The New Normal: Pt I
Last night in the Emergency Department, I took care of a younger patient who genuinely believed it was November 2019, and we could not convince him otherwise. Granted he likely had some sort of a mental break due to the current weight of the world, however, I had almost a feeling of jealousy towards him. Kobe Bryant was still living, Australia was not a burned husk of itself, there were no murder hornets, George Floyd had not been killed on camera, the resultant protests had never occurred, COVID-19 was still just a rumor of a virus ongoing in China, and, most importantly, Prince Harry was still a member of the British royal family. I did not have the heart to tell him about the deaths, the turmoil, and the masks. I felt like, by doing so, it would be akin to Ultron downloading the world’s history upon his creation in Avengers 2 and subsequently going rogue. The new norm of society might have just been too much for him.
COVID-19 in PHOENIX
The reality of 2020’s new norm is a bit sobering when you take a step back. There is civil unrest and political disagreement that may be the worst it has been in decades, maybe even centuries. We have a pandemic that has swept the world and has now made my hometown the new center of media attention’s microscope, as Phoenix has become the new hotbed for COVID-19. It has been a wild couple of weeks, granted not nearly close to the peaks of Italy or NYC (yet?). With the recent shutdown, I hope that we are headed for the peak, rather than continuing to climb. Whereas my patient last night has no memory of the recent events, I am, fortunately, or unfortunately, able to recount the preceding events leading up to this. So let’s examine Arizona, one of the nation's three big hotspots, since its reopening.
COVID-19 in ARIZONA
Approximately six weeks prior (May 15th), Arizona’s Governor, Doug Ducey, reopened the state after a comparatively lower number of COVID-19 patients in our first “wave.” As of May 15th, Arizona had four days of decreasing death tolls and a relative plateau of case positives (though, at the time, testing was far from widespread). A proposed stepwise plan of reopening was to be employed and a “testing blitz” was going to ensue to assist with contact tracing and quarantine. There was plenty of urging to “return smarter.” In theory, ahead of a huge Arizona holiday for travel and celebrating Memorial Day, this was great news to the economy. There were even rumors of baseball (whether spring training or the entire MLB season) coming to Arizona as we appeared to have avoided the onslaught of a COVID-19 attack, which other cities were forced to weather. So what happened? How did we get to a reality where our percentage positive in testing went from about 8% on reopening to nearly 25% now? The COVID-19 diagnosis by day is still increasing daily as are the deaths. We knew it would inevitably arrive in Phoenix, but it did seem we would not have to deal with crowded hospitals and dwindling resources. What went wrong? With July 1st (Canada Day) and July 4th (Independence Day) rapidly approaching, I think it is an important lesson to try to understand, in order to safely enjoy the holiday while minimizing the fallout.
I need to start with a caveat here that I am not an Epidemiologist, but just an Emergency Medicine physician who is watching this unfold. With the understanding that COVID-19 generally takes between 5-14 days for incubation and an additional 1 to 2 weeks to become ill enough for hospitalization, let us look at the data from Arizona in the weeks following the reopening. At the time of opening, there were 13,159 confirmed COVID-19 cases in the state of Arizona and 624 deaths. May 15th, most everything in the Phoenix area reopened with little restriction, relying on the average citizen to maintain social distancing, wash hands and wear masks when able, without having a mandate to do so. At the time of reopening, Arizona had a daily case increase of around 350 and COVID related death average in the low 20s per day, respectively.
A MEMORIAL DAY TO REMEMBER
By May 30th, two weeks later, cases had increased to 790, however, deaths and hospitalizations rates were relatively the same. Increased testing appeared to be the reasoning in the increased positives and nothing new was implemented. Memorial Day Weekend had come and gone. Scottsdale (a Phoenix suburb) was in the news for packed crowds defying social distancing and not wearing any face masks. It was newsworthy at the time, due to other cities, Detroit and NYC mainly, were still in the early phases of recovery from devastation. In Arizona, however, we were hardly affected. So, in a sense, I could understand the general population’s stance against social distancing at the time. However, we will come to find it was likely that initial social distancing which seemed to have been the early savior of the valley of the sun.
Fast forward to June 16th, three weeks after Memorial Day, new cases had tripled to 2,293. The death rate remained roughly the same, however, hospitalization rates rose and available ICU capacity declined steadily. Muddying the waters here somewhat, the Phoenix protests over police brutality had also occurred approximately two weeks prior. Believe it or not, however, the contact tracing that was performed (whether entirely accurate or not) did not reveal a significant amount of blame on the protests in regard to the increase in spread.
Now, at the time of writing, our daily increase in positive cases has continued to climb to a new peak at 3,809 new cases daily and the death tolls have doubled to the mid-40s daily. Having worked the previous evening, I can personally attest to the huge spike in cases I have seen and the tax it has taken on our hospital system. By the end of my shift, we were holding 18 COVID-19 patients in the ED without any further rooms on the inpatient side to put them. The ED was so busy that we could no longer divide potential COVID-19 patients from those not under investigation. We just did not have the capacity to keep them in separate sections of the ED, even spilling out into hallway beds, potentially further exposing staff. This is not an increase in testing issue, as the percent positive more than tripled to nearly 25%. If mass testing was the reason, I would surmise that this percentage would remain constant, or even decrease given the large amount of asymptomatic patients procuring tests. This, however, has not been the case. Arizona now feels like a rapidly filling dam, ready to burst at any moment. My hospital system no longer has much if any capacity and I am not sure how much longer the others have until they’re in the same boat. This is the point, seen in NYC, Detroit, and Italy, where needless deaths occurred due to lack of resources.
So what can we learn from this? If we take Memorial Day (May 25th) as a before and after date, we see a dramatic rise in positive cases begin to upslope in the first week of June, which does lend credence with the assumption that it was a potential tipping point for exposures. The death toll began to increase three to four weeks after Memorial Day, which again makes sense given the protracted course of this illness. The saving grace of this wave in the pandemic of Phoenix has been the relatively young age of those testing positive. As of several days ago, it was 35 years of age. This, again, represents the age likely out for social gatherings involving Memorial Day. Once this inevitably spreads to the elderly retirement areas in North Scottsdale and Sun City, I imagine another sharp rise in COVID related deaths.
HEALTH CITIZENSHIP
Ok, so we see a grim picture here and I apologize for painting it this way, however, it may have been mostly avoidable. The blame appears to be on the citizens of Phoenix and likely revolving around actions taken during Memorial Day and the days following. So, what can be done to prevent this occurring in other cities with the upcoming holidays and prevent needless deaths and needless shutdowns of small businesses struggling to stay afloat?
First and foremost, take it seriously. It is real. It has been here for months and it isn’t going away anytime soon. This is the new norm. Secondly, if you haven't been practicing this, please consider social distancing whenever possible. If you have, please continue. This includes leaving 3-6+ feet (or 1-2 meters) in between yourself and those in public and staying home as much as possible. This is the new normal. Thirdly, when congregating for July 4th or Canada Day, which inevitably is going to occur, keep the parties small. I can not stress this enough. Recently a family party in a home in Texas took place with twenty family members. Eighteen ended up contracting COVID, six were hospitalized and two were admitted to the ICU, due to one person having minimal symptoms.
I do not have a magic number of people to have in your get-togethers, but please stay outside as much as possible and use social distancing guidelines to make your decisions. Fun can still be had. Yard games such as cornhole, ladder ball, badminton, etc can still be played with proper handwashing, masks, and paying careful attention to not touch your face prior to sharing equipment. This is the new normal. Lastly, mask up. The news and data seem to be all over the place (for more details on this, please check the next write upcoming in the next few days). Phoenix chose not to mandate masks until several days ago and we are potentially paying a grave price for it. This is the new normal.
Life will get better. Schools will open. Businesses will again be fully accessible. Curves will one day be completely flattened and defeated. Prince Harry may never again join the Royal Family, but I think we will all be able to get past that. For now, please heed warnings. Work together in maintaining the new normal. It doesn’t have to be that bad if we are all in this as one.
I am Brandon Lawrence, MD. I am an Emergency Medicine physician in Phoenix, Arizona. I am passionate about jump starting our society in as safe a way as possible in light of the ongoing pandemic. This is achieved by ongoing discussion, research and trying to reach as many people as possible. I enjoy creative writing, endurance athletics and spending time with my awesome family. Just getting started with the 21st century, follow me on twitter at Lawre237.
