Interview with Cihan Çelik: “The flattening new infection curve is deceptive”

Doctor Çelik, we talk regularly about your work as a senior physician in the isolation ward for Covid-19 patients at the Darmstadt Clinic. You told us about your own Covid disease three weeks ago. How have you been since then?

After I was released from the hospital, I had to isolate myself at home for ten days. That was an exhausting time in a confined space, I was still weakened from my stay in the intensive care unit. It was difficult to get the cycle going. After the isolation was over, I had a few days for a gentle fitness program and long walks. The biggest complaints were gone. I was able to go back to work the following week. But I still have minor complaints, such as pain in my ribs. I’ve had very severe coughing fits and it takes a long time before a bruised rib is no longer painful. Overall, I’m fine. I’m going to have another x-ray of my lungs soon to make sure there are no leftovers from the pneumonia.

You had a bacterial superinfection in your lungs due to Covid-19. How does that happen?

Proof of the responsible germ is rarely successful, and that didn’t work for me either. If antibiotic therapy is initiated immediately, the germ can usually no longer be detected. In most cases, however, this is not a bacterium that you also catch. With a Covid disease, the whole immune system is severely weakened, so you are more susceptible to infections from other pathogens. In addition, the immune defense is weakened locally in the lungs. So-called opportunistic germs, which we always carry around with us, can then spread in the lungs. It was probably such an opportunistic bacterial inflammation in me. This is a common complication, but it usually doesn’t appear until later in the course of Covid-19. Many people are familiar with the principle of infections of the upper respiratory tract: a cold is often caused by a virus, if a bacterial infection subsequently settles on it, the doctor prescribes an antibiotic.

Was the hygiene concept revised in the clinic after your illness?

The hygiene concept is in place. But we have all become more cautious. Colleagues are even more aware of the fact that they keep their distances from one another and have separate break times and that not too many people come together during meetings. If you work a lot together, at some point you have the feeling of being a household. We are now very cautious because there are also more infections among nurses and doctors, often of course in private life too. This cannot be avoided with such high numbers of infections, but it presents us with additional challenges.

You’re probably immune now. Can you work more relaxed?

I act just like everyone else. I should have antibodies, but haven’t been tested for them yet. In addition, we do not want a two-class society of immune and non-immune. That applies outside and in the hospital.

What was the situation like in the clinic when you got back to work?

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Covid doctor fell ill with Covid: “It left traces”

Doctor Çelik, since the beginning of May you have regularly reported to us about your work as a senior physician in the isolation ward for Covid-19 patients at the Darmstadt Clinic. Two weeks ago you tested positive yourself. How are you?

I am recovering from the rigors of intensive therapy and hospitalization. That doesn’t leave you without a trace. I still feel weak, my circulation is causing problems. Because of the domestic isolation, I can’t get him going by taking walks. And of course I listen deeply to myself, precisely because I know what to look out for. Overall, however, I feel much better. I have had great sympathy and friends and family who look after me very well.

How did your illness start?

Two weeks ago, on the night from Friday to Saturday, I got such a severe headache that I woke up from it, which is very atypical, also for Covid. Nevertheless, I was very irritated – also knowing that I had a risk encounter the week before due to a medical emergency on the ward. That’s why I paid more attention to symptoms than usual. I got attacks of fever that night, and the next day I tested positive.

Are you sure you got infected in the hospital?

I can’t say one hundred percent. But there is no cluster in the private sphere, and I hardly had any private contacts. I had regular contact with the Covid patients, so that makes sense. But the fact that I was the only one who got infected on our ward indicates that there is no systematic hygiene failure. If so, it was a punctual, unfortunate situation. If you work with seriously ill patients in a Covid ward, situations can arise in which the hygiene standard and self-protection suffer from the fact that things have to be done quickly or very precisely. For example, foggy glasses prevent you from making a precise incision to draw fluid from the area around your lungs. Then you cannot use these glasses for a short time. This is an example that many colleagues from Covid stations are sure to know. If the patient coughs at that moment, then you have to be careful and, if in doubt, get tested.

What happened after you tested positive?

In the course of my illness, many things were very atypical. I am 34 years old, in younger people without previous illnesses this disease is more likely to be mild. But I have said it again and again: there is no guarantee that it will, the individual does not always fit into the statistics. I had to find out now. My general condition deteriorated massively within three days, I had a high fever and a cough with strong sputum. Then there was a Covid complication in my lungs, which caused my condition to deteriorate so much within a few hours that I had to go to the intensive care unit on Monday – three days after the onset of symptoms. Only one lung was effectively left for ventilation. The other lung was more or less incapacitated by a major bacterial infection. That wasn’t the typical picture of Covid lung disease, but Covid has caused a bacterial superinfection to settle on the lungs.

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“More than half of the patients were late”

Herr Doktor Çelik, we talk regularly about your work as a senior physician in the isolation ward for Covid-19 patients at the Darmstadt Clinic. What is the current situation?

As expected, there is more going on on our ward. We no longer treat non-Covid patients here, only confirmed cases and suspected cases. For that we need the whole station again. We currently have four Covid patients in the normal and four in the intensive care unit, as well as a high number of suspected cases every day. We expected this increase, it came almost exactly two weeks after the incidence – i.e. the number of new corona infections in seven days – rose here in the circles. 10 to 14 days later, the first patients with severe disease end up in the hospital. We know that if you keep a close eye on the incidence and age distribution, you can prepare well. With the current figures, the hospitals in Frankfurt will definitely be preparing for more patients to come again soon.

So many that you have to worry about capacity?

In the cities where the incidence is rising so rapidly, it is mainly young people who are infected so far. And we tend not to see them in the hospital. However, there is a risk that other age groups will soon be more affected again. Then more people would come to the hospital again. The challenge is to keep protecting the risk populations while the numbers rise. We are preparing for more suspected and positive cases, but fortunately we are still a long way from reaching the limits of our capabilities. But there is a lot more to do than three weeks ago.

Where were the patients who are now being treated by you infected?

It is a combination of the predictable and the unpredictable, which is now characteristic of Corona. The chains of infection are partly incomprehensible: We have patients who credibly assure that they actually never left their homes for fear of infection because they have previous illnesses. You may have been to the family doctor once, but they pay a lot of attention to hygiene. In any case, we are no longer in the situation that primarily affects those returning to travel. Our patients are between 40 and 85 years old, some of them had previous illnesses, some of them are young and were previously healthy. It also happens that this disease takes a very severe course in young patients. Anyone who works on such a station can confirm that.

Do the patients usually get to the hospital on time?

You don’t come as early as I would like. With Remdesivir, we currently have a drug that shows the best effect in the first five days after the onset of symptoms and severe progression. More than half of the patients who have come to us in the past few weeks have been late for remdesivir treatment. You have had symptoms for seven to ten days, then remdesivir no longer helps.

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“Remdesivir can be very helpful”

Herr Doktor Çelik, we talk regularly about your work as a senior physician in the isolation ward for Covid-19 patients at the Darmstadt Clinic. What is the current situation?

We have seen a decrease in inpatient cases over the past few weeks. We currently have two Covid-19 patients, one patient is being treated in the intensive care unit and one patient in the isolation ward. The other cases that I last reported on also had more severe courses with high oxygen requirements. Fortunately, all but one have now been released. Currently, we primarily care for patients with the usual respiratory diseases and patients who have to be inpatient isolation due to a suspected Covid-19 until the smear result is available.

Are you downsizing your isolation ward?

Exactly. We have a variable concept: We can adjust the three areas for confirmed corona cases, suspected cases and patients tested negative depending on the number of patients. We have now reduced the area for the confirmed cases. We always keep at least two beds free in the event of unexpected events. But we don’t want to have too many empty beds on the ward, we want to use our resources optimally. This means that we do not have to care for pneumology patients on unrelated wards.

How does the relaxed situation on your ward fit in with the increasing number of infections in Hessen?

I am reporting here from a single isolation ward in a mildly affected city. The number of patients does not always correlate directly with the national incidence. The situation on our ward can relax, although the number of infections is increasing nationwide at the same time. Conversely, despite the falling number of infections, there could be a chaotic situation on our ward – a local outbreak in a nursing home may be enough.

But there are proportionally less severe Covid-19 courses than at the beginning of the pandemic. Why is that?

I’m not at all surprised about that. Not only the incidence is decisive, but also the average age of the infected. The average is currently 32 years. At the beginning of the pandemic, it was 52 years. Age is very important in determining whether symptoms become severe enough to require hospital treatment. We can obviously protect the endangered groups well, I am very happy about that. I see that as a success of the social measures and the general effort.

Obesity, diabetes and high blood pressure are risk factors that can also lead to a severe course in young people, according to a study. Does that coincide with your experience?

These favorable factors for a severe course have meanwhile been clearly demonstrated in many studies. It is always questionable whether this connection can be understood on a single ward. But in this case it is very clear. Even at the time of admission, you can search directly for factors that lead to a patient under 50 having such a severe course of Covid that he has to be treated in hospital. Obesity, diabetes, or high blood pressure – one of these factors is almost always present. There are also cases in which none of these pre-existing conditions is known. But then we do research – and often these diseases have simply not been diagnosed beforehand.

Individual virologists and politicians are calling for hygiene measures to be less concerned with the number of infections than with the utilization of the hospitals. What do you make of it?

Fortunately, I don’t have to decide. If the patients ended up with us en masse, a lot would have gone wrong beforehand. The goal should be that there are as few difficult gradients as possible. I fear that if we wait too long for the measures to be imposed, we may just chase after what is happening. If we wait for hospital admissions to really increase, then in autumn we could very quickly find ourselves in a situation in which we are no longer able to act because the hospital beds are full and the intensive care capacities are exhausted. So far we have done very well with the strategy of reacting early. In my opinion we should stick to it.

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“There is a very strong social component in this disease”

Mr. Çelik, we talk every two weeks about your work as a senior physician in the isolation ward for Covid-19 patients in the Darmstadt Clinic. What is the current situation there?

The severity of the disease among patients has changed. There are fewer cases, but they are more complex. Some patients have been with us for a long time, and now need to be weaned off the ventilator or high oxygen levels by colleagues in the intensive care unit. On the one hand, these are medically difficult courses, on the other hand, there are also socially complex circumstances in our normal ward. Homelessness, for example, or other situations in which home isolation is not possible. We treated a truck driver who lives in his cab. Overall, after two months of treating Covid-19 patients, we see that there is a very strong social component in this disease. Patients who belong to minorities and are socially weak are the most affected in terms of morbidity and mortality. So they get sick relatively often and die more often from the disease. This has been shown by studies in countries such as the United States, Great Britain and Norway, and this can also be seen in the microcosm of the hospital.

Why is that?

Many socio-economic factors contribute to whether you get this disease and how severe it is. Obesity can lead to a severe course, which is a problem especially in socially weak classes, just like a lack of health education, a healthy diet, and sports. Symptoms are often only recognized later or taken seriously. Poorer people are less well connected to doctors, migrants can sometimes not describe their complaints as well in German. People live in a smaller space and work in professions in which they are exposed to many contacts. Poverty makes you sick, that’s a problem with many diseases. But Corona is currently the global focus.

Treats Covid 19 sufferers: Dr. med. Cihan Çelik in the Darmstadt Clinic

How is the number of suspected cases that you take up in the emergency room developing?

It rises. This is because the Robert Koch Institute’s swab criteria are pretty broad at the moment, so that you never miss a patient with Covid-19. People listen to themselves a lot. They come to us with symptoms that would not justify hospital admission outside of a pandemic. This makes it easier for us to detect the disease early and thus reduce the number of reproductive disorders – i.e. the number of people infected on average by an infected person. We get a lot of suspected cases, but very few of them are really tested positive. Accordingly, the workload on the ward is bearable. There are currently seven positive tested patients in the normal ward, and seven suspected. There are also six patients in the intensive care unit.

How are the patients in your ward physically?

Very different, that’s why it was so difficult to identify Covid’s disease at the beginning. Some patients have only lost their sense of smell and taste, others only have diarrhea, others have many symptoms at once. The most useful symptoms in the diagnosis are shortness of breath when stressed, coughing, other respiratory problems and fever. The most serious respiratory problems only appear at a very late stage of the disease.

Is Covid-19 a Painful Disease?

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“We will probably have to work more in the next few weeks”

Mr. Çelik, we want to talk to you every two weeks about your work as a senior physician in the isolation ward for Covid-19 patients in the Darmstadt Clinic. What is the current situation there?

We have had very fluctuating patient numbers in the past two weeks. The number of suspected cases is high on some days, then we get 16 to 20 patients for our isolation ward, some of which have to be repeatedly tested here. And then the next day it sometimes goes down to a single-digit number of new suspected cases. Every day is different, we just can’t make up our mind whether the overall figures are decreasing or whether the easing of the measures is causing an increase again. That’s why we only plan for a week or two.

How do you deal with the suspected cases?

If the patients come to the emergency room and there is suspicion of Covid, they come to our isolation station. This is a normal ward, the patients here do not need intensive care. But they are also not in a condition to wait for their test results at home, they have clear symptoms of illness. We then wait for the first test results from the nose and throat swab and look at the situation in the lungs with an X-ray. We may check with a second test whether the infection has already descended into the lungs. Then it may be that the throat swab is negative again, even though the patient has an infection. In this case, secretions from the lungs must be examined. We have to do all of this very quickly because some of the patients not only have these symptoms, but also completely different problems, for example the suspicion of a heart attack. Sometimes it is only incidentally noticed that they have symptoms that fit a Covid 19 disease. And as long as Covid-19 cannot be excluded, the patient must be isolated.

How is the Covid-19 isolation station organized?

It is divided into two. There is a hermetically sealed area where the confirmed cases are. You have to go through a closed glass door into a corridor in which you always wear the complete protective clothing with FFP2 mask, smock and safety glasses. And then there is a corridor in the same ward with a suspect patient in every room. We are a coordinating hospital for the Rhine-Main area, our goal is that we can take positive cases and suspected cases at any time. As soon as we have stable patients with Covid-19 in our ward, we make sure that they are transferred to a peripheral house as soon as possible and given further care so that we always have space for new and serious cases. We rely on this really well-functioning cooperation with other companies so that we can fulfill our supply mandate. We have just moved two patients again, now there are three positive cases in our normal ward. There are also 15 patients in the intensive care unit.

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