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Wednesday, April 1, 2020

History Matters—for Influenza and COVID-19

BY MARK MOSLEY, MD, MPH

More people died from influenza than any other illness or plague in recorded history during a few months in 1918. World War I (1914-1918) claimed about 16 million lives, but the 1918 flu epidemic killed more than 50 million people. Nearly one of three people on Earth was infected. It is not an overstatement to say it was the most devastating natural disaster in history, one barely covered in many history courses. (New Engl J Med. 2018;379[24]:2285; https://bit.ly/3amBbaE.)

The word influenza comes from an epidemic in 1357 in Florence, Italy. It was thought to be influenced by fate (by the stars) or by unusually cold weather, and was called influenza di freddo (influence of cold). The term influenza was used throughout history for what is now known to be a viral illness. Dr. Richard Pfeiffer isolated an unknown bacterium from the sputum of his sickest influenza patients in 1892, believing it to be the cause. He called it Pfeiffer's bacillus or Haemophilus influenzae (this well-known bacterium is not the cause of influenza, but we still use this misnomer).

history.jpg
  An emergency hospital at Camp Funston, KS, during the 1918 influenza epidemic.
  Photo by
Cheng-Long Chang/NIH.

It was dubbed the Spanish flu in 1918 because the first reports came from the Iberian Peninsula. We now know this is not where it started. Allied and Axis news sources during the war, however, wanted to print only encouraging news and withheld knowledge of influenza outbreaks. Spain, which was not involved in World War I, was free to report on the pandemic and became responsible for its first reports.

This led Americans to believe it was brought to the United States by European immigrants (which was used politically). The reality is that it likely started in my home state, Kansas. The first report on March 11, 1918, was of many people from Haskell County in southwest Kansas coming down with influenza. One of them was a soldier sent to Camp Funston near Fort Riley. Later that same month, 1,100 soldiers at Fort Riley were infected; 38 died.

President Woodrow Wilson knew of this and other outbreaks, and he was advised by his chief physician not to send soldiers to France for fear of worsening outbreaks. The president went against his advice, sending thousands of soldiers to France. Some 200,000 soldiers became infected on the transport ships, which became known as floating coffins (like cruise ships).

President Wilson may be responsible for more U.S. lives lost from this single decision than any other made during World War I. Eighty percent of U.S. military lives lost were from influenza! Somewhat ironically, it was the presence of influenza in France that likely slowed the German forces from overrunning France and winning World War I. Influenza may be the most influential factor in stopping Germany.

President Wilson contracted influenza on April 3, 1919, at the talks that produced the Treaty of Versailles, which ended the war. Some historians believe his illness affected his decision-making ability, prompting him not to hold to the agreements he had originally made with Germany. These political embarrassments fueled the right-wing German nationalists (Hitler) and World War II.

We must remember that we still had no idea what caused influenza in 1918. The only treatments were quarantine, limiting public gatherings (social distancing), and personal hygiene (handwashing). If you coughed in a movie theater, you were asked to leave. Many regarded this plague, and World War I, as punishment from God. The influenza virus was discovered in the early 1930s, and it was not until 1940 that the vaccine was used on military personnel.

A new strain of influenza (H2N2), dubbed the Asian flu, in 1957 resulted in another pandemic with 1.1 million deaths globally. Annual influenza vaccines were then recommended in the United States for pregnant women, those with chronic illness, and anyone over 65. Several other pandemics occurred, including the recent H1N1 scare in the United States, the bird flu (H5N1), and the swine flu (H1N1) in 2009. And now COVID-19.

Flu vaccination rates for the United States in the 2018-2019 season were 46 to 81 percent for children and 33 to 56 percent for adults. As many as 80,000 people in the United States died from the flu in 2018. Eight percent of the children who died were unvaccinated.

We live our beliefs without knowing our history. Remember 1918. Remember 2020.

Dr. Mosley is an emergency physician in Wichita, KS.

P.S. If you liked this post, we think you'd enjoy the EMN enews, which delivers breaking news and online exclusives right to your inbox.

Tuesday, March 31, 2020

What's Working for COVID-19 Patients

This article is being updated as new information becomes available. Those additions will appear in red the first day they are added, then changed to black to allow for new information each day.

Questions received from readers and answers from Dr. Johnson and Gottlieb are also posted at the end of this article, also in red.

BY STEVEN JOHNSON, DO, & DANA GOTTLIEB, MD

Our large tertiary care ED in Queens, NY, usually sees more than 100,000 adults a year. As we write this, we have 458 COVID-19-likely or -positive patients, 111 of them on ventilators.

We have learned so much from treating COVID-19 patients in the emergency department, on the floor, and in the intensive care unit and by examining the available literature. We hope this summary will help with acute ED management. We will update it here as often as we can.

Initial Presentation

Symptoms of COVID-19 may vary, and may include fever, chills, headache, myalgia, rhinorrhea, throat pain, dyspnea, chest pain, cough, and sputum. Less frequent symptoms are loss of smell and taste, nausea, vomiting, and diarrhea. (EM:RAP. March 31, 2020; https://bit.ly/2Rftgo7.)

The clinical course trends toward two different stages. The first typically includes these symptoms, and is primarily experienced during the first week after onset of symptoms. For some, the second stage starts between days five and seven when sudden rapid clinical deterioration may occur.

We have not yet found any predictive symptoms of subsequent deterioration.

Workup

The workup for patients suspected to have COVID-19 is variable and depends on their clinical presentation at the time of evaluation. For those who have normal vital signs and appear clinically well with an uncomplicated medical history, it would be reasonable to treat and release them with quarantine directions, instructions on supportive care, and strict, detailed return precautions.

These steps below should be taken to evaluate and treat patients who will likely require hospitalization or intensive care.

Lab Evaluation

Complete the following:

  • CBC with differential: The white blood count is usually normal, lymphopenia is common, and mild thrombocytopenia is common. (Clin Infect Dis. 2020. doi: 10.1093/cid/ciaa248. [Epub ahead of print]; https://bit.ly/2UQO8CT.)
  • CMP with magnesium and phosphorus: Liver function tests (ALT, AST) commonly elevated
  • Coagulation studies with D-dimer: PT/PTT/INR is usually normal on initial presentation. Some develop DIC. The D-dimer is commonly elevated.
  • COVID PCR: (RVP if you suspect alternate viral etiology, though coinfection is possible.) We have found false-negative COVID testing in up to 10 percent of cases.
  • Procalcitonin: This is usually not increased with COVID-19. If elevated, it may indicate an alternate diagnosis or superimposed bacterial infection. Procalcitonin is not routinely elevated higher than 0.5 ng/mL in these patients. (N Engl J Med. 2020. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]; https://bit.ly/3bDobxu.) It does seem to go up as disease progresses, however. An elevated procalcitonin in the ED should lead you to consider an alternative or additional diagnosis more strongly.
  • CRP (sometimes ESR too, but difficult for some because it is often performed manually): This is elevated in COVID-19 patients, and it seems to trend upward with the progression of the disease. It may have some prognostic correlation.
  • LDH, ferritin, urine legionella, blood cultures, lactate, troponin, CK, CKMB, ABG, and G6PD: Chloroquine causes hemolytic anemia in G6PD; these are helpful for inpatient teams as well.

Poor Prognostic Factors:

  • Neutrophil to lymphocyte ratio >3.13 (medRxiv. 2020. doi: 10.1101/2020.02.10.20021584; https://bit.ly/3dIp8GG.)
  • Absolute lymphocyte count <0.8
  • LDH >245 U/L
  • Ferritin >300 ug/L
  • CRP >100 mg/L
  • D-dimer >1000 ng/mL. (Lancet. 2020;395[10229]:1054; https://bit.ly/3bIGQYT.)


Imaging

A chest x-ray is typically the most accessible means of imaging. Findings include:

  • Patchy ground glass opacities: The literature suggests this is present bilaterally and predominantly peripherally around 70 percent of the time. (N Engl J Med. 2020. doi: 10.1056/NEJMoa2004500. [Epub ahead of print]; https://bit.ly/2WT5LES; Lancet Infect Dis. 2020;20[4]:425; https://bit.ly/2WWLyOv.) This would fit what we are seeing as well.
  • Clear lungs: Early in the course of the disease, we are seeing many mildly symptomatic patients with clear chest x-rays that quickly progress over days to patchy ground glass opacities.
  • Uncommon: Pleural effusions are uncommon, but Wuhan reported pleural effusions in 13 percent of cases. (Lancet Infect Dis. 2020;20[4]:425; https://bit.ly/2WWLyOv.) Washington state reported no pleural effusions in its case series of 24 critically ill patients. (N Engl J Med. 2020. doi: 10.1056/NEJMoa2004500. [Epub ahead of print]; https://bit.ly/2WT5LES.) Twenty-eight percent of patients had pleural effusions in another study from Washington state. (JAMA. 2020. doi: 10.1001/jama.2020.4326. [Epub ahead of print]; https://bit.ly/2UO0EDm.) This would indeed fit with what we are seeing: Pleural effusions are only present about 15 percent of the time.
  • We initially had been progressing toward CT scans because the sensitivity is higher for picking up subtle opacities, but we have moved away from these unless we are concerned about an alternative diagnosis because a CT scan prompts no real change in management.
  • Ultrasound may be used as an alternative modality as well. There is emerging evidence of findings with COVID-19, though it is not yet well documented. (Intensive Care Med. 2020. doi: 10.1007/s00134-020-05996-6. [Epub ahead of print]; https://bit.ly/3aC5zOg.)

Treatment: Fluids

Patients with COVID-19 appear to be very sensitive to fluid overload. We have found success at preventing the need for intubation by keeping patients net negative despite tachycardia and acute kidney injury.

Hypotension is not the most common presentation we have seen but is certainly a feature for some. We have been leaning toward starting patients on low-dose pressors to support mean arterial pressure rather than multiple fluid boluses if they are on the verge of intubation because of hypoxia.

We have been utilizing the following approach to fluid resuscitation for ED patients with suspected COVID-19:

    • If the patient is normotensive, do NOT give a fluid bolus.
    • If the patient is hypotensive or appears hypovolemic on clinical exam, carefully consider a very small fluid bolus v. pressor for hypotension, especially if the patient's volume is clinically overloaded.
    • In the patient who is hypoxic and normotensive and requires oxygen, consider giving a dose of Lasix. Anecdotally, this seems to delay intubation hours to days. A side note about acute kidney injury (AKI): There appears to be a disproportionate number of patients with AKI from COVID-19 compared with typical viral pneumonia. This may suggest another contributing factor, possibly a microangiopathic component. If this is the case, AKI should not trigger us to give fluids or avoid Lasix. This needs further investigation.
    • Do not fluid-resuscitate to clear the lactate. The elevated lactate in a nonhypotensive patient is likely not from hypovolemia but possibly from a catecholamine surge, severe hypoxia, and/or respiratory distress. DO NOT bolus for lactate, please.
    • The WHO recommendations suggest a fluid bolus only in patients with septic shock, but this recommendation likely carries the same caveat that was used in the 2016 Surviving Sepsis campaign. (WHO. March 13, 2020; https://bit.ly/2UOPjCW.) The idea was that some patients would need to be intubated for the sole purpose of giving more fluids. This is particularly troublesome during a pandemic with a huge uptick in ventilator need. The pathophysiology of shock caused by hypovolemia does not seem to be playing out in this disease.
    • Shock at presentation is rare. (Lancet Respir Med. 2020. doi: 10.1016/S2213-2600[20]30079-5. [Epub ahead of print]; https://bit.ly/3dOx4Gz.) If a patient is in a shock state, consider late-stage COVID-19 complications such as myocarditis or cytokine storm, both of which will not respond to fluids. Obviously, consider other causes of shock as well.
    • Not that any of us normally do, but DO NOT start maintenance fluids.

 

Antibiotics

Coverage for community-acquired pneumonia upfront will likely be discontinued if a patient is found to be COVID-positive despite the presence of pneumonia. Use ceftriaxone and azithromycin for patients you are going to admit. Remember PO azithromycin is just as good as IV. This also allows you to limit the volume of IV fluids by using PO instead. I would consider sending patients who are not critically ill home on azithromycin because a French study showed hydroxychloroquine plus azithromycin resulted in lower viral loads. (Int J Antimicrob Agents. 2020:105949. doi: 10.1016/j.ijantimicag.2020.105949. [Epub ahead of print]; https://bit.ly/2WZbyJc.)

 

AVOID vancomycin. We historically tend to give this to our undifferentiated infectious patients, but COVID-19 patients are developing renal failure upstairs. If there is significant concern for MRSA, consider linezolid instead.

Also consider calculating the patient's Shorr score to see how worried to be about MRSA pneumonia. (Calculate that here: https://bit.ly/MDCalc-ShorrScore.)

Send a procalcitonin if you are admitting the patient. This will help determine if CAP coverage needs to be continued by the floor teams.

Other Treatments

  • Vitamin C: Two reasons to consider using vitamin C in COVID patients are the CITRIS-ALI trial and the data that suggest high serum levels of vitamin C seem to protect the lung epithelium in mice. (JAMA. 2019;322[13]:1261; https://bit.ly/3bCBaiU; YouTube. https://bit.ly/3bIEb1l.)  There is little downside to giving it because of the strong safety profile of IV vitamin C (other than resource utilization). The dose is IV vitamin C 1500 mg Q6 x 6 days. Despite the trial safety data, as mentioned by Paul Marik, MD, vitamin C does pose the theoretical threat of working as a prooxidant when there are high levels of serum iron. He suggests monitoring ferritin and CRP and then possibly reducing the dose of vitamin C if this is a concern. (Paul E. Marik. "COVID Protocol," March 24, 2020; https://bit.ly/2R1pyhx.) From an ED perspective, a single dose of 1500 mg is a good idea, especially when reviewing the animal data, which suggests that you need to reach a steady serum state before you see an effect. (YouTube. https://bit.ly/3bIEb1l.) Of note, effective concentrations were not reached through PO dosing in those studies.
  • NSAIDs: There has not been compelling evidence of harm, but we try to avoid NSAIDs in patients who do not absolutely need them given the anecdotal reports. We know that they are nephrotoxic, and downstream renal failure in these patients is occurring. There is also an increase in ACE2 receptor expression theoretically leading to higher availability of viral binding sites.
  • Hydroxychloroquine and thiamine: These are being recommended on the floors. The data available so far are mixed, but we don't have much. It would be worth considering starting chloroquine or hydroxychloroquine for critically ill patients, depending on availability. Antiviral therapy may be effective primarily early in the disease course, before the development of ARDS. Initiating this in the ED is probably the best bet, but this is not routine practice at this time. Remdesivir is emerging as a frontrunner for antiviral therapy, but it is not widely available at this time. It may end up doing more harm than good, but we will know more with further investigation. Our current dosing on the floors is thiamine 200 mg IV Q12 x 6 days and chloroquine 500 mg BID x 5 days. See below for QTc considerations. Also consider G6PD for patients getting chloroquine; that is why it should be sent with labs at admission.
  • Azithromycin: We are not starting this on everyone. Keep in mind that both azithromycin (although mild) and chloroquine are going to prolong the QT, so be careful and aggressively replete Mg and K as needed. The efficacy has yet to be proven.
  • Steroids: The evidence is definitely mixed here. At this time, the limited evidence indicates we SHOULD NOT be giving steroids in the ED for the majority of cases unless there is clear adrenal suppression or the patient is in the late stage of disease (severely elevated D-dimer, CRP, ferritin, or ARDS requiring intubation). Even then, consider collaborating with the ICU team on this decision. The reasoning against giving steroids in early disease is that early steroids increased viral load in SARS patients. (J Clin Virol. 2004;31[4]:304; https://bit.ly/3bCBgqM.) Steroids would only serve to suppress adaptive immunity theoretically and not help modulate inflammatory response during the early stage of illness. The case study from Wuhan suggested that steroids might help those with ARDS. (Lancet Respir Med. 2020. doi: 10.1016/S2213-2600[20]30079-5. [Epub ahead of print]; https://bit.ly/3dOx4Gz.) They used methylprednisolone 40-80 mg IV daily. As Josh Farkas, MD, noted, dexamethasone could be preferable (7-15 mg daily) because it causes less fluid retention due to lower mineralocorticoid effect, and fluid is a huge issue in these patients, as we have already discussed. (IBCC. March 2, 2020; https://bit.ly/3bGL9nu.)
  • Anticoagulation: This is important for floor care. Prophylaxis is important because of findings of thrombosis with advanced disease.

 

Intubation and Oxygen Therapy

  • Vents are a resource, and many COVID-19 patients need 10 days or more of ventilation. (Lancet Respir Med. 2020. doi: 10.1016/S2213-2600[20]30079-5. [Epub ahead of print]; https://bit.ly/3dOx4Gz; JAMA. 2020. doi: 10.1001/jama.2020.4783. [Epub ahead of print]; https://bit.ly/2wQiXQd; N Engl J Med. 2020. doi: 10.1056/NEJMoa2004500. [Epub ahead of print]; https://bit.ly/2WT5LES.
  • Saving a vent for several days is meaningful. Try to utilize every resource available to prevent intubation of these patients. At our hospital, there is no need to call the MICU for severe hypoxia at this point. Unfortunately, every patient on the floor is developing severe hypoxia. We are currently recommending an NRB at 15L with an NC at 10L underneath with persistent O2 saturation <90% before we even consider intubating for hypoxia. Please send an ABG, and look for other signs of low oxygen delivery to organs such as tachycardia and altered mental status before intubating patients who have low SpO2s and appear well.
  • We are currently not allowed to use high-flow nasal cannula (HFNC) at our facilities because of concern that this will cause aerosolization of viral particles. The Surviving Sepsis Campaign and ANZICS guidelines currently recommend the use of HFNC prior to intubation. (JAMA. 2020. doi: 10.1001/jama.2020.4914. [Epub ahead of print]; https://bit.ly/2RfuShF; ANZICS. March 16, 2020; https://bit.ly/3bz6z5M.)  Michelle Ng Gong, MD, the director of critical care research at Montefiore Medical Center and the chief of critical care and pulmonary medicine at Albert Einstein College of Medicine, both in the Bronx, also recommends HFNC for COVID patients. (AMA EdHub JN Learning. March 23, 2020; https://bit.ly/3dGVcdW.) The WHO guidelines currently recommend HFNC in select patients because there is an unknown amount of aerosolization. (WHO. March 13, 2020; https://bit.ly/2UOPjCW.) Some literature suggests that HFNC does not increase the risk of infection to health care professionals in other disease processes. (PLoS One. 2012;7[4]:e35797; https://bit.ly/2QXGeGA; J Hosp Infect. 2019;101[1]:84; https://bit.ly/3dJz42E; J Crit Care. 2012;27[5]:434; https://bit.ly/2WWBmFD.) Given the increasing degree of hypoxia in these patients, we believe that we should begin allowing HFNC. More adjuncts will save us more ventilators and more ICU beds. HFNC may increase aerosolization but likely not by much, definitely less than intubation, and it likely does not increase the risk of infecting health care workers if airborne precautions are maintained. At a minimum, we should be using HFNC on floors where there are only COVID patients. The practicality of utilizing this in the ED with undifferentiated patients is unclear at this time.
    • If patients are able, have them lie prone while on supplemental oxygen. We have seen significant symptomatic improvement as well as improvement in oxygen saturation on patients who lie prone even if they are not on ventilators.
    • In the ED, if a patient requires a significant amount of supplemental oxygen, please send an ABG. We are considering intubating these patients if they have a PaO2 <60 despite the NRB and NC.
    • We are not intubating anyone just for the work of breathing. These patients generally look terrible on the floor. Please get an ABG and intubate them if they develop respiratory acidosis. They should also be intubated if they are obtunded on arrival. If the ABG shows low CO2 or normal CO2, please try to hold off intubating. See how they do first with all the CO2 flushed out of their system by the NRB and NC.
    • This should be the priority in patients with a very poor expected clinical course (age >80, COPD, diabetes mellitus, coronary artery disease). (JAMA Intern Med. 2020. doi: 10.1001/jamainternmed.2020.0994. [Epub ahead of print]; https://bit.ly/2V3vFTZ; N Engl J Med. 2020. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]; https://bit.ly/3bDobxu;  China CDC Weekly. 2020;2[8]:113; https://bit.ly/2wHYAVv;  Lancet. 2020;395[10229]:1054; https://bit.ly/3bIGQYT.) Let them know if this is COVID-19, then we are likely talking about 10 or more days on the vent. (Lancet Respir Med. 2020. doi: 10.1016/S2213-2600[20]30079-5. [Epub ahead of print]; https://bit.ly/3dOx4Gz; JAMA. 2020. doi: 10.1001/jama.2020.4783. [Epub ahead of print]; https://bit.ly/2wQiXQd; (N Engl J Med. 2020. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]; https://bit.ly/3bDobxu.) And the likely mortality is 50 to 80 percent for patients needing intubation, especially those with pre-existing lung or cardiac comorbidities. (JAMA Intern Med. 2020. doi: 10.1001/jamainternmed.2020.0994. [Epub ahead of print]; https://bit.ly/2V3vFTZ; N Engl J Med. 2020. doi: 10.1056/NEJMoa2002032. [Epub ahead of print]; https://bit.ly/3bDobxu; China CDC Weekly. 2020;2[8]:113; https://bit.ly/2wHYAVv; N Engl J Med. 2020. doi: 10.1056/NEJMoa2004500. [Epub ahead of print]; https://bit.ly/2WT5LES; JAMA. 2020. doi: 10.1001/jama.2020.4326. [Epub ahead of print]; https://bit.ly/2UO0EDm.)
    • If you have to intubate in the ED, consider using rocuronium over succinylcholine. This is not the time to be redosing paralytics. (EMCrit RACC. March 27, 2020; https://bit.ly/2QU4ppB.) Make sure to target deep sedation post-intubation, and assume paralysis for at least 60 minutes after using roc. After paralytics have worn off, please pay close attention to vent synchrony. Target RASS -5 with your sedation package. Discuss starting a Nimbex drip if the patient is still asynchronous with the vent. Start patients on higher PEEPs early. "Changing Ventilation Parameters," a good summary of how to adjust the vent settings, is available in the Brigham and Women's Hospital critical care guidelines at https://bit.ly/2QXxXT2.

 

Operational Changes

COVID-19 hit us hard and fast. We have found that the key to addressing the challenges successfully that came with its onslaught was the ability to adapt to a rapidly changing environment and to reevaluate available resources and layout daily. Mobilizing resources early and quickly ensured that we had the best chance at safely and quickly evaluating and treating patients.

 

Some examples of the changes we made within our hospital and hospital system included:

    • Immediate cancellation of all elective surgeries to open up beds within the hospital.
    • Redeployment of all newly available health care providers to assist with COVID care.
    • Mobilizing as many ventilators as possible.
    • Accumulating PPE, already in short supply, to use for every potential COVID-19 patient.
    • Reformatting spaces near the ED, including our lobby, to be utilized for screening lower-acuity, treat-and-release patients to keep them separate from the general populace.
    • Designating specific spaces in the ED for non-COVID patients, though these are now in the minority.

The findings we describe are dynamic and subject to rapid change based on new evidence as it emerges. We will update these here as often as we can.

The authors thank Michael Pallaci, DO, an emergency physician in Chillicothe, OH, for promoting knowledge sharing.

Dr. Johnson
is the chief resident in emergency medicine at North Shore University Hospital/Long Island Jewish Medical Center. Dr. Gottlieb is an assistant professor of emergency medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health.

table summary gottlieb.JPG

QUESTIONS FROM READERS:
Rebecca Eskew Clawson asked on Facebook: If the QTc is high, do you just not give the hydroxychloroquine or are you just watching more closely? I am assuming it's a hard no if it is >500ms? Still giving Zithromax if heart hx?

Drs. Johnson and Gottlieb respond: This applies if there are no other contraindications to these medications, and the patient has no risk factors for development of arrhythmia or Torsades.

Typically:
If the QTc is < 470ms, you can give hydroxychloroquine and then repeat an ECG two hours after the second dose (of 400 mg). The dose may be adjusted based on changes in the QTc on repeat ECG.

If the QTc is >470ms and <500, then it’s a risk/benefit discussion, but it still might be used with telemonitoring.

If qtc is >500, we do not start it, with very few exceptions.

We are also trending QTc daily. I would monitor anyone at risk for arrhythmia (i.e., LV dysfunction), no matter what their QTc is if starting these medications.

There are other caveats to this, but this is the basic overview. Please check your own hospital protocols for restrictions with the QTc.


Monday, March 30, 2020

The Coronavirus Doesn't Care

BY SANDRA SCOTT SIMONS, MD

Not once in my medical career have I seen a storm anywhere near the magnitude of the coronavirus deluge that is being predicted. It remains mostly on the horizon as I write this in early March, the day after the first two COVID-19 cases were identified in my home state of Virginia.

It feels like the calm before the storm. We hoard hand sanitizer, we watch the media frenzy, we try to ignore the ridiculousness on social media, and we wait, hoping we can find a place to buy toilet paper. We wait for the impending attack by a virulent enemy about which we know frighteningly little. My hope is that what we're dealing with is more akin to influenza than MERS or SARS, but until we have sufficient data, the winds of fear will continue to blow.

goddess.jpg

By the time my fellow EP frontline warriors read this, test-confirmed COVID-19 cases will be pouring down on us. As we're showered with more confirmed cases, we'll have more data to offset the scariness of the unknown. We'll get the answers we need to epidemiological questions about virulence, disease course, at-risk populations, and the fatality rate. As the virus declares itself, however, we may be rudely awakened to a multitude of vulnerabilities in our health care system. There is no truth or weakness the virus is afraid to expose or exploit. It simply doesn't care.

Already Overburdened System
The virus doesn't care if policies benefit Democrats or Republicans, drug companies or hospital administrators, as long as those policies don't put a damper on its foray into more hosts. The virus doesn't care about the stock market, and it pays no mind to what Trump does or doesn't say. While the pundits debate, it will go right on multiplying, blissfully ignorant of any political or economic agenda. Hopefully, we'll follow its lead, stop politicizing and monetizing it, and focus on good medicine.

The virus doesn't care if we run tests to identify who has it; it will happily run its course regardless. The more infected vectors who rush to EDs for testing despite not needing medical intervention, the better the virus is able to spread to health care professionals and vulnerable people who are in the ED for other emergencies. Yes, there are epidemiological benefits to testing everyone, but is it worth the strain on our already overburdened system?

Let's not forget one of the mantras of our specialty: Don't send a test if it won't change management. For patients well enough to quarantine at home, running tests will not only fail to change management but also overwhelm EDs and clinics. The virus will make plain the rude, ugly truth that health care consumers are too focused on knowing precise diagnoses. Folks are going to have to accept a little diagnostic uncertainty and go with presumptive COVID-19.

"But I have to work." The virus doesn't care about our income. The brutal truth is that it's killing septa- and octogenarians, so two weeks of one's pay is small by comparison. That doesn't make it easy, and it will be a struggle for many to refrain from showing up sick for work or sniffling and sneezing their way into the ED for a work note. We live in a me-centered society where the needs of an individual are often allowed to eclipse the needs of the group, and that mentality will put lives at risk in an outbreak. We undoubtedly cannot rely on the healthy population to responsibly self-sequester, so we must take extra measures to protect people who are at increased risk.

Frustrating Reality
The virus doesn't care how many are ultimately forced to quarantine because it can still linger tenaciously on every elevator button, gas pump, and shopping cart that a carrier touched on his way home to quarantine. The virus doesn't care if you cancel your European vacation, cruise, reunion, or wedding because it's already here and poised to spread; it's just a matter of time. The frustrating reality is that we'll sacrifice our spring breaks, and still ultimately find ourselves surrounded by the virus in our hometowns.

The virus doesn't differentiate between patient and clinician; it's an equal-opportunity infector, so we must protect health care workers. It certainly doesn't care if our colleagues will be pulled into a night or weekend shift if an EP doesn't come to work. Just a small percentage of doctors and nurses being out of commission will lay bare the overly lean staffing practices of corporate medicine.

When COVID-19 further diminishes doctor numbers while ruthlessly increasing patient arrival numbers, then what? We will no longer be able to overcome ED inefficiencies and throughput obstacles by sheer might and will power (i.e., hustling our butts off). If the virus is as devastating here as it was in the initial firsthand reports from northern Italy, we are going to need more than our usual hard-working A game; we are going to need more resources. How will it play out when the 100,000 ventilators in this country, for example, are not enough?

As we start dealing with this apathetic jerk of a virus, we're going to stumble and do things imperfectly. When the music stops, there will be complainers, the Monday morning quarterbacks who say we could have and should have done more and done better. That's the nature of emergency medicine. We frequently make life-or-death decisions with little to no information and limited resources. It will be easy, as you're reading this, to look back critically at our mistakes over the past few months. Don't judge us for difficult mass casualty decisions we might have to make. The virus won't be looking back. It doesn't care about pointing fingers and assigning blame. The virus will be spreading onward, so we must focus our energy not on what we screwed up yesterday but on how we will handle it tomorrow.

Are we ready? Is anyone ever ready for a pandemic? I know EPs in the trenches are going to give it everything they have to lead the way through the chaos and help their communities. Whatever happens, we will always have one advantage the virus doesn't: We care.

Dr. Simons is a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns at http://bit.ly/EMN-ERGoddess.


Thursday, March 26, 2020

EDs Should Hoard Every Gown and Surgical Mask and Lock Up N95s

BY MARK MOSLEY, MD, MPH

Every great hero movie has a moment when the enemy is closing in. Everyone in the audience wants the hero to save the day, but he has only one shot. Too early or too late, and we all die. He has to make it count. You hear the hero whisper to himself, “Wait for it, wait for it, wait…now!” Timing is critical for survival.

And the timing must depend on the conditions—the location, the site, and the particular circumstances at that moment. Each emergency department is a separate battalion with its own stockpile of human and material resources. We will not meet this virus at the same time or in the same way. We will blow a quarter or half of all our materials before we need them if a small rural ED in the South or a freestanding emergency department in a medium-sized midwestern town follows the protocols of a large metropolitan city like New York.

Every unnecessary COVID-19 test and every unnecessary gown and mask we use today is one we won’t have two weeks from now when they may be lifesaving. This is all about timing and using our resources at the right moment. Perhaps as you are on shift tonight you will see boxes of surgical masks and N95s. You should know that federal officials have said the strategic national stockpile contains just one percent of the masks that experts predict could be needed for this pandemic. There are plans to add 500 million N95 respirators to the stockpile, but that could take up to 18 months. (Los Angeles Times. March 21, 2020; https://lat.ms/33OjYUV.)

How do we control our fear not to pull the trigger when someone comes to work and says his cousin is an ICU nurse in Seattle and that everyone working in the ED there is wearing a mask? Or the highly respected doctor who walks down the hospital hall with a N95 on? How do you calm yourself when you aren’t the lucky soldier issued a helmet?

Knowledge is power. And that power will allow us to calm that fear. We must start with the knowledge that diagnosis is not usually helpful for the vast majority of emergency patients unless we also have a treatment. Indiscriminate testing will use up our precious materials. For every false-positive, two or more tests prove a patient is negative. Our primary objective is the timing of human and material resource utilization.

Respiratory Protection
The Centers for Disease Control and Prevention has stated that we are to “minimize the number of individuals who need to use respiratory protection.” They recommend using alternatives to N95 respirators, and they allow for extended use or limited use under shortages without knowing their effectiveness in this situation. (CDC. March 28, 2018;
https://bit.ly/2QLwfnM.)

The types of respiratory protection in the ED are surgical masks (molded cup and pleated paper), N95 respirators, and Elastrometric respirators (they look like grasshoppers). Everything is not a mask. Most EDs will have surgical masks or N95s.

Pillars of Knowledge
I propose several pillars of basic knowledge from which we should build our recommendations and protocols. Granted, there will always be important exceptions (e.g., an ED staff member on immunosuppressive drugs), but the exceptions do not change the foundation.

COVID-19 is spread predominantly by large droplets. Airborne particles and fomites appear likely, and they may not routinely come into play with noncritical respiratory patients, especially with a no-touch or one-touch physical exam.

Surgical masks are not necessary for ED staff unless they are seeing a potential COVID-19 patient for respiratory symptoms. If you are sick, you should be home rather than work with a surgical mask on. The surgical mask is intended primarily for sick people, not healthy ones. Its purpose is to block water droplets from being coughed or sneezed out by the wearer. It does not prevent airborne virus from coming into the health professional’s nose or mouth (respiratory therapists doing nebulizations and suctioning are exceptions). Healthy people should not be wearing surgical masks around the community unless they are sick. And why are they out if they are sick?

N95s have proven more effective than surgical masks in vitro to block airborne viral particles, but have not proven better than surgical masks in vivo for real-life situations (whether this is because of improper usage is unknown). (JAMA. 2019:322[9]:824, https://bit.ly/2JkeFTY; CMAJ. 2016;188[8]:567, https://bit.ly/2Jh6Q15.)

You don’t need an N95 for noncritical respiratory patients, and you certainly don’t need one in any routine medical situation or community activity. The CDC agrees that a surgical mask is an acceptable alternative to an N95. (CDC. March 28, 2018; https://bit.ly/2QLwfnM.)

N95s in the ED are needed for all known COVID-19, critical respiratory, and intubated patients and for those on noninvasive positive pressure ventilation, undergoing CPR, with peritonsillar abscess, and perhaps for a small handful of other critical situations.

Finally, we should be reminded regularly that there are no good scientific data from the 2009 H1N1 epidemic that surgical masks or N95s actually decrease infection rates. (Emerg Infect Dis. 2009:15[2]:233; https://bit.ly/2WN6SGe.) The recommendations to use respiratory protection is based on public health judgment. This makes complete intuitive sense and should be followed.

The CDC has been wise to emphasize that the recommendations should be used in the context of local circumstances. If you work in the ED of a respiratory-designated hospital in a large city and patients are coughing and dying around you, your approach to respiratory protection, given your site-specific local circumstances, will be different from a freestanding Kansas ED where you are in the bunker drinking coffee and having the slowest shift in 25 years. Again, our primary objective is the timing of human and material resource utilization.

Finally, there are laws of unintended consequences in which the desire to protect our patients, ourselves, and our families lead us to use surgical masks and N95s (and do COVID-19 tests) unnecessarily, which can lead to increased spread. The CDC recommendation is for those wearing a single-use surgical mask to wear and dispose of them properly. How many patients have you met already where the mask is below their nose and not covering their chin and they leave it behind when they leave? How many health professionals wearing a single-use disposable surgical mask all day pull it down to talk, drink, or eat? One study of nurses showed that nurses touch their faces an average of 25 times each shift. (Am J Infect Control. 2013;41[12]:1218.)

How many times have you seen a surgical mask on a counter and not known if it is new or used? The surgical mask worn or used incorrectly becomes a viral grenade with the pin half out. Wear a surgical mask if you are sick at home, and wear a mask for another week if you are better after seven days and return to work. You may want to wear a surgical mask if you are working closely with those at high risk (e.g., elderly in a nursing home).

And then there are bandanas for which we have absolutely no data and are reserved as a last resort, but we know they are no longer as effective if they become moist (like a surgical mask but worse). A surgical mask or a bandana that is reused, even if in a limited way, is at great risk for self-inoculation and ineffectiveness. (J Occup Environ Hyg. 2014;11[8]:115; https://bit.ly/2xohdO2.) The kind people making these for us is heartwarming, but it is unclear if it is safe to use in our emergency departments (except out of desperation).

Using N95s can also have unintended consequences. Does everyone with a beard and mustache shave them off to use an N95 appropriately? What about not being able to see the video screen during intubation because your glasses are all fogged up? The N95, depending on site-specific location and circumstances, should be used sparingly in the majority of EDs for now. Estimated tolerance for a tight-fitting N95 on a nonbearded person is about an hour at most. And they are less effective if they get moist on the inside, like surgical masks.

Our legitimate fears about running out of N95s prompted the CDC to make allowances for them to be reused no more than five times with a potentially impractical recommendation to store them in between patients in a brown bag. Contrary to hearsay, you can’t use cleansing agents to sterilize them for reuse. Perhaps, this is why the CDC prefers extended use over reuse. How many N95s will a single staff member burn through in a 12-hour shift?

As I write this, our emergency medicine colleagues are sending messages from the big cities reporting apocalyptic conditions: no gowns in the COVID-19 ICU, no N95s, few surgical masks. All emergency department patients and many critical care personnel are using loose cloth or toilet tissue to cover their nose and mouth. Meanwhile, some in quieter EDs are gowning up in full PPE with a N95 for an 8-year-old with a runny nose, cough, and diarrhea. We need to post these texts from the big cities and read them like letters from war. The angel of death may be coming. Maybe it will pass over us as we lay quietly, locked down in the bunker of our town.

But there is hope. We must hoard every gown and surgical mask. We must lock up the N95s. Only by holding on to science can we let go of our fear. And if we can just wait, we might have the resources when we need them.

Dr. Mosley is an emergency physician in Wichita, KS.


Wednesday, March 25, 2020

What Should EPs Say about COVID-19 to Discharged ED Patients?

BY MARK MOSLEY, MD, MPH

The March 16 Centers for Disease Control and Prevention recommendations for patients discharged from the ED with COVID-19 begin with two essential caveats that cannot be overemphasized:

  • The CDC recommendations (not requirements) are a moving target and will change with newer and better data. For all I know, they could be revising them right now.
     
  • These recommendations should be made in the context of local circumstances. How these are used in New York City will look dramatically different from how they are used in a small Kansas town. And they should.

    The CDC offers two options for COVID-19 patients: symptom-based or test-based. Symptom-based requires these four criteria to be met:
  • Seventy-two hours must pass after illness is improved.
     
  • Patients must have no fever without antipyretics for 72 hours.
     
  • Patients must have improvement in respiratory symptoms

  • Seven days must have passed since the beginning of symptoms.

    A patient who tested positive for COVID-19 and has no symptoms must wait seven days before returning to work. A patient who tested positive and has symptoms must have two consecutive negative tests and meet the symptom-based criteria above.

    The same two options exist for health care workers with additional recommendations:

  • You must wear a mask at all times at work for at least 14 days following the beginning of your symptoms.

  • You must restrict your interaction with patients who could be viewed as immunocompromised. These conditions are not listed, but I would assume a short list would include at least the elderly; those with COPD, congestive heart failure, diabetes, or HIV; and patients on dialysis, chemotherapy, or immunosuppressive drugs such as those who had a transplant or have rheumatoid arthritis and multiple sclerosis, among others.

    Pragmatic Difficulties

    I am not being critical of the CDC; this is a moving target, and we will all have to make modifications daily, sometimes twice a day. But there are some issues with this approach:

  • We will (or should) move to a no-test recommendation for all outpatients from EDs, minor emergency clinics, health clinics, and drive-through testing sites. We need a good test with the highest specificity and highest sensitivity we are able to achieve with almost no false-negatives and an attempt to minimize false-positives. We need to use this test very selectively in our sickest patients in the highest areas of prevalence, so that we have enough tests, reagent, and human and material resources to do rapid target testing. If we open this up to anyone who drives a car through a line or comes to the ED, we will run out of tests. We will need the CDC testing option for those equine tests that have already been let out of the barn, but I believe the testing option will become a moot point for the vast majority of EDs.

  • Telling a patient four different if-then scenarios is like teaching a 5-year-old how to play baseball. There are too many rules that will be misunderstood. I had to read the CDC recommendations multiple times, and this is my profession. Am I supposed to translate this into understandable language for the patient?

Here are details in the CDC recommendations I take issue with:

  • No fever without antipyretics for 72 hours. For how many decades have we been saying that a 99°F temperature or even 100°F is not a low-grade fever? And how many times do we say a shift, "Even if your normal temperature is 96°F, we don't call it a fever until it is greater than 100.4°F"? And then you have the whole axillary thing and adding a degree. What if they are taking an NSAID or acetaminophen for myalgias or headache or some flu elixir bought over the counter that has an antipyretic in it? How are we going to tell patients not to take anything for fever, headache, and body aches for 72 hours and then check their temperature regularly to see if their fever is gone?

  • Improvement in your respiratory symptoms for 72 hours. Improvements are too subjective and may not be clearly linear. Do you have to start over if you have two really good days and a really lousy evening? Can any of us really keep track of 72 hours of anything? What if a patient smokes and has a cough for the next three weeks or the next two months?

  • Seven days from the beginning of your symptoms. How many patient interviews have you had where you spent a couple of minutes with the patient, family, and friends trying to figure out when a condition began? It's not easy and takes detective work. We will hand them a paper like the one from the CDC that asks them to count seven days from the start of symptoms and 72 hours after symptoms are improving and not to use antipyretics or over-the-counter products for 72 hours and to determine if respiratory symptoms like coughs are improving for 72 hours. This is a Little League infield pop fly with men on first and third with one out and not enough volunteer parents to coach first and third. We just stand on base with everyone yelling.
     
  • We need to play soccer on this field. Tell everyone we are not testing. Tell all patients if they have a fever, cough, sore throat, difficulty breathing, or flu-like symptoms to stay home under quarantine-type conditions (and you figure out with them the day this started and add seven days and write down the date). Tell them they can go back to life (with restrictions if it's a health care worker) if they are feeling much better with minimal cough and no fever. If they have a cough but it is better, wear a mask for another week. Then write them a work note for the entire time; employers will demand this kind of hard date.
     
  • The no-test return seven days after beginning of symptoms if better. Saying that everything depends on the context of the local circumstances is so much easier to understand for all of us. With simplicity comes compliance. At least we are on the same field knowing where to run to make our goal.

    Dr. Mosley is an emergency physician in Wichita, KS.

CDC Resources

Discontinuation of Home Isolation for Persons with COVID-19 (Interim Guidance)” https://bit.ly/2vNTPci.


Criteria for Return to Work for Healthcare Personnel with Confirmed for Suspected COVID-19 (Interim Guidance)https://bit.ly/2UfRXT8.