The blog and podcast has been a bit quiet recently as we’ve been focused on the preparations for Corona virus1 in the UK and around the world. These are our abbreviated thoughts on where we are now, and where we might be sooner rather than later.
What’s likely to happen?
The bottom line is that we don’t quite know, but there are clues on potential trajectories from other health economies who are a little further ahead of us. Worryingly the data from other areas suggests that we should be prepared to expect a significant expansion of cases in the nest few weeks.
So, on this data it would seem that in the UK we are a few weeks at most away from a significant impact on ED, Acute Medicine and Critical Care capacity. It may not happen like this, but we should be prepared. Note that there may be very little time to prepare.
Many of us have been concerned after reading the following thread from Lombardy. I would recommend a read of this before thinking about what we might face in Virchester
What do we know about treatment on ICU in Italy?
There is little in terms of publications out there at the moment, but there are conversations shared online that may help us plan for the types of treatments and management that is likely in critical care units.
My interpretation here is that the events of this disease will disproportionately land on our critical care and medical colleagues. Although the ED will be a focus, the anticipation is that patients will not be treated long term in our units.
These comments and summaries come from what appear to be pretty reliable #FOAMed sources in Italy.
What should we be doing now in the ED?
How you deal with Covid-19 will clearly vary depending on where you are, what your geography is and what your staffing looks like but we think there are some general principles and questions that need consideration. At organisational and national level there is clearly a lot of planning going on, together with a range of advice and guidelines being issues (that often change frequently). However, there is also a lot we can do at departmental level to prepare. Have you considered all of the following?
Get a small group of lead clinicians to lead and coordinate your departmental response. These might be your normal departmental leadership team, but in our experience there is so much to do that it needs dedicated people to this particular task. Consider taking them off clinical duties for the next few weeks to support this. Preparation and planning are vital. In Virchester we have Siv and Nandini who have been absolute heroes in getting us up to speed.
All staff need to be trained in putting PPE on and off. Mask testing is essential and although many chaps look gorgeous in their beards, they may have to lose them if hoods are not available. In my personal opinion clinicians with beards should shave them for fit testing (unless your hospital has a surplus of hoods). It’s not acceptable to use having a beard as an excuse for not being able to see patients. All ED clinicians need a PPE solution.
We have been running regular simulations for the last couple of weeks. These have been incredibly helpful in the preparation for a seriously unwell patient attending the ED with suspected or known coronavirus infection. We are running the simulations as a process sim to test our processes and procedures and also to train staff in PPE.
The most common scenario is an unwell patient attending the ED with severe respiratory illness. We progress the simulation from initial assessment through to intubation and transfer. There are some great resources out there, but you don’t have to wait for others to design scenarios. Get in touch with your local sim teams and try out some local in situ simulations. Everyponme should be doing this now, and as often as possible. I promise you that you will learn loads by doing it.
Practical Exercises Without Casualties (PEWCs)
A great way for low impact, high frequency, easily reproducible simulation
On the back of the simulations we have developed a ‘Corona team’ to respond to severely unwell patients comprised of ED/ICU/Security/Porters/Radiology. This functions in the same way that a trauma team might respond to get early expertise and diagnostics to this challenging group of patients. Just like a trauma team it provides a reliable and consistent response that then also triggers other actions and promotes urgency in assessment and decision making by senior clinicians.
Clinical assessment in PPE is challenging (try putting a stethoscope on without contaminating yourself) and so imaging will be vital. Get your radiographer team involved in your plans and simulations and consider how you can achieve plain and cross sectional imaging.
Decision making conversations
We have spent a lot of time talking about decision making for critical care referrals and admissions. It is generally agreed that NIV will not be an option for us and therefore the need to progress to IPPV may come at an early stage in the patient’s illness. Similarly we have had some very challenging conversations about ceiling thresholds for intervention changing if ICU capacity is overwhelmed. These are sensitive conversations that explore how we feel about capacity, ourselves, our families and those with pre-existing health conditions. Such difficult conversations are clearly evident in reports from areas with a high incidence and thus it would be naive to think that they cannot happen here.
You might also want to consider the worst of outcomes, the death of family, friends and colleagues. There have been many healthcare worker deaths in this pandemic and it’s likely that there will be more. I’m incredibly lucky to have so many friends and colleagues across the world, but that almost inevitably means that I/we/you will lose some of them this year. Think hard about how you might manage that for yourself and in supporting your colleagues who might face some really tough experiences.
We have advised colleagues to keep a diary of how they feel, what they think about the disease and how it is being managed. We have encouraged them to ensure that they identify positive elements as well as challenges as we go through the next few months. We think that this will highlight positives whilst also providing a record of how our teams contributed to this global problem. We believe this may be important when we look back once this has finished.
We are looking at how we can staff the department in the event of up to 25% sickness across all grades and professions. This is perhaps the greatest challenge that we face. In the UK it has been agreed at national level that it may be necessary to move clinicians from one speciality to another and in a small number of cases this has already happened to support some infectious disease specialist units. However, we must be mindful of how useful clinicians who are not EM specialists would be in the ED. They will need orientation, induction and probably some for of case selection to function well. At this stage you may wish to consider where additional staff might come from and what their needs might be.
In previous epidemics staff suffered psychologically from dealing with critically unwell patients2–5. We need to recognise this and talk to them in advance. Be open about difficult conversations and decisions. Regularly meet with your colleagues, trainees, and help them , and yourself, get through this process. We have incorporated these difficult conversations into our in situ simulations in the ED.
Global health perspective (Stevan Bruijns)
As of 7 March the world passed 100,000 confirmed cases of patients infected with the Corona virus infection; just over 4000 patients have died. For perspective, the Ebola outbreak in the Democratic Republic of the Congo have affected just over 3,300 patients, with 2,130 deaths. The difference though is the remarkable spread of the Corona virus. On 11 March the World Health Organization (WHO) declared the outbreak a pandemic. The WHO describes a pandemic as the worldwide spread of a new disease. Although the criteria they use to define a pandemic is a bit fluffy, 114 countries seems a fair assessment.
It may be worth bearing in mind – given the multi-cultural nature of the NHS – that there exists a fair amount of experience that comes with being from another country: nurses from the Philippines are usually multi-area skilled due to their training involving rotation through just about every setting you can shake a stick at (including ITU); clinicians and nurses from the United Arab Emirates may be accustomed to ventilating patients at home; and most clinicians and nurses from African backgrounds are used to making difficult decisions for far lesser reasons than we may be expected to.
These experiences and more, are not often considered when planning for local responses to significant events like the Corona virus pandemic. Now may be a good time to take stock of the lesser known skill sets of your foreign workforce.
A short note on nebulisers (I did not know this).
This is a fast moving issue and it’s difficult to keep up. There is a lot of information on national sites such as PHE, CDC etc. but they often lack the practical and granular thoughts that we need at the bedside. The following sites are ones that we are using to guide us on education, diagnostics, management and emergency planning. For UK readers I’d recommend starting with @wilkinsonjonny resources at critical care Northampton. He seems to be keeping this up to date and it has many useful resources for critical care an EM clinicians.
The bottom line
Whilst we hope for the best, we must plan for the worst. There is a huge amount of work being done at the moment to increase respiratory and ICU capacity here in Virchester but the unpredictability of what happens next is obviously a concern.
If we follow the trajectory of Italy then the next two weeks and beyond may be the most challenging of our careers as emergency clinicians. That does not mean that we are despondent. Rather we are energised to do our best to prepare. We hope that it is enough.
- 1.Xu X-W, Wu X-X, Jiang X-G, et al. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series. BMJ. February 2020:m606. doi:10.1136/bmj.m606
- 2.Chong M-Y, Wang W-C, Hsieh W-C, et al. Psychological impact of severe acute respiratory syndrome on health workers in a tertiary hospital. Br J Psychiatry. August 2004:127-133. doi:10.1192/bjp.185.2.127
- 3.Wu P, Fang Y, Guan Z, et al. The Psychological Impact of the SARS Epidemic on Hospital Employees in China: Exposure, Risk Perception, and Altruistic Acceptance of Risk. Can J Psychiatry. May 2009:302-311. doi:10.1177/070674370905400504
- 4.Maunder R, Hunter J, Vincent L, et al. The immediate psychological and occupational impact of the 2003 SARS outbreak in a teaching hospital. CMAJ. 2003;168(10):1245-1251. https://www.ncbi.nlm.nih.gov/pubmed/12743065.
- 5.Lin C-Y, Peng Y-C, Wu Y-H, Chang J, Chan C-H, Yang D-Y. The psychological effect of severe acute respiratory syndrome on emergency department staff. Emergency Medicine Journal. January 2007:12-17. doi:10.1136/emj.2006.035089