My personal COVID survival guide by Dr Peter Haug (part 1)
Posted on 14 July 2020
So much has been written about Coronavirus Disease (COVID-19), inevitably causing information fatigue. Still, I have just been released from hospital after having been affected myself. I developed pneumonia, needed additional oxygen but fortunately did not develop a shock lung or require ventilation.
I’m a medical doctor with almost 30 years of experience since qualifying. Amongst others I also qualified as a specialist physician. Via electronic media I potentially have instantaneous access to the pinnacle of medical knowledge 24/7. Knowledge is power, and some idea whether or not there is danger or not can alternatively be comforting, or frightening. Still, going through the experience of being a patient myself for the first time in my life gave me insights that could not have learned through any form of academic study. Some experiences are likely to be experienced by many other patients. There are pitfalls, which seemingly can be avoided by relatively simple means. Some practical solutions hopefully will be worth sharing.
It is said that approximately 80% of patients infected by the coronavirus have little or no symptoms. Whether one develops no symptoms, little symptoms, severe symptoms or even dies from a shock lung not only depends on the virus, but probably also to a large extent on genetic factors. XY chromosomes (male gender), certain blood groups amongst others seem to be associated with a higher risk of developing more severe disease once infected. Nobody seems entirely safe. I have seen healthy young adults die, and older than 100-year-olds with multiple comorbidities laughing off the disease with minimal symptoms. We have no influence on our genes, and this uncertainty creates the experience of a Russian roulette-type lottery.
Stages of the Disease
The battle between the coronavirus and our immune system can be a protracted one. For many affected patients the disease first manifests with flulike symptoms, fever with evening accentuation, headache, muscular pain, persistent nausea or loss of appetite. Having high fevers for more than one week can be extremely taxing and feel never-ending. Still, provided there is adequate support, such patients can potentially be managed at home. Many people experience some improvement of symptoms after 9-10 days. Symptoms can however worsen, potentially rapidly. Identifying this change in symptoms timeously is of the utmost importance to improving the disease outcome. Simple home monitoring technology, if available and accessible, can assist this process. .
Fever and Dehydration
Having high fevers increases our bodies demand for fluid, not being able to take in fluid can lead to further weakening the immune system and kidney failure. Documenting and monitoring fluid intake can assist in ensuring sufficient fluids are consumed. In those who are not diabetic, preferably trying to consume rehydration solution (or a sugary drink) to maintain an energy supply is of benefit. Intravenous fluid and medication for reducing fever, inflammation or nausea may be necessary if the aforementioned treatment fails. Intravenous fluids and medication can be administered in most emergency units and field hospitals, but potentially also by primary healthcare providers in their surgeries, nursing homes, or even at the patient’s home. Prevention is cheaper than cure, it is important not to wait too long.
Pneumonia/Shortness of Breath
One treacherous aspect about COVID 19 disease is the stealthy development of lung inflammation. It is uncertain to what extent this inflammation is caused by the virus, or our immune response. Research has shown that even completely asymptomatic patients can have evidence of pneumonia on CT lung imaging. Red Blood Cells are our body’s means of transporting oxygen. The inflammation as a result of COVID-19, causes difficulty loading red blood cells with oxygen molecules in the lungs.
Our lungs ideally have some reserve capacity, symptoms such as shortness of breath only develop once this capacity to compensate has been used up. This reserve capacity is reduced in patients with pre-existing heart or lung disease, but also exposure to tobacco smoke. A gradually reducing reserve capacity can be masked for a long time, particularly when patients manage to rest. Less muscle activity reduces the body’s demand for oxygen. A sudden increase in physical activity, for instance after a patient reaches the decision to leave the home to seek medical help, can lead to a precipitous mismatch between oxygen consumption and replenishment, and potentially a rapid deterioration.
A pulse oximeter is a small battery-driven device that can be placed over one’s fingertip. It measures the heartrate; a gradual increase can be a sign of worsening inflammation or dehydration. Importantly this device gives a rough estimate of the state of blood oxygenation. Readings should ideally be 95% or higher. Some patients with chronic lung disease start off with relatively lower oxygen saturations, monitoring the trend is therefore important. Levels progressively dropping towards the lower 90s can potentially timeously alert that the system is beginning to fail. Fingertip pulse oximeters can be bought in healthcare shops, alternatively online. The cost starts from approximately R400, but may become increasingly inflated in the near future due to increasing demand. Still, I believe at the time of Coronavirus it is wise for every household not only to only invest in purchasing a thermometer, but also a finger pulse oximeter. Ensuring that the device is correctly applied to the finger and is of suitable quality is of importance when interpreting the readings.
Most patients who develop a “cytokine storm”, leading to a “shock lung” or severe adult respiratory distress syndrome (SARS) seem to develop such early, frequently within the first 5 to 7 days after first developing symptoms. Any symptoms of shortness of breath within the first week of developing COVID symptoms therefore have to be taken extra seriously. We are rapidly learning about new blood tests which can give some indication about the state of inflammation, and the potential risk of requiring ventilation. We recently learned that the timeous administration of corticosteroids (dexamethasone) in patients with negative prognostic factors can lead to substantial life and cost saving. I was personally reassured by the knowledge that, at the time when I needed to be admitted with first symptoms of shortness of breath seven days after testing positive for the SARS-CoV-2 virus, my chance of requiring ventilation was already statistically declining.
Blood Vessel Disease/ Blood Clotting Disorders
We today know that a big part of morbidity, mortality and complications of coronavirus disease depends on the state of health of blood vessels. Chronic inflammation such as caused by obesity/chronic non-alcoholic fatty liver disease, diabetes, hypertension, dyslipidaemia and exposure to nicotine amongst others can lead to build up of soft plaque involving the inner lining of blood vessels. The immune response against the SARS-CoV-2 virus leads to an activation of white blood cells and inflammatory proteins. Such can disturb blood vessel plaque and lead to the subsequent development of multiple micro-clots. If this happens to many very small blood vessels in the lungs it can make it near impossible to oxygenate the blood, even when breathing is taken over by a ventilator on high oxygen levels. Larger clots can contribute to stroke or heart attacks, clots in the venous system potentially to fatal pulmonary emboli. There are blood tests which can warn your doctor about your risk of developing clots. The timeous administration of medication to reduce platelet activation or systemic clotting in susceptible individuals has the potential to prevent serious complications.
Loss of Ability to Smell and Food Intake
After having had almost no symptoms for the first day after testing positive my personal COVID journey started with a very sudden and complete loss of the ability to smell “anything”. This happened over the period of less than one hour, in absence of any symptoms of nasal congestion, or any respiratory symptoms. The sense of my tongue for basic perception of sweet, sour, salty or bitter tastes was not affected. This seems to be a very common manifestation of COVID disease. From brain MRI studies we today know that this loss of smell sensation is possibly caused by direct infection of the brain by the coronavirus (encephalitis), causing inflammation of brain structures such as the olfactory bulbs. This is concerning because we do not yet know whether this causes long-term consequences, such as potential increased susceptibility to develop neurodegenerative diseases.
The return of smell sensation can be delayed and gradual. During the recovery process the sense of smell and taste is frequently distorted. When my sense of smell started to return any form of complex odours emitted by food evoked an extremely unpleasant sensation reminiscent having to eat cold, greasy and burnt bacon and egg leftovers. Trying to eat any cooked food was nauseating and near impossible. My personal experience was that it was easier to eat food that had a clear taste, but little odour. This included apples, raw carrots, plain lettuce leaves and raw almonds.
Concern about Close Contacts
I still have no idea how I eventually caught the virus. I had strictly followed all prevention protocols, assuming that everybody I met with could potentially be infected. Working in the environment and having had contact with several SARS-CoV-2 positive individuals in recent days made me go for a coronavirus swab within the first hour of developing suspicious symptoms, and immediately go into strict self-isolation at home while waiting for the test result. The risk of passing on the disease to other people is estimated to be highest from approximately one day before, to approximately one week after first developing symptoms. Understanding the implication of my testing positive on colleagues, patients, my close contacts, including their isolation requirements was my biggest concern. This was no trivial matter as fellow staff and patients needed to be followed up. Close contacts had just started reopening their businesses after having been forced to shut down for two months due to the lockdown regulations, with all its financial implications. All visitors to my household needed to be stopped.
Fear and Anxiety
Suffering from COVID-19 symptoms and having to be admitted to hospital was traumatic. During the first days of strict self-isolation I frequently felt lonely. Time passes very slowly, particularly when constantly feeling unwell. This can be inevitable at home, even with the most caring of families, as contacts needed to be reduced to an absolute minimum, preferably communicating through closed doors. This did not improve after admission to hospital. I insisted to go home after not having had a documented elevated temperature for 24 hours, but subsequently had to return to hospital only a few hours later with hypoxia and heart rhythm abnormalities. It almost felt as a relief when I was admitted to the ICU for cardiac monitoring, as just the background sound of a busy ICU appeared comforting and breaking the loneliness. Simple caring gestures of individual nursing staff members, and the calm compassion of the colleague who treated me will probably remain etched in my brain for the rest of my time.
Dr Peter Haug, Neurologist, Cape Town
21 June 2020