EDITOR’S NOTE: Dr. Remer reported this story this morning on Talk Ten Tuesdays.

Sunday morning, I received an email from my father’s assisted living facility, indicating that several residents and staff had tested positive for COVID-19 during their newly implemented routine testing of all residents and staff.

For the next 14 days, the facility is on lockdown again. No more outside family visits in the driveway. No more meals in the dining room, with two people to an 18-foot table (if you believe my father, which I don’t). No more outside concerts or indoor bingo with six people in a room that used to hold 50. Residents may only leave the premises for doctor appointments, after which they must restart another 14-day quarantine.

I immediately checked my home phone voicemail to be sure that I hadn’t missed a notification about my almost 90-year-old father. I hadn’t…because the phone call came at 9 p.m. Sunday night.

My heart sank when I saw the head nurse’s caller ID on my phone screen. Apparently, they performed saliva tests on everyone on Tuesday, and the results had just come in that day. Imagine, a five-day lag.

My father, and all of the others involved, are asymptomatic. My father had been at my house on Saturday, because my brother Mark, who was driving across country, wanted to see him. My immediate family and I follow social distancing and masking rules, but I am afraid my brother can be a little more lax. He was standing right next to my dad, helping him get Zoom on his cell phone. After FaceTiming with my dad to see for myself that he was indeed asymptomatic, I called my brother to tell him he has been exposed, and should quarantine for 14 days.

I am sharing this with you to illustrate how insidious this whole SARS-CoV-2/COVID-19 business is. Mark, who hails from Kansas City, was following the rules, wearing his mask to try not to expose my dad, in case he was unknowingly infected. It didn’t even occur to him that he might be the one at risk from my father.

I have been denigrating the phrase “he tested positive for COVID-19” when I hear it on the news. I snort, “that translates to ‘he is infected with SARS-CoV-2.’” The news media makes it sound so passive and harmless. To clarify, COVID-19 is the disease the virus called SARS-CoV-2 causes, but you do not need to have the disease to transmit the virus to someone else – who may in turn get ill and die. If you are shedding live virus, you are infectious.

It is extremely stressful, waiting to see which way this goes. I don’t think there is enough data to know how long the presymptomatic phase of the infection lasts, and if symptoms are going to arise. Can patients be asymptomatic for days and days and then take a turn for the worse, decompensate, and die? How long had my father already been incubating the virus, in relation to when they randomly tested him? Where did he get it from? Did he give it to anyone else?

I contacted the head nurse to determine what kind of test had been performed. They were saliva tests, which are antigen tests to detect proteins and require PCR confirmatory testing. Dr. Ronald Hirsch recently shared with me a Kaiser Health News article exposing the limitations of widespread nursing home point-of-care antigen testing, which the government is distributing. Those tests, per their manufacturers, are intended for symptomatic patients – and a prominent epidemiologist stated that you should always use a diagnostic in the way that it was designed to be used, because you don’t know how it will perform under other circumstances.

However, my dad’s test had been a saliva molecular PCR test looking for actual viral genetic material. False positives from these tests are quite unusual – it is much more common to have a false negative. We have to presume this is a true positive.

There are several lessons here.

First, even though the entire population of the facility was tested, it was not screening, Z11.59. All of the residents who tested negative would be coded with Z20.828; all the positive ones are U07.1, COVID-19. This is a prime example of how there was contact with or suspected exposure for everyone.

Second, EVERYONE is at risk. You are at risk of getting it from someone else, or you are at risk of having it and giving it to someone else, even if you feel fine. You are only one exposure away from getting SARS-CoV-2, and possibly, COVID-19.

Everyone should be wearing a mask over both their nose and mouth. If you can’t wear a mask, you shouldn’t be out. If you can’t be heard, don’t pull your mask down; talk louder and articulate through your mask. If you are uncomfortable wearing a mask, no kidding. Wearing a mask is uncomfortable! You have to get used to it. Mind over matter; you are stronger than that.

If you are out and other people are not wearing their masks correctly, you should remind them. They are wearing their masks to protect you, and that elderly man over there, and that obese woman on steroids over there. This is not political; it is life and death.

Finally, for all of you who are dealing with the Damocles sword over your head, waiting to see if you or a loved one are going to develop COVID-19 from an asymptomatic infection detected by a positive test, or if you are going to get sicker from your coronaviral bronchitis, or if your loved one is going to survive being on a ventilator, thoughts and prayers to you. The uncertainty magnifies the impact of the virus.

If you are suffering from long-term effects from COVID-19, we wish you a speedy recovery. If you have lost a loved one or your livelihood to this terrible illness, our condolences.

Let us remember we are all in this together. And that is the only way we are going to come out of it.


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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