COVID-19: Insights from a Tampa infectious disease specialistMaking strides in social distancing

First in a series of interviews.

Retired OB/GYN Dr. Bruce Shephard of Tampa interviews Dr. Jose Montero, Professor of Internal Medicine at USF College of Medicine, about the local COVID-19 situation.

Dr. Shephard: How did you first become interested in medicine and in the field of infectious diseases in particular?

Dr. Jose Montero M.D.Dr. Montero: I always had a fascination with the human body. Infectious diseases, more specifically. ... [It was] more about being the detective, figuring out, in different situations, what we have with an individual. ... I enjoyed the puzzle and trying to figure out the solution. You got to remember back in the early '90s, we were under the AIDS epidemic and we had that big puzzle to try to figure out. That’s what drew me to infectious diseases.

Dr. Shephard: Did you ever think you would be trying to solve a puzzle as dramatic and difficult as this coronavirus epidemic?

Dr. Montero: This is not as difficult, but it is certainly dramatic, yes. I never thought I would come across this in my career. We always worried about the Spanish flu happening a little over a century ago, but I never thought I would be the one still practicing medicine and it would still be happening again. The closest thing we’ve seen like this in the past couple of decades was the 2009 “Mexican flu” so-to-speak and that was different in many respects. With that one, we had good testing already, good surveillance already, and known treatment plans. The thing that we really don’t have established for this one -- remember, this is April 11 -- we’ve only known about this coronavirus for a little over three months and look what kind of devastation we’ve had so far.

Dr. Shephard: How do you think we’re doing in the U.S. in dealing with this pandemic given the short time we’ve had to learn about it?

Dr. Montero: It’s difficult. In some respects, good; in some respects, poorly. It depends upon how you look at it. Scientifically, it’s incredible that the genome was figured out in just a couple of weeks. It’s our regulations out there that I think has been for the United States a little bit of a problem, specifically testing problems. 

We all heard of countries like South Korea and others that were testing impressively and we didn’t have testing as available. I think part of it is the American health care system. Our system is built upon almost perfection. We want perfection in our health care or close to it, and when we don’t achieve that and there’s a regulation put in to address it, this makes health care a little bit more expensive and it also takes more time. And that’s where we kind of lost it a little bit as far as our ability to respond in a timely fashion because there were regulations in place to protect our healthcare system. We couldn’t just jump through the regulatory hoops to get testing done as soon as possible. And that causes a lot of anxiety and gets to my next problem here.

Anxiety. Everybody had a lot of anxiety. Media. I think they take a lot of bad rap, but honestly, they reported it as they saw it. Unfortunately, it became basically 99% of the news and still is, which is a problem to a certain degree in my opinion. But when it comes to our hospitals in our population, I, as a physician going into the hospital every day, still, am amazed at the amount of anxiety and fear that exists in the general population and also among the healthcare worker populations.

Dr. Shephard: is your practice in an office or hospital setting?

Dr. Montero: I have mostly worked in my career and still do in the hospital setting. I work in a very large tertiary care facility (Tampa General Hospital) where we have a lot of resources, good leadership, and we were able to get testing for our area relatively early. And, yet, when you have some patients who may or may not have coronavirus and also maybe a few health care workers who test positive, probably due to community exposure, that brings a lot of fear and anxiety to everybody -- to your comrades in arms so-to-speak. And then you wonder how susceptible to get this infection you are as well. You see a lot of people talking not necessarily as rational as you want them to talk and that’s true of everybody whether it’s the lay public or the healthcare working public. It is mainly due to a lack of complete certainty.

Dr. Shephard: How do you manage your COVID positive patients?

Dr. Montero: We cohort, as we should, our coronavirus-infected patients into two wards. One is an entry ward where we have testing and evaluation for suspected COVID patients. If they test positive, they remain on the ward. Or if negative, they move on to the appropriate destination whether inpatient or outpatient. The other is a dedicated ICU for COVID patients. We actually have two dedicated ICUs for COVID patients at Tampa General with a total of 16 ICU beds. Plans are in place to expand to other areas of the hospital if and when needed.

When we do rounds in there, it's actually different than for a normal patient. We do group rounds with nursing, the respiratory tech, hospitalist, the intensivist, the infectious disease physician -- whoever is needed altogether. Only one person does the exam because we want to limit unnecessary exposure and conserve PPE (personal protective equipment). And then we discuss. It’s an interdisciplinary discussion, so we all understand every aspect of care. ... So I, as an infectious disease specialist, understand better what the hospitalists are thinking, what the intensivists are thinking, and what other individuals are thinking as far as the health of the patient. We make it a congruent effort as far as the health and welfare of these patients.

Dr. Shephard: Are most of these ICU patients awake?

Dr. Montero: In our facility, in the past few weeks, yes. Very few in the ICU are intubated or on ventilators, but about half in our ICU have ended up on ventilators. It is more difficult than you would expect to remove COVID patients from the ventilator. From autopsy studies, we know that SARS and MERS (other coronaviruses) had more fibrosis (scar) tissue in the lungs, but with COVID there seems to be more drowning of the alveoli in this proteinaceous fluid that forms and can’t exchange oxygen effectively.

Dr. Shephard: Has the use of electronic medical records (EMR) changed? Does one person make the EMR?
 
Dr. Montero: No, we all do. That is one thing that has not changed. The ability to do the exam the way we used to has changed, but not the EMR.

Dr. Shephard: do family members have a way to visit?

Dr. Montero: About two weeks ago, visitors were restricted to come into the hospital. We have one visitor per pediatric patient and one visitor per delivery. We have to communicate with the family via phone. So, one of us, usually the hospitalist, after the interdisciplinary rounds we talked about, will call the family member at home. If their loved one is interactive by all means they can talk to their family on their phone. So, we want to minimize the traffic of potential carriers of the virus in the hospitals with this approach.

Dr. Shephard: How do you account for what appears to be a relatively positive assessment at your facility and overall in Hillsborough County?

Dr. Montero: I do have a theory. We all hear what happened in Italy. We all hear what happened in New York City. I don’t think any of us can work well in a quick flood of patients as we all can become overwhelmed. In a flood, patients that won’t stop, we would naturally become consumed with the mass of sickness, illness, caring for your own family or whatnot. Here in Hillsborough County, we haven’t had that steep incline that we’ve seen in New York or Miami, although we’re starting to see a little bit of it in Orlando. Fortunately, I think social distancing is working. We don’t think we’ve hit our peak but the slope is not steep -- and that’s to our advantage. I am also aware that the other hospitals in the community -- HCA, BayCare, Advent Health, the VA -- everybody has been taking their share of coronavirus patients to spread out the wave so that the wave right now is not insurmountable.

Dr. Shephard: How have you been able to cope with the high demand for health care during this epidemic?

Dr. Montero: Our volume demand is actually a little bit less. We as physicians know the difference between rounding in the hospital on a Monday afternoon or a Sunday night. This feels like a Sunday night where the hospital is half empty. Many elective procedures are not being done. Many physicians are not in the hospital. Visitors are not in the hospital. You have your core nursing staff, core respiratory therapists, and a few physicians here and there. So, it’s actually quiet. However, as Infectious Disease Physicians, we do get a lot of phone calls about nonclinical care and often related to anxiety or specific risk events. We have one physician in our practice who has temporarily stopped seeing patients in our clinical practice to help the hospital with (infectious disease-related) administrative concerns such as how to handle PPE issues or help with infection prevention.
 
Dr. Shephard: How many infectious disease specialists are there at Tampa General Hospital and is that enough to deal with the volume of COVID patients you are treating?

Dr. Montero: There are three different groups. When they’re all present on a typical day, that’s 8-9 physicians. That’s enough right now, but if we had what has been going on in New York this past week, no. I’m very happy to see so far social distancing seems to be working in Hillsborough County.

Dr. Shephard: do you worry about a second wave?

Dr. Montero: I do. I think a second wave in the fall or winter is possible. In Hillsborough County, I worry if we have fewer cases now could we be set up to have a worse scenario if a second wave hits? Will we have less herd immunity? It’s a Catch 22 situation. No one knows.

Dr. Shephard: what is the status of COVID testing at Tampa General?

Dr. Montero: Those nasal swabs, those are the “PCR” tests. Those are swabs that amplify and test ... [for] the coronavirus. That right now is the gold standard for diagnosis for COVID. If you have testing on-site, it takes a couple of hours. What happened early on was that nobody had testing in their facilities and there was a backlog. Now our speed is increasing over this past week. In our facility, we get results in 1-6 hours and that helps how we manage that individual as far as isolation and so forth.
 
Serology testing. Right now, that I know of we don’t know how to use serology testing. Let me explain what I mean by that. I don’t know of any one FDA test so far that is approved but suspect some will soon be approved. Advanced serology tests (to measure antibodies) are looking for antibodies. That takes time. Advanced serology testing won’t help you upfront to diagnose. It may help you later on: Did I get COVID? If I did, maybe I will be protected from the second wave. That’s conjecture. We don’t know if antibody detection equals immunity because in hepatitis C, for example, it doesn’t. You get the hepatitis C antibody but it does not protect you from a future hepatitis C infection. But we do know in measles antibodies, it does. Right now, the antibody test may help us epidemiologically determine how many people in the U.S. really got infected but it won’t help us upfront early on when we first encounter a patient.

Dr. Shephard: how do you see this epidemic affecting our daily lives in the future after we get through the acute phase?

Dr. Montero: I know Dr. Fauci said something about no handshaking. That’s hard. I’m a Hispanic by background. We’re huggers! We love to embrace our family, our friends. To me an elbow bump or fist pump, that’s hard. That’s not who I am. But we’re going to have to learn to do that to a certain degree, reluctantly in my case.

I do know there’s going to be a certain degree of relaxation in the future. Trump said yesterday it was going to be one of the biggest decisions of his life. I think it’s a very tough decision. On the one side, you're going to have businessmen saying, “Why are we holding back when we’re bleeding money from the economy?” and others saying, "If you do it too soon, you might get that quick second wave. If I were to guess now, and this purely a guess, I would say late May or early June would be the very earliest time to begin relaxing social distancing. And it will probably vary by where you are at your peak state by state and locale by locale. Right now, for example, if you live in South Korea, you’re pretty much done although they might have something in the future. Italy and Spain are on a downswing and other countries like Sweden, they’re on an upswing still. It depends on where you are.

As far as the rest of us, I think we all are going to remember this short term. Long term, hopefully, customs come back and I can start embracing people again.

Dr. Shephard: Will we ultimately have a reliable vaccine against Coronavirus?

Dr. Montero: It’s hard to make a vaccine against this coronavirus. There’s something about it that I don’t understand. I’m not convinced we’ll have a 100% reliable vaccine. We all know how effective the flu vaccine is. It is effective but not 100% so. Remember what I said earlier, everyone wants 100%. I don’t think we’re going to get that. And that’s my concern.

Dr. Shephard: How has the coronavirus affected you and your family?

Dr. Montero: Two weeks ago, when I saw what was happening in Hillsborough County, I actually isolated myself a little bit from my wife and my son. They both have asthma. I said if I’m going to bring this home, I’m going to potentially infect two individuals in my household who have asthma. So, for two weeks I was living in a different part of our house. I can only imagine what health care workers are doing in New York to try to protect their loved ones at home.
 
Dr. Shephard: It’s been wonderful to have this informative discussion with you, Dr. Montero. Do you have any parting thoughts for the readers of 83 Degrees Media, the online magazine for which we are doing this interview?

Dr. Montero: I still think social distancing has worked here and I would like to believe the reason we are doing OK currently in this region is because of it. Social distancing is not a guarantee you won’t get infected. But it surely reduces those odds. So, don’t let off the gas on that because we want to get through this.

Dr. Jose Montero is a Professor of Internal Medicine, Division of Infectious Disease, USF Health Morsani College of Medicine. Dr. Bruce Shephard is a retired Tampa Obstetrician-Gynecologist and Affiliate Associate Professor, Department of Obstetrics and Gynecology, USF Health Morsani College of Medicine. Both physicians are lecturers for Continuing Education, Inc., St. Petersburg, FL.

83 Degrees Media's series on local physicians working in the time of COVID-19:
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