Translated by Scott Humor
“Mass coronavirus testings are not just pointless, but also harmful” says Denis Protsenko, the Chief of Medicine at the Hospital no. 40 in Kommunarka, which was made into the main coronavirus treatment center in Moscow.
Q: We are sitting at a distance of about two meters. You came to the meeting from the hospital, that is, literally from the front line, in my opinion – all covered with coronavirus. Where is the guarantee that I won’t get infected?
A: The guarantee is that our clinic is fully equipped with the most modern equipment and protective materials: special suits, respirators of a certain class, and glasses that protect the mucous membrane of the eye. All this guarantees the protection of the doctor and the non-proliferation of the virus beyond the walls of the hospital. Doctors understand the importance of this problem, there is no place for bravado. We have a very carefully organized control zone: we enter the building where the patients are lying through one airlock, and exit through another, leaving there the clothes in which we contacted the patients. This is a guarantee that you are safe, even though we are now not two, but only one and a half meters apart.
Q: When did it become clear to you personally that we were on the verge of a very serious epidemic?
A: In January, I think. When I saw that all foreign magazines on my main specialty — anesthesiology-resuscitation — are more than half filled with articles based on materials from China, full of descriptive statistics: which patients are in intensive care, how they are given a ventilator and so on. The extent to which the professional press and the Internet began to pay attention to the problem, named five letters, COVID, indicated its undoubted seriousness and scale.
Q: Did you understand that the epidemic will inevitably come to Russia?
A: No doubt, we understood this, but we didn’t know when or to what extent. The team that was engaged in protective measures in Moscow understood this a little more deeply and a little earlier than we did. Sanitary measures, cordons of doctors on certain airlines, selective temperature control on arrival from a number of countries — all indicated that we were expecting something very serious. Of course, there were arguments that the swine flu in 2009 spread faster, there were speculations related to the tropicity of the new virus to the Asian race, that the Europeans will not be affected. And then Italy started, and it became clear that Europeans are just as vulnerable to the virus as people in China. Moreover, if in China the virus somehow managed to be curbed, then in the North of Italy it really broke out. We were constantly in touch with our Italian-speaking colleagues and quickly realized that this is not a local story, that tomorrow it will come to us.
Q: How do you explain, then, that with thousands of kilometers of borders with China, and virtually free movement of citizens of both countries along the border zones in Russia, there is still a relatively small number of cases?
A: I don’t think we can safely say that there were no barriers on both sides. I am sure that our Chinese colleagues have definitely taken protective measures. These are measures that are proving effective today: while the incidence curve is creeping up around the world, in China it has sharply declined.
Q: When did your understanding of the scale of the epidemic change?
A: It changed almost immediately, as I have already said-during the development of the Italian scenario. I am the chief of medicine, but I am a resuscitator by profession, and in my heart, and I have always been and will remain one. And my professional attitude changed when I saw the situation in Italy: the cancellation of planned operations, the extreme shortage of resuscitation rooms, the transformation of operating rooms into intensive care unites, colleagues who are resuscitators, in addition to their paid work volunteering in two or three other places…
I took a step that many of my colleagues still condemn: I opened a closed, strictly professional chat for everyone.
We have a Telegram channel that has been subscribed by about one and a half thousand Russian resuscitators. The first thing we did was invite Italian Russian-speaking colleagues to this chat, where they shared current information, just like reports from the front: how many patients were admitted, what treatment protocols are used, what is the effectiveness of therapy. We have started an operational professional telegram discussion.
Q: Were there any infected people in Moscow by then?
A: No. We just opened a hospital in Kommunarka, but there were no serious patients. However, when I saw the growing degree of doubt in society, as a certain category of people — I call them anti-vaccinators that there were no real data, that this all was a conspiracy, that everything will be kept in secret until April, I took a step that many of my colleagues still condemn: I opened for everyone this closed, strictly professional chat — just posted a link with free access on Facebook. So that your fellow journalists, and anyone else, can see how this story develops. We have opened professional chat rooms with a request, of course, to strengthen the ethical and deontological component, which sometimes, unfortunately, in the medical environment is very vague — jargon, reduced professional vocabulary, and so on. And I am still sure, although, I repeat, not everyone agrees with me, that this was absolutely the right decision: in such a situation, we need maximum openness. The result was not long in coming. For example, a community of translators came to the chat almost immediately and said: “Guys, let’s quickly translate materials from Italian and English for free.” I saw that during these 14 days, the attitude of our society towards doctors who are on the front line of the fight against coronavirus has completely changed. I don’t consider myself a hero, but the team that has been working with me since day one are really amazing people.
Q: How has been your team formed? What doctors of other specialties are working with admitted patients?
A: In Moscow, this is arranged as follows. There are institutions that deal with patients with pneumonia, there are infectious hospitals – on Sokolinaya Gora, on the Volokolamsk highway, there is our Kommunarka, where patients with a high risk of coronavirus are brought. All of these hospitals employ multidisciplinary teams: at the head of each team is an infectious disease physician. Each team also includes an epidemiologist, is the anesthesiologist, because on the basis of Chinese and Italian experience, we know that the condition of the patient older than 60 years can quickly become critical, and, of course, our heroic nurses, full and sometimes leading members of this multidisciplinary team. Depending on the specific situation, the team includes pulmonologists, otolaryngologists — physicians of all relevant specialties. In each of these hospitals, expert groups of specialists are gathered to work with patients affected by coronavirus.
Q: Many respiratory methods of treatment of seriously ill patients as an intubation, non-invasive ventilation, bronchoscopic examination — are high-risk factors for nosocomial transmission of infection. What is being done to reduce this risk?
A: The same thing that was always done: disposable intubation tubes, cleaning and disinfection of laryngoscopes, antiseptics, compliance with epidemiological safety — these are all standard, routine procedures that are always followed, and in the current situation — especially carefully.
Q: Are there any cases among your team’s medics?
A: There was a young female doctor who got sick after working with a COVID-infected patient. We immediately hospitalized her, twice tested for coronavirus, both times the result was negative, that is, the working situation coincided with a common cold. The girl has already been discharged and started her usual work.
Q: What exactly is the treatment of a patient with moderate symptoms?
A: Moderate symptoms do not require treatment — only isolation and observation. By the way, this is the reason for complaints such as “I am in the hospital for three days, and I only have my temperature taken and not treated in any way.” Yes, we do not treat, because there are no ideal and safe treatment regimens for coronavirus infection. The schemes that we use for severe cases with antiretroviral therapy have quite pronounced side effects. As with the rest of the world, in these cases, we use drugs that are used to fight HIV infection – it turned out that some of them are effective for fighting the coronavirus.
Q: What point in the course of the disease with moderate symptoms is the turning point? When do you stop observing and start treating?
A: With a prolonged temperature above 38 degrees and the appearance of a negative CT picture in the lungs, accompanied by shortness of breath and a decrease in blood oxygen saturation.
Q: Can a person being at home register this tipping point?
A: Definitely. It’s an appearance of shortness of breath, a feeling of the lack of air, which is easy to assess yourself. A healthy person at rest takes from 9 to 16 breaths, so shortness of breath over 25 breaths combined with a high temperature is a reason to immediately call an ambulance.
Q: For example, I have a temperature of 37.5, have a dry cough, but no difficulty breathing. My actions?
A: Isolate yourself at home. Both, a self-isolation from the society at large and an isolation inside your home are important. You should occupy just one room, every time after your trip to the toilet your relatives should carefully ventilate an entire apartment or a house. If you don’t live alone, only one family member should take care of you. Not just one person at a time to be replaced by another, but one specific person for the duration of your isolation.
Q: What symptoms are definitely not related to this infection? Can we say that a person with a runny nose certainly does not have a coronavirus?
A: There are no specific syndromes in the case of coronavirus infection.
A: No “except”. None.
Q: In other words, it is possible to have an acute course of the disease that is not accompanied, for example, by respiratory disorders?
A: Respiratory disorders can be accompanied by the usual flu or a common bacterial pneumonia. It can also be accompanied by fatigue. With it, there may also be a dry cough. With it, there may be rhinitis or a runny nose. Or maybe not. So, unfortunately, there is not a single clinical symptom that is pathognomonic in one hundred percent of cases, or, to put it simply, uniquely characteristic of a coronavirus infection.
Q: This means that the diagnosis can only be made on the basis of a test.
A: Exactly. The only thing that a person with moderate symptoms can and should do is to self-isolate and control their condition. And in case of a prolonged high temperature — call a doctor.
Q: Are there any palliative ways to ease the moderate severity of the disease at home?
A: As with the common cold: get plenty of rest, lots of fluids, constant ventilation and thorough hygiene.
Q: Should we try to alleviate symptoms with medication? Paracetamol, aspirin? Simply put, should we take fever reducers?
A: There are different antipyretics, and there is a lot of speculation on this topic. The most” promoted ” means is ibuprofen, but somewhere already passed information that patients affected by coronavirus, who took ibuprofen to reduce their temperature, eventually had worse outcomes. But the information is not confirmed clinically, which means that nothing can be definitely confirmed.
Understand that today we have a really unique situation: we are studying a new disease, and the classic methods of evidence-based medicine simply do not work. We — I’m talking about Russia – simply do not have time to gather a group of patients who receive, say, Nurofen, and compare the course of the disease in this group with the group that does not receive the drug. Therefore, we refer to foreign studies, to the observations of Chinese and Italian colleagues, something appears in the German sources. Now is the time for observation medicine: both positive and negative aspects of therapy are formed and formulated literally before our eyes. We don’t have our own big data. There is big data from China, but how much it can be extrapolated to our reality is unclear.
Q: I do not like to catch people at their word, especially in interviews on medical topics, but still – do I take an antipyretic or not?
A: Heroically delirious, like Pavel Korchagin (a character from the novel How steel is made) in typhus, and at the same time to avoid taking medicine — I will not give you such a recommendation. Take me at my word: Yes, take it if you can’t stand the heat. But at the same time, remember that an antipyretic is a medication which means that it can be not harmless. The same paracetamol, if you drink it more than 4 grams per day for several days, it can lead to a liver failure. In any situation, you need a reasonable approach.
Q: Fine, Let’s say that I took an antipyretic but the temperature is still very high. What should I be doing?
A: The persistent high temperature for any reason is when you call a doctor to your house. The doctor will come for a visit, will look into your medical history and will make a decision. In today’s situation – he will take a swab test and send it to the lab. Especially if a person has recently arrived from a country with a tense epidemiological situation. Let’s say from England. Especially if the person has some additional symptom, at least a runny nose. If the test reveals a coronavirus, it will be necessary to isolate the person, analyze his contacts and try to prevent the spread of the infection.
Q: What does a severe course of the disease look like?
A: Severe course of the infection is respiratory failure, when oxygen therapy does not provide any positive effect and we have to switch to artificial ventilation with aggressive modes, with a high fraction of oxygen. Severe course is the introduction of the patient to the prone position, in other words, face down, dorsal side up, and ventral down. The patient lies on his stomach so that the effect of gravity on the fluid in the lungs can improve oxygenation, an oxygen supply.
Q: Are there any fatalities from coronavirus in Moscow?
A: Not as of today.
Q: I had a sore throat in the morning, then it went away. Should I be tested?
A: Where have you been recently?
Q: I came from Israel two weeks ago.
A: Two weeks ago, Israel was not one of the countries with a tense epidemiological situation. It means you don’t need to be tested. Although the whole story is, of course, ambiguous. Let’s say your test is negative, you go to Tverskaya street, and a person passed you by, coughing. So, what should you do? Are you going to go and get tested again?
Q: That’s the question. Where is the line between reasonable caution and paranoia?
A: If a person who does not have clinical symptoms wants to be tested for a coronavirus, it is paranoia.
Q: On March 17, it was announced that within the next month, the network of laboratories “Invitro” will begin mass testing on COVID-19 — anyone who wants to pass the test on a paid basis will be able to be tested.
A: Yes, the founder of Invitro, Alexander Ostrovsky, put a lot of effort into this. This story is commercial. I do not really understand what for us, the medics, will give a situation in which everyone can be tested for a coronavirus.
Q: Are you afraid that crowds of people, including those with false positive results, will rush to you?
A: This is also. Let’s simulate the situation. How are you feeling now?
Q: I feel well.
A: I’m glad. You, feeling absolutely normal, walk past the Invitro and think: “I’ll take the test.” The analysis is positive. But there are no symptoms. Your actions?
Q: Based on what you said earlier — self-isolate and observe. Right?
A: No, this is wrong. You yourself mentioned the possibility of a false positive test. How many of these will we have needlessly self-isolated people? You don’t prescribe antihypertensive therapy to yourself, you go to the doctor. You don’t just come to the pharmacy with the question: “What would I take for high blood pressure? Give me this, in a yellow box.” No, you go to a cardiologist, he talks to you for a long time, interviews you, then makes a decision either to do an echocardiography, or a stress test.
Q: In other words, massive tests for the coronavirus appear to be meaningless?
A: Not only pointless, but also harmful. Think of the story of mass cancer screening: hundreds of false positive diagnoses that distract doctors. This takes the valuable time from the medics, during which people who really have this illness could be helped.
Q: The number of cases is unpredictable. Sooner or later, the system will have to face a choice — whom to save?
A: The system is faced with a choice now, but I would not yet put the question this way “whom to save, whom not to save”. Moscow healthcare has some very powerful capabilities. Taking into account the fact that Moscow has a federal system in addition to the city system, which can also be re-purposed, the city’s bed capacity is very large.
Let’s not forget that there are a lot of research institutes in the city. Right now, we have a respected research Institute of Neurosurgery next to us: it’s several hundred beds, and they are more than twenty in the intensive care unit. In case of a pandemic, they can stop the planned hospitalization of patients with brain tumors and start treating those who have a coronavirus infection.
Q: And leave patients with brain tumors to die?
A: No, why to die? I’m talking about those who can be delayed for various reasons. Once again, there is no question of such a choice yet. As the chief anesthesiologist-resuscitator of Moscow, I can responsibly say that we have 2,500 resuscitation beds in Moscow, that the park of anesthesiological and respiratory equipment is about 5,000 units, that Moscow reacted the fastest and bought everything that was on the Russian market.
Q: Does this mean that we left the regions without equipment?
A: This means that the capital’s healthcare system is working as quickly and efficiently as possible — this is how I feel about it. Moscow is the capital, the port of five seas and four international airports, a giant transit hub, which means that the city will take the first epidemiological blow.
Q: A person flew from Italy or Spain to Moscow, took a train and went to Vladivostok or Kemerovo. What will happen?
A: If there was at least one infected person on his flight, the epidemiologists, along with the Police operatives, will find each passenger and work out his entire route. Let’s say a girl flew in from Milan to attend fashion week. On the fifth day of his having a cold with a cough, she took a swab and results are positive for coronavirus. Then the story begins. “Have you been to Europe? And when? What flight did you take?”All those who flew on this flight are being sought and notified that there was an infected person on board. “”How did you leave the airport?”- “Called” Yandex.Taxi”». – “Check your order, and give us the number of your ride.” Everyone who ordered this car that day is checked. Invisible, but incredible in volume, this is a colossal investigative work that is carried out every day by the city team for the fight against coronavirus.
Q: In your recent appeal via social networks, you spoke about those who left the hospital without permission. These are real biological bombs, right?
A: Exactly. It is important that these people understand that they are spreading the infection. The increase in the number of patients, including the fault of these “runaways”, will lead to the fact that hospital care will be provided more slowly. Extra time will be spent on research of anamnesis, on drawing up a map of contacts — all this can become critical if we are talking about complex medical cases. We need a full understanding between patients and doctors, and it is important that people know that today doctors work with all their strength, and any actions that reduce their work to nothing are simply inexcusable in relation to our society.
Q: In the comments under one of your Facebook posts, you were asked about an increase in the number of cases of community-acquired pneumonia, which oddly coincided with the epidemic. You didn’t answer. Cam you answer me?
A: The person who asked the question referred to the statistics of one of the business publications. With all due respect to your fellow journalists, as a professional, I am not prepared to conduct a medical discussion based on non-medical press materials.
Q: Nevertheless, every day you openly provide statistics on the situation in your hospital and every day there are patients with community-acquired pneumonia among those discharged. Have you noticed an increase in the number of people admitted with this diagnosis?
A: I can’t estimate statistical growth. According to the program for combating coronavirus infection, patients who have a clinical picture of community-acquired pneumonia are purposefully brought to our hospital. This is why they are considered to be at the highest risk of infection with coronavirus. Therefore, the data I provide for Kommunarka hospital cannot be considered representative, and they cannot be extrapolated to the situation in Moscow as a whole, and even more so in the country.
Q: How do you feel about the British government’s “let all those who are destined to get sick get sick, so we will reach the ‘herd immunity” or the population barrier of infection faster”?
A: What if we don’t? After all, there is still no evidence that the acquired immunity in patients who have been ill prevents re-infection. Now, it is very important to track whether the decline in the disease rate in China is stable or whether the Chinese are waiting for a new outbreak in July-August. You know, they say, “the brave risk lives, but only the very brave risk their own.” I think the decision of the British leadership is to risk the lives of others. I am glad that Russian healthcare has a completely different approach.
Q: What is your prognosis for the development of the coronavirus situation? Is there any reason for optimism today?
A: There is no forecast. And the reason for optimism can only be the fact that, working 16 days in the pandemic mode, having hospitalized almost half a thousand patients, we do not observe any shortage of beds, or the inability to provide prompt assistance, or situations of choice – whom to take to the intensive care unit, and whom do not. But we are not complacent: the team of Moscow Chief Physicians and the team of the City Headquarters for the Fight Against Coronavirus are doing everything to increase capacity and efforts. The next, hospitals are being repurposed, the staff is being trained — in this situation, it is better to be overly vigilant. Yes, it will result in financial costs, but human lives are more expensive. It seems to me that now is the time when you should stop scolding Moscow health care and say: “Guys, you give your best and you go a couple of steps ahead of the virus. At least still.”
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