Friday Night Update from the ER in Arlington, VA: “Our total positive numbers for this past week are almost double what we saw the previous week”

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

May 6, 2022
Friday Night Update from the ER in Arlington, VA

One million deaths. 1,000,000. That’s a huge number and probably not one we thought we would cross 26 months ago when the pandemic was declared. Yet, we crossed that milestone this week in the total number of COVID deaths in the US. This week, the World Health Organization reported nearly 15 million excess deaths worldwide between January 2020 and December 2021 though only 5.4 million were reported as COVID. We’ve talked previously about excess deaths within the US because it gives us a better picture on the full impact of how the pandemic impacts health systems and individuals. Based on existing average mortality data, statisticians can predict the expected number of deaths. Excess mortality is the additional number of deaths beyond what is expected. These are really grim numbers. About 405,000 US soldiers died in WWII. About 655K in the Civil War. 116,000 in WW1 and 60,000 in Vietnam. The War in Afghanistan and the Iraq War combined for about 7500 deaths. Flu is generally responsible for 30-50K deaths in the US per year,

As I started my shift yesterday, one of my advanced practice providers said to me that it felt like January. It took me a second to figure out what she meant but then I realized she was about to walk into a room of a family of 4 that had come to the ER for COVID evaluation. Fortunately, home testing is widely available so we’re not being over run again for people requesting tests. But we are seeing an increase in patients presenting with signs and symptoms of COVID. We keep our N95’s in the ER a little bit out of the way so people outside of the ER aren’t just grabbing them when they walk by. I grab one each shift as I’m getting started. Yesterday, each of the APPs I was working with asked me to grab them one as well. We are seeing an increase in the amount of patients we diagnose with COVID. Our total positive numbers for this past week are almost double what we saw the previous week and our asymptomatic patients had a 6% positivity rate. Our symptomatic patients had a 15% positivity rate. That’s low by “surge” standards but 50% higher than last week and almost double the rate 2 weeks before. Fortunately, we’re not seeing big increases in the number of patients requiring hospitalization for COVID.

The hot topic on my listservs this week has been the shortage of IV contrast. About 25% of ER patients get a CT. Probably half of them get a CT with IV contrast. The contrast is critical in our stroke evaluation and it’s the best way to diagnose a pulmonary embolus. Although I don’t use it for routine head CT’s to look for trauma or in CTs done to evaluate for kidney stones, I do use it in patients with abdominal pain related to significant car accidents and to help diagnose bowel issues such as appendicitis and diverticulitis. What I’m hearing is that due to COVID lockdowns in Shanghai, where the plant is located, manufacturing is operating at 15% capacity. The company is looking at an 80% reduction in supplies for the next 6-8 weeks. This is likely to be a very big deal and impact patient care. We’ll be looking at protocols and alternative testing while balancing safety and quality. I suspect there will be a bigger impact where outpatient elective CT studies that are used for monitoring conditions get delayed.

The FDA decided to significantly limit the utilization of the J and J vaccine because of the risk of blood clots. You may recall the discussion about blood clots in the 2-week period after someone got the J&J vaccine shortly after it was released last spring. But the single dose vaccine was thought to be a valuable option with a favorable risk:benefit profile when the world had limited options and the data needed more analysis. As the data is more complete and there is plenty of Moderna and Pfizer for vaccination, the FDA has said the J&J should only be used for people who cannot receive a different vaccine (or specifically request J&J). The risk of blood clots from J&J vaccine is about 3.23 cases per 1 million shots, though more common in women under 50. The J&J vaccine may be used in people who had a severe allergic reaction to Moderna or Pfizer or if someone refuses to get an mRNA vaccine.

Coronavirus is not done with us yet.

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

Mike