It’s going to be a Cold, Hard COVID-19 Winter, but Help is on the Way

There are very few places in the U.S. that are experiencing low levels of disease and hospitalization.

As I and many experts predicted, the COVID-19 pandemic in the United States has ramped up, and the winter is going to be bleak. On Dec. 10 (the day prior to when I wrote this article), 2,923 new coronavirus deaths and 223,570 new cases were reported nationwide. This is an increase of more than 25 percent from two weeks prior. More than 15.5 million people have been confirmed to have been infected since the beginning of the pandemic, and over 293,000 have died.

293,000 people. In 2009, a total of 284,000 people died from swine flu globally. It seems like a huge number, but I was curious as to how many of our Monitor Mondays listeners have actually been touched by this horrible reality (yes, it is a reality. Although there are still swaths of people who believe COVID-19 is not real, they are wrong.)

We polled our listeners on Dec. 8, posing the question, “do you personally know someone (not a famous person) who has died of COVID-19?”

I’m not sure what I expected, because most people I know would answer yes. But the country has about 320 million people, and 291,000 (the death toll on the day we did the survey) is approximately .097 percent of our population. If the listener were in North Dakota, they might be more likely to know someone who had died, because in December, 1 out of every 800 North Dakotans died from COVID-19. In fact, COVID-19 has surpassed heart disease and cancer to become the leading cause of death in the United States. Our broadcast lasted 33 minutes on Dec. 8, and in that time, statistically, 52 people across the country lost their lives to this virus.

Sixteen percent of our audience either has lost a family member or close friend to COVID-19, and our condolences go out to them. Thirty-five percent of our listeners know someone other than a close relative or friend who has succumbed. Forty-one percent of us, in all – that goes to show you how far each of our reaches is, and how small the world really can be.

Why are things so dire right now? Early in the pandemic, hotspots were spotty. Cleveland could send nurses and doctors to New York City to help with their predicament. Right now, the disease is rampant, and there are very few places in the U.S. that are experiencing low levels of disease and hospitalization. Although emergency departments are often eerily empty, intensive care units are full. I read of a hospital in the Great Plains that had to call over 20 other hospitals, including in neighboring states, to secure a bed to transfer a patient.

This is taxing the healthcare workers and system. It’s not personal protective equipment (PPE) anymore, it’s staffing. It is limiting where patients can be transferred. It is leading to rationing of care. To try to deal with the crush of patients, the Centers for Medicare & Medicaid Services (CMS) expanded its Hospitals Without Walls initiative. Acute hospital care is being provided in facilities that were not constructed for that purpose (like ambulatory care centers and convention centers). Patients who three years ago would be slam-dunk admissions are being sent home with oxygen, monitoring, and visiting nursing care.

Yesterday, the Food and Drug Administration (FDA) advisory panel voted 17-4 to recommend EUA (emergency use authorization) for the Pfizer COVID-19 vaccine. By the time this article goes to press, I predict it will be a done deal, and the doses will be in the process of distribution. The four dissenters had a concern about the 16- and 17-year-olds not having been studied adequately; it was not an issue with the safety or efficacy of the vaccine itself. They were supportive of rolling it out for 18-year-olds and over.

It is nothing short of miraculous that they were able to design this vaccine at such warp speed. I use the word “design” with intention. The vaccine wasn’t discovered or developed gradually; the scientists basically selected a protein (the spike protein of the corona), replicated the mRNA sequence that encoded that protein, and determined that antibodies would be produced against the protein if it were injected into the human production apparatus. Our muscle cells produce the protein, and our immune system recognizes foreign proteins (antigens) and manufactures antibodies to attack the antigen. The testing is to ensure that the antibodies could fight off the infectious organism (neutralizing antibodies) and to make sure there are not serious adverse effects.

Our second poll question was, “are you going to get vaccinated against COVID-19 when the vaccine becomes available for you?” There isn’t enough vaccine produced yet for everyone to be vaccinated – it is a logistical nightmare to (hopefully) vaccinate 6.5 billion people, and simultaneous vaccination wouldn’t be prudent even if it were achievable.

The plan is to vaccinate first-line healthcare workers first, but they plan on doing it in staggered fashion. I know I previously shared with you how crappy the Shingrix shot made me feel. I was in bed for two days after each shot. I don’t think I would have been able to manage a shift in the ED if I were still working clinically. It has been noted and they anticipate that folks may have significant irksome side effects from the vaccine. You won’t be able to claim that the shot gave you COVID-19 (like you do with the flu shot now), because there is no infectious agent involved, but that won’t make you feel any better. The vaccination advisors don’t want to compound the staffing shortage crisis with healthcare providers calling out because they can’t function.

My advice is to think of it like I used to think of morning sickness in pregnancy. To me, it suggests that the hormones (or vaccine) are doing their job. I welcome achy muscles, headache, and fever. The test subjects I know interpreted those symptoms as signs that they had received the vaccine and not the placebo. They signal your body is having a robust response.

The vaccine seems to stave off severe illness, but we do not know whether it prevents infection at all and/or transmissibility. There will be multiple vaccines being administered as they are approved. The efficacy will vary. We will need somewhere around 60-70 percent of the population to be vaccinated in order to approach herd immunity.

A total of 51 percent of you said, “yes,” you plan on getting vaccinated. Eighteen percent of you are going to refuse, and 31 percent of you are still unsure. This will not achieve herd protection. I hope that you will reconsider as you see how everything unfolds.

This idyllic world will not arrive until mid-2021, even under the best circumstances. We must wear a mask correctly, physically distance, avoid congregating, and frequently handwash until such time as we have adequate vaccination. Please resist the urge to get together with loved ones with whom you do not cohabitate. I wish you and your loved ones very happy and safe holidays!

See you and the new COVID-19 codes in 2021. Good riddance and goodbye to 2020!

Programming Note: Dr. Erica Remer is the co-host of Talk Ten Tuesdays. Listen to her every Tuesday when the live broadcast resumes on Jan. 12, 2021, 10 a.m. EDT.

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Erica E. Remer, MD, CCDS

Erica Remer, MD, FACEP, CCDS, has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, CDI, and ICD-10 expertise. As physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and is the co-host on the popular Talk Ten Tuesdays weekly, live Internet radio broadcasts.

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