the rest of the country… we’ve been very protected in SF. Even now, our numbers are on the lower side…. I’m so humbled by what the others have shared.”

18/ In Q&A, Carlos notes that businesses are creating mandates, placing an undue burden on them. Today, @Delta kicked off passengers for no masks, but there’s no FAA masking mandate (there IS a seatbelt mandate). “I’m concerned we’re not taking this virus serious enough.”

19/ @ 1:00:20: Rich: “For...150 yrs, Texans have had an independent streak, so many aren't so happy to follow the rules.” But now things are becoming more real. “We’ve had pts come in & pass away, who said, ‘Gee, I thought this was a hoax; now I understand it’s real.’ Very sad.”

20/ @ 1:05:00: Everybody said they were prepped for a surge, but thought it would be in fall, not summer.

All gave hope that Covid would change healthcare for better. Telemedicine, renaissance in clinical research, MDs recognizing their importance as spokespeople for science...

21/ ... and increase in interest in public health. George does a session for @UCSF students on careers in public health. Usual crowd: zero. This yr, 17 students! “I was flabbergasted.” But @ 1:15:00, Carlos isn't confident that strong support for public health will outlast Covid.

22/ @ 24:00, George predicts that Midwest may be next hot spot. But could be Northeast: he doesn’t think NY’s high # of prior Covid cases (~15-20% of people w/ antibodies) will shield region against another surge. A region will need >50-60% antibodies to approach herd immunity.

23/ @ 16:40, George on why CA (& other states) have spun out of control: on L, current pic from Huntington Beach (SoCal) – few masks. Contrast w/ pic of mask wearing during 1918 (flu pandemic) major league baseball game (R). If the ballplayers can mask, the rest of us can too.

24/ Speaking of baseball, we learned today that among Fauci’s superpowers (brilliant, amazing scientist, great public spokesperson & slyly politically adept), we can't add b-ball pitcher tinyurl.com/y3smvhkn It's OK, Tony: many can throw a strike; very few can do what you do.

25/ A terrific & scary session (again, it's here tinyurl.com/y3vyakjs). It's so sad to hear about these surges, which could have been avoided w/ strong leadership.

I’m on clinical duty now so won’t post tomorrow. Be back at some point early next week. Till then, stay safe.