Thread by @Craig_A_Spencer

So what's really going on here in NYC?

You're hearing conflicting information on who is tested, who is admitted, who goes home, and what's going on inside hospitals.

Let me shed some light. NYC ER docs are a small and collaborative community, so let me share the scoop:

THREAD

First and foremost:

Anyone & everyone who is sick & presenting to our ERs is evaluated!

Our work in the ER is still subject to the Emergency Medical Treatment and Labor Act (EMTALA). This means EVERY patient gets a medical screening exam & stabilization. Always. No exceptions.

Also, to reduce risk to providers & patients, many hospitals have drastically ⬆️⬆️⬆️ telemedicine capacity.

This allows patients to talk to a provider virtually. No exposure for provider or patient.

On these calls, we can often tell who needs to go to the ER. And who doesn't.

Testing: Who's Getting It?

🔹Almost invariably, the only people getting tested are the patients getting hospitalized.

🔹Why does that matter? Because hospitals are sending home probable cases every day without any confirmatory testing. We just don't have the capacity.

🔹There's ~93k confirmed cases in NYC. But the true number is likely MUCH higher.

🔹This is frustrating for symptomatic patients who want tests but can't get them in ERs. At this point, we assume if you have symptoms of COVID, you have COVID. A test doesn't change anything.

Hospitalization: Who's Getting It?

🔹There is NO way we could admit all COVID patients to hospitals. Thankfully we don't need to.

🔹Most hospitals have a protocol: even for probable/confirmed COVID patients, if your oxygen saturation is above a certain threshold, you go home.

🔹This means that some patients w/ oxygen levels as low as 94% (or even lower when walking) end up going home [normal is 100%].

🔹Is this different from 'normal' practice? Absolutely. Hospitals have been sending home patients that would've certainly been admitted just weeks ago.

🔹Why is this the case? Because we need to preserve space and staff for the sickest patients. Each severe COVID patient takes a lot of staff & a lot of time. Many hospitals are at capacity.

🔹 So to be very clear, really sick patients aren't being sent home. Anywhere. Full stop.

What about mildly sick patients? What happens if you send one of them home and they get worse?

This happens.

Hospitals are providing follow up. Phone calls. Telemedicine. Some provide pulse oximeters to measure oxygen levels. Some provide oxygen concentrators with education.

The goal is to keep ALL the really sick patients.

Everyone that NEEDS hospitalization GETS hospitalized. Everywhere. All throughout NYC.

But a lot of people are sick and DON'T need hospitalization. Some with low oxygen. Some with pneumonia-like symptoms or nasty chest X-rays.

The bottom line is that anyone who should be admitted IS admitted.

As we plateau or start to decline, hospital admission policies may change.

In summary...

🔹Everyone is getting evaluated.
🔹Not everyone is getting tested.
🔹Everyone who needs to be admitted is admitted.

Life Support: Who's Getting It?

🔹 For many patients, mechanical ventilation (life support) is the only thing that save lives.

🔹 Let's be clear - this isn't being 'rationed'

🔹With an increase in ventilator supply, we're in a less precarious position than even a week ago.😓

🔹If you need to be intubated ('put on life support') AND that is your desire (FILL OUT YOUR MEDICAL DIRECTIVES PEOPLE!), you will be intubated and put on a ventilator.

🔹However, we're finding that many people put on ventilators have very, very little chance of coming off them.

🔹That means that many ERs are involving palliative care services early to talk about 'goals of care'. What would the patient really want???

🔹This is something we are NOT used to in the ER. We are trained to save lives. Not to plan on how to peacefully help withdraw care.

I cannot stress this enough.

Please, please, please.

Take time to think about what you would want if you ever got really sick.

Who would make those decisions for you if you weren't able?

Would you want to be put on a breathing tube? A ventilator? Chest compressions?

These are hard & difficult discussions to have.

But trust me, despite how hard it is to have this discussion when you're healthy, it's much harder to have when you/your loved one is really sick in the ER, struggling.

In summary:
🔹If you need a ventilator, you get a ventilator.

One important thing to recognize right now is that COVID is hitting hard at different spots all around NYC.

One hospital might be 'fine' while another a few miles away is inundated.

This virus is exposing the deep structural inequalities inherent in our city and our country.

COVID hits harder in the outer boroughs, where NYers without the same financial ability to stay home and socially distance live.

This cannot be overemphasized.

Just look at the map 👇

The result is that COVID has a much greater impact on Hispanic/Latino and black/African American communities in NYC.

Again, this cannot be overemphasized.

Just look at this chart 👇

If you made it this far, hopefully you have a better understanding of what's happening with COVID in NYC.

Who's getting tested.

Who's getting hospitalized.

Who's going home.

And what's happening inside hospitals...

But I hope you also takeaway the important message of what's happening OUTSIDE our hospitals, in our NYC communities.

Let's commit now to addressing the reasons why this virus is having an outsized impact on marginalized populations in NYC.

Now, and when COVID is no more.