Lack of rapid coronavirus tests hinders care for respiratory patients, emergency doctors say
On a cool morning in January, Debbie Gandy’s husband turned on the heat to warm their bedroom. Soon after, she collapsed, and an ambulance rushed her to the hospital.
“It was like the heat hit me, and I couldn’t breathe,” said Gandy, 61, who lives in Granbury. “I went down.”
Gandy is one of more than a million Texans living with chronic obstructive pulmonary disease. Now, as a pandemic of another sort of respiratory disease infects nearly 1 million people around the globe and fills intensive-care units with patients who need breathing assistance, doctors say caring for patients in situations like Gandy’s has become more difficult — and they’re sounding the alarm about a lack of available coronavirus tests that could help keep patients and physicians safe.
Many treatments available to people with COPD, asthma or congestive heart failure are risky for doctors to perform if the patient is infected with the new strain of coronavirus, doctors say, because the treatments rely on nebulizers — face mask systems that turn liquid medicine into a fine aerosol mist for patients to inhale — that can spray pathogens into the air.
Without rapid testing available in hospitals and ambulances, doctors are left to make difficult decisions about patients who are struggling to breathe, said Robert Hancock, president of the Texas College of Emergency Physicians.
If a critically ill patient might have COVID-19, the disease caused by the new coronavirus, should doctors risk using a treatment that could spray millions of virus particles in an enclosed space, endangering physicians? Or should they intubate the patient, a more invasive procedure that can lead to worse health outcomes and requires scarce medical supplies?
A Houston emergency room nurse is critically ill from COVID-19, and least two New York nurses have died from COVID-19, according to media reports. Several ER doctors have become critically ill from the disease.
“This is a huge problem,” Hancock said of the lack of rapid tests. “I don’t think you’ll find anybody who’ll say it’s adequate.”
The U.S. testing rate for the coronavirus lagged far behind that of other countries as the virus spread, though the nation’s total number of tests administered has grown rapidly in recent weeks. State officials reported that more than 47,000 coronavirus tests had been given to Texans as of Tuesday.
But most of those tests are performed at laboratories, and doctors and patients are waiting up to 10 days to get results. Physicians say they need access to point-of-care tests, which they can perform in hospitals, doctor’s offices or ambulances, because knowing whether a patient has COVID-19 informs how they provide care for other respiratory conditions.
This week, private firms such as the medical device company Abbott began to sell point-of-care tests after receiving U.S. Food and Drug Administration approval. One Abbott test claims to detect the presence of the coronavirus in patients in as little as five minutes. But Texas doctors said they expect the first shipments to go to parts of the country that have been hardest hit by the pandemic, such as New York and New Orleans, and likely won’t reach Texas hospitals until the end of April.
There is no known cure for the coronavirus, so all treatment is supportive. Patients with severe symptoms from COVID-19 must be cared for in a hospital, and in the most critical cases, doctors snake a tube down the patient’s windpipe and use a ventilator machine to help with breathing.
“We’re running on very little data on a lot of these patients right now, and it makes our job difficult,” Hancock said. “My biggest concern was we were going to withhold appropriate treatment for people because we were concerned about COVID, so we’ve been having to make pretty big judgment calls” about whether to put patients on a BiPap machine, which provides a noninvasive way to help critically ill patients breathe.
State health officials in 2014 estimated that 1.3 million adult Texans had asthma and 1.1 million had chronic obstructive pulmonary disease. During bad flare-ups, the conditions can require hospitalization. Texas Medicaid alone spent about $200 million on acute care treatments for the conditions in 2014.
“One of the things I don’t hear being said very well is that common things are still common during COVID,” said a North Texas emergency physician, who spoke on the condition of anonymity because his employer did not authorize him to speak to reporters. “COPD, congestive heart failure, asthma, we still see those every day.”
Under normal circumstances, a physician would often treat those patients with nebulized medications. But if the patient has the virus, those treatments can aerosolize the pathogen and expose medical staff in the hospital room to large quantities of virus.
“So now those people are getting intubated instead of those [nebulizer] treatments, and that’s taking up more beds and is more dangerous and leads to poorer outcomes,” the physician said.
And in some cases, the physician said, intubation is not an option. Many of the patients he sees with lung problems are older; some have do-not-resuscitate orders. A lack of quick-turn COVID-19 testing makes those treatment decisions much more complicated.
Some hospitals have drawn up plans encouraging doctors to use special kinds of inhalers equipped with viral filters instead of nebulized treatments, though doctors say they may be less effective.
“We have been trying to limit aerosolization of the virus, but we still have to treat patients,” said Cynthia Jumper, a pulmonary critical care doctor in Lubbock. “They’ve said if it’s an infected patient, try not to use nebulizers, try not to use certain equipment, but we cannot always do that.”
Having access to more rapid testing is “vitally important,” she said.
“If we had the point-of-care testing ... it would give you more peace of mind,” Jumper said. Without knowing if a patient has COVID-19, “there’s more physician risk and there’s more patient risk,” she said.
During Gandy’s hospitalization for COPD earlier this year, she was put on a BiPap machine because there were no suspicions that she might have had a coronavirus infection. These days, she said she’s taking extra precautions to make sure she doesn’t end up in the hospital.
“My family won’t let me out of the house right now,” she said. “They say, ‘No, you ain’t going nowhere.’”
Disclosure: The Texas College of Emergency Physicians has been a financial supporter of The Texas Tribune, a nonprofit, nonpartisan news organization that is funded in part by donations from members, foundations and corporate sponsors. Financial supporters play no role in the Tribune's journalism. Find a complete list of them here.