Signs and Symptoms of COVID-19

of my loved ones actually correspond to coronavirus. There's tons of information going around on the Internet, and it's a little hard to know what's reliable and what isn't. I thought it would be useful to talk to a frontline primary care physician who's actually in charge of programs where lots and lots of doctors are seeing patients who are presenting with coronavirus. So I called doctor Rebecca Berman, the program director at the University of California, San Francisco's Internal

Medicine Residency program. That means she's the person in charge of training the actual doctors who are going to become residents in internal medicine. An internal medicine means in a hospital, the main job of seeing patients. I asked Rebecca about how we should be thinking about symptoms, which symptoms actually tell us that we should go to the hospital, what we should do if we're not going to the hospital,

and how preparedness is going inside UCSF. Rebecca, you are literally on the front lines facing the current coronavirus situation. I wonder if you could start us off by telling us how you and your physicians in your training program are doing the first line diagnosis. When someone comes in to the hospital and says, I'm feeling lousy, I think I have coronavirus. What algorithm are you guys using? Well, I think something that's challenging about coronavirus is that for

a lot of people, they functionally have cold symptoms. So we're all kind of worried. I have chronic allergies, and it makes me worried constantly, like is this running nose different than the normal running nose that I always have? And so I think for us in the hospital, the things we're most worried about, and the people were actually testing are those who seem sick, those who are having

shortness of breath or fever. The presenting symptoms can just be cough and running nose, and then some people is asymptomatic. So we're also seeing our primary care clinics kind of

flooded with people who are worried and want testing. But right now, given the limited number of test kits that we have, we're trying to encourage people not to come in if they aren't actively feeling feverish and short of breath, because simply testing someone who's not that sick but symptomatic is going to result in the same treatment, which is to tell them to self quarantine at home for fourteen days.

It is really hard for people to be stuck at home right now, although frankly here in San Francisco most people are stuck at home right now, but that is what we are doing. In terms of diagnosis. At this point, we are trying to triage. We have a COVID nineteen infectious disease doctor on call at all times, and we run cases by them in order to choose who needs testing.

I completely understand that from the hospital's perspective, you don't want to be flooded with people who might be positive but can't at present be treated, So it makes sense to say only come in if you have the shortness of breath and the fever. In terms of people's own self diagnosis at home, though, however, there's sort of like a plethora of information out there, much of it surely inaccurate.

And I've heard all kinds of things, you know, people saying, well, you know, if you have a running nose, that's not it, and others saying, well, if you have a sore throat, that's it, but if you're coughing, that's not it. I mean, I guess what I'm wondering is, first, just at the very basic level of the sis, is this all ridiculous? I mean, is it? In the end, the full range

of cold like symptoms could be indicators of COVID nineteen. Well, I think what's hard is in most people, cough is the presenting symptom, often a dry cough, but sometimes productive. It's true that running nose makes it less likely, but it doesn't rule it out. So about fifteen percent of people with coronavirus are going to have runny nose. So if you have a running nose, it can make you feel a little better, but it doesn't mean definitely you

do not have it. The guidelines that are health occupational health is giving us to help us as healthcare workers know when not to come in. Are saying, if you have two of those symptoms like sore throat and cough or cough and runny nose, and they're getting worse over two days, than you should stay home. And so I think using those guidelines more widely as a wise one. I think, did you say fifteen percent of the people who are positive for the virus do have a running nose.

So the running nose is not a guarante. It's not necessary an indicator that you have it, but it's certainly not a reason to think you don't have it exactly. Then what about the sore throat? Where does the sore throat fall in? Sore throats also are seen in less than fifteen percent of patients, and similarly, GI symptoms like nausere vomiting, or diarrhea are seen in a low percentage

of patients. So it's really a combination of different elements that give you clinically an indication that you're probably looking at a corona case, with kauf being the most significant and fever the next most significant, and then the things like running nose or sore throat they don't have a huge indicating effect. But their absence also doesn't tell you much. If it's fifteen or twenty percent of the people have that symptom, then the fact that they're not there doesn't

tell you very much. If they are there, it might be indicative as well. I guess. I guess if they are there, it's like a little reassuring, but it's not a slam dunk. So I think the advice that if you're not feeling well, stay home and isolate is a good one. And what about the core takeaway question, which is I'm at home. I think I have these symptoms. I have a fever, it's not terrible, but I don't have shortness of breath. And I have let's say, a serious cough. Should I come in or should I just

self isolate? Right away? I would say you should self isolate. If you have underlying medical problems like diabetes, or you're immunocompromised, or you're pregnant, certainly call your physician. But the last thing you want to do is come to a hospital where they're going to be other patients who have this

walking around. You would rather stay at home. So I think our biggest fear is that the health system is going to be overwhelmed by what we call the worried well, people who are relatively asymptomatic or have minor symptoms of this disease, who are worried and come in when they don't need to, and in this instance, well would just mean well enough that they don't have to be admitted, because maybe the worried well in this case actually will

have coronavirus, but they're well enough to stay home. So in that sense, they're they're the worried well. They're not they're not the irrationally worried well. Under these just then not intensely sick. Perhaps we should call them the worried mildly sick. That's not as catchy as the worried well, but it sounds helpful. So for the rest of us will try not to enter the category of the worried mildly sick. But those people at this point should stay

home so as not to overwhelm the system. And when you start to feel genuinely sick, that's the time to go in correct. So that brings me to the really fascinating point that you brought up, that I deflected us from because I wanted to know whether we have we all hell, we know whether we have the virus, which is the idea that is part of your triage. You'd have to deal with the fact that we just don't

have enough tests. And I want to ask you about this because you know, one of the forms of criticism that one hears of us prepared in this here is well, gee, they're just not enough tests here, and there are more tests available in other countries and we should have been

better prepared there. And that seems plausible to me. But I've heard a counter argument as well that said something like, well, look, if ultimately it could be between forty and seventy percent of adults who get this, testing isn't really what's significant at this point. And what's more, if we don't have a treatment for most people except that they're very, very sick and we put them on a ventilator, the testing

isn't really the key. The lack of tests isn't really our problem here, and we should just be more focused on the broader public health response. Do you have a much more informed view on that debate than I have. I mean, to me, there's two different questions, like having limited testing is extremely stressful on the health system. It actually means we can't test doctors who have been exposed, or if we test them, how do we know that those tests are correct should they really come back to

the frontline. So from a workforce perspective, that's very stressful. In my ideal world, we would have so many tests available that we could swab everyone who comes into the hospital every few days and make sure that they are being protected and that they're not bringing any virus into the hospital. So I do think that there's two different questions.

One is does your average person at home where we can't actually really treat it, is it important for us to have that diagnosis versus this second question of healthcare workers. And then I think the other problem with not having widespread testing. Part of the reason Korea's numbers look so great in terms of their number of people who have gotten very, very sick is that they've done widespread testing,

So they're testing a whole bunch of asymptomatic people. They have a much better sense of what the denominator is of how many people have this virus compared to how many gets sick. Here, we're only testing a small portion of people, which means that we don't really know what percentage of people get very sick from this. It seems that it's about three percent of people, but again, we just don't know because we have no idea how widely spread this is. So to me, I mean defunding our

pandemic response was a tremendously large error of leadership. And I'm grateful to our state and local governments who are really trying to step in in this moment. But it would be better if testing were more widely available. Rebecca, I understand that it's tentative, but tell me again, what

was that three percent number? That's the number of people whom you think of at present who are exposed who are getting very sick, or is it the number of people who have the coronavirus who are getting very sick? I think between two and three percent is the number being bandied about of the number of people who will die who get the virus. Right. I've heard that number as well, and based I think it's largely based on the Wuhan statistics, right. Correct. Now, let's move on to

what happens when you're treating a patient. The patient comes in the patient is symptomatic enough for you to give them a test. Let's say you determine their positive for coronavirus, but they're not so sick that they need to be admitted to the hospital, so you send them home into effectively self quarantine. Correct, Correct? And what is that supposed to mean in real practical terms? I think a lot

of listeners out there are wondering. We hear this phrase self quarantine or I guess in that case, self isolation, but we don't really know how much exposure to other

humans that entails. I mean, is it literally meant to be lock yourself in your room and do not see the other people who live in your house, if there are any I mean, in an ideal world, yes, right, it's ideally have your own room, in your own bathroom, and have someone like leave food at the door that you then open the door and get the food and shut it, recognizing that for some people that's not going

to be possible. But you know, there was a case in Asia of a family of nine who, like one of them was on isolation and they all shared hotpot and they all got coronavirus. And so certainly I think trying to really isolate, I mean, luckily we all have computers. I would recommend trying to be in a room with a computer so you can still have contact with the outside world. I'm hearing lots of creative things that people are doing, you know, zoom coffee hours, going to art

galleries online and things, so you don't go bananas. But I do think that it's really important for people to take this seriously, especially if you live with old people or anyone who's immuno compromised. Well, I think probably everybody would take it seriously if they had a positive diagnosis.

The real question, I think is for people who don't have that and are just sort of at home under self quarantine or because there's a broad shelter in place order in effect, the question that is how precise they should be. I mean that it's not recommended that those people self isolate. That's only if you are confident or you think it's a high probability that you have the virus. Right, yes, So, just to be clear, Shelter in place is different than

self isolation. Shelter in place is saying stay in your home and share your germs with your family or the people that you live with, but don't go outside and share it with other people. Sort of keep your germs to your little group. It doesn't matter whether it's you and your family, or it's you and your roommates or the other people who live in a group house with you.

You're going to share. You're going to share germs with those people in an ordinary shelter in place, right, I mean the ideas, try to be a little more cognizant, don't share spoons and forks and things, and wash your hands a lot. But recognizing that it's impossible for people to completely isolate. That being said, if you have symptoms, act like you have the virus. It doesn't matter whether or not you have a positive test. We don't currently

have testing capacity, So people should take this seriously. If you aren't feeling well, isolate yourself from the other people that you live with, and how long should you do that before? I mean, again, this is something that I think has not really fully trickled down to the general listener yet. It certainly hasn't to me. So if you have flu like symptoms or cold like symptoms and your self diagnosis is like, I don't know if I have coronavirus.

I didn't go to medical school, but I'm feeling lousy. Your recommendation is go into self isolation as though you had the virus, correct, And the recommendations are to do that for fourteen days. I think if you start feeling better after it or two, it's probably not coronavirus, and so you can feel better about coming out of isolation. But you know, better safe than sorry. But is that true that if it's coronavirus it's not going to go away that quickly. I mean, what if you just had

a very mild case of coronavirus. I mean, it's a great question. I think in the end it's a little bit hard to know. But those are the recommendations that occupational health is giving us at this time. I think what's hard with coronavirus is there are plenty of people who are asymptomatic who have coronavirus. So I think that's where the overlap of public health and medicine happens. So

public health is keeping people from spreading it to others. Right, most of us are going to get coronavirus and do fine. Some people are not going to do fine, and so what we're trying to do is protect those people. And so my recommendation to the public would be take this seriously, like, don't go out with friends, stay at home, really try to limit your interactions with other people. I think that's just good practice, whether or not you have a cough

or anything else. We'll be back in just a moment. What's the scene like at UCSF at your hospital right now? Is it? You know, I'm sure you're preparing like crazy for things to get out of hand. Where are things right now in that process? I mean, actually we're still in the sort of preparing and waiting, the waiting period rather than the storm that we worry is coming. So you know, the hospital has enacted our disaster plans in

terms of canceling elective procedures. So if you were supposed to get a hip or a knee replacement, we have canceled those procedures things like that to create openings for patients in case other patients gets sick. It turns out a lot of the people who are in the hospital are here for somewhat routine electives, and so by stopping those procedures, you open up a lot of space within the hospital. So actually our censuses are a little bit

down right now here at UCSF. At least as of last night, we only had two patients in the intensive care unit with COVID and none at either of our outlying hospitals. So that's great news, and we hope it will continue like that, but we worry that it will be getting busier. We are upstaffing respiratory urgent care clinics, upstaffing our emergency room, and working with across departments to

upstaff our intensive care units to be ready. I understand that at your hospital, then you're postponing surgery that's technically elective. Should patients proactively, let's say they're not in San Francisco where their hospitals are yet doing the suspension on their own.

Should patients themselves be trying to judge, Gee, if this is elective surgery in the sense that I don't need it right away, I should delay it, partly out of public service to free up hospital beds, or partly because they don't want to be in hospitals because that's where

sick people are. I think that's reasonable. Frankly, I think most hospitals are going to be moving this way, So it's more a question of whether you're going to postpone your procedure before they start postponing procedures, or whether they'll reach out to you. And what about things that the

hospitals are short on? I mean, are there things where ucsfsaid publicly, you know, like we need more ventilators or we don't have subsion in protective gear or are you, guys, because you're sort of at the front end of this and you're also a first class hospital, are you pretty well prepared in those regards? I would say both of those things. We are well prepared, and we are worried about shortages. So we currently have enough protective gear, but there is concern that we have, you know, a few

weeks worth of protective gear on hand. And so another public health thing that people can do is not do things like hoard and ninety five masks at home. You don't need those people who are intibating people with COVID need those. You're doing senior administrative work in this moment. And so I'm wondering what's the tone like in the meetings? I mean, are people managing to sound as calm, cool

and collected as they sound all the time. I mean, I know doctors are all one of the things you train people and is to stay calm in situations where normal people would be freaking out. Is that sort of how it's operating in the meetings. Are there are people exaggerating their calmness in order to seem calmer or is it sort of business as usual in some sense? It's not business as usual in the sense that people are really working together in a way that I think is

actually really admirable. So, you know, UCSF is a big, sprawling place with a bureaucracy like any big sprawling institution, and I've been really impressed with how things that previously would have taken a year to roll out or years to roll out or rolling out in days because people are really working together. So, for example, telemedicine, we had very small percentage of our outpatient visits we're being done

by video visit. And then a week and a half ago, when we had our first sort of disaster planning full day retreat, it was decided that telemedicine should convert like fifty percent of our ambulatory visits in a matter of days. And now we're converting almost one hundred percent of our

visits to video visits. And that has happened that kind of huge change in a complex bureaucracy is usually really hard to maneuver, and so I've been super impressed with how people are coming together across the organization to make these things happen. So every day now within my residency, we have a daily planning huddle where we meet for thirty minutes and kind of plan out what needs to

change next. And then in a hospital level, those are happening, and then we have a special workforce one where we think about how are we going to deploy nurses, what do we do with people who are on home furlough, how can we help them be useful and help while they're in quarantine. So the amount of cross pollination between human resources and nursing and the physicians and the administration has really been amazing. So I wouldn't say that it has been business as usual. I would say it's been

better than usual. And I think while everyone is stressed, people are really working together in a really positive way. That's actually extremely heartening and it's exactly what you know. You fantasize life is like inside of a big hospital and when everyone's preparing for a crisis, But I know that in other areas of life, our fantasies of the way the planning is supposed to go doesn't always bear itself out, So it's nice to hear that that's actually happening.

Can I ask just a broader question for those of us who are not in San Francisco, which is most of us right now. San Francisco is presumably a harbinger of what it's going to be like for us. So what's it like when you get up and come to work every day? Given the shelter in place order? How many cars are on the road? I mean, I know there are lots of people who are exempted from the order, people like you healthcare workers, but also the people who

are doing food service work. And I notice even the biotech workers are exempted under the presumably are people on the streets, So there are still people on the streets. I mean, people are trying to work from home. So I'm here at the hospital today and I was in clinic yesterday, but the day before I did work from home,

which I wouldn't usually never do. So I do think even amongst the people who are exempted, people are trying to kind of honor the idea of self sheltern place when they can, but when you go on the street, you do still see some people. I mean, it's a city, right, So the restaurants still have takeout, you'll see people walk up to the door to get it. People love exercise in San Francisco, and you are still allowed to go out and exercise as long as you keep six feet

between you and others. And Golden Cape Park was still filled with people running and biking yesterday, So it doesn't actually feel like a desolate wasteland. It feels like a quiet day in the city when there's sort of fewer people, a little bit like Boston feels in the summertime when all of the college kids leave. Speaking of kids, your kids are not college age, But what are you telling your kids and how are they how are they relating to it all? I mean they're not usual kids. They

have two physician parents. But nevertheless, I'm curious to know. So my kids are little, they're four, six, and eight, and we have been pretty consistent in the messaging that we're doing all of these things to keep old people safe. We really don't want them to worry about themselves, because frankly, kids do great in this, which is a parent I find really reassuring, and I don't want them worrying about me going to the hospital every day. Yeah, that's good.

By the way, I heard, I heard the siren of the background. And you know, ordinarily, when when we're doing a podcast, we you know, we stop, we rerecord, we don't hear those kinds of sounds. But the truth is that that's the actual world where you are. You are in the hospital, and those are real sirens, and I think it's part of the part of the reality of the moment. I just conclude, rebect, because I want to be respectful of your time and I want you to

go back to actually saving people. What is there that you think people in the medical profession understand and know right now that is not getting communicated to the general public. I mean, I asked all the questions that I could think of immediate things that you know that the rest of us don't know. But I'm wondering, is there something else that I should be asking you that I'm not. I mean, I think that two things are I would

really like to see people taking this more seriously. I was pretty distressed by seeing pictures of like spring breakers in Daytona Beach. If we don't all take this seriously. This is going to last much longer, and so my hope is that even if your city has not formally placed you in shelter and place, that people will take

this seriously and will start self isolating. Rebecca, I just want to thank you for what you're doing now in this effort, and for spending time with us, and for what you're doing every day even when there's no pandemic in the offing, and wish you and your family and your residence and staff very well in the challenging time to come. Thanks so much. It was nice talking to you.

I found that a tremendously useful conversation. Doctor Berman really told us what we should and shouldn't be worried about. And one of the things that I realized is that a lot of the information that's circulating out there about what symptoms you should or shouldn't be concerned about is actually inaccurate, not up to date, and not statistically sound.

I also realized that there are many many people who might be sick and even have corona, who nevertheless probably shouldn't go to the hospital if they're not too sick, and that I think is a very important takeaway that I had not taken on board myself, and I think is very valuable for public health purposes. We're going to continue covering Corona with new and special episodes to keep you up to date on the most important issues behind

the stories associated with Corona. In the meantime, if you're at home, as you probably should be, be well, be safe, take care of yourself and of others. Deep Background is brought to you by Pushkin Industries. Our producer is Lydia gene Coott, with studio recording by Joseph Fridman and mastering by Jason Gambrell and Martin Gonzalez. Our showrunner is Sophie McKibben. Our theme music is composed by Luis GERA special thanks to the Pushkin Brass, Malcolm Godwell, Jacob Weisberg, and Mia Lobel.

I'm Noah Feld. I also write a column for Bloomberg Opinion, which you can find at Bloomberg dot com backslash Feld. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com Backslash Podcasts. You can follow me on Twitter at Noah Arfeld. This is Deep Background.