Grandma Has COVID: What We Did and Our Contingency Plan (3)

Grandma today

Blood pressure 130/80, heart rate 78, blood oxygen 96% (on oxygen), temperature 37.0, in much better spirits, able to get up and eat on her own, able to sleep lying flat — she's doing great!

Honestly, I can breathe again; on the first day I was scared out of my wits. My personal feeling is that getting her on the antiviral promptly was a crucial step. Of course, close monitoring has to continue, but I hope this is the last post about how we're handling Grandma's COVID. Because that would mean no more surprises, no more scares — just good rest, calm, steady, uneventful days.

This time I was in Beijing, taking part remotely in Grandma's medical care, medication and monitoring in Hong Kong, and I came away with two lessons. 1. A contingency plan is absolutely, absolutely, absolutely essential.

2. When caring for elderly relatives, communication, empathy and coordination among family members matter enormously.

Perhaps this will be useful to some of you, so I'll go on at a bit more length; updates are shown in blue. Once again: this is specific to Grandma's situation — 86 years old, with twenty years of high blood pressure. It is not medical advice, just experience shared among friends. If you plan to use any of it, please be sure to consult a doctor and other professionals. Here goes:

0. Contingency Plan

First, ideally, avoid infection altogether and help older people sit out this wave. Grandma caught it when she went out for her flu jab, so keep outings to a minimum.

Make your plan before the elderly person gets infected. Once they're infected, there's no time to research, buy medicine, buy equipment and find a hospital, and you may miss the best window for treatment.

Antigen tests lag behind. Be on alert at a sore throat or fever; at this point in the season, it's better not to count on luck.

Things you can prepare in advance: - A home oxygen concentrator and portable oxygen cylinders (on the way to hospital on your own, a home concentrator is no use, but a portable cylinder is.) - A pulse oximeter and blood pressure monitor - A thermometer (a digital one is better — you can take a temperature without disturbing them while they sleep) - Fever-cooling patches and other physical cooling tools

On medication, work out which drugs can be taken after infection and how - What their regular medications are, when they take them and at what dose - Whether their regular medications conflict with fever reducers and COVID antivirals - Which doses may need adjusting. For example, blood pressure may run low after infection, so measure it before taking blood pressure medication. On medical care, plan your routes and options

• Agree on what situations mean you call an ambulance without hesitation

• Where the nearest hospital is, how long it takes to get there, whether it has ventilators and ECMO. Get the family to agree on all of the above.

1. General

Despise the enemy strategically, respect it tactically: monitor the elderly person's vital signs more closely than usual, but don't panic. Stay calm and give them a relaxed environment that reduces anxiety and tension; a calm state of mind helps recovery.

Frail elderly people may not run a fever at all. Fever is the immune system responding, the body's own protective mechanism. When someone's health is very poor, even that alarm signal may be gone. That's why so many elderly people who passed away had similar readings: blood pressure not high, temperature normal, no fever.

Be cautious about going to hospital: it's an ordeal, and it raises the elderly person's exposure to the virus, so if it isn't necessary, you needn't go;

Encourage them — their state of mind, confidence and will to live all matter. Our agreed line was: Grandma's vital signs are very good and don't meet the threshold for admission, which is why the hospital didn't take her. (Rather than: she couldn't get a bed 😢.) Apparently the will to live has a big effect on physical condition. Being too anxious also hinders recovery.

2. Medication

Paracetamol (compound acetaminophen): likely less of a conflict with blood pressure medication.

Ibuprofen-type drugs: may affect high blood pressure.

Use Lianhua Qingwen with caution: it has strong side effects; if it must be taken, halve the dose for the elderly and children.

Use cough medicine with caution: some cough medicines raise blood pressure or can trigger angina, so read the leaflet carefully, and be careful with anything containing ephedrine-type ingredients.

If phlegm is thick and hard to cough up, consider Mucosolvan (ambroxol).

Doses for underlying conditions may need adjusting: during a fever, if they drink a lot and urinate a lot, blood pressure may drop, so blood pressure medication may need to be reduced appropriately to avoid harm from very low blood pressure, or a misdiagnosis.

Can the COVID antiviral Paxlovid be used?

A very important question — but to be honest, I don't know. What we know is:

People over 60 can take it, but! There are many restrictions;

Special groups, especially patients with kidney impairment, should use it with caution;

It conflicts with many medications for underlying conditions — for example, Grandma's cholesterol-lowering drug. But if fighting the virus is the priority, you can stop that medication and take Paxlovid. This must be done under a doctor's guidance; we have no hands-on experience with it.

Under a doctor's guidance, we used Merck's (MSD's) molnupiravir.

Note: you must complete the full five-day course. Because it works by preventing the virus from replicating, sometimes the symptoms aren't obvious but the virus is still replicating, so finishing the course is the best choice. Reportedly, in clinical trials it was compared against a placebo and its toxicity was no greater than the placebo's.

Click to view: the molnupiravir package insert and the Shanghai Pharmaceutical Association's introduction

Found a very good tool: a CHECKER for whether COVID medications conflict with other medications, which you can use to check yourself before taking anything.

Website: https://www.covid19-druginteractions.org/checker

3. Monitoring

Monitor temperature, pulse, blood oxygen and blood pressure, and assess their overall condition together — do not, do not, do not look at just one indicator.

The second day after testing positive is when it tends to be most serious, so monitor more intensively. Assess temperature, pulse, blood oxygen and blood pressure every 1–2 hours. A fingertip pulse oximeter can be worn continuously.

Blood oxygen: a very important indicator; if it keeps falling to 93% or below, seek medical care.

Heart rate: without fever, an elderly person's heart rate is around 80 beats/minute; for every 1 degree rise in temperature, pulse rises by 10 beats/minute; if there's no fever and the heart rate is above 90 beats/minute, consider a little diuretic.

Temperature: an elderly person's normal temperature may be only 36 degrees, so 37 degrees already counts as raised. A heart rate of 88 beats/minute is within the acceptable range.

A lung CT is an important indicator. When viral pneumonia first causes consolidation, a stethoscope sometimes picks up no positive signs; you only hear them once crackles appear, by which time it may be too late. So if the elderly person's condition and the available medical care allow, getting one can rule out a lot of uncertainty.

Blood pressure: monitor continuously and compare with their normal readings.

Track fluid in and out, i.e. urine output against fluid intake.

Here's a piece of counter-intuitive new knowledge: elderly people shouldn't drink very large amounts of water.

Drink moderately, and fairly warm — just enough to sweat. Drink too much without passing it promptly, and you add to the burden on the heart, increase blood volume in the lungs and add to the burden on the lungs.

Watch the elderly person's mental state and how much they eat. It's not just the vital signs — if they're eating very little or stay drowsy and not fully alert, be on alert too!

4. Care

Drinking: drink warm water, but little and often. Again, keep track of fluid in and out. Count the fluid intake from porridge, water and taking medicine; count the output from urine and sweat too.

Eating: small, frequent meals; some nutrition, to give enough resistance, but beware of foods that increase phlegm; if they're sweating a lot, the food can be a touch saltier, because sweating loses salt — but only if they really are sweating, otherwise extra salt burdens the heart. On nutrition: steamed egg custard, egg soup, finely chopped leafy greens, fruit blended into juice (pear and orange are best), or you can cook the pears and oranges.

Control the home oxygen concentrator's setting carefully. Blood oxygen should stay above 95%; too low and the oxygen flow isn't enough, too high and the elderly person will be uncomfortable. On the Vision Aire 5 we use, the second setting reaches a 27% concentration, but every machine is different, so use your own judgement.

For concentrators with a humidifier bottle, change the distilled water often and keep it clean. If possible, keep the water at around 37 degrees; this little tip humidifies the oxygen so the airways don't dry out, which is more comfortable. 37 degrees is about the same as your hand.

The elderly person's cooperation is important. Tell her that eating, drinking warm water, taking oxygen and taking medicine are four equally important parts of the treatment.

Make good use of tools like a care log. First, you can see the trends; second, when family members take turns keeping watch, the handover goes smoothly. This is the format of Grandma's log, for your reference. My cousin is a nurse, so her records are remarkably detailed and professional. RA is Room Air; 1L/2L is the oxygen flow rate.

5. Symptoms That Mean Going to Hospital

Chest pain, chest tightness, shortness of breath, angina

Increased pulse

Blood oxygen continuously falling to 93% or below

Breathing rate above 30 breaths/minute

Still above 38.5 degrees after fever reducers, for 2 days

Temperature below 35 degrees

Persistent pain or pressure in the chest

Dizziness, unable to wake or stay awake

Pale, grey or bluish skin, lips or nails

Weakness or unsteadiness on their feet

Seizures

Persistent inability to eat or drink, or diarrhoea or vomiting for more than 2 days

Marked worsening of existing underlying conditions

6. Seeking Medical Care

Hong Kong's private hospitals do not admit positive patients. Current Hong Kong health policy is that all COVID-positive patients go to public hospitals; even a patient already admitted to a private hospital who unfortunately catches COVID gets taken by ambulance to a public hospital for admission. A few private hospitals' A&E departments will see positive patients, but won't admit them, and afterwards send them by ambulance to a public hospital.

Going down the list of "Medical services provided by private hospitals for persons tested positive for COVID-19" published by Hong Kong's Department of Health, I called each one in turn. As of 25 December 2022, the hospitals that clearly confirmed they accept positive patients at A&E were:

Union Hospital, Hong Kong +85226083388

Hong Kong Adventist Hospital – Tsuen Wan +85222756688

Hong Kong Sanatorium & Hospital was the only private hospital I could find that would admit positive patients, but beds were nearly impossible to get; we tried every channel and it simply wasn't possible.

Some private hospitals won't do a lung CT for positive patients. Because she was positive, Hong Kong Sanatorium didn't give Grandma a lung CT, so unless it's an emergency, be sure to call and get clear answers before going to a private hospital.

In an emergency, calling an ambulance is the most effective option, because ambulances carry equipment. So make sure you understand the process and plan clearly: what number to call, what to do, where the nearest public A&E is.

6. Communication

The real work happens in ordinary times. When you discuss the "contingency plan" and "treatment plan," everyone's different knowledge and views on the virus, medical care and medication are bound to surface. Communicate more in normal times, communicate promptly, and share knowledge.

Family members who aren't with the elderly person: don't panic too much, don't keep asking questions, and don't disturb the relatives who are on the spot handling things;

Make good use of modern communication tools. You can post the latest updates formally to everyone in a WeChat group, using "sign-up chain" or "announcement" posts; you can also share the care log via Tencent Docs or Google Drive, to avoid repeated, overlapping questions and save everyone's mental energy;

Take lots of videos and post them in the group. Sometimes seeing the elderly person's spirits, how they eat and how they sleep is more useful and more reassuring than any data.

More information is attached below:

LAST BUT NOT THE LEAST

Special thanks to several of my friends 🙏🙏🙏 I've said thank you many times, and it still can't express it.

I didn't ask your permission, so for privacy I won't mention names. The moment you saw my call for help, you messaged me, or even called me directly, and force-fed me the most crucial information; you got me up to speed fast on all kinds of medicines and why they mattered, and scoured the whole market, the whole market, to find medicines for me; you called on resources you don't even use for yourselves to help me find medical resources in Hong Kong; the frequency of your chats and pep talks even hit an all-time high since we've known each other... 😂

Words fail me; I'll keep all of it in my heart. I hope you're all well — let's get together after the pandemic!

Portrait of Ah Ma

Grandma in New York

In front of the grand piano in the hall of the Harvard Club. Painted by Vincent Xeus. Thank you, Vincent & Stella, for your love and support.