NoVa Healthcare Adapts to the Epidemic

Alex Krist

by James A. Bacon

The Washington region, including Northern Virginia, is a looming epicenter of the COVID-19 epidemic. Known coronavirus cases in the metropolitan area now exceed 1,000, according to the Washington Post. And it will surprise no one to know that the number of cases confirmed by medical tests represents the proverbial tip of the iceberg.

Of the 25 patients he has seen so far this week, says Dr. Alex Krist, a Fairfax County primary care physician, he would say that five of them carried the COVID-19 virus. They had coughs, shortness of breath, chest pains, and fever — and a week-and-a-half ago they’d been to New York. Given the shortage of test kits, however, they didn’t qualify to be tested. In Northern Virginia, he says, tests are being used not for epidemiological purposes (to track the spread of the disease) but as a screening device to determine if patients are appropriate candidates for ICUs and respirators.

Things will get much worse in Virginia before they get better, says Krist, a Virginia Commonwealth University research professor who chairs the U.S Preventive Service Task Force.

Spurred by emergency conditions, Northern Virginia hospitals and doctors are changing the way they practice medicine, Krist tells Bacon’s Rebellion. “We’re going to run out of hospital beds. We’re going to start trying to treat people at home.”

The medical practice of which Krist is a part ordinarily sees about 9,000 patients a week. In early March, when people were just beginning to worry about the epidemic, the docs in his practice conducted 0.8% of their consultations remotely — virtual visits. Last week, the percentage increased to 45%. Today, he says, “about 99% of our visits are virtual. I have been seeing patients from my basement.”

There is a desperate shortage of protective gear in Northern Virginia (as elsewhere), and doctors, nurses and others in the front line of health care don’t want to catch the virus. It’s not simply a matter of worrying that the illness might knock them out of the fight, so to speak. They don’t want to become vectors of the disease and unknowingly accelerate the spread of the epidemic.

As Krist sees it, the medical community has three lines of defense.

The first line of defense is to see patients virtually, so as not to spread the disease, and to keep as many patients as prudent out of the hospital. Many of these people may be sick and showing respiratory symptoms but are stable and can recuperate at home. In another day and time, they might have been hospitalized, but now doctors are urging them to stay home. One reason is to free up as many hospital beds as possible for the hard cases. A second reason is to keep people from getting infected in the hospital.

The second line of defense is to treat people at home — to provide them “pseudo-hospital care.” Someone will check them every day in a virtual visit to assess their condition. People in this group might include COVID-19 patients who don’t need oxygen and don’t need to be intubated. The group might include people with advanced directives who don’t want heroic measures. Normally, they’d receive hospice care in the hospital; now they’ll get it at home. “Lots of people go into the hospital who don’t really need to be there,” says Kris. “We’re going to try to keep them out, but we need to check on them daily to make sure they’re OK.”

The last line of defense is the hospitals themselves. “The need is potentially a thousand-fold more than we have capacity for,” Krist says. “If we don’t do well, the system will be completely overwhelmed. If we do well, the system will just be overwhelmed.”

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15 responses to “NoVa Healthcare Adapts to the Epidemic”

  1. Reed Fawell 3rd Avatar
    Reed Fawell 3rd

    Excellent article.

    This disease will, and is right now, changing the way our world works, much of it positive, but obviously many changes will carry unintended and unknown consequences.

  2. Steve Haner Avatar
    Steve Haner

    Incubated or intubated? Preemies are incubated. 🙂

    1. You are correct. Thanks for pointing it out. Correction made.

  3. LarrytheG Avatar

    Geeze – a “no-fault” narrative!

    re: ” Given the shortage of test kits, however, they didn’t qualify to be tested. In Northern Virginia, he says, tests are being used not for epidemiological purposes (to track the spread of the disease) but as a screening device to determine if patients are appropriate candidates for ICUs and respirators.”

    No blame here but amazing to me that South Korea and Germany did take a “test everyone” approach – and apparently had enough tests to do it – and as a direct result, appear to have kept their hospitals and medical staffs from being overwhelmed.

    I’m not sure if we CHOSE to not do that approach or if somehow our ability to create enough tests is just not present or what.

    Just seems the smarter way would be to test…screen, isolate, repeat testing, etc..

  4. Jim, this is a true picture of things here in NoVa. I’ve had a cold that required consultation and so I went through the virtual office visit routine just a week ago. All you hear from the doctors willing to talk at all is about the absurd way the testing ramp-up has been handled, the lack of cheerleading from Northham and counterproductive talk out of Washington, and their dread of what is going to hit us in April.

    The stay-at-home option for known COVID cases is something I haven’t heard about. It makes sense for the patient, but it is not isolation, and probably would not pass muster where that is mandated. Even if the patient can feed and take care of himself, who is going to do his shopping, take the trash out? If you’re tracing contacts, then those helping these patients are exposed, too, along with second degree contacts with everyone else they are caring for. But it beats placing the mild cases in the hospitals and contributing to the overload there.

    Basically this is beyond isolation and quarantine to a more generalized notion of distancing-at-home. Containment is done; we’re simply slowing the spread. Here is a neat little interactive “virus spread simulator” that anyone on this blog may enjoy playing with, showing how different approaches to “spreading the peak” work, from the WaPo online (they say they’ve waive firewall restrictions on their COVID articles):

    We need testing, testing, testing!

  5. djrippert Avatar

    “Given the shortage of test kits, however, they didn’t qualify to be tested. In Northern Virginia, he says, tests are being used not for epidemiological purposes (to track the spread of the disease) but as a screening device to determine if patients are appropriate candidates for ICUs and respirators.”

    Just as I have suspected for more than a week. I kept asking and asking why Northam never talked about testing when it is a keystone of the press conferences held by other governors like Andrew Cuomo.

    Now we know.

    Virginia is not doing the testing at anything like the pace required. That means Northam’s statistics are almost as worthless as he is.

    As for the “Orange Man bad” crowd out there – New York state has administered about 5,500 tests per 1M people since the 70th case was reported. Virginia has administered 6,189 tests ever, or … 728 tests per 1m people.

    728 vs 5,500. Let that sink in. Both states operate under the same Federal government. Other states with more effective testing – WA (4,500 per 1M), MA (3,000 per 1M), LA (2,500 per 1M), CT, CA and NJ (1,800 per 1M), IL (1,000 per 1M), FL (900 per 1M). Meanwhile Ralph the Mime has nothing to say about the level of testing in Virginia?

    Orange Man bad?
    Coonman worse!

    1. One reason New York is doing more testing is that it is a COVID-19 “hot spot” and therefore gets allocated more test kits by the federal government. I don’t know that for a fact, but it’s a possibility that should be checked out. The paucity of test kits may be beyond Coonman’s fault.

      Meanwhile, the University of Virginia is ramping up production of test kits.

      1. djrippert Avatar

        “The paucity of test kits may be beyond Coonman’s fault.” Then that’s what Coonman should say.

        Good for UVA but as of yesterday UVA could handle 100 tests a day. We need to add thousands more tests per day not hundreds.

        I don’t know the testing situation “for a fact” either. Isn’t that why we elect a governor? To take action and keep the citizenry informed of where we stand? I watched Ralph the Mime’s press conference yesterday. In his prepared remarks he never said the words “test” or “testing”. A question was asked about testing which Ralph the Mime basically ducked. He opined that cases across the country are increasing because tests across the country are increasing. Then he asked Dr Peak (sp?) to speak and she opined that private labs take longer than state labs to process tests. When asked about the timing of a peak in Virginia Dr Peak (sp? – ironic) said she had no way of knowing when the peak would come. In New York the peak is estimated to be within 14 – 21 days.

        Here’s the kicker – there will be no press conference today because Ralph the Mime decided that holding press conferences every day was TMI – too much information. So, he backed down to a M – W – F schedule.

        1. Reed Fawell 3rd Avatar
          Reed Fawell 3rd

          Day by day, the attitude of Virginia Governor and leaders becomes ever more remarkable.

          1. djrippert Avatar

            If they would just lay the cards on the table we would all be much better off.

          2. LarrytheG Avatar

            “In the aftermath of a 2015 outbreak of the Middle East Respiratory Syndrome that killed 38 people and cratered the economy, South Korea took a hard look at what had gone wrong. Among the findings: A lack of tests had prompted people ill with the disease to traipse from hospital to hospital in search of confirmation that they had MERS, a coronavirus far more virulent than the one that causes COVID-19. Nearly half the people who got the disease were exposed at hospitals.

            Korean officials enacted a key reform, allowing the government to give near-instantaneous approval to testing systems in an emergency. Within weeks of the current outbreak in Wuhan, China, four Korean companies had manufactured tests from a World Health Organization recipe and, as a result, the country quickly had a system that could assess 10,000 people a day.

            Korea set up drive-through test stations, an approach only now being launched in the United States. Health officials initially focused their efforts on members of a secretive megachurch in Daegu with a branch in Wuhan, but they then broadened their reach to Seoul and other major cities. As of Saturday, South Korea had tested more than 248,000 people and identified 8,086 cases.

            So far, 72 have died, or 0.9% of those infected.


        2. LarrytheG Avatar

          Is UVA doing this on their own or in coordination with the state VDH aka coonman?

          Can any hospital or other medical provider do testing in Va?

          How about other states besides NY? Are they doing state-level testing?

          One might have thought that the US would do testing like South Korea or Germany with the top level govt heading up the effort – both providing the tests and coordinating the protocol and data collection.

          It would seem that failing that – that the States would do that – but not sure how the states get the tests… or if they leave that up to each testing organization down the hierarcy.

          For as much “news” we are getting on this – from all the news providers, there is a lack of clarity and specifics.

  6. LarrytheG Avatar

    Here’s some more ignorance. Where do we get the test kits?

  7. LarrytheG Avatar

    It’s not clear where test kits come from and who is in charge of getting them and how many to get – and who to test.

    In Germany and South Kores, it appears the national govt was in charge of all of this. In the US, it’s not clear at all although it sounds like various entities can get them independent of Fed or State govt and by some convention/agreement we’re not testing all just a smaller number.

    1. djrippert Avatar

      Here’s what I believe (but do not know) to be true –

      At first, test kits had to come from the CDC. There were too few and some of the early test kits were defective due to reagent problems.

      Some states petitioned the federal government to be able to do their own testing with test kits developed in-state. I assume Virginia falls into that category since UVA is conducting tests.

      The level of testing in a state is a combination of what the state can get from the feds and, for states with waivers, what the state can do for itself.

      A child able to understand crayons and a coloring book can look at a map of the US overlaid with COVID-19 cases and guess what is going to happen. The epicenter in New York is spreading essentially along Rt 95 south. New York has, by far and away, the most COVID-19 cases. Second place? New Jersey by a fairly wide margin. Pennsylvania added 560 new cases yesterday to get to 1,687. That’s a 33% increase in a day. Yesterday (Wednesday) the City of Baltimore announced that its COVID-19 cases increased 22% since Tuesday. DC is roughly tracking Baltimore. From there …


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