COVID-19: Where the Heck Are We?

I started this venture back in March in response to COVID-19. I saw many Physical Therapists and other rehab professionals shutting their doors because it wasn’t safe to keep them open. I saw an opportunity to improve our profession by addressing a deficit in practice: the lack of cardiopulmonary skill implementation. It wasn’t even that we didn’t have the skills, because we absolutely do! We learn all this stuff in school and sometimes its just a matter of how much you practice it. Implementation has always been my concern. We have tons of research saying all the best things about exercise, but we don’t implement most of it. Implementation is key. So, I was really just hoping to help people brush up on things they already knew or apply them in different ways so they could keep working and keep practicing even in the midst of a global pandemic.

Along the way, this process became complicated because what we all knew as fact was changing. The view of “science” changed. Lots of things changed. The organizations we thought we could rely on failed us. And, to the entire medical world still practicing, we felt like every day, sometimes every hour, was a slap in the face. COVID-19 sure has made an impact on the world, but I can’t even begin to explain the impact it’s had on the medical community.

So, where does that leave us? COVID-19 is still here and we are still treating it, so let’s take a look at some data on where we are at in this thing.


All the Numbers and Changes Over Time

I hate this part. There are a lot of different data sources to use here. All of them will be different due to different reporting metrics and time frames. So don’t be surprised if all the numbers aren’t EXACTLY the same. There are also different ways to combine, separate, and read the data, which also creates differences in numbers. We are going to go with the data from Johns Hopkins University of Medicine. Why? Because they run one of the largest live updated databases of this information that draws from several other databases. Say what you want, I’m going with the largest amount of information aggregated by the leading professionals.

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At the time of writing this: Global Cases are at 24,563,393. The US has over one fifth of those at 5,901,393. Global deaths are at 833,466. The US has contributed 181,409 of those. Global recovered cases are 16,051,454. The US has contributed 2,101,326 of the recoveries. Total tests performed in the US is at 75,301,306. And the number of hospitalized patients in the US is 365,993.

Lots of number, I know. But we are just going to do some simple things with them. And, for some reason, people seem to want the numbers of COVID-19. They have never mattered before when millions were dying of flu or tuberculosis or malaria but whatever…

These numbers tell us that there are still 7,678,473 people in the world actively suffering from COVID-19 (number of total cases – recoveries – deaths = ongoing cases). This may not include the long-haulers which are usually viewed as “recovered” even though they would sorely disagree. In the US, that leaves 3,618,658 people (about half of the world total) still fighting COVID-19, or just over 1% of the population of the US. I know 1% doesn’t sound like much, but when you know that 1% is more than three and a half million people, that 1% looks pretty big to me.

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We also need to understanding that all of these numbers are an underestimation of the actual picture. We can’t count any cases that happened before testing because we didn’t have testing to prove there were positive cases! So all the cases that happened back in February and March (and some even earlier, researchers are now finding) didn’t make the count. That includes positive cases, deaths, hospitalizations, and recoveries. Doctors at that time were treating COVID-19 based on severity of symptoms, imaging studies, and based on exclusion criteria. We also need to remember that testing has been pretty restricted in the grand scheme. Even if you’ve had an exposure, you can’t be test until you show symptoms, which doesn’t prevent you from spreading it around for a few days first. And, for a while, there were so few tests that only those at highest risk were every tested. So, many cases went unreported.

That’s a lot of numbers… Glad that’s over…


What else is going on?

Symptoms of COVID-19 can range from all the typical symptoms of a respiratory virus (coughing, fever, shortness of breath) to GI symptoms (nausea, vomitting, dehydration) to strange presentations like wounds on the toes. Neurological symptoms are well know to be involved such as confusion, loss of smell or taste sensations, or a headache. Serious presentations may include blood clots, strokes, heart attacks, acute respiratory distress, or altered mental status. It all depends on where the infection takes hold in your body and what the mechanism of entry was. Speaking of how someone gets infected…

We are still experiencing a PPE shortage. And providers who experienced a PPE shortage are more likely to have been infected with COVID-19. N95s are still the most frequently reported shortage item, but even gloves are beginning to be in short supply. Even with the PPE shortage, though, health care providers who wore a mask at every clinical interaction were less likely to contract COVID-19. Healthcare Providers still rank among the highest risk people to contract COVID-19.

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Although the CDC maintains its stance on COVID-19 only being transmitted through droplets (aka droplet precautions), many research studies have determined that COVID-19 is airborne. The WHO has also acknowledged that there is significant evidence to support the likelihood of airborne transmission. Even many employers have acknowledged that their providers at at an increased risk and provided the supplies necessary for airborne precautions. As if things weren’t already confusing enough, even though the CDC maintains their stance on droplet precautions, they recommend airborne precautions when performing aerosol-generating procedures. Thankfully, many professional organizations have come forth to define “aerosol-generating procedure” to help guide treatment safety.

A large field of research has been devoted to determining the ventilation and air purification needs that rooms of different sizes and capacities would require. Healthcare engineering in many capacities, from 3D printing shields and N95s to improving sanitization to HVAC updates, have been working overtime to fuel the needs of providers and patients.

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Long haulers have emerged. These are the folks, whether hospitalized for COVID-19 or not, that continue to experience symptoms of COVID-19 long after the standard infection and illness window. Some people who believe they were infected back in February before testing was even available, are still experiencing the fatigue, shortness of breath, and muscle aches that resulted from their infections.


Have we made any progress? What are we doing about this?

The medical world and the non-medical world have started to blend together, for better and for worse. Post-Intensive Care Syndrome (PICS) has been making headlines and the therapy world (including respiratory therapists) are getting some serious spotlight. The world has become aware of the fact that people don’t just jump back from serious diseases. Proning, an intervention that has been around for a long time, has also been given screen time. These particular topics have placed rehabilitation front and center. Considering most people don’t even know what PTs and OTs do, and think SLPs just play mind games all day, I’d say we’ve made some positive public image impact.

Some professional organizations are also stepping up and providing toolkits, new tools, and educational content regarding treating patients with COVID-19. There is also guidance issued regarding screening for COVID-19 in the outpatient setting to decrease transmission and infection risk.

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Like the numbers above have shown, over 2.1 million people have recovered and therapy played a pretty big role in helping some of those people recover. The early numbers from back in May showed that about 20% of the people who contracted COVID-19 would require extra medical help to recover, and about 10% (half of the 20%) would need long term inpatient care. We’ve gone from dreading the intubation and ventilation phase to seeing many of these people in the home and outpatient settings for treatment, management, and recovery. Outpatient clinics have reopened and begun utilizing technology to help more people than ever!

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Telehealth is the biggest win to come from COVID-19. The implementation of telemedicine into the therapy world used to be a pipedream. It was only for expensive, private-pay therapy. Today, most payers reimburse for telehealth visits to some extent. We can now provide follow ups, evaluations, check ups and check ins, virtual home programs, and so many other services to our patients without have to risk their health or our own. If anything about COVID-19 sticks around for the better, I hope it’s telemedicine for the rehab world. Thankfully, CMS has indicated that they have no intention of repealing the telemedicine reimbursement program. That’s really great because these long haulers are needing long curses of therapy and many others who were hospitalized are needing frequent and long term rehabilitation for severe deconditioning and pulmonary function impairments.

Research has indicated that the suspected time frame that COVID-19 will significantly impact our lives in 18-24 months. The research on immunity from previous infections is mixed with some people showing antibodies long term and some people not showing any antibodies to the infection after a known case. Herd immunity has been discussed as a solution, but that can’t happen is antibodies don’t stick around enough. Not to mention it would require over 1,000,000 MORE deaths to achieve than what we currently have. Not quite an acceptable solution. Vaccines are all in the works from multiple different companies in a race to the cure. From a rehab perspective, we need to be screening every patient. We have the abilities, skills, and knowledge to do so. You can read more about that here.


Overall, our world has completely changed, at home and at work. COVID-19 doesn’t look like it’s going away anytime soon. The SARS-CoV-2 virus has definitely mutated over time with more than 6 different strains already detected. The acuity of illness seems to be decreasing, but the symptoms seem to be lasting longer. It will probably continue to do so. I hope this somewhat brings you up to speed to where we are now. I’ll keep updating you on big changes. And I’ll keep helping you update your skills to best treat your patients, COVID-19 or not.


Are you still experiencing PPE shortages at your workplace? Tell me about it in the comments!

It’s Getting Hot in Here: Body Temperature

How many times have you had your temperature taken lately? I think I’ve had my temperature taken thousands of times in the last few months. We are seeing the increased use of forehead scanning thermometers and temporal scanners, all the non-contact forms of temperature assessment, to screen folks for COVID-19 symptoms upon entry to anyContinue reading “It’s Getting Hot in Here: Body Temperature”

Sternal Precautions

“Patients exchanging habits of activity for complete rest are likely to become rapidly worse.” This quote fuels my everyday. These words have informed nonsurgical and surgical rehabilitation and its evolution from handing out bed rest like Oprah hands out cars to getting people moving early and keeping them moving often. Here’s the crazy thing: ThisContinue reading “Sternal Precautions”

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Resources:

CDC (Updated August 12, 2020). COVID-19 Overview and Infection Prevention and Control Priorities in non-US Healthcare Settings. https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/overview/index.html#:~:text=COVID%2D19%20is%20primarily%20transmitted,be%20inhaled%20into%20the%20lungs.

Dong, E., Du, H., Gardner, L. (2020). An interactive web-based dashboard to track COVID-19 in real time. The Lancet: Infectious Disease: CORRESPONDENCE 20(5):533-534. DOI:https://doi.org/10.1016/S1473-3099(20)30120-1PlumX Metrics.

COVID-19 Dashboard by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). https://coronavirus.jhu.edu/map.html

Self WH, Tenforde MW, Stubblefield WB, et al. (2020). Seroprevalence of SARS-CoV-2 Among Frontline Health Care Personnel in a Multistate Hospital Network — 13 Academic Medical Centers, April–June 2020. MMWR Morb Mortal Wkly Rep. DOI: http://dx.doi.org/10.15585/mmwr.mm6935e2external icon

Other resources can be found on the linked pages to which they apply.

Follow @DoctorBthePT on Twitter for regular updates!

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