“There are three kinds of lies: lies, damned lies, and statistics.”
- a quote with no clear origin popularized by Mark Twain
It’s true. Stats can often be manipulated to support a person's agenda. While I make no claim to be void of bias, here’s my honest attempt to paint a picture of the pandemic by applying a heavy dose of my favorite medium, numbers.
Over the past four months at a community teaching hospital in the Northwest, after 275 encounters with 101 hospitalized patients suffering from Covid-19, here’s what the numbers reveal:
As in 66% of the patients I cared for had been previously diagnosed with high blood pressure. Another 43% had diabetes and 23% had obstructive lung disease (e.g. asthma or emphysema/COPD). While 45% of my patients required advanced means of respiratory support such as heated high-flow oxygen (HHF), non-invasive positive pressure ventilation (NIPPV), or mechanical ventilation (MV), this number increased to 61% among those with obstructive lung disease.
Obesity was also a significant comorbidity. The figure below reveals the average body mass index (BMI) for each level of respiratory support required (NC = nasal cannula, see additional abbreviations in text above).
This suggests that patients with higher BMIs were likely to need more aggressive methods of respiratory support. Such data serve to emphasize that chronic conditions increase the risk of complications from Covid-19.
While some chronic diseases can be treated or even cured, changes don’t always occur quickly. Moreover, some medical conditions and other risk factors such as age and race cannot be modified. Although I don’t have specific details available at this time, I can say with a high degree of certainty that minorities, specifically Native Americans, made up a higher portion of the patients I treated compared to the general population in my community. Caring for those at increased risk for poor outcomes reminds me how important it is to protect this group of vulnerable individuals from exposure. Take a look here for more on how certain conditions and demographics influence risk:
What You Need to Know About Chronic Disease and Coronavirus
A physician explains the finer details
To my surprise, the four patients I cared for over age 90 did remarkably well. Half of them did not require supplemental oxygen, and the other half only needed oxygen by means of a simple nasal cannula. All survived to be discharged from the hospital. Of note, they were, on average, healthier than most of the patients I saw. Among these four patients, only 25% had high blood pressure, 25% had diabetes, and none had chronic lung disease. Their average BMI was 23. That’s not to downplay the role age plays in the risk of complications from Covid-19, but it is curious that some of the oldest patients with coronavirus have, seemingly against the odds, recovered with relative ease. For more on this phenomenon, see the article below:
The Mystery of Why So Many 100-Year-Olds Are Surviving Covid-19
One scientist studying centenarians believes the answer may be in their genes
Patients with a low vitamin D level (less than 20 ng/mL) were over 3 times more likely to die than patients with a level above 20 ng/mL. This is an example of how statistics can be deceiving. It would be easy to look at the first sentence of this paragraph and conclude that vitamin D deficiency causes individuals to be at higher risk of dying from Covid-19. It might even lead someone to start taking a vitamin D supplement to reduce the risk.
It’s important to remember, however, that association is not the same as causation. Besides the fact that this is a small group of patients at one hospital, it’s also noteworthy that I’m looking at a particular group of patients retrospectively as opposed to prospectively. This approach will, at best, only reveal an association and cannot be used to make assumptions about causation. As it turns out, the patients who were started on a vitamin D supplement, either at the hospital or prior to arrival, were no more likely to survive than those who did not take supplementation.
What does this mean about vitamin D? We still don’t know very much, but my suspicion is that vitamin D is more an indicator of nutrition and overall health than a direct actor in the body’s response to Covid-19. On the other hand, a recently-published pilot study indeed suggested vitamin D supplementation could improve outcomes in patients with Covid-19. Certainly, more data is needed before vitamin D can be recommended as a treatment or preventative medication. Although side effects are usually minimal, vitamin D toxicity can occur and supplements like vitamin D should be taken only under the direction of a physician or other medical provider. Take a look here for a deeper dive on D:
Vitamin D for Covid-19: New Research Shows Promise
Studies highlight potential life-saving benefits. But some experts aren’t convinced.
This is the percentage of patients who received the steroid, dexamethasone, as a treatment for Covid-19. So far, dexamethasone is the only medication to convincingly demonstrate a reduction in mortality in hospitalized patients with Covid-19. So why wasn’t it given to 100% of the patients? Because dexamethasone is a strong anti-inflammatory, its positive effects have only been validated in patients with elevated laboratory markers of inflammation or clinical signs such as low blood oxygen levels requiring administration of supplemental oxygen.
In fact, some evidence suggests dexamethasone may be harmful when used to treat patients with Covid-19 who don’t have elevated inflammatory markers or aren’t requiring supplemental oxygen. As you might have guessed, the 15% who didn’t receive dexamethasone fit into this latter group and serve as a reminder that even the best treatments won’t help if administered under the wrong conditions.
Other medical treatments include convalescent plasma, a blood product containing antibodies from patients who have recovered from Covid-19, and remdesivir, a re-purposed anti-viral drug. These were administered to 46% and 48% of my patients, respectively. Recently, however, I have used them less frequently because of new data from the New England Journal of Medicine and the World Health Organization that indicate a lack of benefit. When I present this information to patients, they often decline the treatment.
Blood thinners, also known as anticoagulants, are a mainstay of treatment for hospitalized patients with Covid-19, and 100 out of the 101 patients I saw received such treatment. Because blood clots, particularly in the lungs, are a common and catastrophic complication of Covid-19, treating them and, better yet, preventing them is a high priority. The primary circumstance to avoid anticoagulation is when a patient has a high risk of bleeding as was the case with the one patient I cared for who was not placed on anticoagulation.
Another 36% of patients received an intravenous (IV) form of the diuretic medication, furosemide, also known as lasix. Over the course of a long hospital stay, in part because of decreased mobility and IV saline administration, patients often accumulate excess fluid on their bodies which can include the lungs as well. IV furosemide is twice as strong as its oral formulation and should generally be used only after examining a patient and assessing their volume status (i.e. whether or not they appear to have accumulated excess fluid). Since it is given on a case-by-case basis, the usefulness of furosemide has not been well studied in patients with Covid-19.
Anecdotally, I have found furosemide useful once patients have turned the corner and are starting to improve. It seems to speed up the recovery process and allows patients to wean off supplemental oxygen faster. Another way to accumulate fluid is to eat excess salt. After looking at the hospital lunch menu on Thanksgiving, I half-jokingly said to a colleague that I would be giving all my patients a round of furosemide. It wasn’t quite all of them, but I did dole out a little more than usual that day.
Among patients discharged home from the hospital, arrangements were made for nearly one-third of them to use supplemental oxygen at home. An additional 8% were already on supplemental oxygen at home prior to admission because of chronic heart or lung disease, and this was continued upon discharge — sometimes at an increased flow rate.
In his most recent podcast, Dr. Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota (who, incidentally, earned the salutation, ‘doctor’, by virtue of his Ph.D. in environmental health) recognized that across the country hospitalizations have increased to a lesser degree than what would be expected based on the number of Covid-19 cases. “While case numbers have gone up, the hospitalizations have gone up, too, but they seem to be leveling off a bit while case numbers continue to go up.” He went on to describe how patients with mild to moderate symptoms were no longer being admitted to hospitals if they could manage at home whereas similar patients may have been admitted earlier in the pandemic.
I was privileged to hear Dr. Osterholm speak at my hospital’s medical staff meeting last month and have a great deal of respect for him and the work he is doing as part of the new presidential administration’s Covid-19 advisory team. However, I think his explanation for the lower hospitalization numbers relative to cases tells only part of the story. An additional reason is that patients are being discharged from the hospital earlier in their disease course. A few months ago, most patients with Covid-19 were remaining in the hospital until they were fully weaned off supplemental oxygen, but now, more are being discharged on oxygen with the idea that they can be weaned off it in the coming days while recovering at home.
One very astute elderly woman asked if she should receive the Covid-19 vaccine when it becomes available. At the time, I explained that there was limited published data on any vaccine and that it would be best to talk to her primary care provider about it when the time for vaccination drew closer.
She brought up a great point though. Should those who have recovered from Covid-19 get the vaccine? Currently, the CDC has not released a recommendation one way or the other on this issue, but assuming the safety data continues to look good, I believe vaccination would be a worthwhile means of strengthening immunity to Covid-19. Because there is limited information about the durability of naturally-acquired immunity as well as immunity acquired through a vaccine, an evidence-based answer may be elusive for the foreseeable future.
In contrast, one area of clarity is the astoundingly impressive early data on the effectiveness of vaccines, particularly the Pfizer and Moderna messenger RNA vaccines. I’ll admit I doubted a vaccine could show such high levels of safety and efficacy so early in its development, but thus far, vaccines using the mRNA platform have far exceeded my expectations.
I was fortunate to receive the vaccine this week. Even though I’m at low-risk for complications of Covid-19, I wanted to be vaccinated to honor those who have worked so hard on its development and to be an example to others who are considering whether or not to receive the vaccine.
Furthermore, low-risk isn’t the same as no-risk. Remember stats can lie. If you’re a younger healthy person it might be easy to view the data I’ve presented and say, “That doesn’t look like me.” Don’t let numbers like that lull you into thinking a bad outcome can’t happen to you. There are patients in the hospital right now in their 20s and 30s with no prior medical problems fighting for their lives because of this virus. To those patients and other people who haven’t yet fallen ill from Covid-19, please don’t give up now!
Here’s a look at the most recent data for cases, hospitalizations, and deaths across the country:
It doesn’t take a statistician to see that we are clearly headed in the wrong direction and are in for a devastating winter if mitigation efforts fail to slow these exponential trends.
There is some good news, though, and it comes in the form of more numbers. The latest estimates suggest the number of actual cases across the nation exceed the documented positive tests by a factor of 8. At the pandemic’s current pace, the U.S. is expected to have around 20 million known positives by the end of December. This means that 160 million individuals will likely have been infected by the new year. This is 49% of the U.S. population.
No one knows exactly how many need to become infected until the principles of herd immunity, or protective immunity as I prefer to call it, take effect and the pandemic begins to recede, but whatever the number, 49% is not far from it. With an effective vaccine around the corner, now is the time to focus on prevention.
As much as I love numbers I love people more, and each of these numbers is tied directly to a person — someone’s grandparent, spouse, or best friend. That’s who’s here in the hospital suffering, feeling like they’re drowning, and in many cases enduring or succumbing without the presence of a loved one at their side, without the comfort of a warm hand to grasp. This pandemic can’t end soon enough.
The next six months or so are the home stretch. Yes, we’re getting close to protective immunity, but why travel the deadly route of natural infection when a vaccine can carry us for much of the remaining journey and keep us there safely? Take reasonable precautions to reduce spread. Help prevent our hospitals from overflowing. Follow the guidelines set by your local, state, and (coming soon) federal governments. Wear your mask…properly. Isolate and get tested if you’re ill. Be kind.
Let’s finish well.