Perspective

‘We have had a lot of deaths’

Physicians weigh in on the severity of cases in the third wave

Just several weeks in, the country’s third wave is making a deadly mark.

There were 11 COVID-19 deaths declared for the month of April, based on the latest daily report from the Ministry of Health.

Twelve deaths were declared for March when cases began to spike, and when variant mutations were first detected in samples tested locally.

Another four deaths were reclassified from non-COVID deaths to COVID-related deaths as per the ministry’s May 1 report, but no information was provided in that report on when and where those deaths occurred, and on the age and sex of the deceased.

According to internal medicine specialist and senior registrar at Grand Bahama’s Rand Memorial Hospital Dr. Odia Stubbs, the third wave is bringing with it more COVID deaths on the island than in the previous outbreaks.

In an interview with Perspective last week, Stubbs said, “We have more deaths in this third wave here in Grand Bahama. The patients would come in not so bad, but they would deteriorate very quickly compared to the other waves.

“We have had a lot of deaths in the past couple of weeks compared to before, and we have had many Intensive Care Unit (ICU) admissions, patients we have had to intubate, and those who were airlifted.

“They will come in with oxygen saturations of 91 or 92, and then it will go down to 88 and you will be thinking one day that they are fine, and in the next two days, we have to step them up to the critical area.”

Over the past several weeks, Perspective has learned of several COVID-19 positive patients on Grand Bahama – some who have since passed away – who were admitted to the island’s ICU, but the daily dashboard issued by the Ministry of Health has not listed any ICU admissions for the island.

Thus far, the ministry has reported two confirmed Grand Bahama COVID deaths for the month of April.

Yesterday, it confirmed a total of six Grand Bahama COVID deaths previously under investigation; one in April, four in March and one in February.

Dr. Stubbs disclosed that in addition to a higher incidence of deaths being observed, the internal medicine team is also observing a higher incidence of acute kidney damage in the third wave.

She noted, “We saw a few people who ended up on dialysis. They had acute kidney injury because of rhabdomyolysis, and they ended up needing hemodialysis, which is different from the first wave.

“We had one person earlier on who that happened to, but this time it is more frequent.”

A life threatening condition, rhabdomyolysis is the breakdown of skeletal muscle leading to the release of the muscle’s contents into the bloodstream, which can create complications including kidney failure.

Rhabdomyolysis has a number of causes including infection, and though there is limited literature at this time on rhabdomyolysis induced by COVID-19, there have been reports of the condition in COVID patients in other countries.

Stubbs said none of the patients had a prior history of chronic kidney failure, and those who had diabetes or hypertension often first learned of their comorbidities when they sought medical attention for symptoms, most notably fatigue.

The specialist, who sees all admitted COVID-19 patients in public health on Grand Bahama, pointed out that while older residents are more likely to seek medical care for worrisome symptoms, younger residents are troublingly opting to manage their symptoms at home.

She added that those who do seek medical attention for worrisome symptoms are sometimes in a worse medical state than they recognize.

Stubbs explained, “People may come in moderately symptomatic, and we look for an oxygen saturation between 95 to 100. When patients come with saturations like 93 or 92, we are not comfortable with that.

“They might be mildly to moderately ill, but they are more severe than they think they are based on our examination.”

Those examinations, she indicated, would include chest x-rays that show lung damage, and acute respiratory distress syndrome continues to be the most prevalent of serious COVID-19 complications.

Stubbs shared, “To be honest with you, in this community in Grand Bahama, the patients do not like to come to the Rand. There was a [COVID-positive] gentleman who was very ill, young in his 40s, who refused to come in.

“If you start to get short of breath with moderate activity, get to the hospital. We will preach this over and over, but the younger people will not come. A lot of the young people feel they can do this on their own. The older people will come in because they feel sick and they are scared.

“When the younger people do come in, sometimes it is a little too late.”

Younger patients being admitted to hospital

Cardiothoracic surgeon and consultant physician at Princess Margaret Hospital (PMH) Dr. Duane Sands sees who he describes as “the sickest” of COVID-19 patients, such as those who require surgical interventions and dialysis support.

Those surgical interventions include extracorporeal membrane oxygenation (ECMO) – a critical care therapy where blood is pumped outside the body to a heart-lung machine that removes carbon dioxide, and sends oxygen-filled blood back to tissues in the body.

Sands disclosed that three patients have been placed on ECMO in the third wave thus far.

Data recently provided by the ministry points to younger people in The Bahamas between the ages of 40 and 59, dying of COVID-19 than in previous waves.

For the month of April, the COVID-related death of a 37-year-old New Providence female and a 45-year-old male of Bimini, were confirmed.

Sands said, “We are certainly seeing younger people – even children – presenting to hospital for admission, some in their 20s, some in their 30s, some in their 40s, and I think that is probably different from the last time.”

He pointed out that at least five patients between the ages of 25 and 39 were admitted to hospital last week, and disclosed that some of the younger patients seen in the third wave have no comorbidities.

Countries including the United States, Brazil and India are reporting a marked rise in young people developing severe illness from COVID-19 this year, many with no pre-existing medical conditions.

Though experts say the reasons for this are currently unclear, early research suggests that variants could cause those who are infected to have more of the virus in their body than exists in those infected with the original virus.

‘Third wave could be worse than the second’

Of the exponential spread of the virus in the third wave, Sands argued, “It can’t be that I am the only doctor who is getting multiple inquiries every day about family members, loved ones, friends with signs and symptoms of COVID, or documented with COVID who are being admitted. It is certainly increasing.

“In my personal practice we have seen a number of deaths recently, and we just wait for them to show up on the dashboard. I don’t know what the process is. It is supposed to be a process whereby I guess the case is reviewed, and then a determination is made that this is a COVID death or non-COVID death, and I don’t know how long that process takes.

“But certainly, we are aware of a death of someone who clearly died of COVID, and it would be a while before it shows up on the dashboard.”

Prior to April, there were 15 deaths under investigation that had not been classified since last year, with no explanation from ministry officials as to why the deaths remain unclassified.

Throughout the third wave, ICU admissions for New Providence have been reported only at Doctors Hospital on the ministry’s dashboard.

Those in ICU have been listed at four, falling briefly to three, and rising to five late last week.

All other hospitalized patients in New Providence have been listed as moderately ill.

When asked about the prevalence of seriously or critically ill COVID patients, the former minister of health noted, “There are people in PMH that are on ventilators, and by all intents and purposes they are not moderately ill, they are seriously or critically ill.

“So I think it’s a matter of semantics or definitions, and as we seek to make these dashboards more informative, and we have changed them many times since this pandemic started, it might be a helpful thing to refine that classification.”

Sands is of the view that the country’s third wave could be worse than the second.

When questioned on his rationale, he pointed to the impact of suspected variants, adding, “we have lost a number of our team members, specifically we have lost nurses to either resignation, retirement or death, and so you are trying to fight a battle with less human resources.”

With Dr. Stubbs’ observation that the incidence of COVID-19 deaths in patients on Grand Bahama has increased, and that more patients are deteriorating at a faster rate, we questioned Sands on what this could mean in terms of the strains that could be in circulation.

He opined, “We have more experience and so if you think about it, there’s an offset in morbidity and mortality based on the accrued experience of the teams. In the first wave, we were discovering this thing, in the second wave we refined some of those skills.

“Now you have a pretty seasoned team that is pretty experienced with the management of COVID and despite that, you have some people going on to death or major complications even with the advanced therapies, better diagnosis, and better teams.

“So what does that mean? Maybe we are dealing with a more lethal or aggressive disease.”

Continuing, Sands explained, “Bear in mind that we have more therapeutic options now than we did in the second wave. We have monoclonal antibodies, we have Remdesivir, we have dexamethasone.

“We don’t have the type of monoclonal antibodies that the [former] United States president received, and some of them are only useful in people who are not admitted to hospital and who are not on oxygen, so they have to be given very early.”

The White House advised last year that former US president Donald Trump received monoclonal antibodies developed by drug maker Regeneron to treat his COVID-19 infection, in addition to several other drugs, including zinc and vitamin D.

The US Food and Drug Administration (FDA) states that monoclonal antibodies are laboratory-made proteins that mimic the immune system’s ability to fight off harmful pathogens.

Sands said, “Some of those therapies we do not have and cannot get, not because we haven’t tried, because the companies won’t sell them to us, or they won’t allow us to import it.

“They are restricted to the United States, in the specific instance when we tried.”

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