Has the Emergency Department Ever Been More Boring — or Terrifying?
BY MATT BIVENS, MD
After an exhaustingly long day, a group of us were still discussing
fomites, objects that can carry contagious particles. Anil Shukla, MD, the chair
of emergency medicine at St. Luke’s Hospital in New Bedford, MA, had just laid out
for us when,
he planned to take off his scrubs after a shift and where in his garage and for
how long he would quarantine said scrubs before bringing them in for washing.
“You should write a book about this,”
someone said to me . I was a journalist before I was an EP, so I get this a lot.
Before I could squelch the idea, they were already debating Hollywood megastars
who would portray us when the book was made into a movie. “This would be the most
boring movie in the history of cinema,” I replied.
Planning future laundry doesn’t scream
bestseller. Nor would Hollywood share our excitement over how, in one single magical afternoon, we
had collectively changed a longstanding workflow for obtaining and reading ECGs — nasty
pink paper fomites carried filthily to physicians — to an entirely paper-free, germ-free,
But to us, coming on top of dozens
of other frantic preparations for a predicted wave of sick patients with contagious
viral pneumonia, this was an achievement of note. A revolution in how ECGs are obtained,
delivered, and interpreted in a 96,000- visit emergency department conceived and forced through in a single
day? The stuff of legends. Clear your schedule, Brad Pitt!
That’s the geekfest today anyway.
We are told we’ll be overwhelmed
tomorrow, but emergency department volume across Massachusetts has actually been
low so far. Many who would normally come to the ED are avoiding it because of
the pandemic. Those who do come are discharged home with ruthless efficiency or
they are whisked upstairs — lots of room at the inn since we cancelled elective
surgeries. It leaves the emergency department in an odd lull.
Just as actors speak of “the Scottish
play” instead of saying Macbeth, EPs and ED nurses will never describe the emergency
department as “not loud”—the dreaded Q word. (The Telegraph. Sept. 18, 2015;
One of our colleagues, Richard Wolfe,
MD, the chair of emergency medicine at Beth Israel Deaconess Medical Center in Boston,
has characterized this as the moment when the sea goes out before the tidal wave
No More Chin-Stroking
We are and are not prepared. It is maddening that there is still only
limited access to a quick test for SARS-CoV-2, the coronavirus that causes COVID-19.
A swab of the nose or throat can capture viral particles in human secretions, which
in turn can be tested for viral RNA. It’s like finding human DNA at a crime scene.
This is routine medicine. It’s the same type of molecular assay we use for detecting
influenza A and B and many other respiratory viruses.
I work at two hospitals, St. Luke’s
in New Bedford and Beth Israel Deaconess Medical Center in Boston. At one of these
hospitals, we have had a relatively recent addition, an expensive little gem called
the viral respiratory panel-20 target, which proudly detects 20 different viruses — adenovirus,
enterovirus, human metapneumovirus, and intriguingly many different flavors of the
To my mind, it’s a useless gimmick.
A few months ago, many of us were carping that these 20 particular adenoviruses
and coronaviruses were mostly just colds — what is the point of running up the bill
to characterize the common cold?
These panels often detect two or even
three different viruses at the same time, suggesting a lot of unrecognized background
colonization. In pre-COVID-19 days, we might debate if it was even safe to use this
novelty test to make medical decisions — what if the patient really has a bloodstream
infection coincidental with an adenovirus? Did the viral respiratory panel, with
its 20 official-sounding targets, encourage premature diagnostic closure?
These days, of course, that chin-stroking
is out the window. All we want to know now is whether the respiratory viral panel
could at least rule out
a coronavirus like SARS-CoV-2. Figuring this out (the answer: no) was exactly the
sort of nerd heroics my colleagues thought might make a book-turned-movie.
Like the flu swabs, it turns out the
viral respiratory panel-20 target uses up nasal swabs and viral culture medium broth — both
of which are exasperatingly starting to run short, even while tests for the COVID-19
virus are only slowly coming online. Meanwhile, initial practices of high-fiving
about a positive flu swab and then telling a patient, “You have influenza, not COVID-19,”
have also collapsed in reality: Study populations in China are reporting significant
co-infection rates of COVID-19 and influenza. Yes, you can have both.
What to do with all of these swabs? At one hospital where I work, to
manage our limited COVID-19 test capacity (run through the Massachusetts Department
of Public Health and still with two- to three-day turnaround times), policy follows
DPH rules: We obtain swabs for influenza and a respiratory viral panel 20-target,
and, theoretically, a swab for COVID-19 only when those results are back. In reality,
many docs order all three right up front. At the other hospital, which is running
short of nasal swab sticks and viral media, physicians have been told to stop ordering
anything other than the COVID-19 test.
Every emergency physician at one of
these hospitals is also ordered to
wear a surgical mask at all times; at the other, to conserve masks,
staff have been told to stop the
foolishness of wearing a mask at all times.
For a handful of EPs who work at both
places, it’s hard to remember what exactly gets you in trouble where. This same
chaos is across the board. Throughout Massachusetts, we have been telling the general
public to self-quarantine for two
weeks if they may
have COVID-19; we tell health care workers who test positive for COVID-19 that
they can return to work in one
week, provided all symptoms have been resolved for three days. (So,
if you may have COVID-19,
stay home two weeks;
if you definitely
have it, stay home one
week. Got it?)
As an EMS medical director, I help
manage paramedics throughout my region. One company called to say a hospital stopped
a crew arriving with a patient to ask screening questions and take the crew’s temperature
at the ambulance bay entrance, — and then refused to let one of the paramedics in
because she had recently been to Mexico! The paramedic was asymptomatic; the CDC
was not flagging Mexico travel at the time; could this paramedic still work? Like
a good doctor, I made an utterly arbitrary decision and made it sound authoritative:
“She can work but has to wear a mask, and check her temperature twice a day for
Staff at one emergency department recently
berated the paramedics for not wearing masks and gloves upon arrival with a patient
who had no particular viral symptoms — “Anything could be COVID-19!” — while staff
at another emergency department yelled at paramedics for showing up with a similar
case in full protective gear — masks, gown, eye protection, and gloves — “You are
contributing to panic!”
Lessons from Italy
Many of my colleagues and I huddled this week around a podcast interview
with a physician from Bergamo, Italy. (St. Emlyn’s. March 14, 2020; https://bit.ly/2vHLOFK.) Dr. Roberto Cosentini’s
hospital in a village north of Milan is comparable in size with ours in Massachusetts,
and it was sobering to hear his account.
On February 15, well aware that nearby
Lodi, Italy, was deep in a surge of COVID-19 pneumonias, he went on a fact-finding
visit to an emergency department there. He came back and adopted the Lodi model,
immediately dividing his entire department in half to isolate COVID-19 on one side.
(Podcast listeners around the world including us have followed suit.)
By February 21, cases started trickling
in. “We had time to prepare because the first phase of the epidemic is typically
smooth, with an upper airway presentation: cough, pharyngitis. So, we had three
to four days to recognize it was arriving because it was the exact same phenomenon
as in Lodi,” he said.
A second phase was notable for prostrating,
prolonged fevers. These cough, sore throat, and fever cases amounted to about 150
people over a week or so. Then came the pneumonias. Up to 80 sick pneumonia
patients a day at the peak, all of them requiring hospitalization and respiratory
support, usually a full ventilator.
As of the March 14 podcast, Dr. Cosentini
said they had seen and admitted 400 sick pneumonia patients over just the previous
10 days (at an 800-bed hospital). The patients all have prolonged stays, he warned,
at least seven to 10 days on ventilators.
In southern Massachusetts, our entire
three-hospital system has 815 beds. Admitting 40-80 sick pneumonia patients a day,
every day, for 10 days, with none of them getting discharged would be very bad.
Even limited COVID-19 testing has unmasked
this highly contagious virus in all 50 states. We are told it is on the way, and
health care workers are already falling severely ill with it: A nurse in her 30s,
intubated at a Midwest hospital. An EP in his 40s in critical condition in Washington
state; another in his 70s in his New Jersey hospital’s ICU. All against the background
of events in Italy where Dr. Marcello Nataly died March 18 at age 57 from COVID-19,
after sounding the alarm about the failure of his hospital to provide enough masks,
gloves, and other personal protective gear. (Business Insider. March 20,
2020; https://bit.ly/2Ut26Le.) He was among
110 of 600 doctors in the province of Bergamo who have fallen ill with COVID-19.
(Newsweek. March 19, 2020; https://bit.ly/3bnUL6y.)
Reports about this have some on the front lines of emergency medicine
insisting on more protective gear — not just gloves, eye protection, gowns, and
masks but booties and bouffants, and even powered air purifying respirators (PAPRs),
hoods with air hoses we’ve practiced donning and doffing this week for encounters
with the sickest cases.
In contrast, leaders of hospitals and
ambulance services across the region — a step back from the front but acutely aware
that the cupboards are bare — have been pulling in the opposite direction, trying
to ration supplies of protective gear that we never expected to run short. Who knew
the public would develop a craze for the scratchy, uncomfortable N95 face mask?
Old studies have been dug up about
ways to reuse the supposedly single-use N95 mask. (https://bit.ly/2y3diGO.) It turns out it can be
soaked in bleach, baked in ovens (at 80-120° for a half hour), microwaved on high
for two minutes, gas-sterilized with hydrogen peroxide, or irradiated under an ultraviolet
bench lamp for 45 minutes. (Ann Occup Hyg. 2009;53:815; https://bit.ly/3dqRXXM.) Microwaving seemed problematic
because most N95 masks have small metal staples and a metal nosepiece, but they
microwaved them anyway. They reported no damage to the microwave, and very few N95
models melted or burned. The majority were microwaved up to three times in a row
with no loss of lab-tested filtration integrity.
Something once billed as one-time use
now gets my name written on it in magic marker, to be worn all shift, put into a
paper bag, and set aside for future use. We’ve asked the local college biology department
(closed anyway) if they have any UV light benches to spare, but in the meantime
the microwave in the nurse’s breakroom looks promising.
Dr. Bivens is an emergency physician at St. Luke’s Hospital in New
Bedford and Beth Israel Deaconess Medical Center in Boston. He is also an EMS medical
director and works on disaster response and preparedness for Southcoast Hospitals
Group, which includes St. Luke’s. Follow him on Twitter https://twitter.com/matt_bivens.