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
I worked a lot clinically this week (at least for me). I had evening shifts on the main side of the ER on Sunday, Monday, and Thursday. Tuesday and Wednesday were pretty full meeting days. Today has been spent catching up on email, mixed with a couple of meetings, plus finding a little time to write this post.
My clinical shifts were busy. We are back to our pre-COVID volumes, but the overall acuity is higher. A percentage of the lower acuity patients we used to see have figured out ways to get care via telemedicine and urgent care. This leaves the ER with a higher percentage of patients who require prolonged and complex care in both the ER and the hospital.
Our department admission rate has bumped from about 20% prior to COVID to 25% currently (we were as high as 30% over the last 2 years). Our main side admission rate is always much higher. I admitted about half of my patients this week and about a third of the admissions required critical care for the evaluation/stabilization of life-threatening emergencies. I did have several COVID patients (probably the most I’ve seen in any one week in months) and I also had several patients with influenza.
As ER docs, we’re pretty used to seeing patients with alcohol related illness and psychiatric illness. This week it really jumped out at me. I had a lot of patients with alcohol related issues. Whether you’re found passed out in the street or in the bathroom of a bar, it could be related to drug or alcohol intoxication or trauma (plus a myriad of other things that can make you unconscious). I feel like I saw it all this week. I also had patients with complications from alcohol use, such as life-threatening electrolyte disturbances and gastrointestinal bleeding.
And then there’s our psychiatric patients. Prior to the pandemic, it wasn’t easy to find psychiatric beds for patients who required hospitalization. The pandemic has made it much more challenging (bed closures, nursing shortages are two reasons). There’s also more patients in need of emergency psychiatric care and hospitalization. There’s plenty of news stories that have talked about the pandemic’s impact on mental health and we’re definitely seeing more patients, most concerning to me are the teenagers and young adults with severe depression and suicidal thoughts who hadn’t previously had mental health issues. Patients can often stay 24+ hours in the ER waiting on a psychiatric bed to open. Colleagues in the DMV tell me they’ve held patients for 7+ days waiting for a bed to open. This is far from ideal for the patient plus these patients impact care to the other patients in the ER.
On the hospital side, the number of patients admitted with COVID is back into the double digits. COVID is an incidental finding in at least some of these patients but still requires the careful infection prevention methods to minimize the risk of transmission to staff. In the ER, we had a slight uptick in the number of cases and percent positivity rate compared to last week and are in the same ballpark as 2 weeks ago, which was our recent high-water mark.
Published in the MMWR this week, the CDC estimates that about half of the US population has been infected with COVID, including upwards of 75% of those <18. Between December 2021 and February 2022, prevalence went from 34% to 58% in adults and about 44-45% to 74-75% in those 12-17 and 11 and younger, respectively.
Certainly, a subset of these had minimal symptoms or were asymptomatic. The higher percentage in kids is thought to be related to the lower vaccination rates. The study looked at antibodies related to the nucleocapsid protein, which only occurs after infection and does not occur after vaccination. The dramatic increase in prevalence came during the Omicron surge last winter. Omicron remains responsible for essentially all new cases in the US, with about 68% being the subvariant BA.2 and 30% being BA.2.121. The sub variant BA.2.121 is estimated to be about 25% more transmissible than BA.2 but does not cause more sever disease.
It does appear that South Africa is on the brink of another surge with another Omicron subvariant called BA.4. Cases are up to 6000/day from 300 a day a few weeks ago and the percent positivity rate has gone from 4% in mid-April to 19%. We’re not seeing BA.4 here in the US yet.
Pfizer has submitted an application for a booster shot for kids 5-11, highlighting the 36 fold increase in antibody levels against the Omicron variant in the study population of 30 kids. Meanwhile, Moderna has applied for EUA for its vaccine to be used for children 6 months to 5 years old. The company looked at 2500 children ages 6 months to 24 months and 4200 children ages 2 to 5. Data shows that a quarter of the adult dose produces a similar immunologic response to the 18-25 year old group. Although the vaccines were only 51% effective for 6-24 month old’s and 37% effective for 2-5 year olds in preventing symptoms, those numbers were similar to the effectiveness among adults during Omicron. The expectation is that as with adults, the amount of severe disease will decrease. The vaccines were also found to be very safe. I personally feel like we’ve reached the critical data levels and political momentum to get those 5 and younger their vaccine, Hopefully approval will be soon (meetings scheduled for early June).
So now let’s talk again about why COVID is different than the flu. In a study out of Spain that looked at hospitalized patients who required oxygen, the risk of death was 3 times higher for those with COVID compared to those with influenza (the flu). There was a 3-fold increase in the risk of death at 30 days as well as 90 days. Over twice as many COVID patients required the ICU than influenza patients and COVID patients spent more time in the hospital and the ICU than influenza patients, This also leads to a higher cost of care for COVID patients.
Coronavirus is not done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.