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
- 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.
- 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.
- 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.
- 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.
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.
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.
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.