The 30th WACEM-ACAIM Weekly Summit: e-EMINDIA2020

 

The Effect of UV-C Radiation Against Different N95 Respirators Inoculated with SARS-CoV-2 

Dr. Shanthi Narla, MD

Dermatology Resident Physician

St. Luke's University Health Network, 

Pennsylvania, United States

Dr. Narla presented her topic of research on the UV-C Radiation on various N95 respirators. She emphasized that ultraviolet radiation degrades polymers, thus inducing DNA damage to prevent viral replication, rather than "eliminating" the virus. The topic of N95 mask reuse and PPE shortages became a topic of conversation early in the pandemic in both developed and developing countries. Without going into details of her fantastic study (available to read at: https://onlinelibrary.wiley.com/action/doSearch?ContribAuthorStored=Narla%2C+Shanthi ), her presentation yielded some take-home points. UV-C at doses of 1.5 J/cm^2 to both sides is effective on some models of N95. Further consideration is required for disinfection of mask straps (alcohol swabs were found to be effective, with due caution not to allow dripping onto the mask itself). It's important to note that this decontamination for SARS-CoV-2 does not apply equally to all hospital respiratory pathogens, and that fit testing following irradiation should be considered.

Sree Gokulam Medical College, Thiruvananthapuram, Kerala

Accepting, Adapting, Awakening - Administrative Modifications During COVID-19 

Dr. Amrithanand V T, MD, 

Assistant Professor, 

Department of Emergency Medicine

Dr. Amrithanand gave us a look into the handling of COVID-19 by his department. Kerala, like other parts of India, and indeed the world, saw an alarming rise in coronavirus cases. Initially they faced bottlenecking due to a combination of insufficient knowledge of this new virus, supply-demand issues, the task of providing a safe working environment, pandemic hysteria, and existing disease burden. Their hospital administration was on their toes, carrying the memory of dealing with the Nipah outbreak, and were quick to establish a command center. They generated surge capacity and ensured up to date training. They followed a 2 - step (Questionnaire and Vitals) Triage system. They anticipated a mass casualty incidence following Attukal Pongala (a celebratory gathering of worship) and prepared themselves to face the worst. Floor plans were changed, and management steps thus far enacted only in simulated scenarios, were put into action. Their infection control department took charge of developing areas for safe donning/doffing, waste disposal and provision of PPE for all staff. They ran drills. Their "Break the Chain" campaign took the message of "our health, our responsibility" to the public. Engineering and administrative issues were quickly dealt with, and standard operating procedures were put into effect and communicated throughout their hospital. Importantly, they also partook in raising community awareness of the disease. Leading by example!

Unmasking COVID-19

Dr. Reshma Douglas and Dr. Nidhi Mohan

EM Residents

Dr. Douglas presented her case of a gentleman in his 60s who walked into their department, in the early days of the pandemic, with complaints of rhinitis, productive cough and fever, but no breathlessness. Their quick 2 step Triage revealed a silent hypoxia, with saturations in the mid 70s. She elicited a history of the patient having attended 4 funerals in the recent past with as many as 50 in-person contacts in that period. He was diagnosed with mild ARDS and had point of care ultrasound in department. The patient was referred early to the COVID center as a strongly suspected COVID case. His first PCR test was negative, however the patient was retested after he developed neurological features and needed intubation. The second test was positive. Her second case was that of syncope in a COVID patient, in whom troponins revealed myocardial involvement, and the patient succumbed to a myocardial infarction. Both her cases emphasized the unusual presentations of COVID-19. As we have come to learn with time, that initial symptom complex of flu-like symptoms can be fairly misleading when it come to COVID-19. 

Dr. Nidhi's case was in a similar vein. Her patient, too, initially tested negatively. However a high index of suspicion and evolution of symptoms called for serial testing with both imagining and RT-PCR which indeed then showed evidence of COVID-19. Her presentation reminds us all that though investigations have their place, they do not displace clinical gestalt. A high index of suspicion is necessary, which comes through knowledge, experience and instinct. Not are presentations of COVID-19 come solely with respiratory symptoms, and one must conduct a thorough assessment when it comes to unmasking diseases such as COVID-19.

P.E.S. Institute of Medical Sciences and Research, Kuppam, Andrapradesh

A comparative study on severity of pulmonary versus cardiac involvement in COVID-19

Dr. Befin K, MD

Assistant Professor, 

Department of Emergency Medicine

Dr. Befin said it best in his slide, "Heart and lungs are the two vital organs most commonly affected with COVID-19," which is what led him to conduct his interesting study. As a matter of routine, his department categorized the disease based on the degree of severity, and followed a well-laid out algorithm to determine investigations and management. Amongst the various biomarkers and imaging modalities, this study took a look at high sensitivity troponins (hs-troponins) and HRCT in COVID-patients. The HRCT findings, in keeping with other published data, were ground glass opacities and consolidation, with diffuse GGO being the most common early finding in patients who died. In several patients with positive hs-troponin values, HRCT revealed significant ground glass opacities and consolidatory changes. Though there might be other explanations for the hs troponin rise, and high mortality rates in certain patients, his study, and presentation generated interest in looking further into the topic of troponins, and other biomarkers in COVID-19. 

Emergency Medicine - A Game Changer

Dr. S. Prakash Babu, MD, 

Assistant Professor, 

Department of Emergency Medicine

Dr. Prakash's presentation highlighted the role of the emergency physician and the emergency medicine department in the management of a pandemic such as COVID-19. The pandemic brought along with it havoc and demoralization, alongside stringent government and state led guidelines, and political influences. Through step-wise implementation of changes early on, including role allocation, public awareness programs, division of blocks, while also considering non-COVID patients, the ED played a major role in excellent management. Emergency Medicine specializes in rapid assessment and stabilization. This is not limited only to individual patients but also to dynamic scenarios. Resident training includes disaster management and preparedness, which helps in times like this to draft protocols and more importantly, in their smooth implementation. Communication and management are core EM skills. Emergency Medicine is the game changer!

An Unusual Presentation of COVID-19

Dr. Rajeev, 

EM Resident

Dr. Rajeev presented his case of a gentleman in his 70s who attended the ED with fever, cough, and sudden onset dyspnea with unilateral pleuritic chest pain. Early in the course of his attendance, Dr. Rajeev suspected that this patient had a tension pneumothorax, and had features of COVID-19. His POCUS, fitting with his suspicions, revealed a pneumothorax, and an immediate needle decompression was carried out. A chest radiograph following the decompression also confirmed the pneumothorax, which still appeared large, therefore a tube thoracostomy was performed. The patient also underwent other routine investigations and tested positive for COVID. He was treated as per their local management algorithm. The likely pathogenesis is proposed to be inflammation induced pulmonary parenchymal injury and necrosis, and treatment in this case involved following routine management of pneumothoraces in combination with treatment initiated for COVID-19. 

Defeated COVID, Succumbed to Renal Failure

Dr. V. R Tejasvi, 

EM Resident

Dr. Tejasvi's case came with the unfortunately underlying diagnosis of chronic kidney disease. Her patient of COVID-19 who had an ongoing oxygen requirement and imaging findings consistent with ARDS, also required emergency dialysis which was arranged with due care following the COVID-19 positive report. Due to his precipitously worsening condition, he developed hyperkalaemia, reflected by typical changes of peaked tall T waves and wide complexes on his ECG. Through the course of his admission, careful respiratory management improved his lung function, with serial investigations showing pulmonary recovery. On the other hand, through the course of his admission, he developed recurrent hyperkalaemia and acidosis despite haemodialysis. His management proved difficult through fluctuating hypotension and hypertension. Finally, and tragically, he succumbed to his recurrent hyperkalaemia and renal failure. The message Dr. Tejasvi presents is an important one. Not all patients who have COVID, have COVID alone. There are several patients with underlying conditions, which we know pose a threat even without the added disease burden of COVID. We must not be blinded to other diseases, to comorbidities, and to diseases that can exacerbate other conditions. 

The 29th WACEM-ACAIM Weekly Summit Presents: e-EMINDIA2020

 

Endorsed by WACEM & The World Health Organization Collaborating Center for Emergency and Trauma, AIIMS, New Delhi, India in Partnership with The Emergency Medicine Association and The Academic College of Emergency Experts as well as The American College of Academic International Medicine

The 28th WACEM-ACAIM Special Global Web Conference on COVID-19

 

28th in the series of WACEM-ACAIM Joint Group Meetings

We starting this weekly meeting with the grim recognition that Europe is indeed seeing a second wave of infection. We spoke again about the influence of blind spots on this second wave.

COVID-19: The Sri Lanka Story

Dr. Eranga Nrangoda (Sri Lanka)

The National Institute of Infectious Diseases (NIID), Colombo, Sri Lanka, is the only designated quarantine hospital and only specialized hospital for communicable diseases in Sri Lanka. 

The first case of COVID-19 in Sri Lanka was a Chinese tourist visiting Sri Lanka in January 2020. She presented with fever, retro-orbital pain, loss of appetite and sore throat. The hospital sent a nasopharyngeal swab for PCR, which confirmed coronavirus infection. She fortunately recovered from a mild course of disease in a period of 10 days. 

The first Sri Lankan patient, reported to hospital in early March. He again, had mild illness with good recovery. Most early patients had contact from international travelers. Studies from Sri Lanka showed a male preponderance, and mean age of 40.8 years, as well as co-morbidities, similar to those noted across the world. 

Like any other place, NIID also faced challenges initially. Among these, anxieties of healthcare personnel, short supply of PPE, poor understanding of a new disease, limitations in isolation rooms, labs, and imaging, which they overcame quite magnificently. 

Antibodies and Biomarkers

Dr. Neelika Malavige (Sri Lanka)

Dr. Malavige presented where Sri Lanka is presently, compared to other countries, which in short, is better positioned than most, with low level of cases and low mortality rate related to COVID. But her focus of discussion was antibody responses and vaccines.

They studied neutralizing antibody responses, but were faced with infrastructural limitations, not having the specialized laboratories to study these. With some help, they received kits to progress beyond this obstacle. They studied antibody responses and followed up patients in community. They found that the mean duration of hospital stay was 17 days. Many patients had prolonged viral shedding (in some cases, up to 50 days). Of the antibodies that were generated against the virus, neutralizing antibodies were thought to be associated with protective function, and they seemed to be present up to 8 weeks in relation to clinical severity. Nearly all patients had detectable antibodies after 5 weeks of illness, but became undetectable in many patients after >90 days of illness. 

Reinfection was confirmed by the differences in the virus strain causing the first versus the second infection. The second infection had a more severe illness. 

In developing vaccine, scientists have measured antibody responses, but not memory B cell responses, this provides some hope for future studies. Viruses, historically, also become less virulent with time, providing some more hope.

Role of Military in COVID

Col. (Dr) Saveen Semage (Sri Lanka)

Sri Lanka saw clusters of infections, mostly brought back from travel abroad, or brought to from travelers to Sri Lanka. Quarantine process, contact tracing and isolation, and point of entry operations (decontamination, thermal surveillance, passenger handling and seafarer crew exchange) were run by the military, in addition of course to maintaining law and order. They had a dedicated treatment center for military cases. Additionally, the military was assisting communities during the lock down. 

Their contact tracing system was a hybrid of public health surveillance and state intelligence services. Tracing carried on till the 3rd degree of contact. Decision between institutional quarantine versus home quarantine was dependent on vulnerability. People returning from overseas were tested, but regardless required to self-quarantine at home. 82% of infected patients were in quarantine centers. 

Some of the strengths of their response came from effective communication between health and military, hybrid contact tracing as mentioned above, testing strategy and timing, leadership commitment, strong public heath system, and of course the degree of military involvement in the pandemic response. 

The 27th WACEM-ACAIM Special Global Web Conference on COVID-19

 

27th in the series of  weekly WACEM-ACAIM Joint Group Meetings

The 26th WACEM-ACAIM Special Global Web Conference on COVID-19

 

26th in the series of weekly WACEM-ACAIM Joint Group Meetings

Plant Products Nanotechnology: Integrated Indian Herbal (Ayurvedic) and Nanomedicine for COVID-19, by Dr. Shyam Mohapatra (USA)

Dr. Mohapatra opened his fascinating talk with the concept of integrated medicine: a combination of experimental and experiential, holistic and analytical, functional and structural aspects of care. He highlighted some benefits of herbal medicine, such as better membrane permeability, good bioavailability, decreased toxicity, and many more. With the advent of nanotechnology and the progress made in the last few decades, the ancient macroformulations of ayurvedic medicine can now be manufactured as nanoformulations. He gave an example of Withania somnifera (ashwagandha), a long used plant with medicinal properties. Scientific studies looking for adverse effects on multiple organ systems showed Withania somnifera to have a relatively safe drug profile, and its bioactive ingredients have been used in prevention and treatment of arthritis, amnesia, impotence, anxiety, cancer, cardiovascular disease, etc. It was shown to have immune-modulating action in other animal studies. Finally in relation to COVID-19, it is shown to engage ACE 2 receptor proteins. There are other similar examples of plant based therapeutics, which in Dr. Mohapatra's words, when explored in combination with nanotechnology, will prove to be a marriage made in heaven.

COVID 19 in Japan, by Dr. Jumpei Tsukeda (Japan)

Dr. Tsukeda regaled us with the fantastic approach toward COVID-19 which was used to good effect in Japan. He mentioned that the key to a well engaged response, was the availability of 24/7 information sharing. They implemented messaging, mobile and computer based voice applications, tele-ICU. Teams were divided to play to their strengths, and redeployed to areas that needed the redistribution. There were in-hospital teams and out of hospital teams with excellent follow up provided to both sets of patients. Hospitals were renovated to establish COVID units, COVID triage, and COVID ICU. The government and health sectors put out simple to understand messages, such as "AVOID 3 Cs - Closed Spaces, Crowded places, Close-contact settings". They, too, faced several challenges, but have continued to prove how Japanese discipline and understanding of healthcare of their people is a priority. 

Metamorphosis of COVID, by Dr. Indrani Sardesai (UK)

I had the honor and pleasure to be included in this wonderful panel of speakers. My topic alluded to the metamorphosing of COVID-19 from "just another viral infection" as thought back in January, to one that has caused devastating to the global population, to the economy, to both physical and mental health. At first thought to affect just the vulnerable above-60 population, to now affecting all without discrimination. In the current climate of social connection and the power of media-driven narrative, there has been information coming out fast, sometimes too fast to the detriment of trust between the common man and the healthcare sector or those who represent it. However, in all this, we also bear witness to the rising new disease as witnessed by people who understand science and those who don't. The scientific community is so focused on this disease, papers, publications, therapeutic trials abound. We have resigned ourselves to the fact that this disease is here to stay, but we are determined in finding out more, and taking away the power of the unknowns.

COVI-Sepsis from Qatar, by Dr. Hassan Al-Thani (Qatar)

Beginning his talk about the variety of ways COVID has presented at its worst, from the fatal pneumonia raving the lung, to the necrotizing fasciitis feasting on the body, Dr. Al-Thani highlighted the serious nature of the disease. The Qatar model of healthcare is particularly inspiring in its proficient and remarkably rapid response in dealing with the disease. In their anticipation of COVID reaching Qatar, they generated surge capacity for both ICU beds and general hospital occupancy. They went from a hundred ICU beds in one week to a thousand in the next. Their inpatient capacity increased by five fold. They paid a great deal of attention to staff health and well-being, realizing very early that weaknesses in staffing (be it from illness of self or family, burn-out, etc.) would result in a domino effect to take down the whole system. The speed of the response, government support, and subsequent results prove that Qatar means business. 

Malaysian COVID Response, by Dr. Mohammad Alwi (Malaysia)

Malaysia put into action the lessons learnt from its experiences with SARS, nipah virus, and MERS. Their regular table top exercises and simulation exercises kept them up to date and ready to deal with anticipated and unanticipated events. They were able to rapidly establish command centers, triage areas and communication hubs. They put a lot of effort into regular open communication which helped with a trusted and effective work environment, ultimately leading to safe and effective patient care. Dr. Alwi's hospital even managed to make their local and national news. The key to their success for regular training and good communication.

Operational Restructuring in COVID: The ED in NHS, by Dr. Joydeep Grover (UK)

Just like a lot of hospitals around the world, the NHS trust hospitals in the UK also created surge capacity at the outset in anticipation of COVID reaching the UK. Fortunately, more beds were created than utilized rather than the other way around. Secure areas or secure corridors/paths were created to limit cross contamination throughout various in-hospital areas. There was the general principle of process development, attended by experienced clinical and non-clinical staff, communication on a regular basis, and finally putting plans into operation in a systematic manner. Attention was paid to staff well-being across trusts, addressing the need to recognize and care for staff's health and morale. Risk assessment scores were developed taking into account that staff can also belong to the vulnerable groups, and due precautions taken to ensure safety. A pleasant experience for the NHS was the public lauding and "Clap for carers" initiated by the public themselves. Members of the public, local eateries and businesses would drop off spare PPE, food, cards etc, in a show that was touching and motivating to front-line workers in hospital and community based teams. 

 

These last 3 weeks, we have celebrated the occasion of regular weekly international meetings, and the completion of 25 meetings - no small feat - with a line up of speakers from across the world, experts in their field, all invested in the betterment of our handling of COVID and the wider aspects of the practice of medicine.

The 25th WACEM-ACAIM Special Global Web Conference on COVID-19

 

25th in the series of WACEM-ACAIM Joint Group Meetings

COVID lessons, by Dr. Sagar Galwankar:

The pandemic highlighted a variety of problems - from the disease itself, people involved, supply and demand dynamics, hysteria. Practices lacking an evidence base were taking place generously. It is interesting to note and important to recognize the sometimes apparent but sometimes subtle difference between improvised practice versus compromised practice. With time and experience; with data, papers, analyses - solutions also came to light, in fact some are solutions are still evolving. 

Case based learning, by Dr. Chauhan:

Dr. Chauhan presented an unusual case of a young patient who died from a short neurological presentation with fever. The case had symptoms and signs, and events suggestive of rabies, alongside symptoms of COVID with a positive PCR test. We talked about the neurological presentations of COVID-19, as well as the potential to activate or exaggerate other concurrent illnesses, whether viral, bacterial, other or mixed causalities. 

POCUS/CT in COVID in the Netherlands, by Dr. Prabath;

This presentation, including a summary of an exciting study, talked about the use of point of care ultrasound and CT scans and their predictive values and usage in COVID-19. Coming to the conclusion that POCUS was indeed found to have excellent negative predictive value in the hands of trained users, however CT was the better imaging modality for ruling-in a diagnosis and providing further information.

Environmental Coronology, by Dr. Thakur:

Dr. Thakur's presentation was not only a nifty recap of the coronavirus, but also provided an insightful look at the environmental impact of COVID-19 and the impact of the environment on COVID-19 as well. Where it is fairly easy to become hyperfocused on singular aspects of the disease, the pandemic made us learn to divide our focus, necessitating the process of prioritization - to think about human factors, PPE, supply chain dynamics, diagnostics, data, and ever-changing discussions. 

Supply-chain resilience, by Prof. Venkat:

This much talked about topic reminded us of the behind-the-curtains processes that never ceased to persevere through the pandemic in its efforts to keep the "system" running. Apart from the vast array of clinical problems, this working and resilience of the supply chain - transport, waste management, equipment provision, etc. has also had its hurdles. Through a joint process of collaboration and innovation, perhaps the reason it is so under-recognized is because of how well it has coped.  

Telemedicine in Italian COVID-19, by Dr. Salvatore:

Italy was one of the pioneers for pushing the concept and demonstrating the execution of telemedicine in COVID-19. Circumstances necessitated innovation, quick-thinking, and optimal utilization of resources to allow reductions in avoidable admissions to hospitals while balancing the practice of safe medicine in recognizing the dynamical decision making in a rapidly evolving disease. Several papers came from Italy, and Dr. Salvatore presented the protocols suggested and used by his hospital which proved successful in sifting out the low severity COVID patients who benefited from avoidance of institutionalization while still receiving adequate, and frankly impressive medical tele-follow up. 

COVInventions from Israel, by Dr. Tal Or:

Israeli medicine is often involved in innovations and process exploration. In his presentation, Dr. Tal Or spoke about the nasal scent recorder, a unique little device which analyses exhaled breath of the individual being tested for coronavirus, and delivers the results to their smartphone application with results in remarkably short duration of time. The tests showed 85% accuracy. Combined with different considerations when evaluating patients, this would and has saved time and resource utilization.

More to come on September 12th...

The 24th WACEM-ACAIM Special Global Web Conference on COVID-19

 

24th in the series of WACEM-ACAIM Joint Working Group Meetings

ED & COVID-19: Where are the patients gone? presented by Dr. Lateef 

Talks for this week kicked off with Dr. Lateef's insightful talk about the trends of ED attendance during the pandemic. Hospitals across Singapore, and more widely, across the world, saw a significant reductions in hospital attendances at the beginning of the pandemic. A qualitative analysis showed multiple reasons as to why this phenomenon occurred, ranging from altered health-seeking behavior to cultural influences, from attempts at self-management to lack of manpower. The concept of Behavioral Immune Responses (BIR) was also introduced, which refers to the psychological processes that infer infection risk based on perceptual clues through activation of various behavioral, emotive and cognitive responses that motivate pathogen-avoidance behaviors. 

Blind Spots, presented by Dr. Stawicki

The topic of discussion by Dr. Stawicki alludes to the concept so regularly repeated in medicine, 'The eyes see what the mind knows'. Rather, the corollary, what the mind doesn't know, goes unseen. There are multiple areas in and outside of health care which led to the less than efficient handling of the crisis and learning from these instances will help us, not just with the ongoing pandemic, but future outbreaks. The paper is still in production. 

HCW in COVID, presented by Dr. Sahu

Dr. Sahu presented results of his meta-analysis about healthcare workers infected by COVID-19. (Link: https://www.ajemjournal.com/article/S0735-6757(20)30483-6/fulltext ). The study concludes a significant risk of contracting COVID-19 among healthcare workers, but low incidence of severe morbidity and mortality. 

Other papers co-authored by Dr. Sahu: 

https://www.researchgate.net/project/COVID-19-and-emergency-department

https://www.researchgate.net/profile/Ankit_Sahu3 

 

Evolution of Medical COVItrature, presented by Dr. Tiwari

Dr. Tiwari's paper and presentation highlighted the patterns and trends of literature during this pandemic, of which there were admittedly many. The difference in publications about clinical discussions and education and training for instance, among other examples, showed the trends in publication, or indeed, readership. 

Clinical Update, presented by Dr. Downing 

Dr. Downing's presentation of New York data confirmed obesity as being a significant indicator common between adults and children with COVID-19. The other notable point was the discrepancy in infection incidence and severity based upon latitudinal variations which led to the idea of a link between vitamin D deficiency and COVID-19. 

Goals of Care in COVID, presented by Dr. Garg 

Dr. Garg talked about topic that many a clinician has struggled with. The introduction of discussions regarding advanced directives - always difficult in the acute setting, and even more in the presence of a pandemic. Particularly one where there is already some healthcare paranoia, and specifically in the case of a disease with such high numbers of morbidity and mortality. Dr. Garg shared her hospital's introduction of a protocol nudging clinicians to have appropriately timed difficult conversations, which unfortunately remain vital in our communications with patients and their relatives. 

More to follow next week...