New Times speaks with a local emergency physician about COVID-19



Editor's Note: Staff Writer Karen Garcia spoke with Dr. Brad Knox, an emergency physician at Sierra Vista and Twin Cities hospitals, over the phone. Knox, who is also the chair of Sierra Vista's Department of Emergency Medicine, agreed to do a Q&A. Answers have been edited for clarity.

New Times: How has the virus impacted Sierra Vista and what is the hospital doing to prepare to treat individuals with severe symptoms of COVID-19?

FRONT LINES Dr. Brad Knox is an emergency physician at Sierra Vista and Twin Cities hospitals and he's on the frontline of the COVID-19 pandemic. - PHOTO COURTESY OF TENET HEALTH CENTRAL COAST
  • Photo Courtesy Of Tenet Health Central Coast
  • FRONT LINES Dr. Brad Knox is an emergency physician at Sierra Vista and Twin Cities hospitals and he's on the frontline of the COVID-19 pandemic.

Dr. Brad Knox: Trying to keep the emergency room functioning just like it would have two months ago. People are still having their heart attacks, their strokes, their appendicitis, and their broken bones. We're still there to serve that need. I think as far as what we have seen, from an administrative standpoint in the past week or so, has been a huge drop in patients around the county. Our numbers are down about 60 to 70 percent, whereas we would have seen typically 80 patients on a busy day in a 24 hour period, we're now seeing maybe 30 or 25. That has changed drastically, and as a result, we've been kind of cutting back some of our physician hours. We don't want to have a bunch of doctors just lying around. That's kind of been the immediate change. But again, the plus side of that is we can dedicate that energy to preparation and kind of getting everything as ready as possible.

NT: Have any of SLO County's Tenet Health hospitals cared for an individual with COVID-19 symptoms?

Knox: Yes.

NT: What has that experience been like? I understand that an individual who might be experiencing coronavirus symptoms must first call their primary before going to the emergency room. Can you elaborate on that process?

Knox: Right now, the only patients who are being tested through the hospitals are patients who are going to be hospitalized. If a patient is sick enough to need to stay in the hospital, then those are the ones that are being tested through the hospital. ...

Unfortunately, due to resource limitations on the part of the SLO County Public Health Department, they can't test everybody, so for the patients—we use the term "the walking well," the ones who have mild symptoms, and are still able to stay at home and use supportive measures—those are the patients who should be reaching out to their doctors. Their doctors can then decide if they want to order the test and get the specimen. It's a nasal swab—a big, long tube that they stick up the nose, it's very uncomfortable. And they can then send that to one of the outpatient laboratories like WestPac or [Quest Diagnostics]. One of those facilities can then run it. The turnaround time for those outpatient tests is going to be about five days. The big thing to keep in mind is it doesn't necessarily change management from an outside or an outpatient perspective. So those patients should be at home quarantined. They should be making sure they're washing their hands, covering their mouth if they're coughing or sneezing, and minimizing contact with others to minimize the spread.

A lot of people have been calling the emergency room or asking for the test. As testing ability ramps up, it'd be great to just be able to get it out there, because that will give us the first true idea of how prevalent it is in our community. But right now, those resources just aren't there. So it's not a test that's going to change management for anyone who's out there. The only way it changes management is really in the hospital, because it allows us to cohort these patients in particular wings. We're still a hospital that's functioning to take care of traumatic patients, or like I said, strokes or people who have any number of conditions. And we want to keep those patients isolated away from COVID-19 patients. That's where the test really becomes important. The other way that it becomes important is in health care workers, and they're also getting tested through the Public Health Department. To the concerns of if a health care worker has it, obviously, we don't want them coming into contact with patients. But if they don't have it, we need them. We need them to be there.

NT: At what stage of having COVID-19 symptoms should an individual seek help from the hospital?

Knox: The big thing about this virus is, for most people, they will be fine over the course of about a 10-day period. Day eight to 10 is really kind of where the coin-flip comes. If a patient's going to decompensate, that's when it's going to happen. And the reason it happens is because this virus directly attacks the lung tissue and the lungs lose their structural stability. So, the biggest complaint you're going to see or the biggest thing you're going to see if this is starting to become more severe is shortness of breath. The work of breathing is going to be much higher, and they're going to feel like they can't catch their breath. That's going to be the biggest red flag. I think, with anyone who's having minor symptoms, it's good to stay home to minimize any kind of contact with others. The moment someone starts feeling short of breath, they need to come to their local emergency room for evaluation and potential treatment.

NT: What is it like treating and caring for someone who has COVID-19 symptoms?

Knox: That's something that in emergency medicine, we're all trained for that, whether it's a patient who's gone into flash pulmonary edema from a severe heart attack, or someone with congestive heart failure. I mean that's what we do, so they're not any different than those other patients. They're sick, and we do what we can to intervene and try and fix the underlying problem.

I think right now, because it's a pandemic; because we know it's in our community, again; because we're not testing as abundantly, we don't know how prevalent it is in our community. We're kind of reverting back to in the 1980s, when HIV was rampant, and the rule of thumb was treat everybody like they have it. So make sure you've got gloves on, make sure you're protecting your skin, and any kind of exposures. Right now, we're kind of doing the same thing with this. For our household providers, most of them are going to have a mask on just to try and give a little bit of protection to themselves in the event that some patient who's coming in with acute appendicitis may happen to have it. You know, that's the tricky part, where patients have this illness and aren't necessarily symptomatic from it. So we're just kind of being overly cautious as a result.

I mean, no one alive, pretty much has seen anything like this before. You look at the last pandemic, like the Spanish Flu in 1918. So there's really no guidebook for this.

But that being said, we train on infectious disease throughout our residency training in emergency medicine. Just like we trained for bioterrorism or bombings. It's all part of what we do. I think we're definitely cognizant of the infectious nature of this.

NT: How do you make sure you're being safe when you go home after a shift?

Knox: My wife and I are both ER doctors and we have a 17-month-old at home. So we're doing precautions as far as making sure we go straight into the shower, have a separate hamper for scrubs, and make sure we clean awfully good before we see him.

We're definitely cognizant of our whereabouts and we're trying to minimize any unnecessary activities. There have been friends asking us to come over for a cocktail or something, and we said, "No, we're gonna hold off right now" because we realize that we're on the frontline. We pulled our child out of day care for the same reason. There's only so much paranoia you can have, and beyond that, you just need to do what you can to minimize any risk.

NT: How much communication does the hospital and San Luis Obispo County have?

Knox: It's extensive. Picture breaking up with somebody and they just keep calling you and calling you. We're in touch with them daily, multiple calls a day. And then there's a weekly roundup between all facilities and physicians. We're in touch with our community physician, obviously, with the [Public Health Department] and with our compatriots over at Dignity Health and Cal Poly. This is an all-hands-on-deck community first effort.

NT: How would you explain that any individual could get the virus and be fine, but maintain that the virus can still be severe?

Knox: The easiest way to do that is to point out why health care providers get the flu vaccine. Most of us are going to be fine from the flu, however, we're not doing it for ourselves. We're doing it to protect our patients. And with the shelter-at-home order and that kind of minimizing social contact—while yes, a majority of the people who get this illness, especially the young stuff, are going to be just fine, ultimately, they have to remember that they can get this illness and not know they have it. And then be a source of infection for someone else, a loved one or a neighbor or someone else in their community. Just asking everybody to step up and act as health care providers, in a sense, and take on that restriction and that responsibility to protect themselves in the interest of protecting their neighbors.

NT: If we do have a surge in individuals testing positive with COVID-19, how prepared do you feel with ventilators, ICU beds, and space in the hospitals to keep them quarantined?

Knox: Right now, speaking as one of the people that is helping to guide the preparations, I'm a little biased. I do feel like we're as prepared as we can be at the moment with the resources we have. Short of building another hospital or suddenly having just a wealth of additional equipment and manpower show up, I think we're ready. Every day that this doesn't hit, we're becoming even more ready. It's kind of like you've done all the training, you've done the practicing. Now, you're just waiting for that Friday night game and ready to get out on the field and do it. We've actually increased our equipment drastically in the past month or so as we were watching what's happening worldwide and the predictions. Thankfully, we've taken it very seriously from the get-go. And I believe in our neighbors in the community, the county Public Health Department, everyone is on the same page. We're doing everything possible, and I feel, as a member of the community, very safe and very prepared. And I'm thankful I'm not living anywhere else right now.

NT: SLO County Public Health Officer Penny Borenstein said that Paso Robles is going to be a hot spot in the county for coronavirus, and Twin Cities is the closest hospital in North County. How is Twin planning to tackle the surge?

Knox: Twin is definitely doing preparations. Speaking personally, it's our sister hospital, so they've been mirroring a lot of what we've been doing. What we run at one institution, we're trying to create a similar set-up at the other. I think the reason Dr. Borenstein said that is because that's where a majority of the cases in the county have been thus far. But I would not take a false sense of security from that if you happen to live in South County. On the Johns Hopkins map, you can see how much thing is spreading all over. Thankfully, we're a very small community, so there's a chance that we're not going to be hit as hard as some of our neighbors are. But I think ultimately, when you look at a virus like this, you know, probably half of our population will get infected. Thankfully, again, most of these people are going to be just fine. You have to assume that this is going to hit all of us.

NT: Public health officials are encouraging people who might be sick to stay home. The New York Times reported that it's led to coronavirus patients to be much sicker when they arrive at the hospital, warranting a higher level of care than it would if they went to the hospital sooner. How do we address this or what are your thoughts on that?

Knox: Well, I think the first thing to mention is we're open 24-7. I want to see anyone in our emergency room that feels short of breath or feels like they're having any emergent medical complaints, whether that's "I broke my arm" or "I'm having chest pain." I want to see all of them in our emergency room. I think the suggestion that patients staying home is making them sicker before they show up doesn't really fit the way this disease progresses, so it's really like that day eight or 10, where if a patient's going to get better, they're going to get better. If they're going to get worse, they're going to get worse. And there isn't a particular treatment that we can give them, say on day six, that's going to make it go one way or the other on day eight or 10. I think the point I want to really echo to the community is, if you feel like you need to be in the emergency room, come to the emergency room. We're open and ready to take care of you. If you feel like you need to come, come. I'd much rather see a patient and tell them that everything looks OK and it's OK to send them home, but this is what to watch out for, then to have someone wait too long at home.

NT: What message do you have for the local community?

Knox: This message to get out right now is that we're prepared. We have got appropriate equipment right now and protective equipment, and we're obviously planning for the weeks down the line. Something that kind of stood out to me: I'm 38 years old and my attitude toward this, from a personal perspective is that I may get sick, but I don't have any co-morbidities, I should be fine. But what we're actually seeing is that 40 percent of people who are being hospitalized are between the ages of 20 to 54. So, I think the message to get out to a lot of our youth is that—especially in light of spring breaks and things like that—this is still serious. While you may not get it and die from it, you still may get it and have to be hospitalized or have to be in a critical care unit for a few days and nobody wants that. That sucks. So whatever you can do avoid the hospital by taking it seriously and not exposing yourself and putting yourself at undue risk should be something that 80-year-olds are doing as well as their 20-year-old.

NT: What illnesses make people more at-risk for contracting COVID-19?

Knox: Diabetes, high blood pressure,congestive heart failure or other heart disease, patients who are immunocompromised, and patients who are in chemotherapy or have had organ transplants. Those would be definitely some of the key ones. Patients who are on an immunocompromising medication, so someone who has rheumatoid arthritis or lupus, those are patients that we obviously have to be concerned about. Patients that have chronic obstructive pulmonary disease or emphysema for smokers, because they don't have healthy lung tissue at baseline—again, this is a virus that directly seems to attack the lungs. While kids can get it, they don't appear to get very sick from it, which is a huge blessing. And then, of course, the elderly, regardless of having any medical conditions, just because at baseline their body has some wear and tear in the mileage.

NT: How would you suggest keeping up with the ongoing updates and news coverage of the virus in a healthy way?

Knox: For our local community, is a great website that has updates. Our local Public Health Department website has updates. I think, for the mental health, I would say, for the general public keep it at bay a little bit. I personally have been burning through my phone battery at an unprecedented rate trying to keep track of all the new articles coming out and new recommendations, things like that. But let us do that. Right now, one of the beautiful parts about this time is that people are spending more time with their family. My understanding is that dogs have never been happier so take advantage of that. You have to be careful inundating yourself with this stuff, because it can become an obsession. And there's a lot of false information out there—or there's a lot of anecdotal information out there—and we have to be very careful taking anecdotal information and making it truth or thinking of it as truth. I think as a person, it's always good to kind of check the news in the morning or check the news in the evening, but around-the-clock stuff is just not good for mental health.

NT: Any last comments?

Knox: We're all in this together. My understanding is there's been some frustrations about getting tested and turnaround times with lab results. The medical system has never seen anything like this before, so it's adapting at an unprecedented rate.

But know that these people really are working hard and do have personal skin in the game. You know, it's not just a matter of the fact that this is our community. I mean, you're seeing surgeons are canceling elective surgeries. We've been getting retired physicians and nurses reaching out to see what they can do to help. Hospitals are shutting down elective procedures, which tend to be one of their most lucrative avenues. My heart goes out to a small business owner who took out a loan to open up their new business right now. I think we still do have to kind of help them out. But know that everybody is on the same page. We're all trying to make sacrifices for this and we're out putting the patients in the community first.

NT: I don't know if you can answer this, but from your perspective, do you see us being in this situation for several months, weeks, or what are you thinking?

Knox: I think we're going to need more time. I don't know how much more time because there's a lot about this virus we don't know. Is it going to be something where as the temperatures creep up the viability of the virus is going to drop and the contagiousness of it is going to drop and we're kind of out of the woods like the seasonal flu? Or is this going to be something like the Spanish Flu of 1918 that disappeared briefly and then came back with a vengeance? H1N1 was a summer outbreak not like the traditional flu. So there's a lot of stuff I think we just don't know. Right now, the goal of just hunkering down and minimizing transition and the spreading of this thing is the single best thing we can do. It's going to be more time. It's going to be more time than I want it to be, I'm sure. Δ 

Correction: This article has been updated as it incorrectly stated the emergency physician's name is Drad. His name is Brad Knox.


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