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Monday, March 23, 2020

BREAKING NEWS: COVID-19 Chaos and Boredom

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, where, and how 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, computer-only system.

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; https://bit.ly/39caIet.)

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 arrives.

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 coronavirus.

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.

Different Rules
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 one week.”

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.)

Limited Supplies
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[8]: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.

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