April 3, 2020 -- A little over 3 weeks ago, Emory University Hospital emergency room doctor Justin Schrager, MD, was living at home with his wife and two young children, awaiting the birth of their third child.
Slowly, his ER began to fill with patients who had COVID-19, the disease caused by the new coronavirus. “I work in the area with the semi-critical patients, the ones that need higher-level care. I haven’t to my knowledge been exposed … but I’m sure I have been, because it’s been pretty wild.”
Once his wife had their baby, they made the difficult decision for him to isolate himself in a garage apartment for the foreseeable future. “I just didn’t feel like it was safe for me to be around a newborn … the data [on newborns and the coronavirus] is so sparse, I just didn’t feel comfortable,” says Schrager.
His wife, Rachel Patzer, PhD, an epidemiologist at Emory, tweeted about the heart-wrenching decision, only to have her tweet about the family’s struggles go “viral” when former President Barack Obama then retweeted her thread. Obama encouraged all Americans to thank front-line staff and show appreciation for their sacrifice by practicing social distancing.
In the 3 weeks since his “exile,” Schrager says he has been working nonstop to help patients struggling with life in a world with COVID-19. He works not only on the front lines in the ER, but as part of a team that’s created an online, globally accessible tool, C19check, that they hope will help calm patients who are worried about milder symptoms and help make emergency rooms less crowded.
A Surge of Cases
As cases surge in the U.S., ERs are being flooded with many people who are well, but worried about upper respiratory symptoms, Schrager says. The goal of his tool, and others like it, is to help people “self-triage,” find out if their symptoms may by consistent with COVID-19, and to help them feel comfortable managing at home, based on how severe their illness is.
According to Schrager, “The idea is that we decrease surge on the health care system. … If the ER becomes overwhelmed, then everything starts falling apart.”
Limited Tests, but Wide-Ranging Symptoms
Emory’s symptom checker is one of many now available to help people manage the uncertainty of their illnesses, including some developed by front-line doctors like Schrager.
Without widespread testing, many patients with mild and nonspecific symptoms are left to wonder if they have COVID-19 and what they should do. The symptoms really could feel like anything from a cold, to the flu, to allergies as reports come out of people with pinkeye, sore throat, a headache, loss of smell and taste, fatigue, body aches, diarrhea, and nausea, along with the fever, dry cough, and shortness of breath that are more commonly linked to the disease.
As more and more information about symptoms comes out, it’s easy to see why patients would be confused and unsure if they have COVID-19 or something else. About 25%-30% of people have mild symptoms, and in some cases no symptoms at all. “It’s hard to tell anyone that they definitely don’t have it, so the next best thing is to help reassure people about when they should go to the [emergency department] or seek medical care,” Schrager says.
Elizabeth Baynes, a 36-year-old social worker in Atlanta, understands this unease. As allergy season heightens in Atlanta -- where everything is covered in a sheen of green pollen -- it’s hard to know what’s going on. She’s looked online and tried a COVID-19 symptom checker. She reports that it helped calm her fears. “I wasn’t having any of the most worrisome symptoms, so that helped me feel better. … I’m just going to keep doing what I’m doing and stay home.”
But symptom checkers are not foolproof. Some users report that it can be hard for the checker’s algorithms to distinguish between allergies, flu, and other illnesses.
Doctors at the Front Lines of Triage Tools
Emory’s C19check asks about symptoms, high-risk conditions, and how severe your illness is. Then, the tool recommends the best place to care for symptoms -- from isolation and self-care at home to emergency care -- and provides CDC resources to learn more. As new COVID-19 symptoms are identified and published, Schrager’s team works constantly to update the tool with new symptoms.
Five days after going live, their tool served 400,000 people in almost every country in the world. It’s now available in 13 languages, with plans to expand to many more. The educational messaging in the U.S. aligns with recommendations from the CDC, but it can be customized to those from the World Health Organization or local public health agencies. “Our goal is to serve patients anywhere the virus is,” Schrager says. There is also an SMS feature that would text people regularly and follow their symptoms over time that the company may activate in the future.
Bhargav Raman, MD, co-founder of CoolQuit, has also used his work to help with the COVID-19 crisis. CoolQuit began as an online telehealth company aimed at helping people quit smoking, but the focus has shifted to screening patients for COVID-19 and recommending where to seek care and testing if needed.
“We decided to use our telehealth infrastructure to help with the pandemic, specifically to do screening evaluations to keep people from crowding urgent cares and ERs and potentially exposing themselves unnecessarily if they are low-risk,” Raman says.
More than 1,000 people requested to be screened in the 2 weeks that they began their coronavirus work in California, Texas, and Florida. According to internal data, 98% of their patients had mild symptoms but were thinking of going to urgent care or the ER before their telehealth visit. Instead, patients were educated about self-isolation, given prescriptions for symptomatic relief, and encouraged to stay home and monitor their symptoms.
Though they bill insurance where they can, Raman says, “all patients have been seen free of charge.”
“Obviously, this is not a sustainable business practice, but we all feel strongly that during a time of emergency such as with the coronavirus pandemic, we all have to make sacrifices for the greater good of our patients and our country. … This service we provide helps significantly reduce the burden on our health care system, saving PPE [personal protective equipment], protecting doctors, and protecting patients,” he says.
More Tools You Can Use
The CDC also launched a COVID-19 symptom checker. The chat bot experience (built on Microsoft’s Healthcare Bot service platform) can be found on its website and is called the Coronavirus Self-Checker. Like several other tools, it allows the user to check off from a list of symptoms that could be related, other health problems, severity of illness, and risk factors for having come in contact with someone who may have COVID-19.
For most people without red-flag symptoms, like shortness of breath, or life-threatening symptoms from other conditions, like severe chest pain, severe dizziness, or seizures, the recommendations are mostly for self-care at home or calling your doctor for more information.
On March 27, Apple unveiled a COVID-19 website and app with a screening tool and resources to help people protect their health during the COVID-19 pandemic. These tools were created in partnership with the CDC, the White House Coronavirus Task Force, and the Federal Emergency Management Agency (FEMA).
This tool joins others from Google and Amazon that provide similar services.
No Real End in Sight
None of the tools are intended to replace medical care. At a time when there is very limited capacity in hospitals and extremely limited testing for COVID-19, those who report mild symptoms, with no red flags, are being advised to self-isolate and to monitor for worsening illness.
Krista Pine, MD, a psychiatrist in Richmond, VA, has been volunteering her time to support doctors who are also mothers by providing mental health treatment. She agrees with the basic premise of providing patients with these types of tools. “Feeling in control helps a person alleviate anxiety and stress. If [people] feel they are ‘doing something’ like monitoring symptoms and following basic advice, and ‘doing their part for society,’ it is protective against panic.” She cautions that people should only use validated tools from trusted institutions.
For Schrager, it’s all about “flattening the curve ... but even then nobody knows when it’s going to end.”
“I get to kick the ball around with them … but that’s about it,” Schrager says of his children, wistfully. “We just don’t know when this is going to end. … It’s been a crazy 3 weeks. … I just want out of my garage. [That was] … the deal I made with my wife when I moved out here. … I had to do whatever I could to get back in the house.”