Hi, I’m back as Robin-the-Boston-cancer-doctor-who-writes-about Covid.

(And it’s okay with me if you want to share this.)

In Massachusetts, numbers are definitely better. As of Friday we “only” had another 630 deaths, down from last week’s 900.  And there’s 700 fewer people in the hospitals (down to 2300) and only 630 in the ICU (last week 750). Yay, downtrend! 

Every week there are FOUR THOUSAND medical journal articles about Covid.  We are “building the plane while we’re flying it.” Some become click-bait for a day and then disappear, but some are giving us good information about how to live our lives.

New York City, which is a few weeks ahead of us, is settling down.  Some of their doctors made the time to publish what happened with 257 critically ill Covid patients during the month of April (out of a total of 1150 Covid admissions).

It’s similar to what we’ve seen in China and Europe: a minority of Covid patients needed to be hospitalized (something like 10-15%) but a good number of admitted patients become critically ill and these are the ones we worry about most.

Most came to the hospital short of breath.  Some, not all, had fever.  Most had cough, muscle aches, diarrhea. 

The average age of the 257 critically ill patients was 62. Two-thirds had high blood pressure, 36% had diabetes, and almost half had a BMI>30. 80% ended up on a ventilator for weeks.  A lot (31%) ended up needing dialysis. 

39% have died (37% were still hospitalized when the paper was written) and the 39% were more likely to be older, to have high blood pressure or chronic cardiac or pulmonary disease like COPD/emphysema or interstitial disease. People who died also had high lab values that measure inflammation (D-dimer and IL-6 for the lab-geeks among us). 

So in New York as well as other places, the people at the highest risk are the people with bad lungs or bad hearts. Theirs are the risks of the awful outcomes: long periods of being critically ill, high chance of needing a ventilator, high risk of dying. 

These are the people who need to be most cautious with reopening. 

Another study of interest this week:  MGH did a very cool combined nose-swab “PCR” study (which shows if you HAVE it) and an antibody study (which shows whether you HAD it) in Bostonians who had no symptoms and no previous tests. 

They did testing in areas with both high and low levels of Covid.  They found:

a) 1 in 38 people (2.6%) were PCR positive (ie had Covid right that minute even though they had no symptoms) 

b) 1 in 10 people (10%) were antibody positive (had already had it but didn’t know).

They also found that people were more likely to have unknowingly already had Covid (eg have a positive antibody test) if in the last month they:

a) thought they had had it (I call this the “‘I told you so’ syndrome”)

b) had had a fever at some point

c) had lost their sense of smell or taste

So this says two things to me. 

One, 90% of us in Boston haven’t been exposed to the virus yet (don’t have antibodies). 

Two, the 1 in 38 number of people who turned out to be actively infected with no symptoms — this is a very interesting number.  These are the people who are a real risk to you and me — they are almost definitely contagious. 

Some people hear that number of probably contagious people —1 in 38 — and it feels super scary.  But other people feel reassured.  It’s all about perception of risk. 

My cancer patients have taught me a lot about perception of risk.

Sometimes I tell Patient A in the morning that she has a one in eight chance of having her cancer come back and she says, “OMG, that’s so high, I’m doomed.”  Then that same afternoon I tell Patient B the exact same thing — that she, too, has a one in eight chance of cancer recurrence — and she says, “OMG I love those odds, that’s fantastic, I’m so relieved.”

Same thing with this.  Say you’re on the Red Line with 38 other people in your car.  Do you look around and go, “OMG, one of these people has Covid right now and I’m going to get it for sure?”  Or do you sit and smile to yourself and say, “37 of these people are totally healthy — I’ll be fine!”

People experience risk differently and that’s important to know about yourself when deciding what to do about reopening. 

Some people see all risk as too high or scary and are only comfortable with close-to-zero risk.   And some people are truly at higher risk of dying from Covid (as revealed in the New York study and others: people with COPD or heart/vessel disease). Both groups will probably continue with our March/April brand of very serious physical distancing. 

But most of the rest of us are going to be part of our reopening and will need to figure out how much risk we’re willing to take and how. 

As we “fly the plane while building it,” we are starting to see some studies that maybe can help us makes sense about what are big risks and what are smaller ones.

A recent study looked at people talking unmasked.  Conclusion: people talking normally are relatively low-risk. 

Prior studies:  People shouting/singing: higher risk. People behind masks: low risk.  People more than about six feet away: low risk.  People we’re with less than 15 minutes (maybe 10): lower risk. 

Not no risk.  But lower risk.

Inanimate objects: increasingly the evidence shows they are low risk.  A German study trying to find infectious live whole viruses (as opposed to viral particles or the viral RNA in earlier studies) found you need to touch the contaminated surface less than 30 minutes after the virus lands there, and you need to inhale 1000 intact viruses all at once, at least, to get sick. 

So the chance that there’s enough infectious live viruses on your long-awaited Wells Fargo Wagon/UPS package or Trader Joe’s Orange Chicken? Very very low (unless you see the Trader Joe’s guy or Wells Fargo Wagon driver actually sneeze on the right-hand corner of the box and then you grab that right-hand corner with your right hand and touch your mouth and inhale).

So we fold all of this into our decision-making now.  Are we on six meds for our heart or lungs?  Are we seeing cautious friends who will wear masks? Does our dear old Uncle Bart yell-instead-of-chat? Is it church choir belting it out (particularly that alto) or is it me sitting praying motionlessly two pews away from anybody? Is it a brief encounter (eg passing while hiking) or prolonged, eg a massage? Is it croquet in the park or a high-intensity volleyball game where we slam into each other and everybody grunts and coughs? 

And how do we approach risk?  Are we a 1 in 38 worrier or a 37 in 38 optimist? 

Reopening is all about questions.  And gradually acquiring answers that will help us build the plane. 

Want to be in a study? Here’s a few: https://rally.partners.org/coronavirus?code=PHSBroad_20200520_b

Want to be a contact tracer?  Some places are full but the need is on-going and the work is often remote.  In Massachusetts, https://www.pih.org/covid-team  In Louisiana contacttracing@la.gov.  In NY, https://1w20ju1nsz1k2xqrjx3ccsd1-wpengine.netdna-ssl.com/wp-content/uploads/sites/76/2020/04/CT-I.pdf?fbclid=IwAR0-w1kVNinmTlIcJARiovUM2lcPmL5xoqeGYedBVdYX3ehgLguxXl0v3wI   Or just google. 

Want to get tears in your eyes? https://static01.nyt.com/images/2020/05/24/nytfrontpage/scan.pdf

Thanks for reading.