Friday Night Update from the ER in Arlington, VA: “Although we all know people who are testing positive, generally the vaccines and boosters are working to keep people out of the emergency department”

Thanks as always to Dr. Mike Silverman, Chair of the Department of Emergency medicine at Virginia Hospital Center, for these helpful updates!

Friday Night Update from the ER in Arlington, VA

Between spring break, Passover, and Easter, this is posted a few hours later than usual. I hope you started happy hour without me.

Our COVID hospitalization numbers look good. COVID hospitalizations is one of the primary drivers of the CDC Community Level determinants (low, medium, high). I also look at the amount of COVID isolation orders placed by our ER team. This is a symptom and exposure based trigger system that allows us to include patients who come to us knowing they are positive. Although there was a little uptick in these numbers the week ending last Friday, this past week we returned to the lower numbers we have primarily seen the last couple of months. One of the key stats we track has been the number of new COVID cases we diagnose each week. We continue to have a slight upward trend of new cases. Our percent positive rate among “symptomatic” patients bumped up to 15%. This was <2% a month ago. Our general screening numbers also ticked up from the prior week and that percent positivity rate also crept up to 2.74%. To some extent, the asymptomatic group mimics society, since in theory, the patients are asymptomatic. (keep in mind, however, that our “asymptomatic” patients are in the ER so already they are sicker than the general population and therefore I have always believed that our asymptomatic rate is higher than your typical asymptomatic person) However, as I sat on a plane and at a conference this week, I started to do the calculations of how many people likely have COVID. Overall, our total cases climbed again, and our overall percent positive rate was 4.1%. Although we all know people who are testing positive, generally the vaccines and boosters are working to keep people out of the emergency department.

I spent most of this week at an emergency medicine conference in Las Vegas. It was my first big conference in a long time. It was fun to see people and be at a conference. It was also a little weird after doing everything virtually for 2 years. The timing was also a little odd as the reports were coming out about the 70+ cases that occurred at the Gridiron Dinner in Washington, DC. The dinner had about 630 vaccinated attendees (about the same size as my conference). All of the ER docs at the conference realized there was some risk by attending, despite being vaccinated and boosted. I had several discussions with friends about what we really thought are risk was.

Because of the conference, I didn’t work clinically yet this week (I work Sunday), but let me share a couple of recent cases. First, I treated an adult with flu. His whole family was sick, though he was the only one who felt sick enough to come to the ER (shortness of breath and chest pain). We are starting to see some flu and certainly more than we’ve seen in a while. I had another patient who had C. diff colitis related to antibiotics. She had been prescribed antibiotics for an upper respiratory tract infection (URI). Over the last several years, we’ve tried very hard to avoid using antibiotics for URIs, which are typically caused by a virus. One of the risks with antibiotics is developing C. diff, so we carefully weigh the risk/benefit ratio before prescribing antibiotics. We obviously prescribe antibiotics all the time, but this was a clear reminder that there is risk to these generally safe medicines and there are many times when antibiotics aren’t indicated despite an illness going on. I have patients request antibiotics all the time when they’re not indicated. I try to patiently walk through my rationale about why they’re not indicated and appropriate, but it’s these types of issues (like C diff colitis or even an allergic reaction) that we’re trying to avoid.

There’s a couple pieces of news on the Federal level. First, the COVID-19 public health emergency was extended for another 3 months. This allows for people to continue to get free tests, treatment, and vaccinations, regardless of insurance status. Also, the CDC extended mask mandates for airline travel for another 15 days. Having just flown and experienced the crowds, I’m glad people had masks on. Airports were packed and the Southwest boarding area certainly puts you shoulder to shoulder with lots of people.
Although air circulation in planes is good, it’s not the same as having a mask on. I wear a mask when I’m in a COVID patient’s room when there’s a HEPA filter, so why would I not wear a mask when I don’t know the status of people around me?

Pfizer has new data showing the benefits of a booster shot in the 5-11 year old age group. Currently, everyone 12 and up is able to get a booster. Pfizer’s newest study included 140 5-11 year old’s who had already received the 2 shot vaccine, and found that a booster shot 6 months after the initial series improved their immune response. Scientists did a very close look at 30 kids and found a 36 fold increase in antibodies—this is believed to be a high enough level to fight off the Omicron variant. We are all still waiting on more info about vaccinations for the <5-year-old crowd. One cool thing I came across this week was that the 1st breath test for COVID received emergency use authorization by the FDA. The testing instrument is still the size of carryon suitcase (it will be really cool when technology gets it down to the size of a breathalyzer), but it’s possible that this test will be useful in doctor’s offices and mobile clinics. Test results are available in about 3 minutes. The study data included 2409 patients, both with and without symptoms. The test was 91% sensitive (the percent of patients who truly had COVID and the test got it right) and was 99% specific (the percent of negative samples the test correctly identified). It missed a small number of positives and didn’t give a lot of false negatives. I don’t see this being used in the hospital setting, but it is pretty cool.

The Omicron BA.2 variant continues to be the dominant variant leading to new cases. Nationally, BA.2 makes up >85% of new cases. However, there are now two subvariants, BA.2.12 and BA.2.12.1. These two subvariants make up >90% of cases in parts of New York.

I got my second booster today. Arm is a little sore but otherwise feel fine.

The Coronavirus is not done with us yet.

Science matters. Get vaccinated (or your booster). Keep a mask handy.

Mike