Has the Emergency Department Ever Been More Boring — or Terrifying?
After an exhaustingly long day, a group of us were still discussing “fomites,” objects that can carry contagious particles. Dr. Anil Shukla, chair of emergency medicine at St. Luke’s Hospital in New Bedford, Massachusetts, had just laid out for us when, where and how he planned to take off his scrubs after a shift, and where in the garage and for how long he would quarantine said scrubs, prior to washing.
“You should write a book about this,” someone said to me — I was a journalist before I was an ER doctor, so I get this a lot. Before I could squelch the idea, they were already on to debating Hollywood megastars who might portray us, when the book became a movie.
I replied, “This would be the most boring movie in the history of cinema.”
Planning future laundry — to me this doesn’t scream bestseller list.
Nor would Hollywood likely share our excitement over how, in one single, magical afternoon, we had collectively changed a longstanding workflow for obtaining and reading EKGs — nasty pink paper fomites, carried filthily out of rooms 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 EKGs are obtained, delivered and interpreted, in a 96,000-annual 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.
Tomorrow we are told we’ll be overwhelmed, but for now, emergency department volume across Massachusetts has actually been low.
Many who would normally come to an ED are avoiding it, because pandemic.
Those who do come are discharged home with ruthless efficiency or they are whisked upstairs — lots of room at the inn ever since we cancelled elective surgeries. It leaves the emergency department in an odd lull.
(Don’t say the Q word. Just as actors will speak of “the Scottish play” instead of saying Macbeth, ER doctors and nurses will never describe the emergency room as “not loud”.) One of our colleagues, Dr. Richard Wolfe, chair of emergency medicine at Beth Israel Deaconess Medical Center in Boston, has characterized this as the moment when the sea goes out, in the hours before the tidal wave arrives.
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We both 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 the COVID-19 illness.
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 or B or 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 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 “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, say, a blood stream 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 wanted to know now was whether the respiratory viral panel could at least rule out a coronavirus like SARS-CoV-2.
Figuring this out (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 — and both swabs and medium are, exasperatingly, also starting to run short, even while tests for COVID-19 virus are only slowly coming on-line.
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 under realities: Study populations in China are reporting significant co-infection rates with COVID-19 and influenza. Yes, you can have both.
So what to do with all of these swabs?
At one hospital where I work, in order to manage our limited COVID-19 test capacity (run through Massachusetts Department of Public Health and still with 2–3 day turnaround times), policy follows DPH rules and we obtain swabs for influenza and a respiratory viral panel 20-target, and theoretically only with those results back a swab for COVID-19. (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 test.
Also, at one of these hospitals, every emergency department physician is ordered to wear a surgical mask at all times; in the other, to conserve masks, staff have been told to stop the foolishness of wearing a mask at all times.
For a handful of ED doctors who work 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 might have COVID-19; we tell healthcare 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 might have COVID-19, stay home two weeks; if you definitely have it, stay home one week. Got it?)
As EMS medical director I help manage 911 system paramedics throughout my region. One company calls 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’d 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 kit — masks, gown, eye protection and gloves — “you are contributing to panic!”
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Many of my colleagues and I huddled this week around a podcast interview with a physician from Bergamo, Italy. Dr. Roberto Cosentini’s hospital in a village north of Milan is comparable in size to ours in Massachusetts, and it was sobering to hear his account.
On February 15, well aware that nearby Lodi, Italy, was deep into 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 3 to 4 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 pneumonias a day at peak, all of them requiring hospitalization and respiratory support, usually a full ventilator.
As of the podcast March 14, Dr. Cosentini said they’d seen and admitted 400 sick pneumonias over just the previous 10 days (at an 800-bed hospital). The patients all have prolonged stays in-house, he warned, at least 7 to 10 days on ventilators.
In southern Massachusetts, our entire 3-hospital system has 815 beds. Admitting 40–80 sick pneumonias a day, every day, for 10 days, with none of them getting discharged — that 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 healthcare workers are already falling ill with it, some of them severely: A nurse in her 30s, intubated at a mid-west hospital. An ER doctor 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 Wednesday 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. He was among 110 out of 600 doctors in the province of Bergamo who have fallen ill with COVID-19.
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, or even PAPRs (Powered Air Purifying Respirators), 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 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 single-use N95 mask. It turns out it can be soaked in bleach, baked in ovens (at from 80 to 120 degrees for a half hour), microwaved on high for 2 minutes, gas-sterilized with hydrogen peroxide, or irradiated under an ultraviolet bench lamp for 45 minutes. Microwaving seemed problematic, since most N95 masks have small metal staples and a metal nosepiece — but in these studies they microwaved them anyway. They reported no damage to the microwave, and only a very few N95 models that melted or burnt. The majority were microwaved up to 3 times in a row with no loss of lab-tested filtration integrity.
And so something once billed as “throw away after encounter” now gets my name written on it in magic marker, to be worn all shift, put into a paper bag, and set aside for a rainy day. We’ve asked the local college biology department (shut down anyway) if they have any UV light benches to spare, but in the meantime the microwave in the nurse’s breakroom looks promising.
Matt Bivens, MD, is an emergency medicine physician at St. Luke’s Hospital in New Bedford and at 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. A version of this article was published first at Emergency Medicine News.