Outpatient COVID 19 Care

 

 

I picked up the phone.  It was the third time that day that I was making this sort of call.  “Ms. Nellie?”  I asked when someone picked up on the other end.

“Dr. Waldron,” the voice on the other end said, the words pouring out.  “I don’t know if you know, but I tested positive for COVID.  I guess my daughter gave it to me after Thanksgiving.  I’m so worried.  Some folks have told me at my age that it is a death sentence!  What should I do?”

Over the next several minutes, I talked to my distraught patient about her diagnosis and some things to do and some things not to do.  Most of all, I tried to instill in her a sense of hope.  Things would be OK.

What we know at this point is that most people with COVID will have mild illnesses.  At least 90 percent will be able to take care of themselves at home without requiring hospitalization.  The younger you are, the less likely you would need anything more than supportive care.

When to Get Tested

It is often difficult to know if you should go get tested for COVID.  You have a little tickle in your throat and maybe your nose is stopped up a little.  Maybe your neighbor stopped by for a quick chat and then called you a couple of days later to let you know that he tested positive for COVID.  There are a myriad of symptoms that we can experience and it is sometimes hard to know when to go get a test.

Common COVID symptoms are cough, fever, and muscle aches.  Loss of sense of smell is an obvious one that we associate with COVID infections, but to be honest, only about 60 percent of symptomatic people will have this symptom and so I wouldn’t put too much stock in the fact that you can still smell.  If you have the other symptoms you should probably get tested.

There are a lot of people who have other symptoms – GI (diarrhea, nausea) or simply confusion when their infection starts

If you have these symptoms and you need to be around other people, it is important to get tested.

If you have no symptoms but a possible exposure, it is probably best to wait.  Testing early is very prone to false negative tests.  Remember that you must have a certain level of virus in your system for the test to detect it.  Running out to get tested the day after an exposure may make you feel better, but it won’t really tell you if you are infected.

Dealing with a Negative Test

One of the hardest things is to figure out what to do with a negative test result.  Quite simply, a lot depends on your level of suspicion.  If your symptoms all fit COVID-19 and you had a known exposure, I wouldn’t trust a negative test.  Too often it is a false negative – either the swab wasn’t good enough, or some other factor made the test negative.

Of note is that Rapid COVID tests seem more prone to false negatives and so should be trusted a bit less than the standard PCR tests.

But if the test is positive, what should you do?

Isolation

Probably the hardest thing if you test positive for COVID is staying away from other people.  Many individuals don’t feel too bad and they want to get back to normal as quickly as possible.  The current recommendation is that you stay home for at least ten days.  At that point, as long as your symptoms have resolved for 24 hours, you can get back to normal.

It is not OK to continue with normal activities, even if you wear a mask and aren't really sick.  Quite simply, you may have gotten a mild illness, but you could easily infect someone else who might give it to someone else and eventually, one of those folks could get really sick with it.  The goal is to break that chain of transmission.

While you are isolating, it is a kind thing to notify the people you have been around for the last several days of your positive test.  Some states are doing "contact tracing," but it is probably taken better if you let your friends know yourself.

Don't Feel Guilty

I think all of us know that we could "do a little better" at social distancing and wearing masks.  If you come down with COVID-19 there is a tendency to blame yourself or, others for your infection.  Those sorts of feelings aren't helpful and could lead to destructive emotions like anger and bitterness.

As Scarlett said, "Tomorrow is another day."

Rest

Much of what we do for COVID is “supportive care.”  These are things like pushing fluids, resting, and deep breathing exercises.  The whole point of this is to give your body the care it needs in order to fight the infection off and avoid a superimposed bacterial infection.  We know that this can happen with influenza and it can happen as well with COVID.

Some have suggested using a device called an incentive spirometer.  This is something that people use after surgery to make sure they are taking deep enough breaths and while there is not testing showing it prevents more serious lung infections with COVID, it would make sense that it would help.

Fever Control

I have met some people who believe that it is important to “sweat out” their fevers and they avoid medications like ibuprofen and Tylenol.  There is no particular benefit to letting your temperature go way up and certainly you will feel a lot worse if you do.  My experience is that it is easier to keep your fever down than to get it down once it shoots up.

It is probably better to keep the temperature under 100 with either Tylenol or ibuprofen.

Vitamin D Supplementation

We know that people who have low Vitamin D levels seem to get worse cases of COVID than those who have normal levels.  That said, it doesn’t seem to help very much to start taking it once you get sick. 

My recommendation would be that if you are planning to get COVID down the road you should go ahead and start on a Vitamin D 2000 unit a day now.  If you aren’t sure if you plan to get it, it wouldn’t hurt to take it anyway.  https://www.covid19treatmentguidelines.nih.gov/adjunctive-therapy/vitamin-d/

Zinc

A lot of people think that Zinc is the wonder supplement when it comes it respiratory infections.  There is some indication that low zinc levels can increase risk of bad COVID infections.  There is no indication that taking zinc if you aren’t deficient does much.

I still generally recommend folks take 25 mg of Zinc a day while they are combating COVID.

Vitamin C

Vitamin C is another vitamin that is a "wonder vitamin."  It is the sort of thing that most of us take more of when we come down with colds.  There have been studies done looking at mega doses of Vitamin C (6000 mg) with COVID and did not indicate any benefit.

On the other hand, there was a study that showed that taking between 1000 and 2000 mg at the first onset of cold symptoms seemed to shorten colds duration by a little bit.  This is the dosage that I recommend people to start on.  It is safe and may help a little bit.

Other Over the Counter Medicines

Some people complain of stomach upset with COVID-19 and it can be helpful to take some Pepcid as this is pretty effective at calming that down.  Typically the cough with COVID is a dry cough, but if you have much mucus production, Guaifenesin (Mucinex/Robitussin) can be helpful to thin that out so that it doesn’t gum things up as much and is easier to cough out.

I do not recommend the “D” versions, as the pseudoephedrine in them tends to raise blood pressure and heart rates without a whole lot of benefit.

Monitoring

Hopefully you have a thermometer and can keep track of your temperature curve.  I am surprised how many moms think they can tell someone's temperature by a hand on the forehead.  "Feels like about 101, Honey."  Even if you have this skill, it is nice to have a calibrated instrument capable of giving an accurate reading.

The handiest thing to have if you are dealing with a COVID infection is a pulse oximeter.  A pulse oximeter used to be a very expensive piece of equipment that only medical offices and clinics could afford to have, but the prices have come down a lot.  It is a little device that goes on the end of a finger (or a toe) and gives you an oxygen saturation and pulse reading.  These are two important things.

Typically, even if you feel bad and are working a little harder to breathe, your oxygen level should stay up.  Three reasons to consider heading to the hospital for further evaluations are (1) decreased oxygen level (less than 95 percent for someone without chronic lung disease), (2) fast pulse rate (over 100), or fever that stays elevated despite medications to bring it down.

Other Medicines

It is hard to know what to say about other medications.  If you have asthma, certainly COVID can worsen your control and increasing inhalers and even adding steroids would be in order.  As far as steroids and COVID in patients without asthma exacerbations, they don’t help, unless people need to be hospitalized and placed on supplemental oxygen.  I have tried nebulized budesonide and despite reports to the contrary it really didn't seem to make much difference in how my patients did (they generally did fine, but there was no sudden turn around with this).

Hydroxychloroquine really doesn’t seem to be effective and isn’t recommended, despite some doctors claiming that it is helpful.  I know this has become very political, but if Dr. Zelenko's treatment regimen has any benefit it is from the Zinc.  I can't find any studies that replicate his retrospective study findings.  Hydroxychloroquine to treat COVID-19: Evidence can’t seem to kill it | Science-Based Medicine (sciencebasedmedicine.org) 

Antibiotics are not generally helpful unless someone begins to show sign of a bacterial infection on top of their COVID.  This will typically either be in a patient who requires hospitalization or someone who thought they were getting better and then a few days later begins to have recurrent infectious symptoms.

I will mention Ivermectin only to say that I don’t know about it.  Some are recommending it now, at various stages of COVID infection.  It may help, but it probably needs some formalized testing.  This is a summary of the issues with studies dealing with ivermectin.  Ivermectin is the new hydroxychloroquine, take 4: Bret Weinstein misrepresents meta-analyses | Science-Based Medicine (sciencebasedmedicine.org)  The studies all seem to include lots of other medicines including lactoferrin, hydroxychloroquine, doxycycline, steroids and Zithromax making it difficult to sort out what benefit is really from ivermectin and what is from other things.  Further, one of the biggest studies that showed benefit from ivermectin has recently been withdrawn due to some issue with plagiarism and fraudulent data.  Flawed ivermectin preprint highlights challenges of COVID drug studies (nature.com) If your health care provider is comfortable prescribing it, it probably wouldn't hurt, but I have not found it be helpful in my practice.

Monoclonal Antibodies

The number one thing that we know helps people avoid hospitalization are infusions of monoclonal antibodies.  These are infusions of antibodies that are targeted at the COVID virus, basically to help our immune systems fight of COVID more effectively.

The studies that looked at REGEN-COV antibodies found an 81 percent reduction in "events" (deaths or hospitalizations) between the antibody group and the placebo group.  1.5 percent of those who got antibodies required hospitalization, while 7.8 percent of those who got placebo ended up in the hospital.  Phase 3 Prevention Trial Showed 81% Reduced Risk of Symptomatic SARS-CoV-2 Infections with Subcutaneous Administration of REGEN-COV™ (casirivimab with imdevimab) | Regeneron Pharmaceuticals Inc.

It is important to note that these antibodies are most helpful if given early -- they are not approved for people requiring hospitalization and oxygen therapy.  They probably show the most benefit in patients who are at high risk for developing complications from COVID -- people over 55 years of age or those with risk factors.  They are not approved for people under 18 years of age.

Many states require a referral from a medical provider to give these infusions, but some states have set up infusion sites where people can self refer upon receipt of a positive COVID test.

Antiviral Agents

There are a couple of antiviral agents that are likely to be available soon in the United States.  The first one, from Merck, is called molnupiravir.  It is moderately effective for those who have mild to moderate COVID and cut people with those symptoms need for hospitalization by 30 percent.  The benefit of this is that it will probably be cheaper than an antibody infusion and of course, it is a pill, so it doesn't require a visit to a specialty pharmacy.  At this point, if someone is high risk for developing severe COVID, I would still do an antibody infusion as it seems more effective than this antiviral medication.  9 Things You Need To Know About the New COVID-19 Pill > News > Yale Medicine

Pfizer is releasing a protease inhibitor called Paxlovid.  Early data suggests that it is about 90 percent effective at preventing progression to severe COVID.  This pill is a little farther away from release, but my guess is that the benefit of this will replace monoclonal antibodies for the majority of people.

Obviously, there are many scientists working on specific agents against COVID and there will be more things coming out that will be quite effective.

Primary Care Provider

I know a lot of folks get their routine care from places like Urgent Cares, but it is really helpful to be established with a primary care provider.  Even if you get your COVID swab at an Immediate Care, the follow up will be done by a primary care provider.

Our office has been calling patients daily to check up on them after a COVID positive test, until they seem to have turned the corner.  If there are issues that develop, we are able to treat or help them sort out what the next step is.

I think it is important, even in a quarantine period, that people realize they are not alone.

Hospitalization

Probably only about ten percent of people with COVID will end up in the hospital.  Obviously at this point, you are in the hands of someone else and will need to rely on the doctors at the hospital for good care.  Typically now, depending on how sick you are, hospitalized patients are being treated with dexamethasone (a steroid that has the best data for reduction of COVID mortality), oxygen, and low molecular weight heparin (for prevention of blood clots). 

Remdesivir is a medication that is used in some ICU settings.  It has gotten a bad reputation due to some doctors (who don't work in ICUs) claiming that it causes kidney failure in a high number of patients.  Studies do not show that when Remdesivir is used to treat COVID pneumonia that increases the risk of kidney failure.  I will say that some pretty major trials have shown minimal benefit to using Remdesivir.  The Cochrane Review analyzed data from multiple trials and indicated that it is pretty ineffective at reducing length of hospital stays or deaths.  Remdesivir for the treatment of COVID-19 | Cochrane  There is no indication that Remdesivir makes anything worse (the same Cochrane Review says that there are "fewer side effects with Remdesivir than other treatments"), but it may not be beneficial in the way that we hoped.  

Some patients will require ventilation.  ICUs are trying to position patients on their stomachs (prone positioning) to try to keep fluids from collecting at the back of the lung.  Obviously, this isn't the easiest position to care for someone in, but it does make a difference in survival rates.

We are doing much better at taking care of patients who are admitted to the hospital.  Even for people who require ICU admission, at least 70 percent will survive, although it will probably be a long road to get out of the hospital.

Hope

The most important thing to me with any diagnosis is not to lose hope.  This is true with COVID-19 as well.  Regardless of the things that you have read about how terrible things “can” get with COVID-19, chances are good that you won’t ever need to cross that bridge.  Worry does not change a thing about the future, but it certainly makes the present less enjoyable.

I have made lots of these sorts of calls to inform people of positive COVID test results.  The most important thing for me in those calls is to remove the sense of despair that many, particularly the elderly, experience with this news.

As I think about it and what to do with the time you have while isolating, I would encourage you to pray – not just for your own healing, but also for those who are experiencing it first hand, the health care workers who are stressed out, and just for general healing in this nation.

Real good can come out of any experience.  Even wading through the waters of a COVID-19 diagnosis.

“When I am afraid, I put my trust in you.”  Psalms 56:3