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False negatives and true recovery

DR. RUSSELL HILL • Apr 27, 2020 at 10:00 PM

Editor’s note: Emergency room physician Dr. Russell Hill is on the front lines locally of the fight against COVID-19. In the following column he shares the story of one local patient and of the difficulties medical professionals face in treating this novel coronavirus.

She looked me in the eyes and asked quietly, “Dr Hill, am I going to be OK?”

Eyes can communicate plenty on their own without words or any other facial expressions. Fear most of all. A mask covered most of her face, except her dark eyes said all I needed to see. Apprehension about whether she was going to survive. I stared back with my N95 mask hiding my encouraging smile and a bulky helmet with plastic visor over my head. I placed a gloved hand on her shoulders.

“You are going to be fine. You are right where you need to be,” my reply slightly muffled as it reverberated inside the mask and helmet.

“Priscilla’s” illness unfolded alarmingly, if not predictably, with the COVID-19 pandemic’s percolation in our hospital system. A female in her 20s who started feeling symptoms over a week before she sought medical treatment. Her first visit to the emergency department came on the same day her results from a drive-thru screen came back negative. Today she felt more short of breath, but didn’t have a cough or a fever.

On that first visit her X-ray showed pneumonia, but not one typical of COVID. Most reassuring, her oxygen saturation levels were good. She had been started on Azithromycin that same day. After initial treatment she was up walking, talking, laughing; a sure sign she was stable. She was discharged home with a suspicion of a COVID infection, and instructions to quarantine.

As I do with every patient that I see, I reminded her that if symptoms changed or got worse to come back to the hospital.

She came back the next night, and all of those signs I had used to reassure myself and her had changed for the worse. She came in by ambulance, she needed oxygen to keep her saturation levels up, she was breathing faster, and her x-ray findings were now present in both lungs.

Despite her negative test a week before, this was textbook of a COVID patient deteriorating rapidly. Except there is no textbook. The text available for thousands of doctors around the country on the front lines are printed in Facebook group posts, tweets, and the daily amended CDC website.

Her negative test came from an outpatient drive-thru screening location. It was early in her sickness, likely when the number of viral particles were very low or the screening test was insufficient or both. It didn’t matter that her test was negative. She was classic for an illness that was ravaging the lungs of an otherwise mostly healthy 22 year old.

That night I messaged with our hospital pathologist about the capability of our tests to give us a negative result when the disease is present, a false negative. We discussed the limitations and timing of the screening exam and where the pitfalls could occur.

Our current testing ability is still limited and still unreliable. Testing those who have already acquired the disease and have now built up immunity is still in trial phases and will not be ready for a few weeks. Yet an anxious and cooped up population around the country clamor for loosening restrictions. Returning to normal behavior now will continue to place those frontline workers in peril, with unknown levels of protection.

Currently a rapid test that gives results in 13 minutes is finding significantly high false negative test results.

I admitted “Pricilla” to one of our most trusted hospitalists and we decided to start controversial and unproven medicine. I relayed that for now, her oxygen levels were fair, but I correctly predicted that she would need to be placed on a ventilator within the next 24 hours.

She was in the right place, in fact, there was no better place for her to be than in our community hospital. The ivory towers of the Mayo Clinic or Johns Hopkins do not have a better grasp on how to treat the severe lung disease that the virus triggers. The same protocols and treatments available to oxygenate, ventilate, and protect the lungs are all we have to rely on.

“Pricilla” is still in critical condition and on a ventilator 10 days later, but is showing signs of improvement. Much like our country and the world, recovery contains many unknowns, likely setbacks, and an unpredictable timeline.

We are still navigating an uneven path that will lead us to readjustment. Treatment options, antibody testing, and an eventual vaccine all have early signs of progress, but in a timeframe beyond just our current day to day perspective.

In the coming days restrictions will lift even as the fear lingers, slowly replaced by a hope we will come out better.

Dr. Russell Hill is a board certified emergency medicine physician who lives in Church Hill and practices at Holston Valley, Bristol, and Hawkins County Medical Centers. When not working he is either running trails or chasing his four outdoor loving kids. You can follow his discussion of running, family adventures, and medicine on his website: therollinghillsfamily.com and contact him at russellmhill@gmail.com.

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