, chief of infectious diseases at in Teaneck, New Jersey, doesn't wait the several days needed for COVID-19 test results to come back.
"That takes too long," Saggar told 鶹ý. "If it looks like [COVID-19] ... we go ahead and treat it."
Holy Name is at the epicenter of New Jersey's COVID-19 outbreak. As of Tuesday, the hospital had 38 cases, including eight in the intensive care unit.
Saggar said the age of patients with severe disease is skewing younger than in China, with patients in their 30s and 40s being hospitalized. The youngest ICU patient is 28; the oldest is 89, but seemed to be doing the best and was likely to be extubated, he said.
Three of those patients in the ICU are medical center employees -- not clinicians -- who likely acquired it in the community.
"It's beyond overwhelming," Saggar said. "And it's just a harbinger of things to come."
Testing Unreliable
Saggar said the slow turnaround for tests, paired with low sensitivity as documented in Chinese data, makes them less useful.
"There were a lot of false negatives [in China], especially early on in asymptomatic patients," Saggar said. "It gives a false sense of security."
The Chinese realized early on that the sensitivity wasn't good, he said, so they would add on a CT scan to diagnose the disease. But that's not practical because the machines have to be shut down for cleaning after each case.
Instead, Saggar and his teams rely on the symptom "triad" -- fever, cough, and shortness of breath -- to guide diagnosis. They also use chest X-rays and other lab markers -- leukopenia, lymphopenia, monocytosis, transaminitis, elevated C-reactive protein, normal procalcitonin -- to determine whether a patient has COVID-19. Elevated d-dimer may be particularly predictive of who might have respiratory failure, Saggar said.
They also do rapid testing for other respiratory illnesses, and co-infection seems to be low at this time: "If it comes back as influenza B or parainfluenza, we'll say, okay, that's what it is."
The problem is that COVID-19 symptoms can be very varied, he said.
Gastrointestinal symptoms, for instance, can precede pulmonary symptoms. In one case, a patient was initially suspected to have food-related illness, but Saggar felt the time period that had elapsed was too long. He immediately isolated the patient as COVID-19, "and slowly but surely he became more hypoxic, and was ultimately intubated and ultimately tested positive."
This was just before data came out of China indicating the presence of GI symptoms in COVID-19, Saggar said.
Patient Mix
About 80% of Holy Name's patients are male, similar to what was seen in China, Saggar said.
Given the unexpected young age of patients with more severe disease, Saggar and his team looked for other trends, observing that central or morbid obesity seemed to indicate worse disease course, including the need for mechanical ventilation.
"Obesity could be an issue because if they're more likely to have sleep apnea, they may aspirate the virus and it makes it into the lungs," he said.
Disease course is still unpredictable. Saggar noted that in some cases, patients seem to start improving, but then take a turn for the worse, "and when they go south, it's relatively quick."
"They go from 2-, 3-, 4-liter nasal cannula to 50% venturi mask to high-flow oxygenation to 100% non-rebreather mask to BiPAP, then we just say we have to intubate them," Saggar said. "That usually happens within 24 hours. And it's a prolonged course of mechanical ventilation, more than 5 days."
"These are healthy people who need to be intubated for quite some time," he added.
Other Treatments
Treatment protocols have been shifting, Saggar said.
Many of the severe cases have been treated with the antiviral lopinavir/ritonavir (Kaletra), but "we're not seeing great results with Kaletra," he told 鶹ý -- just before a published Wednesday showed it was ineffective in a randomized trial.
"So we're looking at chloroquine and zinc plus vitamin C," Saggar said, explaining that there's a synergistic relationship between the anti-malarial drug and zinc, and vitamin C can be helpful for its anti-inflammatory properties.
In some cases they've also opted for the . While getting the drug has been relatively quick, he said, there's a narrow window for using it -- patients need to be "sick but not too sick." That means they have to be intubated or on extra corporeal membrane oxygenation (ECMO), but they can't have multi-organ dysfunction.
There's been some talk about using the flu treatment oseltamivir (Tamiflu), and for those who develop acute respiratory distress syndrome due to cytokine storm, the anti-IL-6 drug tocilizumab (Actemra) may be considered.
Prone ventilation and using fluticasone (Flovent) or a phosphodiesterase-4 inhibitor to dilate the lungs for better aeration are also under consideration, he said.
He and his team are being cautious about using NSAIDs because there's been some suggestion -- albeit controversial -- that these may prompt overexpression of ACE2 receptors, which the virus uses to enter the cell. Thus, the team doesn't treat fevers unless they get dangerously high.
'What If I Bring it Home?'
Though Saggar said the hospital has been preparing for COVID-19 since January, taking steps to boost surge capacity, dealing with the stress and anxiety is a difficult part of the job.
While healthcare workers across the country are reporting shortages of personal protective equipment (PPE) like masks and gloves, Saggar says his hospital has enough for now -- but they are planning for contingencies. Perhaps not every specialty needs to go into a patient's room; N95 respirators may be able to be reused.
"The federal government isn't giving us a lot of confidence that we'll have access to PPE for the long-term," Saggar said.
Personally, the toll is high. When Saggar returns home each night, he leaves his hospital clothes in the garage and showers before he interacts with his wife and son. He self-monitors his symptoms and tries to stay as healthy as possible.
"There's some degree of dread, anxiety, depression, fear, guilt -- what if I bring it home?" Saggar said. "It's unlike anything I've ever faced."