Goals of Care During COVID-19
We were joined this week by Dr. Nidhi Garg, director of emergency medicine research at Southside Hospital/Northwell health, and assistant professor at Donald and Barbara Zucker school of medicine Hofstra/Northwell. She led her talk discussing the policy developed by their hospital to outline processes promoting transparent, fair and ethical clinical decision-making regarding allocation of life-sustaining resources if crisis conditions prevail. The policy also defines advanced illness - patients with chronic illness, including frailty or dementia, and two or more further criteria out of a preset list. The pandemic revealed the need for guidelines such as this one, regarding life sustaining treatment decisions for all patients in time of public health emergency. An important step in these treatment decisions is understanding the goals of care. The purpose of these discussions is to ensure that patients are aware of their prognosis and expected treatment outcomes or effects, while also allowing the physician to understand the patient's desires and values. The policy encourages shared decision-making choices so that patients continue to receive comprehensive care aligned with their values, including questions about resuscitation and intubation. These discussions and decisions should be documented clearly. Northwell Health provided an easy to follow, algorithmized approach to the goals of care program. The pandemic brought stress to everyone - including families of patients. Advanced directives such as living wills, physician orders for life-sustaining treatment, and DNR orders, are legal documents which were designed to understand the values and wishes if a person undergoing medical care no longer had the ability to make decisions for themselves.
MOSC Medical College, Kolencherry, Ernakulum
Dr. Ajith Venugopalan, head of department
Dr. Mervin Christo C, senior resident
Moving COVID dealt with the question of patient transport between hospitals (inter-hospital) and within hospitals (intra-hospital). The MOSC emergency medicine faculty recognized the challenges of a poorly understood disease with high risk of transmission, risk of clinical deterioration in transit, issues of disinfection and decontamination, and maintaining a closed environment. It is important to first answer the question of why a patient is being transported, in determining how to do so safely. Key in this determination is the clinical status of the patient being transported - e.g. the need for mechanical ventilation, inotropic support, critical care intervention or admission, and continuous monitoring. MOSC uses a communication proforma that allows for a smooth handover of patient care. They made interesting changes to their ambulances - equipment had transparent covers, a logbook was meticulously maintained, an oxygen reserve was ensured, drugs appropriately stocked, and the ambulance divided into three zones with dual-exhaust air conditioning to avoid cross contamination. Staff were trained to deal with complications, and the receiving unit kept notified about patient status and estimated time of arrival.
Intra-hospital transport also needed careful planning. Theirs being a 50 year old hospital, a separate block or COVID was impossible. They developed isolation zones within the hospitals, identified transit routes, and worked on restricting contamination. The first floor of the emergency department was converted to receiving suspected or confirmed COVID cases. Even for transport within the hospital there is a need to stabilize the patient. There should be dedicated trollies, equipment, and crash carts. There should be an adequate supply of PPE for the transporting staff. Procedures should be planned, and conducted by the bedside whenever possible, with limited personnel. Meticulous documentation including consent and charting should be diligently maintained. Preplanning of transit routes, for instance, choosing the shortest route, with minimum exposure to others, dedicated elevators, security coordination, and separate line of communication help to prevent cross-infection. MOSC also identified areas of development - complete online and e-reporting, ambulance tracking, telemonitoring, and uniform guidelines and protocols. Transportation medicine is still in its developing phase, but indeed an area allowing for growth and innovation.
Dr. Aravind V,
Dr. Aravind shared his case of a patient attending with persistent cough after a recent COVID infection. Their cough worsened and they developed a breathing difficulty leading to an admission. Imagining revealed bi-basal atelectasis and bronchiectasis, along with patchy ground glass opacities. Dr. Aravind shared an interesting poster of non-respiratory manifestations of COVID-19. He therefore highlighted the need for an emergency department plan including screening for post-COVID symptoms and red flag signs, and prioritizing treatment of post-COVID complications. He also suggested telemedicine for follow-up and centralized communication within the hospital.
Mass Casualty during COVID Pandemic
Dr. Tigi C Varghese,
In the middle of challenging pandemic, MOSC received news of a mass casualty incident - they were to receive 50 patients coming to the emergency department following a landslide at Munnar. Their institute was one of the nearest tertiary centers, so they put into practice the PRE-DISASTER paradigm. A helpful mnemonic to prepare - Planning and practice, Resilience, Education and training, Detection, Incident management, Safety and security, Assessment of Hazards, Support, Triage and treatment, Evacuation and Recovery. Disaster planning entails a vicious cycle of mitigation, preparedness, response and recovery. In this instance, MOSC secured a separate ward, with assigned ICU beds and isolation beds. They enacted aggressive resuscitation and stabilization measures, all whilst maintaining staff safety measures. A post-event briefing was conducted whilst maintaining adequate distancing and PPE measure. They made an amazing job of integrating the disaster protocol with the COVID protocol.
Sri Ramchandra Institute of Higher Education and Research, Chennai
Dr. S Jagadeesan,
Dr. Jagadeesan presented the latest guidelines of advanced resuscitation by American Heart Association and Resuscitation Council UK. Emphasis is placed on carrying out resuscitation whilst maintaining safety of all personnel involved. Guidelines allow for outlining standards of care for the emergency medical services pre-hospital, during transport, and in-hospital care. Planning for closed room resuscitation, limiting personnel, mitigating risk by reducing exposure during aerosol generating procedures. Dr. Jagadeesan talked us through each step of the COVID resuscitation guidance, is beyond the scope of this blog, so I will encourage all readers to update your resuscitation practice with the latest guidance.
Double Trouble: An atypical presentation of COVID-19
Dr. Amritnandan Pillai
Dr. Pillai shared some interesting cases from his department. One amongst them was a patient in his 40s attending with diffuse acute abdominal pain, and left upper extremity weakness and numbness. The patient had no comorbidities. His examination revealed a tachycardia, and was significant for 3/5 power in the left upper limb, distended and generally tender abdomen, with absent bowel sounds. He was aggressively resuscitated, and imaging conducted. The CTA revealed SMA filling defects, and labs were significant for lactic acidosis. He was also COVID positive. The case highlighted the prothrombogenic nature of COVID-19. Proinflammatory cytokines, lupus antigen, antiphospholipid antigen have been implicated.