Listen and subscribe on Apple, Stitcher, and Spotify, so you don’t miss the next episode. And if you like what you hear, a five-star rating goes a long way in helping us share the story side of medicine!
This story is from the Anamnesis episode called Infectious and starts at 2:30 on the podcast. It’s from Suraj Saggar, DO, chief of infectious disease at Holy Name Medical Center in Teaneck, New Jersey.
Following is a transcript of his remarks:
We Had No Idea
So my name is Suraj Saggar. I’m the chief of infectious disease at Holy Name Medical Center in Teaneck, New Jersey.
So when we first heard about the outbreak and an epidemic in Wuhan city and Hubei province in China, that was on December 31. We formed a leadership team in early January to address our response. Little did we know how impacted we would be. So initially we were meeting weekly and it was a multidisciplinary team of infectious disease doctors, infection preventionists, leadership from all different departments of the hospital — nursing, environmental, etc. — to try to put up a plan in place of how we would approach the COVID-19 outbreak, and at that time epidemic, as we did have the expectation it would eventually become a pandemic, that is, spread globally. Of course, we had no idea at that time in January, middle of February, exactly how hard we would be hit.
By the middle of February, we were realizing that it was spreading globally and already into the United States.
At that time, we ramped up our preparations in terms of considering how we would treat these patients, looking at the data coming out of China. And most importantly, at that time trying to make sure we identified patients in a timely manner who may have risk factors. Of course, that, as we learned later, was a quickly evolving situation, where every day we were expanding who we would place under suspicion for possibly having COVID-19.
The reality of this virus is that our knowledge was evolving as the pandemic was unfolding before our eyes. And what we were doing one day was outdated a week or four days later. And that includes not only our diagnostic capabilities, our therapeutic capabilities as well, but also what we were looking for in terms of identifying a patient. During the height of our hospitalizations, we assumed anyone and everyone coming in had COVID.
Now, if we backtrack to early March, we were still looking predominantly at fever, shortness of breath, and cough as an indicator of someone who may be affected by COVID. And if I go back to even earlier in March or into February, at that time, we were still looking at travel history — had some been to China, had someone been to Hong Kong, had someone been to Italy, Japan, South Korea. Then once it reached the United States shores, we said OK, we can no longer look at travel history, but we’re still going to look at the typical clinical characteristics. Again, the lung, pulmonary characteristics.
One of my earliest cases, which was from a medical point of view an incredible teaching case, but from a humanitarian point of view, just a terrible case that affects me to this day. We had an employee of the hospital, not someone who’s a physician, but an employee who was very well known, very well liked by everyone, including myself, who I was called early in March by the ER to see because of gastrointestinal complaints — nausea, vomiting, diarrhea, and the ER had said, “Well, you know, he had some sushi a couple days before.”
So I mentioned, I was on a different floor, I said, you know, get a CAT scan, and I’ll come down later to see him. I was called later that his CAT scan was negative. But when they look at the abdomen, they sometimes catch the lower part of the lungs. And at that time, they said, well, we see what we call ground glass infiltrates, which, if you remember, was one of the characteristics first described in China of people who had COVID and had what we call pneumonitis, ground glass infiltrates.
So when I went to examine him, he seemed very comfortable. The only thing that was odd was that the timeframe from when he ingested sushi and think about a foodborne illness, and his onset of symptoms was too long, there was a too long lag period. So I realized very quickly that no, it’s not actually a foodborne illness. So I decided, because he worked in the hospital, just out of abundance of precaution to isolate him and test him for COVID-19, or SARS-CoV-2, which is the virus causing COVID-19.
This is a time where we had very limited testing capability. This is when we had to first ask permission by the state health department and they had to be approved by the CDC. And so it took several days at that time, sometimes more than three to four days to get an answer.
Is it Really COVID?
In the meantime, I kept him in isolation. And I remember I saw him on a Saturday. Then Sunday, he was watching soccer on TV, in isolation, and he looked very bored. He looked very stable.
And he said, “Doc, you know, do you really think I have COVID? I mean, come on here.” And I said, “No, I don’t think so.”
And in my mind, I was feeling guilty that I was preventing him from going home. Because he had really essentially recovered from his gastrointestinal symptoms. But I felt I didn’t want to send him home until I at least knew the results of the testing since I’d already sent and thought about it, it was one of the things when you think about it in your mind and you need to follow through.
And that was Sunday, and he looked very stable. Monday, I had decided in the morning that you know what, I’m just going to send him home and we’ll let him quarantine at home until we get the test results.
By Monday afternoon, evening, we noted that he was desatting, so he was requiring some supplemental oxygenation, which was odd. So I held his discharge. Tuesday, he very quickly decompensated, where he was requiring a non-rebreather 100% oxygenation, and ultimately, Wednesday, required intubation, tragically. By Thursday, we got the results of his PCR testing, polymerase chain reaction, which indeed was positive.
I remember around that time, is when I saw some early literature saying well, you know, be aware, in a segment of patients, they may have gastrointestinal symptoms preceding lung or pulmonary symptoms.
Unfolding in Real Time
That’s why I said this was unfolding, evolving in real time right before our eyes. I remember getting this article and saying, geez, this is exactly my patient, he had gastrointestinal symptoms, then developed pulmonary symptoms. And then between that Monday to Wednesday morning, within 36 hours, was intubated. So it almost fit it to a tee. So that’s why medically, it may be fascinating and a great example of how to learn from a case. But from a humanitarian point of view, it’s tragic. Because ultimately, despite our best interventions at that time, he succumbed to his illness a week later.
And I think one of the last conversations I had with him was Monday morning when I told him that you’ll probably go home later today. Monday afternoon, I got the call that he was desatting or having low oxygenation, so I’d held his discharge. And by Tuesday he was already so uncomfortable and on high flow oxygenation and non rebreather, I could really barely have a conversation with him. And like I said, by Wednesday morning, intubated and never was able to communicate with him again. And that’s an incredible case of, one, how we’re learning in real time about this virus in terms of clinical characteristics, and of course, much more, including our diagnostic, our therapeutic modalities, etc.
But also incredibly humbling. Because it really makes you realize that, you know, I kept him there because of dumb luck. You know, I cannot say that I had any intuition or knew that this was going to play out the way it was. But because we were slowly at that time seeing an increased ramp of cases, I felt it was prudent to at least check him. But you know, I had reassured him on Sunday that I really didn’t think this was COVID and I was just being overly abundantly cautious.
As physicians, we’re always humbled, all the time, and those that are not, would be lying. So while we try to be informed about everything, especially within our specialty, all of us would lie if we said we knew everything. And we’re constantly challenged and humbled by medicine throughout our careers. And this is a stark example of that. And indeed a case that I would carry with me for the rest of my career.
Check out other stories from the Infectious episode including “I Was Right” and “Attacked by Anti-Vaxxers.”
Want to share your story? Read the Anamnesis Storyteller Tip Sheet and when you’re ready, apply here!
Last Updated August 07, 2020