by Michael D. Cohen, M.D.

In the April issue of Prison Legal News, I discussed the nature of the disease called COVID-19 (COrona VIrus Disease-2019) and ways to protect yourself and your facility through personal cleanliness, social distancing and environmental cleanliness. This month I will continue those themes and also give suggestions about how to take care of yourself if you get sick.

Higher Risk for Severe Disease

The most common risk factors for severe disease have been older age, hypertension, diabetes, and heart disease. But anyone, at any age, even without existing chronic illness, can get very sick. Be extra careful to protect yourself from infection if you have any chronic medical condition. Here is some more information about HIV infection and heart disease.

• Inadequately treated HIV infection: All HIV patients should be tested for viral load (counts of viruses in the blood) and CD4 lymphocyte count (a special type of white blood cell). Viral load tells whether the person with HIV is infectious to others. CD4 count is a measure of the immune system’s ability to fight infections. The normal CD4 count is above 500 cells per cubic millimeter. It appears that people with HIV taking effective treatment who have no viruses in their blood and normal CD4 counts are not at greater risk for severe COVID-19 disease. However, if the CD4 lymphocytes count is less than 200 the immune system is weakened and there is very high risk for severe COVID-19 disease.
• Heart disease: Experience treating COVID-19 has shown that even people with stable heart disease are at higher risk for severe disease. For example, people who have no heart pain or other symptoms after having stents inserted to open up partially blocked heart arteries are still at higher risk.

Personal Cleanliness

• Hand washing: Public health programs have encouraged people to use a particular approach to hand washing that is most effective. Wash with soap and warm water for at least 20 seconds (the alphabet song takes about 20 seconds). Wash the palm and the back of the hand. Wash the thumb and each finger one at a time so all 10 are well washed all over. Wash wrists, too. If you don’t have hot water, use the water you have. If you have push button taps on your sinks you may need a buddy to hold the water on for you while you wash.
• Protect your lungs: Smokers are at higher risk for severe disease. Stop smoking if you can. Avoid second hand smoke as much as possible. Avoid dust and fumes that irritate the lungs.
• Strengthen your resistance: Eat well. Do aerobic exercise to strengthen the heart and lungs. Try to sleep and rest before you are tired out. Reduce stress if you can by doing the things that help you relax like listening to music, thoughts of loved ones, or meditation. Don’t drink bootleg alcohol. Exercise regularly. Take vitamin D supplements if you can get them (2000 units per day is a good maintenance dose). Go out in the sunshine daily if you can. Sunshine makes vitamin D in the skin. Stay normally hydrated by drinking 2 to 3 quarts of water or other clear fluids a day.

Social Distancing (perhaps better named Physical Distancing)

• Head-to-foot sleeping in dorms: In crowded dormitories it may be helpful to increase the distance between your face and the faces of the people sleeping next to you or above and below you in bunk beds. This is because some of the infectious droplets that are expelled from one person settle out of the air over a distance of six feet. Rather than sleeping with everyone’s heads lined up at the same end of the bed, rearrange yourselves so your head is next to your neighbor’s feet. This increased separation may reduce disease transmission.

Environmental Cleanliness

• Ventilation of public spaces: One way to reduce disease transmission is to move old air out of a room and bring in new fresh air from outside. This is particularly effective at removing infectious droplets that are so small they stay floating in the air instead of settling out onto the floor. Proper ventilation requires an inlet for new air and an outlet for old air. Open two windows on opposite ends of the room. Use two fans if you can: one blows new air in, one blows old air out. If there are no windows to open, at least make sure nothing is blocking the supply and return vents of the HVAC system. The returns are taking the old air out while the supply vents are blowing new air in.

Also, be aware that a single fan blowing air around in the room may actually make it worse. That is just air circulation, not ventilation. You may feel cooler, but it is just moving the infectious droplets around the room more vigorously, not clearing the air. It moves the larger droplets and prevents them from settling out of the air. It moves the smaller droplets more widely around the room putting more people at risk because it defeats the beneficial effects of social distancing in that room.

Take care of yourself if you get sick

• Symptoms: The U.S Centers for Disease Control (CDC) defines typical COVID-19 symptoms of fever, dry cough and shortness of breath. But some people have none of these at first and other initial symptoms may occur, including headache, nausea, abdominal pain or diarrhea. In an epidemic like this, any new illness, especially with fever, could be COVID-19.
• Testing for infection: People with symptoms should be tested for the presence of the virus in their nose or saliva. These tests are not widely available in the free world yet except for people who are hospitalized, so incarcerated people probably will not get tested. If you have symptoms, assume you have it.

Isolate yourself: If you are sick, isolate yourself as much as possible. Some correctional systems have started quarantine units where sick people are gathered together to separate them from the rest of the population. Other systems want sick people to stay in their cell. Stay isolated if possible to protect others from exposure to your disease. Wear a mask all the time if you can.

Rest: Get as much rest as possible when you are sick. Do not undertake vigorous activities.

Hydration: Maintain normal hydration while you are sick, that is 2 to 3 quarts of water or clear fluids a day. More fluid intake is needed if you have fever or sweats.

Symptom control: While it is not necessary to treat symptoms, control of symptoms helps you feel better while you are ill. Use acetaminophen (Tylenol brand, for example) for control of fever, body aches, and headache. The usual dose is 650 milligrams (mg) every 4 hours, but never more than 3000 mg per 24 hours. In general, people with active liver disease should not take acetaminophen at all. If you have active liver disease and cannot take acetaminophen, then aspirin, ibuprofen (Motrin brand, for example), or naproxen (Alleve brand, for example) also provide symptom relief.

Breathing exercises: Shortness of breath and cough are common symptoms of COVID-19 disease. These symptoms may not occur at first and sometimes show up late in the course of the illness after it seems to be getting better. The most severe COVID-19 lung disease occurs when the lungs fill up with fluid (mucus).

The following breathing exercises were adapted from the website of the Cystic Fibrosis Foundation. Don’t do these breathing exercises in a public place. The exercises can expel infectious droplets into the air. Wear a mask to limit this if you can.

Cystic fibrosis (CF) is the most common inherited disease of European Americans, but it is uncommon among other ethnic groups. Excess fluid in the lung is a common symptom of CF. Breathing exercises are used by CF patients to clear fluid out of their lungs. Similar breathing exercises are used by people with other chronic lung diseases like emphysema, chronic bronchitis or severe asthma.

The exercises use “abdominal” breathing. This is breathing that makes the belly swell up rather than the chest. If you relax and let your belly swell as you breath in (inhale) you are doing abdominal breathing. On the other hand, if the chest expands more when inhale you are not doing abdominal breathing.

The exercises use “pursed lip” breathing. The easiest way to understand this is to breath out (exhale) in such a way that your cheeks puff out. When you do this the mouth is partially closed with the lips fairly close together so that pressure builds up in the mouth and air passages in the lungs as you exhale. This increased pressure in the air passages helps keep them open.

Everyone knows what a cough is. In these breathing exercises “huff” means expelling air forcefully with the mouth open, as you might do when trying to fog up eye glasses to clean them, but stronger.

Cystic Fibrosis Foundation Airway Clearance Technique:

a. Controlled Breathing: Slowly breath in through the nose using abdominal breathing and breath out slowly through your mouth with minimal force through pursed lips. Do this six times.

b. Chest Expansion: Breath in deeply expanding the chest this time, hold your breath for three seconds, let the breath out slowly without forcing it.

c. Repeat Controlled Breathing for another cycle of six breaths

d. Forced Expiration: Sit up. Breath in until not quite fully inflated. Hold breath for two or three seconds. Breath out with mouth open (huff) forcefully but slowly and continuously. Do this two more times.

e. Cough: Take a deep breath and cough to move fluids out of the airways into the mouth. Spit it out into a tissue and dispose of it safely in the toilet.

Repeat the whole cycle (a. to e.) again to make sure you removed as much lung fluid as you could. After successful breathing exercises you may feel less short of breath.

• When to seek medical care: You need health professional assessment when you feel short of breath, are breathing too fast, have trouble catching your breath, or get winded easily with minimal activity. If your finger nails look gray instead of pink, you have waited too long and need care urgently. Normal, relaxed adults breath 12 to 16 times per minute. Count your breathing for a full minute by a clock or watch. If the count is 20 or more that is too fast. Take notice if you are panting or breathing heavily without doing any physically strenuous activity. Stopping to catch your breath after walking a short distance or climbing one flight of stairs is not normal for an otherwise healthy adult.

Other symptoms that may indicate the need for medical care include persistent pain or pressure in the chest and confusion or difficulty waking up.

At the clinic, medical staff will assess your condition. They should take a complete set of vital signs (temperature, heart rate, breathing rate and blood pressure). They also should assess your lung function with a pulse oximeter. This device clips onto the end of a finger and shines a bright red light on the fingertip to measure how much oxygen is being carried in the blood. In a healthy person breathing room air the blood is over 95% saturated. Extra oxygen is needed if it is 90% or less. People with chest pain or confusion need additional assessments too such as an electrocardiogram (EKG) to assess the heart and assessment of level of consciousness and awareness of your surroundings.

Many prison infirmaries can give extra oxygen by face mask or through plastic tubes that fit into the nose. Sometimes they can give oxygen under low pressure with a tighter fitting face mask. Improvement of the pulse oximeter reading into the normal range above 95% indicates that the oxygen treatment is working. However, the patient must be closely monitored while on oxygen treatment because COVID-19 patients can get much worse very fast. When the pulse oximeter starts going down in spite of oxygen treatment, the patient’s lungs are failing. Patients should be transferred to a hospital for more advanced care before there is a life-threatening breathing crisis.

Please continue to practice personal cleanliness, social distancing, and environmental cleanliness to the best of your ability. Try to enlist the cooperation of the correctional officers to make a safer facility for everyone. Watch out for each other to make sure people who get sick and have trouble breathing get the medical attention they need. Hospital transfers are necessary for adequate treatment of more severe COVID-19 disease. Working together we can get through this. 

Michael Cohen was the Medical Director for the New York state juvenile justice system for 20 years and previously provided medical care for incarcerated adults at the New York City Rikers Island jail and at Greene CF in Coxsackie NY. For 10 years he participated in a support group for people with diabetes at Great Meadow CF in Comstock NY. With the group, he co-authored the Prisoner Diabetes Handbook published by Southern Poverty Law Center and distributed by Prison Legal News. Heal the sick. Raise the fallen. Free the prisoners.

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