Maimonides Medical Center (MMC) is Brooklyn’s largest hospital, an academic quaternary care center with, in normal times, 711 total beds, 66 intensive care beds, and an Emergency Department that treats approximately 120,000 patients per year.
On March 9, the first patient with a novel coronavirus infection was admitted to MMC. At its peak, on April 9, there were 471 patients with confirmed or suspected COVID-19 admitted to the hospital, with 139 patients designated to be occupying a critical care bed and 184 patients receiving mechanical ventilation. On May 7, after 2 months of strict physical distancing across the city, the hospital discharged its 1000th COVID-19 patient, as the surge of coronavirus cases that is estimated to have killed 25,000 New Yorkers1 was drawing to a close.
From April 6 to May 3, in response to the rapidly-evolving approach to treatment of severe COVID-19 infection, and to accommodate an unprecedented demand for critical care resources at our institution, we implemented a novel patient care program, the Emergency Department Admitting Team (EDAT), which adapted intensive care paradigms to Emergency Department logistics, staffing, and flow. Every patient admitted to the EDAT was followed to the conclusion of their hospital course; the development of this unit and patient outcomes resulting from its execution are presented here.
In the last week of March and first week of April 2020, hospitals across New York City were overwhelmed with critically ill COVID-19 patients, many of whom had unprecedented oxygen requirements. Endotracheal intubation was the dominant treatment modality during the initial phase of the NYC surge,2-4 and ICU capacity was quickly saturated. Frontline providers pivoted to noninvasive oxygenation strategies,5-7 but these patients required a level of care exceeding the capabilities of a general medical ward. At the same time, emergency department (ED) arrivals for conditions not related to COVID-19 dropped precipitously.
In response, we determined that the safest way to care for critically ill COVID-19 patients who could not be adequately oxygenated on low-flow oxygen (i.e. conventional nasal cannula or face mask) but could be stabilized on noninvasive ventilation (NIV) or high-flow nasal cannula (HFNC), was that they should remain in the ED and cared for longitudinally by the ED team. Because of these patients’ rapidly evolving (and poorly understood) critical illness, holding them downstairs was tantamount to creating a makeshift intensive care unit in the ED.
Administrative logistics demanded that patients receiving ongoing care in the emergency department be formally admitted to the hospital; we were therefore enjoined to admit these patients to ourselves and therefore formed the Emergency Department Admitting Team. At our institution, Emergency Physicians are afforded admitting privileges which had not been exercised previously. A geographic space within the high acuity zone of the department was designated for EDAT patients, all staff entering the zone were required to don full personal protective equipment. Any patient requiring high acuity care not thought to be infected with coronavirus was cared for in a different area that had previously been a low acuity zone, but which was subsequently equipped for resuscitation.
The EDAT was staffed entirely by Emergency Medicine attendings, only one of whom was board-certified in both Emergency Medicine and Critical Care (C.K.S.), and Emergency Medicine residents, in 12 hour shifts. We scheduled providers in blocks of 2, 3, or 4 consecutive shifts (12 hours on, 12 hours off) to facilitate continuity of care. At its peak volume, the EDAT was staffed by 2 attendings and 3 residents per shift. Emergency nursing, technician, and clerical staffing was unchanged compared to usual staffing for the zone, with far higher patient:nurse ratios than allowable in a proper ICU, as all other critical care resources were engaged on the units and were not available to assist in the direct care of these patients.
The criterion for EDAT admission was HFNC therapy, which had been used on a smaller scale in our institution for several years. HFNC was in most cases set up by respiratory therapy. Patients who failed HFNC and required endotracheal intubation (ETI) were transferred to a conventional inpatient service; however many of these patients were delayed in their ascent upstairs and while physically located in the ED remained under the care of the EDAT. Patients who improved on HFNC and could be transitioned to low-flow oxygen were transferred to a lower acuity inpatient service for continued care.
During the study period, there were no established specific therapies for COVID-19. Treatment protocols changed rapidly and were devised by departmental and hospital consensus. The EDAT adopted a hybrid of intensive care and emergency department paradigms; for example, patients were evaluated and transfer of care occurred using a systems-based format, but the primary activity of the physician team was to reassess patients constantly by continuous rounding, as is typical in EM practice.
The focus of treatment for most patients was maintenance and titration of the HFNC, prone positioning, chest physiotherapy, and other forms of supportive care. Particular effort was required to keep family members, who were not allowed in the hospital for risk of contagion, apprised of their loved one’s status.
After admission to the EDAT, documentation was performed on the inpatient electronic health record (EHR), which at MMC is a different platform than the ED EHR. All patients admitted to the EDAT were identified on a daily report and their clinical course abstracted from the EHR onto a structured database by 2 research fellows and 7 emergency medicine residents. The study was approved by the MMC institutional review board.
From April 6 to May 3, 2020, 90 patients were admitted to the EDAT. Of these, 10 patients did not have curative goals of care (i.e. had DNR/DNI orders), 5 patients were transferred from an outside institution, and 6 were determined not to have COVID-19; these 21 patients were excluded from this analysis, as well as a single patient who at the time of this writing was still in ICU after over two months of mechanical ventilation and ECMO, leaving a cohort of 68 patients. All 10 DNR/DNI patients and all 5 transfer patients died; 4 of 6 non-COVID patients cared for by the EDAT died and 2 were discharged. The average number of patients admitted to the EDAT over the study period of 28 days was 11, with a maximum of 23 patients on April 12, 2020.
Results are presented in Table 1. The average age of the 68 patients treated on the EDAT was 65.6 years; 63% of patients were male. 19 patients (28%) were discharged from the hospital and 49 (72%) expired. Of the 49 patients that did not survive, 7 died in the emergency department, 15 died on the medical wards, and 27 died in the ICU. Discharged patients were on average 13 years younger than patients who expired. Hospital length of stay was similar between the two groups.
There were significant differences between the groups in the use of different forms of respiratory support, with discharged patients more likely to receive low-flow oxygen and expired patients more likely to be treated with mechanical ventilation; this likely reflects illness severity rather than negative or positive effects of the oxygenation modality. HFNC was strongly favored at our center over NIV in patients who could not be stabilized on low-flow oxygen, and HFNC use, the focus of EDAT therapy, was similar between the two groups.
Discharged patients were significantly more likely to be treated with convalescent plasma and tocilizumab, with expired patients more likely to be treated with hydroxychloroquine and remdesivir. Because the mortality among EDAT patients decreased in the last half of the study period (10 out of 19 discharged patients presented after April 21), and because therapy choices were often guided by illness severity among rapidly shifting trends in COVID-19 treatment (e.g. hydroxychloroquine fell out of favor), we do not draw causal inferences from these trends. Remdesivir was restricted to critically ill, intubated patients and could only be given via an experimental protocol. Other agents, also part of research protocols, were not similarly limited to intubated patients.
The surge of COVID-19 patients in New York City from late March to April 2020 imposed a crisis of emergency care, the full magnitude and impact of which will require years to measure and reckon with. The crisis was caused predominantly by a deficit in critical care capacity not experienced domestically in modern times, compounded by inadequate testing capability and scientific uncertainty around a novel disease. This uncertainty included a nearly complete absence of data to inform treatment decisions and extended to shifting theories of virus transmissibility and lethality, generating fears magnified by nationwide shortages of personal protective equipment.
The first wave of coronavirus arrivals were mostly stable patients with flu-like symptoms who requested diagnostic testing. During that early phase of the surge, the challenge for Emergency Medicine was to determine which patients required ancillary studies (including COVID-19 testing, which was usually not available) while maintaining the type of infectious isolation precautions customary in normal times. “Hot” and “cold” zones were set up, as well as detached screening/testing locations, and many ambulatory patients were assessed and released without ever entering the ED.
Community spread in early and mid-March advanced unchecked by the use of masks or physical distancing, mitigation strategies not yet embraced by the public. The natural history of the virus therefore quickly replaced the worried well with progressively ill patients who required escalating levels of respiratory support. The city entered lockdown on March 22, and the wide spectrum of illnesses typically seen by emergency clinicians was reduced to steadily worsening presentations of a single disease.
Based on the experience of the earliest outbreaks in China and Italy, emergency physicians adopted a strategy of intubate early, which stipulated that patients who were not stabilized by low-flow oxygen (nasal cannula less than 6 liters per minute) should be managed with intubation and mechanical ventilation.5 This strategy arose from the rapidly progressive oxygen requirements observed in the earliest days of the pandemic, as well as from concerns that noninvasive forms of advanced oxygenation–NIV and HFNC–posed an unacceptable risk of aerosolization of viral particles. However, preliminary data emerging from besieged hospitals in Asia and Europe showed high mortality in intubated patients.8-12 Furthermore, as the magnitude of disease prevalence came into view, it was clear that critical care resources would quickly be exhausted if intermediate oxygenation modalities were not deployed.
Providers across the city therefore moved to NIV and HFNC therapies in the hope that ICU resources would be conserved and patient outcomes would be improved.2,5 Unsedated patients were also able to participate in awake proning, which was demonstrated to improve oxygenation and (at least temporarily) prevent progression to intubation.13-15 These patients were initially admitted to general medicine wards; however, it was quickly learned that their dependence on oxygen was so profound, their disease so unpredictable, and their physiology so fragile that they could not be safely managed behind the closed doors of a typical inpatient unit.
Given the perceived harms of early intubation and the citywide shortage of critical care beds, the EDAT was created to make use of the only available venue to provide acceptable monitoring and treatment of the ongoing surge of patients with severe COVID-19. The team was developed to apply continuous intensive care within a framework designed for, and by clinicians trained in, episodic emergency care. EM attendings and residents were scheduled in shift blocks, with a single intensive care-trained emergency physician providing daily supervision, consultation, and administration. This allowed maximal continuity of patient care within an ED staffing model, as well as rapid reorientation to quickly shifting treatment principles.
EDAT providers contended with myriad challenges. Inpatient-type care relies on a skillset and mindset unlike the focused, compartmentalized attention required of emergency clinicians, and longitudinal management of critically ill patients demands mastery of an even more specialized expertise normally acquired in a 2-year fellowship.16 Usual hospital processes were constantly revised to accommodate repurposed spaces, services and personnel. Clinical testing and treatment protocols changed almost every day. Many critical supplies, especially respiratory equipment, were scarce or unavailable. Providers carried out their tasks using foreign ordering and documentation pathways within an EHR that had to be learned immediately and without training. Additionally, all staff worked with rapidly deployed, unfamiliar equipment, most notably recently acquired ventilators, in addition to novel devices and workflows to reduce viral contagion.17-19 The greatest challenge was the emotional toll of caring for scores of patients suffering from a disease for which there were no known effective treatments and who therefore often deteriorated despite all efforts.
EDAT treatment was centered on the use of noninvasive oxygenation modalities, with most patients managed using HFNC according to a departmental protocol. (Figure 1) Though every patient admitted to EDAT would have otherwise been intubated and placed on mechanical ventilation, and therefore those patients who returned to health may have been well served or even saved by a delayed intubation approach, most EDAT patients ultimately were intubated and the majority of these patients expired. Outcomes did improve over the course of the study period, which, in addition to decreased illness severity, may be the result of one or a combination of factors. As the surge continued, providers developed more comfort with profound hypoxemia and with the assiduous attention to continuous high-flow oxygen therapy that allowed intubation–especially the rushed intubation procedures resulting from patients accidentally coming off oxygen–to be delayed or avoided. Crystalloid infusions, therapeutic anticoagulation (as opposed to prophylaxis), dexmedetomidine (for anxiolysis), and chest physiotherapy were used more liberally over time. Perhaps most importantly, EDAT workflows that were completely new to the department and implemented without the opportunity for vetting or training became more functional and less prone to error as ED staff gained experience and expertise in managing a cohort of critically ill patients dependent on uninterrupted high-flow oxygen.
The optimal oxygenation technique for patients with severe COVID-19 remains controversial and informed by few experimental data.20-22 In our cohort of 68 patients treated according to a HFNC-first paradigm, 18 patients were successfully managed without mechanical ventilation and discharged. However, of the remaining 50 patients who were intubated, only 1 survived. Whether the alarmingly high mortality rates of intubated patients seen in this series (and across all of New York City23-27) during the surge was due to mistimed application of mechanical ventilation, due to other errors in treatments offered or treatments not offered, due to disease severity, or due to the mass casualty dynamics that prevented optimal critical care, is uncertain.
Reuben J. Strayer, MD
Cameron Kyle-Sidell, MD
Daniel Dove, MD
Ashley R. Davis, MD
Eitan Dickman, MD
John P. Marshall, MD
The authors acknowledge the following physicians for their assistance in data collection: Humaira Ali, Elizabeth Fruchter, Suman Gupta, Michelle Haimowitz, Tome Levy, Meagan Murphy, Eric Quinn, Kestrel Reopelle, David Shang, Maisa Siddique, Kazi Sumon, Sabena Vaswani and Jung Yum.
We wish to further acknowledge and salute the Emergency Department staff of Maimonides Medical Center, all of whom confronted and overcame previously unimaginable challenges to providing care to a Brooklyn community struck by the worst public health disaster in a century.
Photographs courtesy of Duncan Grossman, DO.
1. Weinberger DM, Chen J, Cohen T, et al. Estimation of Excess Deaths Associated With the COVID-19 Pandemic in the United States, March to May 2020 [published online ahead of print, 2020 Jul 1]. JAMA Intern Med. 2020;e203391. doi:10.1001/jamainternmed.2020.3391
2. Patel M, Chowdhury J, Mills N, Marron R, Gangemi A, Dorey-Stein Z, Yousef I, Tragesser L, Giurintano J, Gupta R, Rali P. ROX Index Predicts Intubation in Patients with COVID-19 Pneumonia and Moderate to Severe Hypoxemic Respiratory Failure Receiving High Flow Nasal Therapy. medRxiv. 2020 July 3.
3. Ziehr DR, Alladina J, Petri CR, et al. Respiratory Pathophysiology of Mechanically Ventilated Patients with COVID-19: A Cohort Study. Am J Respir Crit Care Med. 2020;201(12):1560-1564. doi:10.1164/rccm.202004-1163LE
4. Zareifopoulos N, Lagadinou M, Karela A, Platanaki C, Karantzogiannis G, Velissaris D. Management of COVID-19: the risks associated with treatment are clear, but the benefits remain uncertain. Monaldi Arch Chest Dis. 2020;90(2):10.4081/monaldi.2020.1342. Published 2020 May 5. doi:10.4081/monaldi.2020.1342
5. Rola P, Farkas J, Spiegel R, et al. Rethinking the early intubation paradigm of COVID-19: time to change gears?. Clin Exp Emerg Med. 2020;7(2):78-80. doi:10.15441/ceem.20.043
6. Berlin DA, Gulick RM, Martinez FJ. Severe Covid-19 [published online ahead of print, 2020 May 15]. N Engl J Med. 2020;10.1056/NEJMcp2009575. doi:10.1056/NEJMcp2009575
7. Alhazzani W, Møller MH, Arabi YM, et al. Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19). Crit Care Med. 2020;48(6):e440-e469. doi:10.1097/CCM.0000000000004363
8. Yang X, Yu Y, Xu J, et al. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study [published correction appears in Lancet Respir Med. 2020 Apr;8(4):e26]. Lancet Respir Med. 2020;8(5):475-481. doi:10.1016/S2213-2600(20)30079-5
9. Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention [published online ahead of print, 2020 Feb 24]. JAMA. 2020;10.1001/jama.2020.2648. doi:10.1001/jama.2020.2648
10. Grasselli G, Zangrillo A, Zanella A, et al. Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy [published online ahead of print, 2020 Apr 6]. JAMA. 2020;323(16):1574-1581. doi:10.1001/jama.2020.5394
11. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published correction appears in Lancet. 2020 Mar 28;395(10229):1038]
12. Barrasa H, Rello J, Tejada S, et al. SARS-CoV-2 in Spanish Intensive Care Units: Early experience with 15-day survival in Vitoria [published online ahead of print, 2020 Apr 9]. Anaesth Crit Care Pain Med. 2020;S2352-5568(20)30064-3. doi:10.1016/j.accpm.2020.04.001
13. Thompson AE, Ranard BL, Wei Y, Jelic S. Prone Positioning in Awake, Nonintubated Patients With COVID-19 Hypoxemic Respiratory Failure [published online ahead of print, 2020 Jun 17]. JAMA Intern Med. 2020;e203030. doi:10.1001/jamainternmed.2020.3030
14. Coppo A, Bellani G, Winterton D, et al. Feasibility and physiological effects of prone positioning in non-intubated patients with acute respiratory failure due to COVID-19 (PRON-COVID): a prospective cohort study [published online ahead of print, 2020 Jun 19]. Lancet Respir Med. 2020;S2213-2600(20)30268-X. doi:10.1016/S2213-2600(20)30268-X
15. Caputo ND, Strayer RJ, Levitan R. Early Self-Proning in Awake, Non-intubated Patients in the Emergency Department: A Single ED’s Experience During the COVID-19 Pandemic. Acad Emerg Med. 2020;27(5):375-378. doi:10.1111/acem.13994
16. Jayaprakash N, Pflaum-Carlson, Gardner-Gray J, et al. Critical Care Delivery Solutions in the Emergency Department: Evolving Models in Caring for ICU Boarders [published online ahead of print, 2020 Jul 8]. Ann Emerg Med. 2020;S0196-0644(20)30349-8. doi:10.1016/j.annemergmed.2020.05.007
17. Ponnappan KT, Sam AF, Tempe DK, Arora MK. Intubation box in the current pandemic – helps or hinders? [published online ahead of print, 2020 Jun 30]. Anaesth Crit Care Pain Med. 2020;S2352-5568(20)30127-2. doi:10.1016/j.accpm.2020.06.011
18. Malysz M, Dabrowski M, Böttiger BW, et al. Resuscitation of the patient with suspected/confirmed COVID-19 when wearing personal protective equipment: A randomized multicenter crossover simulation trial [published online ahead of print, 2020 May 18]. Cardiol J. 2020;10.5603/CJ.a2020.0068. doi:10.5603/CJ.a2020.0068
19. Lau YF, Wei W, Lau CP. Are stethoscopes risky in COVID-19?. Postgrad Med J. 2020;96(1137):431. doi:10.1136/postgradmedj-2020-138085
20. Tobin MJ, Laghi F, Jubran A. Caution about early intubation and mechanical ventilation in COVID-19. Ann Intensive Care. 2020;10(1):78. Published 2020 Jun 9. doi:10.1186/s13613-020-00692-6
21. Marini JJ, Gattinoni L. Management of COVID-19 Respiratory Distress [published online ahead of print, 2020 Apr 24]. JAMA. 2020;10.1001/jama.2020.6825. doi:10.1001/jama.2020.6825
22. Gattinoni L, Marini JJ, Busana M, Chiumello D, Camporota L. Spontaneous breathing, transpulmonary pressure and mathematical trickery. Ann Intensive Care. 2020;10(1):88. Published 2020 Jul 8. doi:10.1186/s13613-020-00708-1
23. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area [published online ahead of print, 2020 Apr 22] [published correction appears in doi: 10.1001/jama.2020.7681]. JAMA. 2020;323(20):2052-2059. doi:10.1001/jama.2020.6775
24. Petrilli CM, Jones SA, Yang J, et al. Factors associated with hospital admission and critical illness among 5279 people with coronavirus disease 2019 in New York City: prospective cohort study. BMJ. 2020;369:m1966. Published 2020 May 22. doi:10.1136/bmj.m1966
25. Goyal P, Choi JJ, Pinheiro LC, et al. Clinical Characteristics of Covid-19 in New York City. N Engl J Med. 2020;382(24):2372-2374. doi:10.1056/NEJMc2010419
26. Paranjpe I, Russak A, De Freitas JK, et al. Clinical Characteristics of Hospitalized Covid-19 Patients in New York City. Preprint. medRxiv. 2020;2020.04.19.20062117. Published 2020 Apr 23. doi:10.1101/2020.04.19.20062117
27. Gayam V, Chobufo MD, Merghani MA, Lamichanne S, Garlapati PR, Adler MK. Clinical characteristics and predictors of mortality in African-Americans with COVID-19 from an inner-city community teaching hospital in New York [published online ahead of print, 2020 Jul 16]. J Med Virol. 2020;10.1002/jmv.26306. doi:10.1002/jmv.26306
In the beginning, there was awake blind nasal tracheal intubation, a brutal and often unsuccessful technique that thankfully disappeared when non-anesthesiologists gained access to paralytics. The primary tool for emergency airway management then became the traditional laryngoscope, a device little improved since the 1940s, until the advent of video laryngoscopy in the early 2000s which changed everything.
The age of VL was ushered in by the 2001 Glidescope, which simultaneously introduced two technologies: video (putting a camera at the end of the blade and projecting the image onto a screen), and hyperangulated geometry (blades with a much steeper curve that are designed not to move the tongue out of the way, but to advance around the tongue). It took us a decade to figure out that video was a transformational advance, but not hyperangulated geometry, which is a trade-off compared to conventional standard geometry (Macintosh or Miller) blades. But because they were introduced together, in the same revolutionary device, another decade has passed and there is still much confusion about how these technologies fit together.
Direct laryngoscopy uses a blade to push the tongue out of the way, establishing a direct line of site between the eye and the glottis; intubation is carried out by looking in the mouth. Video laryngoscopy uses a blade with a camera at the end; once the blade is positioned, the operator intubates looking at the screen. VL can employ either SG or HA blades. HAVL, which uses a blade that goes around the tongue, requires that the operator look at the screen. SGVL uses blades that move the tongue out of the way, allowing the operator to look in the mouth and perform DL (usually more difficult), or look at the screen and perform VL. Traditional laryngoscopy is using an old-school 1943 laryngoscope, which of course can only do DL.
The hopefully over VL vs. DL debate
For many years, there was a raging debate about VL vs. DL, but this has become less relevant with the rise of VL systems that incorporate hot-swappable SG and HA blades, allowing providers to switch between HAVL and SGVL in seconds. Because you can perform DL using an SGVL blade in the same way you would perform TL, SGVL is direct and video, SGVL contains TL, and now that we can instantly flip between SGVL and HAVL, it has become obvious to most (I hope) that there is no longer a role for TL. I still see pockets of enthusiasm for the 1943 laryngoscope, but this seems to me usually a demonstration of machismo similar to how an aged cardiologist recently condescended to me for relying on ultrasound to diagnose tamponade. All airway providers must be competent in DL, but only because video is not always available.
The real debate: SGVL vs. HAVL
The question now is which video blade to reach for. Practitioners who are highly skilled at either SGVL or HAVL will successfully intubate nearly everyone; both techniques are excellent.
HA blades produce an excellent view of the glottis almost every time with very little practice, and can get good views when SG blades can’t. This is a very important advantage, especially for folks who intubate infrequently, because seeing the cords calms you down, and you do a better job when you’re calm. HAVL requires less force, head/neck movement, and tissue displacement, which is an advantage in neck immobility, limited mouth opening, or an oral lesion that would bleed if disturbed. However, the fantastic view easily obtained with HAVL comes at the price of more difficult tube delivery, because the view from the camera points up, while the trachea points down. This can be overcome with maneuvers designed to flatten the angle between camera-view and trachea, but these maneuvers involve degrading your view, and are therefore against your instincts, and also don’t apply to SGVL or DL, where you want to optimize your view.
SGVL is quicker than HAVL, because tube delivery is (literally) straightforward, and this advantage is powerfully magnified by a bougie, which can be used with HAVL but is simpler with SG. Similarly, suction is easier to apply with an SG blade, and this can make a big difference in heavily soiled airways. The view-optimizing goals of SGVL are intuitive and work with your instincts, and the SGVL skillset applies directly to DL/TL, which is not true of HAVL.
The Era of Single-Use Flexible Endoscopy
Flexible endoscopes, often called fiberoptic bronchoscopes, are immensely powerful airway tools that until recently have been available in a small minority of emergency settings, because the conventional devices are expensive, fragile, and require a sterilization process that often doesn’t fit into EM workflows. The development of single-use, disposable endoscopes has brought this technology downstairs, and these devices are now available from several vendors.
Most emergency providers have little experience with flexible endoscopy, but they are not hard to use and a reasonable degree of proficiency can be acquired in a single mannequin session. The gadgets are often referred to as fiberoptic, though most of them no longer use fiberoptic technology, and often referred to as bronchoscopes, though they are rarely used for bronchoscopy in the ED.
Their classic use is as a primary intubation modality using meticulous local anesthesia, in a patient who is fully or nearly fully awake, and breathing normally. Topicalized Awake Intubation (TAI) is a core skill for anesthesiology but not always easily applied to emergency practice because it requires time and some degree of patient cooperation, as well as materials and topicalization skills not always present. It is still a skill that should be taught and practiced in EM training, because it is the safest way to intubate patients with a high degree of known or predicted difficulty, and absolutely can be performed successfully in many emergency scenarios. An alternative breathing intubation technique that provides some (not all) of the safety of TAI but is much easier to deploy in the ED is the use of dissociative dose ketamine without a paralytic (KOBI). More discussion around the merits and demerits of these two techniques can be found here and here.
Most ED patients, however, are (appropriately) intubated using a paralytic, and flexible endoscopy, now more available in the ED, is perhaps even more important as part of an RSI-based airway strategy. Using an endoscope by itself (often through the nose) is the traditional way to execute TAI, and this can work well in other techniques where the patient continues to breathe (such as KOBI), but if used after a paralytic, flexible endoscopic intubation is best accomplished in combination with either a video laryngoscope (where you can go fast) or laryngeal mask (where you can continue to ventilate during the procedure).
I got my hands on a disposable flexible endoscope years ago and described an ED Double Setup that incorporates 2-provider video laryngoscopy + flexible endoscopy; a single-provider variation on this procedure using a channeled VL was published by Sowers & Kovacs. Operating room-based case series and correspondence report on this “dynamic stylet” or “smart bougie” technique, and there is even an RCT.
SGVL or HAVL can be used, though the VL-flex endo technique uniquely leverages the strength of HAVL (obtaining the best view of the glottis) while addressing its key weakness (difficult tube delivery). If VL intubation is unsuccessful, a second operator slides in from the right wielding a flexible endoscope loaded with an endotracheal tube. The VL operator holds the best achievable view (left hand) and utilizes suction (right hand) as the FE operator advances the endoscope to the glottis and into the trachea viewing the mouth directly, then the VL screen, and finally the FE screen as needed.
Airway Strategy with Many Choices
Many modern emergency departments and ICUs have immediate access to VL with hot-swappable SG and HA blades in a variety of sizes, flexible endoscopy, and second generation laryngeal masks that are nearly foolproof to place and designed to easily transmit an ETT. These new tools can work together in extremely powerful ways, and we haven’t properly updated our airway strategy to take advantage of this. Here is an example of a strategy that does.
The first step is to decide on paralysis vs. breathing; you’ll usually choose RSI, which is usually the right choice, but make sure you know when it isn’t the right choice and the alternatives.
Plan A is going to be HAVL or SGVL, and I recommend, unless you’re already excellent with HAVL, that your go-to approach should be SGVL with bougie. When combined with view-optimization maneuvers, you will rarely encounter an airway that cannot be intubated with SGVL+bougie.
When you do encounter such an airway, the best move is not bag-mask ventilation but laryngeal mask ventilation. We’ve known for many years that LMV is both easier to do and more likely to be successful than BMV, and this is even more true now with 2G supraglottics.
Once you have placed an intubating SGA and restored oxygenation, you can go for any Plan A2 you like, but you are now well positioned to intubate through the SGA using flexible endoscopy, which can be done as ventilation continues if you have a swivel adaptor. Alternatively, removing the SGA and performing HAVL will often be successful, especially if you can perform VL-Flex endo, as described above.
Recent years have brought incredible advances in emergency airway management that have made intubation easier to learn and less dangerous. Take a critical look at the devices you stock in your department, what you should stock in your department, and how you can best take advantage of many choices to improve airway outcomes.
There is lots / of / evidence / that / using / a / bougie will increase your intubation success rate, compared to a styletted endotracheal tube. This is because the bougie is much smaller and easier to maneuver than an ETT, and does not block your view of the target at the last moment, as is often the case with a styletted tube. The Coudé tip allows operators to successfully intubate grade 3, epiglottis-only views, which means if you are practiced with the bougie and can get a view of the epiglottis, you will be able to intubate.
A less discussed but powerful feature of the bougie is its capacity to be molded; this can be done prior to laryngoscopy (e.g. to conform to the shape of a curved laryngoscope) or during laryngoscopy to allow the bougie to act as a poor man’s flexible endoscope by allowing real-time adjustments to the tip’s trajectory.
This 4-minute video discusses the conventional floppy vs. newer malleable bougies and presents a case where molding a malleable bougie during laryngoscopy turned what could have been a very difficult airway with limited mouth opening into straightforward procedure, even for a junior operator.
There are many manufacturers of floppy and malleable bougies, I have no relationships with any of them.
Package includes course overview, materials for 3 cases, pre-session worksheet, post-session worksheet, and anonymous course feedback form as well as supplementary OUD reference materials.
OUD Simulation Package [print-ready .pdf]
OUD Simulation Package [editable MS word .docx]
Each case includes an overview, simulated patient notes, physician briefing, and reference materials.
Case 1: Prevention of OUD
Case 2: Management of opioid withdrawal
Case 3: Harm reduction in OUD
Credits: Amish Aghera, Reuben J. Strayer, Sergey Motov, Nubaha Elahi, Michael Lamberta
The first time I really took notice of coronavirus was when a few providers started wearing masks during their shifts. This was in mid-February when the virus was a Wuhan problem, and we were screening people with travel questions. If you weren’t recently in Hubei Province, weren’t in contact with someone recently in Hubei Province, and weren’t in contact with someone known to have coronavirus, you were deemed to not have coronavirus. If you screened positive on any of those criteria, we got on the phone with our city department of health, and if they agreed, they coordinated testing with Atlanta; at that time only the CDC had a diagnostic test for SARS-CoV-2. I asked my colleague Matt why he was wearing a mask. His response: You don’t think it’s coming here?
I’m pretty sure I hadn’t contemplated that question, until that moment. Meanwhile, our hospital administration was discouraging us from wearing masks, because they are needed for surgeries, and because it presents badly. Meanwhile, boxes of masks started disappearing.
It wasn’t long after that, early March, when the well patients started coming in, mostly with fever but also chest pain, gastrointestinal symptoms, fatigue, and of course shortness of breath. Most of them were doing fine, ambulatory. They wanted to be tested for coronavirus. During this period we had some tests, then we had no tests, then we had tests, then no tests. We set up a “COVID clinic” across the street from the ED to keep these patients away from the department and process them quickly. Almost all of them were discharged home, with or without a test.
A small number of these early patients were sicker, and needed oxygen, so they had to be admitted. We started to notice alarmingly low saturations, much lower than expected for their clinical condition. We were doing a lot of chest xrays and labs, and some chest CTs. Nearly all these chest CTs showed bilateral ground glass opacities. COVID pneumonia. There was no treatment for COVID pneumonia, but there was a suggestion that hydroxychloroquine was effective, so we treated everyone with hydroxychloroquine. These patients were put in isolation rooms, which quickly filled up throughout the hospital, so they were boarding in the ED, waiting for an iso room.
It was becoming clear that circumstances in Italy were dire, and Italy isn’t China, Italy is across a much smaller ocean. NYC hospital administrators began to grasp the magnitude of the problem and were furiously trying to increase capacity. Elective surgeries were canceled and all the PACUs became ICUs, as did the ORs, then the cafeterias. Tents started going up outside the hospital. The first of three refrigerated trucks arrived.
We separated the ED into cold and hot zones. In the hot zone, we were wearing N95s. Providers who had contact with patients who were found to be COVID+ were quarantined for 14 days. This seems so quaint in retrospect.
The arriving patients started getting sicker. The paradigm at the time was that if the patient was not stabilized with low-flow oxygen (6 liters/min nasal cannula), they should be intubated. This was based on the notion that these patients would all end up requiring intubation anyway, and noninvasive high-flow oxygenation strategies such as high flow nasal cannula (HFNC) and NIV (CPAP/BiPAP) would aerosolize virus, infecting providers and other patients. We had never seen this disease before, so we accepted the intubate early paradigm, and sent dozens of intubated patients to the ICU in the first days of the surge, at least five times as many ICU admissions as usual.
By mid-March, we were practicing in disaster mode, our threshold to admit went way up. We stopped doing tests on patients who obviously had COVID but were ok–if you didn’t need oxygen, you went home, come back if you can’t breathe. At this point everyone in the ED is wearing cap, goggles, N95, surgical mask, gown and gloves their entire shift, regardless of where they were stationed in the ED. There were still nominally hot and cold zones but we all knew that was pointless because everyone had COVID, which we were diagnosing primarily by CT. Every patient with fever and respiratory symptoms had peripheral ground glass opacities, but, as time went on, every patient regardless of their symptoms had peripheral ground glass opacities. And we were doing CT chest on a lot of patients, because the upstairs teams for a while thought they could separate the COVID from the not, but then some non-COVID patients who came in with, for example, appendicitis, turned out to have COVID. And so we were asked to start doing a lot more CT chests, and they all showed COVID. I saw a middle aged man who was on mile 40 of a 60 mile bicycle ride, came in in full spandex after getting hit by a car, fractured femur. No chest complaints, fever, nothing. Was on a 60 mile bike ride. CT chest: peripheral ground glass opacities. That was when I realized how prevalent COVID was in New York City. On March 20, Governor Cuomo announced that starting two days later, March 22, New York State would go on lockdown.
Health care providers started getting sick with COVID. One of our docs, a healthy, active woman in her 30s, who intubated 6 patients in one shift, ended up in the ICU (she went home, is doing ok now). The PPE shortage captured the attention of the entire country. We had enough PPE for everyone to use one set of PPE per shift; this was of course PPE designed to be discarded after a single patient encounter. It is very unpleasant to wear PPE for an entire shift. It’s hard to breathe in a mask, it’s a pain to eat or drink or pee so you are less likely to do any of those things. Nobody can hear anyone so everyone’s shouting and misunderstanding, and of course the pressure sore on the bridge of your nose, a painful badge of honor.
On March 27 I retweeted my colleague Cameron’s video showing a pulse ox saturation of 44% with otherwise normal vitals. I suggested, “Consider withholding intubation in hypoxic patients who are otherwise OK.” Some folks who had noticed the same thing chimed in in agreement, but most of the replies were skeptical or disparaging. Over the next days, however, scores of providers broadcast similar findings, including another one of my colleagues, Eric, who photographed a woman texting comfortably with a saturation of 54%. Enter the term happy hypoxemic, and within a week, no one doubted that this was happening, that this was some strange feature of COVID. This was when we, as a community, started to question the early intubation strategy, especially given the outcomes of intubated patients emerging from China and Italy. We began to see intubation as something to be avoided until unequivocally required, and started using HFNC and NIV to manage critically ill COVID patients, despite the aerosolization concerns.
That said, everyone was freaking out about aerosolization concerns. At least 100 aerosol-responsible intubation checklists were unleashed onto the world. The intubation box was born, and will hopefully soon die. Some hospitals allowed HFNC but not NIV, some hospitals allowed NIV but not HFNC. Some hospitals allowed neither, so everyone in those shops got intubated.
Everyone was freaking out about cardiac arrest. Chest compressions and bag mask ventilation were thought to be high risk for aerosolization, and since we were learning from Italy and China that so many who got intubated for COVID died, some in the EM community suggested that all patients who arrived to the ED in cardiac arrest should be immediately pronounced without resuscitation attempts. Fortunately this solution did not carry the day, and we developed techniques for balancing our responsibility to patients and our own safety. Our protocol is to halt chest compressions and rescue ventilation as soon as EMS arrives, until two fully-PPE-donned providers place an LMA attached to a viral filter; cardiac arrest care can then proceed as usual.
Everyone was freaking out about ventilators. Every day the media came up with some way to make a story out of physicians deciding who lives and dies because we don’t have enough ventilators, even though no hospital actually ran out of ventilators. I was asked to write the institution’s ventilator allocation policy; we didn’t need it and I don’t think anyone ever read it. We all had to learn to use a variety of newly acquired ventilators, and ventilators are tricky.
Everyone was lionizing healthcare workers, who, while the rest of the country was learning how to bake bread on lockdown, were going to work in a lake of coronavirus, putting themselves in harm’s way to care for the severely afflicted. Every media outlet was desperate for any frontline doc to tell them how terrible the situation is, and how terrible their lives are. Nevermind that putting themselves in harm’s way is what firefighters and police do every day (for much less money and esteem), nevermind that healthcare workers have a job and continued income while so many others were suddenly in dire financial straits, nevermind that being trapped at home feeling useless is for lots of folks harder than going in to work, even when your work is more challenging than usual. I noticed that shifts that were vacated (generally for providers getting sick) were immediately snatched up, much faster than usual. Some of this was camaraderie in a disaster, but some of it was: if I’m not at work, I’m trapped at home with my family, I’d rather be at work. Meanwhile, at 7p every day in NYC, everyone claps and celebrates healthcare heroes. I think the focus of attention shifted a little too much to healthcare heroes.
I did appreciate getting messages (and cookies, and brisket) from 100 people I hadn’t heard from in ages.
Well patients stopped coming to the ED, and sick patients too. Strokes, MIs, opioid overdoses, mostly disappeared. It’s distressing to think about what happened to them.
In the last week of March, the emergency department became a place familiar only to those who do battlefield medicine. The census was lower than usual, but every patient who presented was extremely sick. There were no ICU beds left in the city, so critically ill patients started accumulating in the ED. And were they ever critically ill–these patients had oxygen requirements we had never seen before. They came in saturating in the 50s, we put them on HFNC and their sats went up, but as soon as the cannula fell off, the saturation would drop down to nothing, in seconds. We then understood why everyone was getting intubated in China and Italy.
The emergency department was now a huge, open ICU, filled with patients who were either intubated or on HFNC/NIV, and the patients on HFNC/NIV required more intensive care than the intubated patients, because they’re awake. They turn to one side and the cannula falls off, causing a sudden emergency. They need to use the restroom. They want to talk to their families, who are not allowed in the hospital. The ICU teams were overwhelmed upstairs and in fact all the doctors in the hospital were now repurposed to intensive care, with orthopedic surgeons adjusting vents. So we in the ED were on our own managing a sea of critically ill patients, and we had to pretend to be intensivists too.
We learned that we could improve oxygenation by having these patients flip on their bellies. Awake proning was born, and a few days and some thousands of tweets later, everyone was awake proning their patients.
The patients who seemed stable enough to go to a non-ICU setting upstairs often turned out to not be. Code blues were called overhead seemingly every 30 minutes. We learned that the HFNC/NIV patients simply could not be managed on wards behind closed doors, and the ICUs could only accommodate intubated patients, so we stopped admitting the HFNC/NIV patients. We formed our own “ED Admitting Team” and admitted the patients to ourselves, they stayed downstairs and we just watched them as closely as we could, never knowing when to intubate them. Some of these patients after many days on HFNC/NIV could be downgraded to low-flow oxygen and admitted safely, but many got intubated. One young man was prone on HFNC on an ED stretcher for 12 days, and he never turned the corner. We pulled the trigger and intubated him, he went upstairs and was immediately put on ECMO. He was with us for 12 days, we all got to know him and were collectively heartbroken to send him to the ICU on a vent.
There was a period of a couple weeks where the demand for intensive care resources so exceeded supply that the shifts felt like walking through a fog, moving from one dying patient to the next. The absence of any scientific guidance made us feel and behave like helpless homeopaths. We had no effective therapies so we threw all sorts of likely ineffective therapies (azithromycin, hydroxychloroquine, zinc, vitamin C, steroids, nitric oxide, prostacyclin, convalescent plasma, remdesivir, tocilizumab) at them. No one in the world knew when these patients needed to be intubated or how to manage the vent once they were intubated. Saturations in the 70s felt normal, pronouncing patients dead proceeded like a drumbeat, and there were moments when it perversely felt like a relief. Perhaps because we had never felt like we could do so little for so many who needed so much, there were moments when it seemed better to be dead than be a dying patient in a pandemic-overwhelmed hospital with your loved ones not allowed to visit, your care coordinated by doctors powerless to stop the disease laying waste to your lungs.
On April 11 I was much more tired than usual; the next day I was on shift and developed a pounding headache, I never get headaches. When I got home late in the evening I felt awful and that was when I realized. The next day was like a truck hit me. Sweats, chills, nausea, no appetite, no energy, aching all over. I told my boss I had coronavirus. My boss said you need to come in and get tested. I said why, I know I have coronavirus, I feel like shit, I don’t want to come in and get tested. He said you need to come in and get tested. I went in and got tested. Days #4 and #5 were the worst. I barely got out of bed. Constant high fevers, debilitating headaches, dizzy whenever I tried to stand up. I ate nothing. But the worst part was the uncertainty about how things would go over the next week; lots of healthy young healthcare workers were getting very sick and I’ve seen more than a few people my age killed by covid. My test came back positive. Things were a little bit dark. I was anxious and miserable. On day #6 I started to feel a bit better, and I very slowly improved over another week, until I could do my usual activities again. It was the sickest I’ve ever been, but no complaints, I feel fortunate.
The surge abated in mid-April, but the arrivals numbers remained very low, everyone in the community (rightfully) scared to come to the hospital. Many of the admitted patients were discharged, and many died. Most of the ED patients went upstairs.
Now the department is slow. There is still coronavirus, lots of people dying of coronavirus upstairs, and still people dying of coronavirus downstairs, and we expect this to continue for many months, but now we can handle the volume. And we have a lot more experience managing COVID, though still very little science to guide us.
The countrywide lockdown is a mitigation strategy designed to flatten the curve so that hospitals aren’t overwhelmed and so we can transition to a containment strategy which requires the development of a robust test/trace/isolate infrastructure. Americans were frightened by what they saw in NYC, so they isolated much better than anyone predicted, and we flattened the curve better than anyone predicted. But a sophisticated and committed federal government response is needed to quickly build a test/trace/isolate infrastructure, and that hasn’t happened and looks like it’s not going to happen. So most states, including New York, are nowhere near ready to come off of lockdown, from a public health perspective. But the public won’t tolerate this much longer, so we’re going to open up, and new cases/deaths will start to rise. As long as most of the dead are old, and we don’t see conditions like the mass casualty that was visited upon New York City for three weeks in March and April, I think most americans will trade a steady stream of deaths for an open economy. And that’s what I think will happen, until we get a vaccine, a cure, or herd immunity. I hope this is a once in a lifetime event. For untold hundreds of thousands, it definitely will be.
Thanks to Lois Isaksen, Michael Turchiano, Nick Schwartz, Josh Schiller, Matt Friedman, Eric Lee and Ram Parekh for their review and suggestions.
Illustration by Lian Chang