Thanks as always to Dr. Mike Silverman, Chair of the Department of Emergency Medicine at the Virginia Hospital Center in Arlington, for these superb updates!
Friday Night Update from the ER in Arlington, VA
There’s still a lot of COVID going around. Just check in with a few friends and I bet you don’t have to look too hard to find someone who tested positive this week. With that said, the total number of patients we diagnosed in the ER this week was down a handful compared to last week and the percent positivity rate is also down a touch. The numbers from the last 4 weeks have been similar. We’ve seen a little bump up in our asymptomatic positives this week with a little dip in our symptomatic numbers which leads me to suspect some docs are being a little more open in what defines asymptomatic.
I saw plenty of COVID patients during my last main side (higher acuity) shift. It almost felt like the early days of COVID when elderly patients would fall and break a hip and would test COVID positive on their screening (asymptomatic positive). In reality, their fall was likely due to weakness and dehydration from COVID. I’m also seeing patients from skilled nursing facilities with confusion and dehydration, (sometimes critically ill), and diagnosing them with COVID. In these cases, the likely initial insult to their body leading to the dehydration was COVID, which can readily lead to kidney failure in elderly nursing home patients. We’re also seeing more psychiatric patients test positive again. Although I admitted 4 COVID patients during my shift, which is a lot for one doc in one shift these days, the total number in the hospital remains pretty steady, and is still running about 20% of the max we saw during the winter.
I recently wrote about the IV contrast shortage due to a plant closure in China. As someone who never took an economics class (admittedly one of my academic regrets along with not learning Spanish), it’s hard to fathom how connected the global economy and supply structure really is. Anyway, every radiology department has had to make some adjustments to the contrast shortage. ER’s probably account for about 50% of a hospital radiology department’s CT contrast use. You shouldn’t be surprised to hear that there are some tests we cannot compromise on and eliminate contrast. However, many we can. In part, this is due to the enhanced technology and image quality that comes with each new CT generation (thank you biomedical engineers and physicists). It also helps to have really good radiologists that are somewhat flexible with the situation, so I’m really appreciative of the ones I work with. The good news is the plant reopened last week. Although some hospitals are really short on contrast, and we’re still not out of the woods, we do expect this situation to resolve over the next month or so. If you get quarterly cancer screenings with contrast CTs, don’t be surprised to have your doctor suggest you wait a month until contrast is readily available or perhaps your doctor (or the radiologist) will change it to an MRI.
After watching the January 6th Committee hearings last night, I can’t help but reflect on the experience we had in the ER that night. I got my second COVID vaccine around 115pm that day, before my 2-10pm shift. I was scrolling through Facebook during my 15 minute “wait” period after my shot and I saw a post about the protests at the Capitol. By 145pm, I had walked to the doctor’s lounge to see the TV and get a sense of what was going on. By 3pm, we had heard about the riots and had been briefed on what a protective response might look like for the hospital if the rioters crossed into Virginia. Shortly thereafter we started to get patients who had been at the Capitol. I saw three patients that had been at the Capitol. One was a 70ish year old guy with chest pain after walking a far distance. This is a pretty standard patient anytime there is an event in DC. There’s a lot of walking as a tourist and there is lots of heart disease out there. Next up was a young adult with new onset seizures. He had COVID which likely means everyone he traveled with got COVID—remember this is really pre vaccine and the main prevention strategies were social distancing and masks. Finally, was a patient who came in with altered mental status. It was unclear to me what the cause was—stroke, drugs/alcohol, trauma, etc…Ultimately, it was “shock” when the patient collapsed after seeing someone critically injured and bleeding at the Capitol. We had several other patients who my colleagues took care of. Things started to calm down as darkness arrived and the rioters dispersed. It was a really stressful shift. (as with other patients I discuss, please keep in mind I change details to protect patient privacy)
The White House and CDC are going to end the requirement to have a negative COVID test when returning to the US from abroad. This is a step towards normal and likely overdue. When my family was thinking about an international trip last winter, we decided not to go because we didn’t want to risk testing positive and not being able to return to the country as planned—lost work and school weighed heavily on us (plus the extra cost of staying abroad). It makes sense to remove this requirement. But if/when I travel, I’ll still wear a mask on the plane, regardless of where I’m flying.
Hopefully next week’s post includes the approval of vaccinations for those <5 years old. The government has plans to roll out vaccinations the following week. Fingers crossed.
Coronavirus is not done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.
Mike
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