A Mass Casualty In Slow Motion: Emergency Medicine During the COVID-19 Surge in New York City

 

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

 

 

 

 

3 Weeks of Coronavirus in New York City

NYC at this moment (April 6, 2020) seems to have crested with a wave of very sick patients, many many of them requiring intubation or other aggressive forms of oxygenation. The patients are arriving more slowly in recent days, but arrivals are often very ill. Most of us have watched many patients–not all of them old–deteriorate and die, sometimes very quickly, and this is psychologically traumatic. I find it particularly demoralizing to manage so many patients who are succumbing to a disease that is so poorly understood, and where all our treatment strategies are currently based on anecdote and theory, which is just slightly better than being based on nothing. We desperately need experimental data to determine what works. It is very difficult to deploy a serious research effort when the clinicians are getting crushed and the research teams are on lockdown, but we need to do better. We don’t have time for the usual publication-focused machinery of research to churn out papers in 6 months, we need trials now, every covid patient should be enrolled in a trial so we can learn something about how to treat this awful disease.

So all of what follows is based on opinion and consensus, some observational data, because experimental data does not yet exist. It would therefore not surprise me if much of it is ultimately demonstrated to be entirely wrong. 

 

Assessment of Well Patients

Early on, there was an emphasis on COVID testing, ancillary testing (e.g. CXR, CT, labs), and discharge guidelines often based on oxygen saturation. As the epidemic has evolved, COVID testing has disappeared and the rest has become less useful. Currently, I think most of us have adopted a strategy where patients who present with COVID symptoms, but are able to walk around without oxygen, are assumed to have COVID and discharged with isolation precautions and indications for return. It is expected that some of them will return requiring admission. My main concern is not that we’re inappropriately discharging COVID patients who bounce back–it’s essential to keep people out of the hospital right now until they absolutely need admission–rather that we’re attributing every symptom to COVID and not adequately working up other causes of the patient’s symptoms. That said, it is astounding how many patients have classic COVID symptoms, it really does seem that everyone in the city has this disease. The positive test numbers you hear reported in the media are useless, we’re not testing anyone. Focus on admissions and deaths to get some sense of disease prevalence in a region.

If we had access to reliable and rapid coronavirus testing, we could have done much more, from a public health perspective, than discharge these patients with instructions to isolate, which is impossible for many folks to do in their homes. I hope such testing will become available in regions that aren’t already saturated with coronavirus, before they become saturated with coronavirus.

 

The ‘intubate early’ paradigm, where patients who “fail” low flow oxygen (e.g. 6 L/min nasal cannula) are intubated and mechanically ventilated, has been abandoned by most centers, because intubated patients with COVID lung disease are doing very poorly, and while this may be the disease and not the mechanical ventilation, most of us believe that intubation is to be avoided until unequivocally required. Also, a low threshold to intubate further strains already-strained hospital resources.

What should be the trigger for intubation is a very difficult question right now, but saturation should not be used in isolation. Reasonable markers are respiratory distress (not simply tachypnea), altered mentation, and rising CO2. In general, when not sure, wait, augment noninvasive therapies, and reassess. This is the converse of the usual EM paradigm, which is when you’re not sure whether or not to intubate, intubate.

Here is the guidance we have come up with based on Gattinoni’s two-phase theory of disease. Many are reporting much better results using APRV instead of conventional modes of ventilation.

 

Noninvasive oxygenation therapies 

  1. Proning. This should be done for all patients with COVID lung disease sick enough to be admitted to the hospital, regardless of oxygenation therapy. A “proning” team (e.g. providers otherwise idled by societal lockdown) can round on all the patients to prone them, or turn them on one side or another, which seems to improve oxygenation for many patients. 
  2. Encouragement of deep breathing. Many COVID patients take very rapid but very shallow breaths. We have also noticed that many COVID patients have painful breathing, and some present with a complaint of pain instead of dyspnea. Incentive spirometry, with or without treatment with opioids, may be of benefit.
  3. High flow nasal cannula. Consensus seems to be to start with high FiO2 and low flow rate, increase flow rate as needed. Cover with surgical mask to reduce aerosolization.
  4. Noninvasive ventilation. Again it is the high concentration of oxygen that seems to be of value here rather than the pressure, so some have advocated for CPAP with a low pressure, FiO2 100% as an initial approach. Use viral filter at the level of the mask to reduce aerosolization. 

To the extent that you can isolate or cohort patients on HFNC/NIV, do so. As the epidemic worsens, your ability to do this diminishes. 

Pulmonary hypertension seems to play an important role in very ill COVID patients and there is some enthusiasm for using pulmonary vasodilators like inhaled nitric oxide or prostacyclin.

 

Anticoagulation

Prothrombosis is one of the many not-yet-understood but repeatedly observed aspects of this disease. Many institutions are moving to aggressive anticoagulation practices in COVID patients, based on trending d-dimers. At a minimum, everyone admitted should probably be prophylaxed. I’ve heard two reports of COVID patients doing very poorly, not stable for CT, treated with lysis, to immediate improvement. Was it PE? Was it diffuse microthrombosis? Was it something else? Was it coincidence? We have no idea.

 

Cardiac Arrest

All sorts of chitchat on who should be resuscitated and how. If a patient is already intubated and receiving maximal therapies for COVID, and deteriorates and arrests, it does not seem appropriate to pursue further resuscitation, assuming no immediately reversible cause (e.g. ventilator disconnection/obstruction) is found. Undifferentiated patients arriving to the ED in cardiac arrest should, in my opinion, be managed like a patient arriving in cardiac arrest in normal times, with one exception: the patient should be assumed to have COVID, and appropriate measures should be taken to protect staff and other patients from aerosols generated during intubation and chest compressions. See this impossibly well-produced video.

 

Ventilator Allocation

Despite the media clickbait frenzy on this topic, to my knowledge there has been no need for any hospital to go on an allocation protocol, but that time may come. You do not want that time to come without a protocol that you have established and vetted. Here is one protocol.

 

Emergency Department and Hospital Flow

At first, departments try to separate into hot and cold zones, but as the prevalence of COVID increases in the community, most of us have noticed that everyone presenting for any reason has evidence of COVID (e.g. the man who was in the midst of a 40 mile bicycle ride gets hit by a car, breaks his leg, has no other symptoms, but CT shows lungs full of COVID, all of us have seen this repeatedly). So, at least in NYC, the entire ED becomes a COVID zone.

I have nothing to add to the national referendum on PPE other than to say that wearing PPE for the duration of an ED shift is difficult, and I think every ED worker in the city is now wearing a single full PPE getup for their entire shift, regardless of where they are in the department. Think about where providers are going to don/doff PPE, where providers are going to store PPE if it has to be reused. Where in the department/hospital/offices PPE will be allowed, and not allowed. For example, is PPE allowed in the breakroom? What will you do with the food that is donated by the community, that your providers will really want to eat? Seems like a trivial problem but it isn’t, frontline gotta eat. Useful to designate a (nonclinical, probably) person to manage food and PPE donations.

Non-COVID ED visits have dropped off precipitously, no one has any idea where all the strokes, heart attacks, intoxicated and withdrawing patients are. However the fraction of patients requiring admission has skyrocketed; the majority of people who arrive to the ED now require significant oxygen support and admission. 

Many if not most of these patients are on advanced oxygen therapies (HFNC, NIV, or MV) but most hospitals do not have even close to the personnel or structural resources required to optimally care for this volume of ICU/Stepdown patients. This is perhaps the greatest struggle in the latest stage of the epidemic in NYC: providing intensive care to 10x the number of patients the hospital is set up for. Many ED’s at the moment are functioning as huge ICUs, caring for enormous numbers of critically ill patients awaiting inpatient beds. It’s even worse upstairs, because standard medical wards are now also ICUs/Stepdowns filled with patients who have very high oxygen requirements, but unlike the ED, these patients are behind closed doors and wards are not resourced to provide the level of monitoring required, and if someone knocks off their NIV mask or HFNC, they can run into trouble very quickly. The number of “Anesthesia, STAT” calls to ward beds is a jarring reflection of the grim conditions. Plan to augment ward staff (physicians, nurses, technicians, anyone) to keep more eyes on these patients. 

Because the arrivals volume is so low, very few ED staff are needed to do emergency medicine, and many of us are repurposed to provide ICU/Stepdown inpatient care to the admitted patients. It would be wise to plan for this transition, because it’s very disorienting, especially when you’re trying to do it in a Tyvek suit for 10 hours. Many units are attempting to leverage other services that are inactive during societal lockdown, and there is a role for just about everyone: The patients, if nothing else (and there is a lot else) need food, water, hygiene, their home meds, an update on their condition (if they’re conscious), someone to talk to their families who are not allowed inside. Any healthcare provider can do this. In one NYC hospital, the surgical service has taken over an entire wing of the ED filled with ICU/Stepdown patients and is just running it, caring for these patients as though they’re in the SICU, because they might as well be. It is an awesome demonstration of our shared purpose and the petty illogic of our usual balkanized culture. People are ready to step up. Utilize them.

COVID-19 Data Sharing Project

Use the links below to access anonymized patient-level data for patients seen in our COVID-19 ICU. This data is updated in near real time.

Because New York City has been seriously affected by COVID-19 before most other cities, we have gained experience in managing many of these patients before severe cases have accumulated in other regions. This database aims to inform clinicians who haven’t yet cared for severely ill COVID-19 patients, but will, soon.

First sheet in each patient notebook is a summary; following sheets correspond to subsequent hospital days. Patients who are discharged or deceased are marked as such, unmarked patients are currently admitted. More patients are added daily.

Credits: Daniel Dove, Ashley R. Davis, Aneri Sakhpara, Cameron Kyle-Sidell.

 

Patient 1 (discharged)

Patient 2 (discharged)

Patient 3 (discharged)

Patient 4 (discharged)

Patient 5 (deceased)

Patient 6 (deceased)

Patient 7 (deceased)

Patient 8 (discharged)

Patient 9 (deceased)

Patient 10 (discharged)

Patient 11 (discharged)

Patient 12 (discharged)

Patient 13 (deceased)

Patient 14 (deceased)

Patient 15 (deceased)

Patient 16 (deceased)

Patient 17 (deceased)

Patient 18 (discharged)

Patient 19 (discharged)

Patient 20 (discharged)

Patient 21 (discharged)

Patient 22 (deceased)

Patient 23 (discharged)

Patient 24 (deceased)

Patient 25 (deceased)

Patient 26 (deceased)

 

[4/14/2020] Given the profusion of descriptive data now becoming available, we have ceased enrollment of this cohort at 26 patients. We will continue to update all these patents until disposition.

[7/23/2020] I presented on our ED Admitting Team (not the patients reported on on this page, but a similar cohort that was cared for downstairs, in the ED) at our hospital weekly COVID rounds. 20 minute presentation, followed by 20 minutes of questions/comments.

Ventilator Allocation Protocol

Ventilator Allocation Protocol  [pdf]

Ventilator Allocation Protocol  [docx]

Ventilator Allocation Protocol [google doc]

May be freely edited and used without attribution

Based on remarkable and comprehensive 2015 New York State Ventilator Allocation Guidelines

 

 

I’ve been getting a lot of questions. Below are points of clarification and explanation, most of this is just my opinion.

Yes you can use the protocol however you want, you do not need to ask me or provide any attribution. If you’re developing a protocol, you should read the original New York State 2015 guideline, there’s also a brief Hopkins paper, a Washington State guideline, a Henry Ford guideline created specifically for COVID19, and a CHEST consensus statement

Do everything feasible to not have to use an allocation protocol: reduce the burden of disease and increase capacity. Find vents in unusual locations (we’ve engaged our community where there are many thousands of unused vents from homebound ventilated patients who have died), 2 to 4 patients can share vents, look in every closet, decommissioned respiratory units, decommissioned hospitals. 

Goal is saving the most lives, in accordance with important societal values such as protecting vulnerable populations. You want to provide ventilator therapy to patients who are most likely to have their life saved by ventilator therapy, and remove ventilator therapy from patients who are unlikely to have their life saved by ventilatory therapy. In our minds we think about this problem as choosing among patients who will clearly die if they don’t get on a vent, but it’s important to remember that in this pandemic there has been a STRONG push to intubate early, that alternative forms of support don’t work and are more likely to aerosolize the virus so we should intubate early, and that is a big problem, from a scarce resources perspective because if ventilator therapy is a scarce resource, every patient who would fly off the vent that you intubate leads to another patient dying because they couldn’t get the vent they needed. Early reflection on the Italian response (by the Italians) suggests that they intubated too many patients too early and I’m concerned we’ll do the same. At the moment we are pushing HFNC under surgical mask, as the initial approach to COVID patients who need support; 30 lpm, FiO2 30%, titrate up until sat falls below 93% on maximal high flow support, then move forward with intubation. Is that the right approach? I don’t know. But last week, when we were in intubate early mode, we intubated 7 patients in one shift and that is clearly not sustainable.

You need vents, beds, and people trained to provide critical care. As a routine, in normal times we operate near capacity on all three, especially beds. There are of course other critical supplies in addition to ventilators, like PPE, oxygen. Per the NYS document, estimated 9000 ventilators in NYS, 10% suitable only for peds. Normal hospital utilization rate is 85%, so the vast majority of the 9000 vents are being used. The NYSTF calculated that in a severe influenza pandemic, about 19000 patients would require ventilators simultaneously, resulting in a shortfall of over 15,000 ventilators.

The ventilator triage committee must know the status of ventilators and critical care availability in the hospital moment to moment. We receive two reports per day. Patient’s attending provides clinical data to the triage committee, who determines that patient’s priority status based on the clinical data. Before the patient has been triaged, the committee should not be in contact with the patients, and in fact really they shouldn’t know the names of the patients being triaged. The triage committee should be identified well before they are needed, and the usual model would be that there is a single triage officer on duty at any given time, and that duty rotates among members of the committee. Since the triage decisions are entirely clinical, non-clinical members of the hospital staff or community don’t need to be on it, but how a hospital staffs its committee is a local decision.

Three steps: 1. Apply exclusion criteria 2. Assess mortality risk 3. For intubated patients, perform protocolized interval reassessments (48h, 120h, and every subsequent 48h). The original document stipulates that based on the observed characteristics of a particular pandemic, 48 and 120h may not be an appropriate interval, and the intervals should be adjusted based on what is observed for a specific syndrome, so for example if we find that COVID patients all have high SOFA scores for 10 days and then recover, we should push the intervals out, and if we find that all patients who are doing poorly at 72h end up succumbing to the disease, we should pull the intervals in.  Also if a patient develops an exclusion criterion at any point, such as a cardiac arrest or a change in goals of care, ventilator therapy should be removed at that point, you don’t wait for the next protocolized interval reassessment.

Age was rejected by the NYS task force as discriminatory – age of course indirectly contributes to exclusionary criteria and SOFA scores. The exception is children, based on strong societal preference. 17 and under are favored. The Hopkins protocol does use age or what they call life cycle considerations as a secondary criterion.

If you stipulate that being subject to the protocol is dependent on diagnosis, you will change diagnoses. Diagnoses often aren’t clear. Although all patients needing a ventilator are subject to the allocation protocol, I think an exception should be made for patients who are thought to require intubation temporarily for unrelated reasons, e.g. someone who has perforated diverticulitis may need to be intubated for the surgery, but should probably be exempted from the protocol.

SOFA is used as a proxy for mortality risk. Some experts disagree with this, suggesting that SOFA performs poorly as a mortality predictor in primary lung disease. SOFA score has limitations – does not predict mortality nearly as well in ILI compared to sepsis. GCS component difficult to evaluate in intubated/sedated patients, uses outdated hypotension criteria (dopamine, dobutamine). Much better would be a disease-specific predictor of short-term mortality, which, for COVID, we may soon have.

You want to start classifying patients as blue red yellow green somewhat before you run out of ventilators–you don’t have to act on exclusion criteria until you run out, but if you start early, you will know exactly who is removed from ventilator therapy when you do run out. If you wait until you actually run out, it’ll be a mess. And what that means is that you have to stratify every patient in the hospital on a vent as blue red yellow green, which in many centers will take a while, before you run out. 

Should family members be allowed to bag indefinitely? It’s an interesting question, the NYS task force“discouraged it” and I do too, because I think it places a burden on the family that most would prefer to not have, though that’s very paternalistic. Also, it places a burden on the facility, compromising the care of others. Who takes over when the family has to pee? Or when they pass out? Should we allow teams of family members to be at bedside, bagging, exposing them to all the sick patients on the ward, potentially making patients out of them? These family members will contract the illness and transmit it. But I can see counter-arguments. See page 70 of the source document.

Regional command centers seem crucial, so that resources like beds and ventilators can be shifted from places of surplus to places of shortage, and patients can be transferred to facilities that have capacity. 

Withholding or withdrawing a life-sustaining therapy without the consent of patient or proxy is a profound, devastating decision that will severely affect some healthcare workers, and these consequences, along with the possible legal ramifications of these decisions, are partly why it is essential that they are undertaken according to an established protocol, ideally a protocol that is as objective as feasible. NEJM perspective piece suggests you can’t withdraw care; they suggest that withdrawing care has been determined to be illegal and will harm healthcare workers, and both of those things are true but I don’t see how that absolves us of our mandate to ethically allocate resources during a disaster. Disallowing withdrawal of ventilator therapy installs a first come first served system that is in my view profoundly unethical, it’s not hard to imagine huge numbers of patients on vents for weeks or months who have little to no chance of recovery.

Should healthcare workers receive priority? There is a whole section on this and the task force decided no, and I agree. It is our duty to run into the fire, that’s what we signed up for. Once a healthcare worker needs a vent, she’s not returning to care for others in a pandemic, so the argument that we get priority so we can continue to care for patients is moot. Many others put themselves in harm’s way during a pandemic, where do you draw the line? Do all technicians, janitorial staff qualify? What about a home health aid taking care of someone affected at home? There are actually so many healthcare workers in the community that in a shortage, only healthcare workers would get vents. Also, the notion that we are more valuable to the community, even in a pandemic, is probably bunk. If all the doctors disappeared during this pandemic, there would be a lot of needless deaths, but it would be a lot worse if all the police officers, or all the sanitation workers disappeared. Also it seems particularly self-serving to prioritize healthcare workers in a policy designed primarily by healthcare workers, and such a feature of the policy would erode public trust in the policy and in healthcare workers more generally. Emanuel et al take the opposite view in their NEJM essay

There are all sorts of special categories of people that seem to have justification for being favored or disfavored in a policy: the elderly, pregnant patients, parents, prisoners, undocumented immigrants, community leaders, there’s no end to it and I agree with the task force that a triage system based on clinical features alone is the most sound.

The New York State guideline did not use functional status as an exclusion criterion to avoid judgments around quality of life. I am comfortable with such judgments though, especially when they include an objective criterion, which is why I included the ECOG scale criterion (I used ECOG score of 4, some might say it should be 3). However, these criterial (e.g. metastatic cancer, which I suggest as a criterion for poor prognosis and exclusion), are open to challenge. There are more explicit criteria listed in the Hopkins document, under Table 1.  You may not know if a patient has very poor functional status at the outset of care, but it’s reasonable in my opinion to assume it if the patient has, for example, bedsores.

If a patient is intubated prior to the discovery of an exclusion criterion, ventilator therapy should be removed as soon as an exclusion criterion is known. It is reasonable to intubate DNR patients in a non-shortage, but not, in my opinion, in a shortage, though this stipulation is also open to challenge and diverges with the NYS guideline.

SOFA < 7 OR single organ failure in the initial triage is odd. My read on it you are allowed to classify a patient as red even if they have a high SOFA if it is clear that they have only a single organ system down, which would be a sort of failure of the SOFA score; i.e. if you have a only one system down you should not have a high SOFA, but if you for some reason do have a high SOFA with one system down, you can still be red.

Comparing patients within class evokes a “war of all against all,” one of the key features of the system is that within a class, triage is made by randomization (i.e. a lottery). I think this is a very strong feature of the system. Trying to further clinically differentiate among red patients using an objective system I think would be very difficult and open to interpretation/exploitation/gaming. First come first served favors the rich/educated/empowered.

When the need for a vent is identified, are there vents available right now? If no, classify patient. If red, that patient is added to the pool of reds and as soon as a vent becomes available (because a red vented patient has been reclassified or died) all reds are randomized to that vent.

Keeping the public informed on the possible need for removal of ventilation, and ongoing data collection, are essential. Relatives must be informed that all ventilator therapy during a shortage is a trial of therapy that may be discontinued if it does not result in clinical improvement at a pre-specified pace. Seattle Tough Conversations Document.

Hopkins group suggests the triage officer (with other administrators in tow) tell the family about allocation decisions. I think it should be both–triage officer, attending, and possibly others (high ranking hospital official such as the CMO or CNO, pastoral care, ethics committee liaison). 

If a chronically vented patient comes in with their own ventilator it seems appropriate to me to exclude them from the protocol.

ED must know when no vents are available, so that ETI is avoided. If a patient comes in intubated (without their own ventilator) and there are no vents available, and all vented patients are red priority, the newly intubated patient should be extubated. If there is a lower priority patient (i.e. a blue/yellow patient already intubated), that patient should be extubated while the new patient is bagged. If uncertain at any given moment, err on the side of ETI and bagging, until the situation can be more comprehensively assessed. Extubating is logistically/emotionally harder but ethically identical to not intubating.

Airborne Isolation / COVID19 Intubation Checklist

AIIC [pdf]

AIIC [image]

more pearls: make sure cuff is inflated prior to manual ventilation. attach viral filter directly to ETT, if circuit disconnection needed, disconnect circuit on vent side of filter.

References: Zuo 2020, Wax 2020, Weingart 2020, ecuus 1 and 2, Farkas & Thomas 2020

CDC 5 min video on proper donning/doffing, pdf, pulmcrit cheat sheet

 

CDC CV19 Discharge Instructions

LAC DOH CV19 Discharge Instructions

 

Scott’s BVM-on-NIV mask oxygenation setup (6 min vid)

 

How To Present to an EM Attending

The major challenge as a trainee presenting to a supervising attending is that every attending is different, wants different things, has a different approach, which makes your job impossible. You will do better to have a system. Here’s one system.

Before presenting the case at hand,  provide an update on what’s going on with your other patients. How are they doing? What are they waiting on? Now you’re ready to start in with the present case.

Frame First. Open up with a very brief one-sentence summary of the case, with your conclusion. This frames everything else you’re about to say.

“I think Ms. Jones has pneumonia.”

“I think Mr. Smith will need a CT scan for rule out appendicitis.”

“I think Mr. Lee will need a workup for chest pain, but if negative can be managed as an outpatient.”

Next is the chief complaint.

“Mr. Jones is a 34 year old male with abdominal pain.”

Past medical history follows, most important first. 

“He had a kidney transplant in 2004 for polycystic kidney disease. He is also known for diabetes and hypertension.” 

Notable medications, especially important are recent changes in medications or noncompliance, and relevant allergies to medications.

“He’s on cyclosporin and mycophenolate, as well as glyburide, amlodipine, and hydrochlorothiazide. His amlodipine dose was recently doubled. He reports a penicillin allergy, which gives him a rash.”

Pertinent social situation follows, as it pertains to the situation. This is often omitted, but social situation plays an important role in admit/discharge decisions;  how can you discharge a patient without knowing the environment you are discharging to?

Who does the patient live with? (alone / with family / with spouse, who also has advanced dementia)

What sort of living environment does the patient reside in? (apartment / group home / nursing home / homeless)

What does the patient do during the day? (works as an administrator / is a left-handed pianist / is unemployed / is a student)

What is the patient’s level of function? (fully functional / able to do some but not all ADLs / fully dependent) 

How much help does the patient have at home? (24/7 home health aide / home health aide twice per week for 6 hours / visiting nursing every day)

Bad habits? (drugs, alcohol, cigarettes. history of withdrawal)

Does he have physicians looking after him? If the patient was referred to the ED by a physician, this is particularly important. If there are clinicians who play a particularly relevant role in the present concern, report this. Taking care of patients is a team sport.

Does the patient have any advanced directives? What are the goals of care?

“He lives with wife, works as a bus driver. Denies bad habits. Is supposed to follow with Dr. Green in the renal transplant service at Heartbreak Hospital, but hasn’t seen Dr. Green in six months.” 

Next is a good place to comment on prior visits to the ED.

“He’s never been to this department.”

“He has 48 similar visits to this department, has been extensively worked up dozens of times.”

Next is the history of present illness. This should start with “[The patient] was in his usual state of health until…” and then provide a chronological sequence of events that led up to the present visit; the first part of the HPI should report all the patients complaints, which were elicited with open ended questions, and end with the complaints that led to his coming to the ED, and then what complaints he has at this moment. The next part of the HPI is the focused review of systems, which you can delineate from what the patient offers up without prompting by using phrases like, ‘on questioning,” ‘endorses,’ and ‘denies.’ This is not a complete review of systems, but a focused review of systems with pertinent positives followed by pertinent negatives. A good way to end the HPI is to comment on prior episodes.

“Mr. Jones was in his usual state of health until 3 days ago, when he developed dull periumbilical pain that was intermittent but progressive until this morning, when he developed vomiting and the pain became constant, sharper, and moved to the right lower quadrant. He went to see his family physician, who referred him to the emergency department. At the moment he complains of severe right lower quadrant pain and nausea. On questioning, he endorses diarrhea and chills, but denies mucus or blood in the stool, recent travel or antibiotics, urinary or testicular complaints, shortness of breath, and rash. He had a similar, much less severe episode a few months ago that resolved in one day by itself.”

After the HPI comes the physical exam, which should always start with general appearance and vital signs, and then proceed from head to toe, with a level of detail appropriate for your level of training. I think it is best to leave the area of interest for last. 

“Mr Jones is well appearing, calm, and mildly uncomfortable in abdominal pain. His vitals are normal except for a heart rate of 106. His head to toe exam demonstrates no findings about the head, neck, heart, lungs, and extremities. His abdomen is moderately tender in the right lower quadrant, without signs of peritonitis. His GU exam is normal.”

Now you’ve finished the H&P, and the next question is what has been done for the patient already, if anything, and results

“He was treated with 4 mg of IV morphine and 4 mg of IV ondansetron, and a CBC, chemistry, LFTs and lipase were sent, as well as a urine analysis, according to the abdominal pain nursing protocol. He was uncomfortable when I saw him, so I ordered another 4 mg of IV morphine. The UA has been resulted and shows trace blood, all other studies are pending.”

And now your assessment and plan. I think the best way to provide a summary of the key features of the case, and then answer these questions:

  1. What do you think the patient has?
  2. What dangerous conditions or complications could be causing or associated with this patient’s symptoms?
  3. What tests are indicated to rule out or rule in these dangerous conditions?
  4. What therapies or symptom relief measures are needed?
  5. If the tests that you order are negative, what is the plan for the patient?

“Mr. Jones is a healthy young man with abdominal pain, diarrhea, and fever for 36 hours, his exam is reassuring but he has mild lower abdominal tenderness. Most likely, Mr. Jones has a self-limited GI illness, but I’m concerned about appendicitis. Bowel obstruction and perforated ulcer are unlikely given the relatively benign abdomen. Given a normal GU exam, I don’t think we need to further pursue a lesion there; his abdominal tenderness makes thoracic causes of abdominal pain like pneumonia or cardiac etiologies very unlikely. If his labs show no diagnostic abnormalities, I think he needs a CT scan of the abdomen with IV contrast to rule out appendicitis. If that’s negative, I think he’s safe to be discharged with a nonspecific diagnosis and followup. He’s comfortable right now but I’ll continue to treat for symptoms as needed, and I’ll also give him a liter of fluid.”

The most important way that this system differs from the most common presenting style is that the HPI is presented after the patient’s background information is presented. Most attendings will want to hear the HPI first; I believe that in a stable patient, the HPI can only be properly interpreted in the larger context of the patient’s medical history, social history, etc.

How much detail you present depends on the complexity of the case and how senior you are as a trainee. If you’re about to graduate your residency, your attending may not want to hear anything else than, “Mr. Jones is a healthy 34 year old with a flu-like syndrome, I discharged him with follow up.”

Send thoughts, comments, suggestions, objections, additions to emupdates@gmail.com

 

Related:

Trainee worksheet, with specific guidance on how to succeed during an EM shift. Designed to fit on one page, front and back.

List of ways that I might practice differently than other attendings, to save residents some trouble.

Older, detailed guide to patient assessment.

Update: 1. facts 2. opinions 3. questions

The Abortion Pill

Pregnancy termination is now very difficult to get in many regions. The abortion pill–medication abortion–is one dose of the antiprogesterone mifepristone followed by one or more doses of the prostaglandin misoprostol. The therapy is well studied and unequivocally safe and effective up to 10 weeks gestation.

For women who have access to both medication and surgical abortion, there are plusses and minuses to each but the main difference is that a surgical abortion is a brief procedure requiring anesthesia and uterine instrumentation, whereas a medication abortion occurs over several days in the patient’s home.

But medication abortion allows women without access to surgical abortion to  safely terminate pregnancy. In the US, federally authorized abortion pills are highly restricted for reasons that are political, not medical. So a network of activists have developed robust programs for getting this treatment into the hands of women who need it.

The role of emergency providers in managing women who request elective termination of pregnancy depends on the resources available in your community, but all of us need to know about medication abortion, if for no other reason than it is a rising therapy and you’re going to get asked. Especially if you practice in an area where surgical abortion is poorly available or unavailable, familiarize yourself with the relevant options so you can properly counsel appropriate patients. This is another way that emergency clinicians stretch the scope of their practice to meet the changing needs of the patients they serve.

Plan C

Aid Access

New York Times, Farhad Manjoo

Narcotica podcast

Ketamine-Only Breathing Intubation

This 9 minute video demonstrates the strengths and weaknesses of an intubation strategy that relies on dissociation with ketamine.

The essential strength, compared to RSI, is that a breathing technique keeps the patient breathing during laryngoscopy, which transforms the procedure from high-adrenaline to highly controlled. You see in this video that my (fabulous) resident was able to take his time, try different blades, slowly advance and adjust while using view optimization techniques as the patient continued to breathe. This is an extremely powerful way to add safety to the riskiest procedure commonly performed in acute care. We would have been able to carry on with his attempts for longer, had we not been inconvenienced by the arrival of a trauma patient.

Keeping the patient breathing during intubation has a long history in emergency medicine, starting with the brutal and often unsuccessful blind nasal intubation, which, fortunately, is now seldom performed. Many of us learned to do operating room style awake intubation, which relies on thorough local anesthesia using atomized/nebulized/topicalized/regionalized lidocaine, so the patient can remain truly awake and breathing during the procedure. Lidocaine-focused awake intubation is a fabulous technique that requires expertise and equipment not available to all acute care providers, but also–depending on your level of skill–time and patient cooperation. Time and cooperation is something we may not have downstairs or on the side of the road,* but what we lack in time and cooperation, we can make up for in ketamine.

When we use dissociative-dose ketamine to do the heavy lifting in allowing the patient to tolerate laryngoscopy, we obviate much of the needed topicalization expertise/supplies, abbreviate the needed time, and add cooperation with ketamine, cooperation in a vial.  The patient becomes dissociated, breathing but unconscious, which is why I use the term breathing intubation rather than the much more accepted term awake intubation to describe it.

Many patients who receive dissociative-dose ketamine without a paralytic will have some muscle rigidity, and some will develop laryngospasm (which is glottic muscle rigidity).  The patient in this video had some rigidity, which resolved and was not a problem, and this is usually the case. But patients who get ketamine to facilitate laryngoscopy are at much higher risk than procedural sedation patients (who are not having their airway instrumented) to develop laryngospasm and occasionally jaw rigidity, which, together, can cause an immediately dangerous cannot intubate cannot ventilate scenario. Anytime KOBI is being undertaken, a paralytic must be immediately available, ideally drawn up in a syringe, so that the procedure can be converted to a paralyzed technique at any point.

How KOBI fits into our expanding airway toolkit is expertly described by Andrew Merelman and Michael Perlmutter in this WJEM paper.

 

 

 

*some airway experts disagree