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COVID-19 Advice from EM Doctors in the U.S. and Italy

Andrea Duca, MD - Milan, Italy / Interview by Sam Ashoo, MD, FACEP

Yesterday I interviewed Dr. Andrea Duca, an EM boarded physician in Milan, Italy. I learned a lot during the VERY sobering interview with him. If you'd like to listen, the episode is live here:

blubrry.com/emplify/57487286/...

or you may search your podcast app for "EMplify" and listen there instead.
Scary stuff... like looking into our potential future.

Colleague from Pacific Northwest

For those of you who haven't hit the surge yet: please pay close attention.  Demand that your hospital get ready. Don't be passive. If your admins don't get it, go above and beyond until someone listens or do it yourselves.

Important things to have in play in no particular order:

1. The surge starts suddenly. We went from low low volumes for a week and then one day the waiting room was full of respiratory patients.  Don't be lulled by the lull.
2.  Get a Plan to have admitted patients tested and cohorted. There won't be room for all the ISO's. Testing should be more available soon and allow for this
3. Find safe treatment area for non-covids.  Cafeteria, lobby etc.
4. Get a tent. Yesterday. Some are using it to screen non respiratory, others respiratory that can go home.  Just get one and use it how you need to. You will need it.
5. Get an intubation team plan. Many places have anesthesia do all intubations. Be clear who is in the room and wearing what gear.  There are hepa filters for the bag and vent.  Order these now.  Some folks have a plastic like tent for the intubation space to contain particles.
6. Discuss changing your schedule to benefit the staff.  When you are at work, give each other breaks to get non covid air.  Cut staff down to a minimum to avoid constant exposure.  Spread out your shifts if you can.
7.  Leave all your crap at home. Get a plastic bag to hold any necessities like your phone and id. You will start to feel like you are trailing virus everywhere and this will help keep home clean. Ditch your fleece or white coat.
8. Assume every patient has it. Weird presentations have included: diverticulitis, alcohol withdrawal, diarrhea. GI only is not unusual. Afebrile is not unusual. Finding many on belly CTs that show lung bases with viral pattern.  X-ray liberally. I'm starting to think toe fractures might need a chest X-ray.  If you saw them yesterday and they were fine and they come back, get another X-ray

Dr. Vasquez, Arizona

Read this study on 3/17.  It's a well done study worth reading.  By 3/18 I was emotionally prepared for what is to come.  There are some very important conclusions to take from this for Emergency physicians.  Take them for what you will, but I invite discussion (although admittedly they sound not happy)

Conclusions:

  1. No matter what we do, all ER's will be overwhelmed starting mid April and it will last until July/August
  2. There are only so many of us in ER/EMS and our responsibility will shift from saving all lives to saving what we can
  3. ER's are not going to be able to care for our "normal" business AND the pandemic
  4. Standard of care (which has always been greatly dependent on supply) will suffer
  5. This means a lot of people are going to die, either from COVID19 and/or from possibly preventable diseases that suffer from lack of access or resources (ex: sepsis, asthma, stroke, MI, trauma)

So for me, I'd propose each state ACEP chapter ask some questions to your hospital and political leaders:

  • What messaging can be done to reduce use of the ER for "normal" business?  PCP's offices need to stay open and have a way to deal with issues OTHER than sending them to the ER
  • What plan can hospitals put in place to limit care for patients if intubation isn't enough?
  • What plan is there for the deceased if morgues are full?
  • Can the public be asked to bring in their N95's that they bought last month and donate them to EMS/hospitals?

I apologize if this is morbid but...

Dr. Todd Taylor

Impact of non-pharmaceutical interventions to reduce COVID19 mortality and healthcare demand

Imperial College COVID-19 Response Team - 16 March 2020

Attached & at: www.imperial.ac.uk/media/imperial-college/medicine/sph/...

SUMMARY OF SALIENT POINTS

·         For an unmitigated epidemic, the authors predict critical care bed capacity would have been exceeded as early as the second week in April, with an eventual peak in critical care bed demand 30 times greater than the maximum supply (Figure 2).


·         It is necessary to balance the timing of introduction of mitigation with the scale of disruption imposed and the period over which the interventions can be maintained. In this scenario, interventions can limit transmission to the extent that little herd immunity is acquired – leading to the possibility that a second wave of infection is seen once interventions are lifted.

·         The most effective combination of interventions is predicted to be a combination of case isolation, home quarantine and social distancing of those most at risk (those over 70 to demand on critical care capacity).

·         In combination, this intervention strategy is predicted to reduce peak critical care demand by 2/3 and cut deaths in half.

·         However, this "optimal" mitigation scenario would still result in an 8-fold higher peak demand for critical care beds above capacity in both Great Brittian and the US.

·         Stopping mass gatherings is predicted to have relatively little impact because the contact-time is relatively small compared to the time spent at home, in schools or workplaces and in other community locations such as bars and restaurants.

·         The single most impactful suppression strategy is quarantine of entire families at the first sign of infection.

·         Our results demonstrate that it will be necessary to layer multiple interventions, regardless the overarching policy goal.

·         Overall, our results suggest that population-wide social distancing applied to the population as a whole would have the largest impact; and in combination with other interventions – notably home isolation of cases and school and university closure – has the potential to suppress transmission below the threshold of R=1 required to rapidly reduce case incidence.

·         A minimum policy for effective suppression is therefore population-wide social distancing combined with home isolation of cases and school and university closure.

·         To avoid a rebound in transmission, these policies will need to be maintained until large stocks of vaccine are available to immunize the population – which could be 18 months or more.

·         We therefore conclude that epidemic suppression is the only viable strategy at the current time.