June 24, 2020
“So hard to decide what’s safe!” That patient quote nails it. With King County now in phase 2 of Washington’s Safe Start Plan, case counts seem to be increasing a bit. But so far hospitalization and death rates remain flat. ‘So far’ is the operative term since hospitalization and death rates lag weeks behind infection rate. Meanwhile, all of us are having to grapple with our individual and family risk tolerance for extending our social contacts. Even adhering to phase 2 guidelines that allow us to gather with five or fewer people from outside our household per week, personal questions remain: outside only gatherings?, sleep overs?, hugging our elders (e.g. grandparents)?, hug their legs only? mask up the 3 year-old? Eat in a restaurant? Can I use my mask as a napkin? OK, we haven’t heard anyone ask that last question. Yet.
Know this: you are not alone in your pandemic anxiety. We all get at least a bit torn up over these questions that have no concrete answers. For most people, the goal can’t be zero risk of COVID-19 infection, because zero risk is as elusive as it is in driving cars and riding bikes. Fortunately though, the low hanging fruit in infection prevention is there to be picked, washed, and eaten. Here are two big examples:
Masks decrease droplet dispersion profoundly, including from the common asymptomatic/presymptomatic spreader of COVID-19. When social distancing can’t be achieved, mask use in public settings seems like a no brainer and hence Governor Inslee is declaring it a no brainer. We firmly believe that indoor and outdoor-when-crowded mask wearing in public are even more important than exactly which type of business opens when and at what capacity.
Respect your elders and those with predisposing medical conditions. The age discrimination of this virus remains profound. 90% of deaths in Washington are age 60+ (https://tinyurl.com/y9hhr2l3). Decisions we all make on behalf of that age group are sure to affect the death toll. A similar case can be made for extra caution around anyone living with chronic cardiovascular or respiratory conditions such as hypertension, heart disease, diabetes, COPD, and asthma, just to name some.
Three to four weeks from now we should have a much better sense about how flat or not flat are hospitalizations and deaths amid King County’s move into Phase 2. Meanwhile, may we do what we can to decrease risk to ourselves and others without an unrealistic expectation of zero risk. May we treat one another kindly, and create little joys in each day.
Dexamethasone is the first drug for COVID-19 shown to save lives.
That is, since we have little choice but to continue to accept the science-by-press-release and preliminary report standard imposed on us by the urgency of the COVID19 pandemic: https://www.medrxiv.org/content/10.1101/2020.06.22.20137273v1.full.pdf+html.
At face value the study design was thorough and comes out of the efforts of the widely respected RECOVERY Collaborative Group in the UK (https://www.recoverytrial.net/). The full extent of their data will soon be available. Dexamethasone is cheap too! Here are the take-homes:
- 2104 patients randomized to receive dexamethasone 6mg once per day (by mouth or IV) depending on the patient’s ability to swallow, for 10 days, and compared to 4321 patients randomized to usual care without dexamethasone.
- Dexamethasone reduced deaths by one-third in patients needing a ventilator.
- Dexamethasone reduced deaths by one-fifth in patients needing oxygen therapy but not needing a ventilator.
- There was no benefit among those patients who did not require oxygen or a ventilator.
In terms of ‘number needed to treat,’ that means that 1 death would be prevented by dexamethasone treatment of around 8 ventilated patients or around 25 patients requiring oxygen alone. Pause a moment to think on these numbers in light of the carnage this virus has caused so far in our world. This is no small breakthrough, even though it was of no benefit to infected people not ill enough to need hospital-based care.
Pride Month comes with Wins and Losses
On June 12th, the federal dept of Health and Human Services, as directed by the Trump administration, revised section 1557 of the Affordable Care Act to remove regulations prohibiting discrimination on the basis of sexual orientation or gender. In plain-speak, protections for LGBTQ people were stripped from the ACA.
It is our opinion that this is unconscionable, particularly because as the government’s own data shows, LGBTQ people already have greater health disparities, including higher rates of some cancers, higher rates of suicide, higher rates of violence, and decreased rates of accessing preventive care.
In the huge win column however, is the SCOTUS decision on June 15th that the Civil Rights Act includes protecting LGBTQ people from discrimination in the workplace.
HHS’ decision to revise rule 1557 of the ACA was based on (in their words) aligning the ACA with the rights as described in the Civil Rights Act. Since the Civil Rights Act now is affirmed by the Supreme Court to include protection from discrimination regardless of sexual orientation or gender, we hold out hope that these now unlawful changes to the ACA will not be implemented.
Regardless of the political winds, we will remain steadfast in our commitment to providing informed and compassionate care to people of all sexual orientations, genders, and gender expressions. You are seen, you are always welcome, and we are honored to be on your healthcare team.
Words of Wisdom
Do not be daunted by the enormity of the world’s grief.
Do justly now,
love mercy now,
walk humbly now.
You are not obligated to complete the work,
but neither are you free to abandon it.
– The Talmud