• Russell Hill

False Negatives and True Recovery

Updated: Apr 20

She looked me in the eyes and asked quietly, “Dr Hill, am I going to be OK?” 

Eyes can communicate plenty on their own without words or any other facial expressions. Fear most of all. A facemask covered most of her face, except her dark eyes said all that I needed to see.  Apprehension about whether she was going to survive. I stared back with my N95 mask hiding my encouraging smile and a bulky helmet with plastic visor over my head. I placed a gloved hand on her shoulders. 

“You are going to be fine. You are right where you need to be.” my earnest reply slightly muffled as it reverberated inside the mask and helmet.  

I firmly believe it's these brief moments of raw humanity that create both a rift and a resolve in any physician's soul.  A resolve to keep caring for people at their most vulnerable, and to give them hope for the best outcome. Yet a rift knowing a thousand variables are beyond our control when and our minds continually plan for the worst. I have seen the look of trepidation on patients and family members a thousand times as I explain the game plan before a simple procedure, a routine surgery, or even an admission to the ICU. Almost without fail I can tell that my calm transfers just enough to ease some of their fears. 

Priscilla’s illness unfolded alarmingly if not predictably in the early weeks of the COVID pandemic’s percolation in our hospital system. A female in her 20s who started feeling symptoms over a week before she ever sought medical treatment.  Her first visit to the emergency department on the same day her results from a drive-thru screen came back negative . Today she felt more short of breath, but didn’t have a cough or a fever.  

On that first visit her X-ray showed pneumonia, but not one typical of COVID.  Most reassuring her oxygen saturation levels were good. She had been started on Azithromycin that same day. After initial treatment she was up walking, talking, laughing; a sure sign she was stable to be discharged home with a suspicion of a COVID infection, and instructions to quarantine.

As I do with every patient that I see I reminded her that if symptoms changed or got worse to come back to the hospital.

She came back the next night, and all of those signs I had used to reassure myself and here had changed for the worse. She came in by ambulance, she needed oxygen to keep her saturation levels up, she was breathing faster, and her x-ray findings were now present in both lungs.  Despite her negative test a week before this was textbook of a COVID patient deteriorating rapidly. Except there is no textbook. The text available for thousands of doctors around the country on the front lines are printed in facebook group posts, tweets, and the daily amended CDC website. 

Her negative test came from an outpatient drive-thru screening location. It was early in her sickness, likely when the number of viral particles were very low or the screening test was insufficient or both.  It didn’t matter that her test was negative. She was classic for an illness that was ravaging the lungs of an otherwise mostly healthy 22 year old.

That night I messaged with our hospital pathologist about the capability of our tests to give us a negative result when the disease is present, a false negative.  We discussed the limitations, and timing of the screening exam and where the pitfalls could occur. 

Currently a rapid test that gives results in 13 minutes developed by Abbott Laboratories, approved by the FDA, and shipped out to test half a million people is finding a significantly high false negative test results. Independent validation finds that it depends heavily on the solution a swab is placed in after collection. This is one example, among hundreds of individual testing brands, but has already been used on thousands of people.  What will be uncovered after rushed antibody testing, tests used to determine if someone has built up immunity to a disease, acquires approval and yet has similar limitations?

I admitted her to one of our most trusted hospitalists and we decided to start controversial and unproven medicine.  I relayed that for now her oxygen levels were fair, but I correctly predicted that she would need to be placed on a ventilator within the next 24 hours.

She was in the right place, in fact, there was no better place for her to be than in our community hospital.   The ivory towers of the Mayo Clinic or Johns Hopkins do not have a better grasp on how to treat the severe lung disease that the virus triggers. The same protocols and treatments available to oxygenate, ventilate, and protect the lungs are all we have to rely on.

Pricilla is still in critical condition and on a ventilator 10 days later, but is showing signs of improvement.  Much like our country and the world, recovery contains many unknowns, likely setbacks, and an unpredictable timeline. 

We are still navigating an uneven path that will lead us to readjustment.  Treatment options, antibody testing, and an eventual vaccine all have early signs of progress, but in a timeframe beyond just our day to day perspective.  In the coming days restrictions will lift even as the fear lingers, slowly replaced by a hope we will come out better.

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