Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 143

Happy Friday. Today I’ll begin with a deeper-than-usual dive into our local situation: SF, @UCSF, and CA. I’ll follow with a few observations from my recent stint caring for patients on the wards @UCSFHospitals.

2/ @UCSF & SF trending better. @UCSFHospitals, 29 pts (lowest since July 27), 9 on vents (Fig L). Fig R is admits/discharges, showing more d/c’s. Avg length of stay is 8d for non-ICU pts, 22d for ICU pts, which explains lag between less virus in community & fewer hosp pts.

3/ Overall @UCSF case-positivity rate is 2.4%. Rates in pts with Covid symptoms (6.55%) & without (0.57%) both falling. Latter # is my quick-&-dirty way of estimating the odds that a person on a SF elevator with me is infected. Not quite at May levels (~0.3%), but getting closer.

4/ SF also better. 93 cases/d (down from peak of 126; Fig L); hospitalizations 89 (vs peak 114) (Fig R). While it's a no-brainer to keep schools closed during a surge, these lower numbers (if they continue improving) should cause us to reconsider choices about schools in fall.

5/ CA also better. Test positivity rate down to 5.1%, from peak of 8% (Fig). Scarce testing and data glitches are real (& need fixing), but I doubt they explain improvements – if anything, might push pos % up, w/ tests prioritized for symptomatic pts. So drop to 5% is comforting.

6/ Also reassuring: CA's transmission rate (Rt) down to 0.87 (Fig on L); it's now 3rd lowest in U.S. (via Rt.live; Fig R). As you’ll recall, the baseline transmission rate for Covid is ~2.5; getting it below 1 drives cases down; >1 predicts an increase in cases.

7/ Nationally, I predict we’re on the cusp of a 3rd phase. Southern states, & CA, that had been surging are now improving (yet still at too-high case numbers & deaths). @NYTimes data shows only 11 states have increasing cases (down from ~20 in July) – none in South or California.

8/ I’ve worried about Pandemic Ping-Pong: regions surge, then they cool off (due to closures & behavioral changes), then others surge. Looking at states with upticks (above), we see several from Midwest (Illinois, So Dakota) & NE (NJ, RI, MA). Perhaps these portend coming waves.

9/ More evidence that we’re exiting the June-July phase of Covid: Fig on L shows cases (by population) in previously surging states (AZ, CA, FL, GA, TX) – all are falling. Fig R is deaths in same states; mostly still rising; they should start falling in 1-2 wks if history holds.

10/ More evidence of possible new phase (via 91-Divoc): in 4 US regions (Fig on L) – South is cooling, but now worrisome uptick in Midwest. Northeast still stable for now, though a few states (MA, NJ, RI) have rising transmission numbers (Fig R) that may be harbingers of badness.

11/ Shifting gears, I did 10 days of clinical service @UCSFHospitals in July. I wasn’t on a Covid unit and, as you know, UCSF has been hit lightly by Covid (~30 out of 700 pts in hospital). So my observations are mostly about how pandemic has changed life in an academic hospital.

12/ To start, things feel very safe, both for patients & clinicians. There’s none of March's franticness, no scrounging around for PPE, no hourly changes in policies & practices. We’ve settled into a slightly surreal new normal, which is good for everybody. Frenzy breeds errors.

13/ A Day in the Life: Every morning, I completed my online symptom checker, squirted my hands w/ gel, & donned a surgical mask and goggles, which everybody wears all day. All patients are tested on admission, so by the time I saw them I was pretty confident they were Covid-free.

14/ One of the things I love about working @UCSF is the collegial environment, best exemplified by our always-packed residents’ room, where there’s food, charting, gossip, and lots of “can-I-run-something-by-you’s." (Pic is pre-Covid.) Now, ward teams are atomized into ~10 rooms.

15/ Like most workplaces, our new communal space is Zoom. Around the hospital, I see clusters of residents watching the same conference on a dozen monitors in various rooms. This is Distancing 101 in a big hospital, and it's appropriate. But the hit to collegiality is palpable.

16/ Another hit: in my book, The Digital Doctor tinyurl.com/y4zluvhn, I described how digital radiology led to the demise of radiology rounds, as we no longer had to visit the radiology dept to look at films. I’m a big advocate for visiting radiology – we always learn a ton.

17/ But, in Covid-World, going to the radiology dept is verboten. Instead, we call the radiologists to discuss our films (but mostly we just read their reports).

Again, a totally rational step meant to decrease potential viral spread, but another hit to collegiality & learning.

18/ Rounds are another challenge. With all in masks/googles (some face shields too), we have ~6 people on a team sort-of trying to stay 6 ft apart. But it doesn’t work – particularly since person speaking is muffled by mask & you just can’t hear at 6 ft. Many such balancing acts.

19/ We now “require” pts to wear masks when we come into rooms, but few do – and it’s not easy telling a sick patient that they have to, particularly when they’re PCR negative. It’s different for visitors (who aren’t tested) – most wear masks, which is comforting & appropriate.

20/ Clinical volumes @UCSFHospitals are nearly back to baseline, incl. of hospitalized pts, surgeries, & ambulatory visits (latter are now running ~70% in-person, 30% virtual). The only service that's still way down is ER visits (Fig), which remain about 50% of pre-Covid levels.

21/ ED visit drop is happening all over (see tinyurl.com/y6xj9lru). Yet our ED admissions are nearly normal, meaning patients must be self-triaging – either foregoing care if they’re not too sick or getting care elsewhere (telemed, urgent care). Not necessarily a bad thing.

22/ To be clear, patients clearly HAVE missed out on some necessary care since Covid began. During 10 days in the hospital, I saw 3 pts whose admissions were due, at least in part, to having missed follow-up care for things like cancer, high blood pressure, & thyroid disease.

23/ Overall, @UCSFHospitals felt safe, things are odd but work OK, & I’m grateful UCSF & SF have dodged surges that beset many hospitals. As always, my clinical time was busy but invigorating – pts are fascinating, our residents awesome, & it's a welcome break from Life-of-Zoom.

24/ Closing the week: Trump-Swan @axios interview was wild, especially the dust-up over measuring deaths/case (Trump’s preference–to be fair, it has some value) vs deaths/population (Swan’s #; it’s the far-more-meaningful metric). ICYMI, interview is here: tinyurl.com/y5vr92sa

25/ … But I hope you'll check out this version, which overlays the classic Monty Python dead parrot sketch on the Trump-Swan visuals tinyurl.com/y4xnk8wp. Whatever your politics, I dare you not to find this amusing.

Enjoy your weekend and stay safe. Back next week.