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Baylor College of Medicine

Rescue Care Update from Dr. James McDeavitt

Master
Content

Aug. 5, 2020

To Members of the BCM Community:

I will start this week with an apology. In this message, after a brief review our recent viral numbers, I will pose a question. I think the question is an important one. I apologize because I do not know the answer.

Regarding recent COVID-19 dynamics in Houston and the TMC, much of the news was bad three weeks ago, but there was a degree of certainty in the modeling. The R(t) value – the measure of infectivity – was high. High R values leads to a high rate of community new cases, which leads to increased hospitalizations, which leads to growing hospital censuses and full ICUs. That is exactly what we saw.

This week, overall the news is good, but the story more ambiguous. Over the past month, the R(t) has oscillated: Up to almost 2, down below 1; after the July 4 holiday back up to 1.5, then back below 1.0; over the past week a climb back up to 1.4, and a more recent downward trend, but not yet back below 1. Recall, when we are above 1.0 the community prevalence grows, below 1.0 it shrinks. (You can follow the R(t) on a daily basis by selecting here.)

A high R should drive an increase in community cases. For Harris and surrounding counties, over the past month the new daily case rates have been variable, but are generally climbing. As a seven-day rolling average, the community was experiencing 1,350 new cases per day; this has risen to a recent high of 2,400. Recall, back in April and May that rate was 200-300, a level where it would be theoretically possible to perform true community-based contact tracing. Also recall, as this metric captures only new COVID-19 cases who are tested, this certainly underestimates actual new case counts.

A climbing new case rate should drive more hospital admissions, but we have seen a very steady decrease in COVID-19 patients admitted to hospitals over the past month – from 360 admissions per day, to less than 200. New cases are going up, hospitalizations are going down. Opinions vary regarding the reason. Some think the community cases are ultimately going to feed a new wave of hospitalizations. To me, it appears the curves are disconnected in a way we have not seen before; perhaps younger people with fewer comorbidities are being tested at higher rates, and are not developing severe disease. Stay tuned.

In summary, the data – at least from the perspective of hospitals – has improved. The pressure on ICUs is beginning to lessen.

In April, we saw the same dynamic. A significant economic shut-down, change in individual distancing behavior, improvement in R(t) and drop in hospital demand. Success. How did we react then? We breathed a sigh of relief and went about getting back to normal life. In retrospect, our collective rush back to normality was premature, and set the stage for a much more significant surge. Here is the question I cannot answer, and it is a critical one: How do we keep from making this same mistake again, and setting ourselves up for yet another surge come autumn? How do we maintain an appropriate sense of urgency around masking and distancing when the wolf is no longer directly outside our door? We clearly need to keep our guard up, if we are going to stress our community by reopening schools, relaxing restrictions on business, or dealing with a seasonal flu outbreak. Our vigilance will allow us to regain a degree of normality at the earliest time possible; our complacency will put us at risk for another round of the COVID-19 crisis.

I do not have a good answer for this question, because we, nationally, are better at dealing with the acute crisis in front of us, than making changes to prevent a bad outcome at some point in the future. By way of analogy, imagine two people with a family history of heart disease. Our first is an ideal patient – he responds to the distant threat of cardiac disease by exercising regularly, maintaining ideal body weight, and controlling every modifiable disease factor possible. He knows he may be able to prevent or delay a cardiac event, and if it occurs, all his attention to his today health may help to improve his outcome tomorrow. Our second patient is the opposite – he is sedentary, overweight, smokes, and his cholesterol and blood glucose less than ideal. He knows he may have a heart attack one day, but he lives near the Texas Medical Center. If that day comes, he will have access to the best technology to open his coronaries and replace his leaky mitral valve.

Both these patients are caricatures, but I would suggest most of us are more similar to the latter patient than the former. We have a great ability to deny the potential adverse consequences yet-to-come, and an outsized faith in the system’s ability to provide rescue care when they do. We cannot manage the ongoing COVID-19 crisis by resuming behavior as usual and expecting the overrun health system to be there as a backstop. We need good habits now, not another heroic health system response in the future.

I will finish with two important issues in Houston, related to this rescue care point. Baylor is justifiably proud to be playing a major role in vaccine development and testing. It is an important part of our unique contribution to our region. The accelerated effort to find a vaccine, establish its safety and efficacy, manufacture it to scale and distribute it effectively has the undivided attention of the nation. Many are obviously pinning their hopes on a vaccine as our path back to life as we knew it.

The second issue is perhaps as complex as the vaccine challenge, but in a different way. Houston, like many other metropolitan areas, is seeing a sharp acceleration in evictions of economically vulnerable people. When people lose housing they often move in with friends or family, increasing housing density, and creating a more favorable environment for spread of COVID-19. Ask yourself, how much of the daily news coverage is focused on vaccine development versus care of the vulnerable? Again, we put our faith in rescue care.

In this transitional week, I would ask everyone to reflect how they can positively impact their circles of influence to stay in “COVID shape.” Mask, distance, maintain hand hygiene, and avoid social gatherings outside your household. Lead by example. Hold others accountable. It looks like we are going to make it through round two. Let us not have a round three.

Stay safe.


James McDeavitt, M.D.
Incident Command Center