Thread on some ED Doc's thoughts on dealing with #COVID19US on frontlines
1/ First PPE: At this point, everyone should be wearing a surgical mask at your desk and in ED. No eating or drinking unless in Staff lounge, away from patient care
2/ When going into a potential #Covid19 room, wear a N-95 if you have it. Put a surgical (eg. regular) mask over it to protect it, then wear a face shield over that. Googles not as good, but we'll take what we can get.
3/ Assume anybody with cough, malaise, diarrhea (without vomiting), fever or extreme fatigue has it until proven otherwise. Any travel on airplane (anywhere), healthcare provider, working in public (eg TSA) is a Risk factor
4/ At this point, if patient is not sick (eg ER sick, not doesn't feel good), discharge pt and their contacts home with home isolation for 14 days. We need to ration tests at this point. It's Schrodinger's patient--you both have and don't have #COVID19 --just assume you do
5/ If the Pt is sick (ER sick), with unstable VS's, subjective dyspnea w/ tachypnea, etc., they're gonna need a w/u. MINIMIZED GOING INTO THE ROOM. Forget a complex PE. Have RN or tech get all labs (Sepsis labs, 2 viral swabs and OP swab) at one time.
6/ When it's you and the patient, you are captain of the ship. Do not let (HD/people in white coats from other departments, etc.) tell you best way to test or manage. I
7/ If you don't have in-House testing (and your HD won't test locally, CC: @HealthyFla) , assume worst, send out test, and get pCXR. If negative, get CT scan. (If mutifocal pna, you have COVID-19 unless pt comes back influenza or H1N1 positive)
8/ Do NOT let pt leave room except to get tests. Seeing diarrhea with sx's (it was my first symptom). DO NOT let them use public ED toilet and flush (poof, aerosolized SARS-Cov2)
9/ #COVID19FOAM mimics: PE (D-dimer is + in COVID 19), COPD, gastroenteritis, PNA, CHF. Closest thing is H1N1 (bil infiltrates, look sick, febrile, coryza, injected conjunctiva, etc.)
10/ Just a hunch, but Tachypnea IS MORE sensitive for COVID than fever. BS's sound clear (although it could just be those crappy $5 throw away stethescopes).
11/ If you order CT (and if you suspect, you should, even w/ neg. CXR), please put " dyspnea eval for " or "dyspnea, r/o COVID" on CT order. We want rad techs safe, want Rads to comment quickly, and they'll have to clean CT scanner after. READ YOUR OWN CT'S (it's not subtle)
12/ Multifocal PNA w/ neg. flu/H1N1 and viral panel is #COVID19FOAM until proven o/w. OF course, for now, can still cover with ceftriaxone/azithromycin (which actually may be helpful--yay Zpacks save the day again!). Remember sensitivity running about 80% on PCR's
13/ I've yet to intubate a #COVID19US patient. Will leave for guys @emcrit to better discuss. DO NOT give Duonebs in suspected pt (order inhaler from pharmacy), give bedside MDI's as needed). emcrit.org/emcrit/covid19…
14/ My thoughts on intubation. priority for who intubates goes like this: 1) most experienced 2) younger/previously recovered from COVID 3) person in PAPR (that's one step up form N-95
14/ Intubating person should be 1) experienced, 2) use Glidescope (covered in bag, use condom caths for US to keep clean). Have everything ready to go when you walk in room. Do not BVM! At very least full PPE with N-95 covered by surgical mask and face shield (PAPR "space suit")
15/ At some point, if multiple people require intubation, a person with PAPR space suit, glidescope, RSI meds ready. There should be a dedicated physician-led intubating team (Gas or EM) going from pt to pt
16/ Once COVID confimred, start on Hydroxychloroquine 400 mg PO BID x 14 days. Consider Azithromycin. If real sick (ICU, possible high mortality), consider Remedesivir or other antiviral
17/ Make sure you communicate with admitting doctor, House AOD/Sup, ICU, etc. on these patients. Communicate with staff. PROTECT your staff--you are captain of this ship
18/ Basic things I learned--avoid going in to room as much as possible. Minimize lab draws, meds. DO NOT NICKLE AND DIME YOUR NURSES. Also, GET PATIENT'S CELL PHONE! and CALL THEM for hx, further questions/to discuss stuff. Use 2-way call if possible through HUC desk
19/ Finally, take care of yourself AND STAFF. Change your scrubs in hospital. When you go home, shower immediately, change in garage if you can. Don't wear jewelry. Your cell phone is gross--bleach that thing. Do not drink at station, eat hospital non-packaged food
20/ Eat in lounge. Pretend JC is there and don't drink anything at desk. I think we've really underestimated the oral-fecal (gross I know) spread of this. No hospital in US should be serving salad bar in cafe or lounges, every food should be pre-packaged. At home, don't eat out
21/ Finally, if you get Covid
22/ You have exceptional odds to overcome it. We really do have any amazing system here in US, and #BAFERD nation as well as all doctors, nurses, techs, RT's etc. will be here for you. I do recommend starting Plaquenil 400mg bid (no, there are no RCT's)
23/ Take care of yourself, everyone. ✌️🤟💪
