On May 3 2020, Twitter user Bess Kalb tweeted that her father, an intensive care unit doctor, claimed that COVID-19 damaged blood and vascular systems of victims like “sticking your finger in an electric socket”:
My dad is an ICU doctor treating COVID-19 patients. In the past WEEK he has set more “I’ve never seen a heart rate/RBC count/etc. like this” records than in his decades-long career. What this virus does to the body is like “sticking your finger in an electric socket.” Stay home.
— Bess Kalb (@bessbell) May 3, 2020
Kalb followed with a thread, repeating the things she claimed her father described:
“He had a patient who needed 8 blood transfusions in a morning even though he wasn’t bleeding. The coronavirus was just eating his red blood cells faster than his bone marrow could make them. It’s fucking mystifying and brutal.
“EIGHT. Eight blood transfusions.
“If you are lucky enough to make it off a ventilator (the equivalent exertion required for that is running a marathon without training), you will likely get put on dialysis and a feeding tube next. It’s a nightmare. It’s hell. It’s what you’re risking on your beach day.
“Young, healthy people are dying from a COVID-19 effect called a ‘cytokine storm.’ Basically, you make it off a ventilator (maybe!), you get your appetite back a little, you think you’re turning a corner, and then your immune system rips through your lung tissue and you drown.
“The other common way young people are falling off the face of the earth from this are the random strokes it causes. Talking one minute, stroking out the next, and then the nurses have to go through the cell phone to find ‘Dad’ because ‘Mom’ usually insists on coming.
“There have been a few ‘Papa Bear’s or ‘Daddy-O’s in the cell phones who have tried to come in to hold the bodies.
“Send this thread to any idiot fucker who posts an Instagram at the beach or a crowded park. Tell them my dad says see you later.
“Also have an advanced directive because a lot of fiancés and parents are being put in UNCOMFORTABLE situations deciding. Truly, before you head to the crowded beach or nail salon or bowling alley, decide if you’re a chest compressions guy or feeding tube vegetable queen.
“Healthcare workers: Share your stories (without identifiable details obviously) from the front lines. People are GALAVANTING out and about. Explain to them what they’re facing. Or worse, what they’re doing to a loved one.”
Even if the individual claims made by Kalb were verifiable, privacy provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) would prohibit doing so. Having said that, elements of her claims were verifiable, such as:
- Doctors for COVID-19 patients are reporting that the virus — known broadly as respiratory in nature — is causing complications affecting patients’ blood and vascular systems;
- Otherwise young and healthy patients are suffering “random strokes,” complications which can be and are often lethal;
- COVID-19 is causing something called a “cytokine storm”;
- Patients who die of COVID-19 must die alone and be buried alone.
Another element of Kalb’s Twitter thread was neither fact-checkable nor particularly in dispute — two or three of the tweets pertained to the number of young people both dying of COVID-19 and pre-deceasing both of their living parents. An axiomatic belief across cultures is that children ought never die before their parents, and Kalb described a number of parents suffering the loss of a child before the death of either parent.
Among responses to Kalb’s tweet were counter-assertions that if the claims were true, they would most certainly be prominent news:
Then why isn’t this making national headlines?
— wyatt (@wk3003wk) May 3, 2020
Kalb’s first and most widely-shared tweet paraphrased her father’s assertion SARS-CoV-2 was like “sticking your finger in an electric socket” in terms of hematological damage. Although we are unable to say precisely what Kalb’s father may have been describing, high-voltage electrical shocks are known to damage blood cells and vascular systems.
An April 22 2020 Washington Post article (via MSN.com), “A mysterious blood-clotting complication is killing coronavirus patients,” reported that doctors observed complications similar to those Kalb referenced in her Twitter thread — a novel finding about a novel virus:
One doctor replied that one of his patients had a strange blood problem. Despite being put on anticoagulants, the patient was still developing clots. A second said she’d seen something similar. And a third. Soon, every person on the text chat had reported the same thing.
“That’s when we knew we had a huge problem,” said [Craig] Coopersmith, a critical-care surgeon. As he checked with his counterparts at other medical centers, he became increasingly alarmed: “It was in as many as 20, 30 or 40 percent of their patients.”
One month ago when the country went into lockdown [in March 2020] to prepare for the first wave of coronavirus cases, many doctors felt confident they knew what they were dealing with. Based on early reports, covid-19 appeared to be a standard variety respiratory virus, albeit a contagious and lethal one with no vaccine and no treatment. They’ve since seen how covid-19 attacks not only the lungs, but also the kidneys, heart, intestines, liver and brain.
Increasingly, doctors also are reporting bizarre, unsettling cases that don’t seem to follow any of the textbooks they’ve trained on. They describe patients with startlingly low oxygen levels — so low that they would normally be unconscious or near death — talking and swiping on their phones. Asymptomatic pregnant women suddenly in cardiac arrest. Patients who by all conventional measures seem to have mild disease deteriorating within minutes and dying at home.
With no clear patterns in terms of age or chronic conditions, some scientists hypothesize that at least some of these abnormalities may be explained by severe changes in patients’ blood.
Immediately thereafter, the article reported that “concern is so acute some doctor groups have raised the controversial possibility of giving preventive blood thinners to everyone with covid-19 — even those well enough to endure their illness at home,” and referenced COVID-19 autopsies indicating that victims’ lungs “fill with hundreds of microclots,” which can subsequently “break off and travel to the brain or heart, causing a stroke or heart attack.”
Doctors consulted for the piece repeatedly described effects unlike anything observed in common conditions, which often added their stuggles to understand the mechanism by which these complications were able to occur.
In their comments, doctors voiced their discomfort with the complications. While they felt confident anticipating or reacting to clotting abnormalities in diseases like cancer and in trauma cases, the COVID-19 clotting complications remained a mystery:
Lewis Kaplan, a University of Pennsylvania physician and head of the Society of Critical Care Medicine, said every year doctors treat people with clotting complications, from those with cancer to victims of severe trauma, “and they don’t clot like this.”
“The problem we are having is that while we understand that there is a clot, we don’t yet understand why there is a clot,” Kaplan said. “We don’t know. And therefore, we are scared.”
Providing several examples of blood-related complications which were alarming, unexpected, and without clear cause in patients, with equipment, and during autopsies, Coopersmith acknowledged “a universal understanding that [COVID-19] was different.” Doctors at the time had “no consensus” on the cause of the clotting abnormalities, but were able to uncover evidence in early case reports from China and Italy:
Although there was no consensus on the biology of why this was happening and what could be done about it, many came to believe the clots might be responsible for a significant share of U.S. deaths from covid-19 — possibly explaining why so many people are dying at home. In hindsight, there were hints blood problems had been an issue in China and Italy as well, but it was more of a footnote in studies and on information-sharing calls that had focused on the disease’s destruction of the lungs.
Harlan Krumholz, a cardiac specialist at the Yale-New Haven Hospital Center, explained that because this particular coronavirus is novel, it meant that doctors were ill-equipped to understand such complications as they arose:
“There’s lots of speculation … That’s one of the frustrating things about this virus. We’re in a lot of darkness still.”
The American Society of Hematology (specialists in blood diseases and disorders) maintained a page, “COVID-19 and Coagulopathy: Frequently Asked Questions,” which described complications of COVID-19 involving blood. The page referenced a sub-condition described as “COVID-19-associated coagulopathy (CAC)”; “coagulopathy” is disordered blood clotting.
An April 15 2020 review in the Journal of the American College of Cardiology noted that “Coronavirus disease 2019 (COVID-19), a viral respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), may predispose patients to thrombotic disease, both in the venous and arterial circulations, due to excessive inflammation, platelet activation, endothelial dysfunction, and stasis.”
In one of Kalb’s tweets, she said that another way that young people “are falling off the face of the earth from this are the random strokes [COVID-19] causes”; an April 28 2020 New England Journal of Medicine case report was titled “Large-Vessel Stroke as a Presenting Feature of Covid-19 in the Young.” It described at least five cases of large-vessel stroke in patients under the age of 50 in New York City facilities during a two-week period from late March through April 7 2020:
We report five cases of large-vessel stroke in patients younger than 50 years of age who presented to our health system in New York City. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all five patients.
Over a 2-week period from March 23 to April 7, 2020, a total of five patients (including the aforementioned patient) who were younger than 50 years of age presented with new-onset symptoms of large-vessel ischemic stroke. All five patients tested positive for Covid-19. By comparison, every 2 weeks over the previous 12 months, our service has treated, on average, 0.73 patients younger than 50 years of age with large-vessel stroke … Coagulopathy and vascular endothelial dysfunction have been proposed as complications of Covid-19[.]
On April 29 2020, NPR quoted Coopersmith, and reported:
“The dialysis machines almost never clot,” Coopersmith says “And we were finding that the machines were clotting two or three or four times a day.”
Even so, blood thinners are able to reduce clotting in most patients with COVID-19. And if a dangerous clot does form, it can often be dissolved with a clot-busting drug.
But drugs that prevent clots or break them up can also cause uncontrolled bleeding, so patients on them have to be watched closely, Coopersmith says.
“We have literally five different teams in the hospital specifically and only looking at blood clotting, just because of COVID,” he says.
And some hints about how COVID-19 affects clotting are coming from lab tests of patients, says Dr. Tiffany Osborn, a professor of surgery and emergency medicine at Washington University in St. Louis.
“We are seeing lab values that are off the wall,” she says.
An April 28 2020 Popular Science article emphasized once again the novel nature of novel coronavirus SARS-CoV-2 and COVID-19, and the challenges faced by doctors in anticipating and responding to unexpected complications like clotting disorders and strokes:
[Doctors] do have some ideas. They think that the virus may bind to receptors on endothelial cells, which are found on the inside of blood vessels, like veins and arteries. It’s possible that the virus’s presence there triggers an immune reaction to the foreign substance which results in clotting, Mocco says—and it’s those clots which, if they travel to the brain, can cause stroke. In other organs, they can cause damage by preventing blood from flowing normally. Doctors are seeing an uptick in these conditions, too, in young COVID-19 patients who without the infection would rarely develop them.
It’s important to underline that researchers are not certain about any of this yet. “Whether COVID-19 can cause a stroke is a question mark,” says Renyu Liu, a critical care professor at the Perelman School of Medicine at the University of Pennsylvania. Some medical centers, though, are taking no chances and have started using blood thinners as an early part of their COVID-19 treatment, says Mocco. Others are doing lab work exploring the usefulness of medicines used to break up blood clots. Again, he says, the research is in early stages.
COVID-19’s ‘Cytokine Storm’
Kalb specifically described a “cytokine storm” in her tweets, the sort of complication one might expect to be “national news,” if accurate.
It has been. An article published on April 27 2020 in The Lancet (“COVID-19 cytokine storm: the interplay between inflammation and coagulation”) reported:
The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-induced ARDS has similarities to that of severe community-acquired pneumonia caused by other viruses or bacteria. The overproduction of early response proinflammatory cytokines (tumour necrosis factor [TNF], IL-6, and IL-1β) results in what has been described as a cytokine storm, leading to an increased risk of vascular hyperpermeability, multiorgan failure, and eventually death when the high cytokine concentrations are unabated over time. Therefore, therapeutic strategies under investigation are targeting the overactive cytokine response with anticytokine therapies or immunomodulators, but this must be balanced with maintaining an adequate inflammatory response for pathogen clearance.
Activation of coagulation pathways during the immune response to infection results in overproduction of proinflammatory cytokines leading to multiorgan injury. Although the main function of thrombin is to promote clot formation by activating platelets and by converting fibrinogen to fibrin, thrombin also exerts multiple cellular effects and can further augment inflammation via proteinase-activated receptors (PARs), principally PAR-1. Thrombin generation is tightly controlled by negative feedback loops and physiological anticoagulants, such as antithrombin III, tissue factor pathway inhibitor, and the protein C system. During inflammation, all three of these control mechanisms can be impaired, with reduced anticoagulant concentrations due to reduced production and increasing consumption. This defective procoagulant–anticoagulant balance predisposes to the development of microthrombosis, disseminated intravascular coagulation, and multiorgan failure—evidenced in severe COVID-19 pneumonia with raised d-dimer concentrations being a poor prognostic feature and disseminated intravascular coagulation common in non-survivors.
An April 2020 pre-print in The Journal of Infectious Disease, “The pathogenesis and treatment of the ‘Cytokine Storm’ in COVID-19,” defined the term in its abstract:
Cytokine storm is an excessive immune response to external stimuli. The pathogenesis of the cytokine storm is complex. The disease progresses rapidly, and the mortality is high. Certain evidence shows that, during the coronavirus disease 2019 (COVID-19) epidemic, the severe deterioration of some patients has been closely related to the cytokine storm in their bodies. This article reviews the occurrence mechanism and treatment strategies of the COVID-19 virus-induced inflammatory storm in attempt to provide valuable medication guidance for clinical treatment.
A May 1 2020 Health.com piece indicated that doctors were hamstrung by a lack of existing data on the illness and cytokine response:
There isn’t much data available on how many patients recover from cytokine storms, especially ones caused by the novel coronavirus, though Dr. Fichtenbaum says the fatality rate is higher for patients who experience this heightened inflammatory response.
COVID-19 Victims Die Alone, and They’re Buried Alone
In one of her later tweets, Kalb said victims of COVID-19 “die alone from COVID,” and “will be buried alone.”
Similarly, the banning or discontinuation of funerals during the pandemic has been a feature of it both within and outside the United States. Footage of mass burials in New York City showed the internment of dozens of COVID-19 victims without a single witness:
Then Why Isn’t This Making National Headlines?
Various elements of Kalb’s tweets appeared in reporting by the Washington Post, NPR, Popular Science, and Health.com — those just being articles we included in our references. Additional citations appeared in major medical journals such as The Lancet and The New England Journal of Medicine, among many others. Although COVID-19 as a topic dominated headlines, related coagulopathy and “random strokes” were a major portion of medical reporting — as was the “dying alone” and being “buried alone” aspect.
Are the Tweets Accurate?
Kalb’s first tweet said that COVID-19’s effects on a patient’s blood were like “sticking your finger in an electric socket”; she went on to describe clotting disorders, strokes, and other cardiovascular features of COVID-19.
Those complications have been widely covered by news outlets and medical journals, many of which emphasized the virus was affecting patients (and the young) in unexpected and frightening ways. Her claims about blood disorders, clotting, and strokes were supported by this reporting, as are claims that COVID-19 victims often died in isolation.