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!
The last 6 weeks have been pretty consistent when we look at the number of positive tests and our percent positivity rate in the ER. We are seeing at least twice and sometimes 3 times as many cases per week compared to March and April. I am sure you are having plenty of friends test positive for COVID, just like we’re seeing staff members test positive for COVID.
The Omicron subvariants BA.4 and BA.5 have increased to represent about 52% of new cases, according to the CDC. This number will likely increase in the coming weeks. The FDA is in favor of updating the COVID-vaccine this fall. As I have written about, both Pfizer and Moderna have created updated formulations that include targeting the Omicron variant that caused last winter’s surge. These new formulations appear to upgrade the body’s antibody response. The better the antibody response, the more likely you don’t develop a symptomatic infection. One of the concerns, however, is that the BA.4 and BA.5 are so different from the original Omicron variant, the vaccine will already be a bit outdated. Although it is possible to develop a more targeted vaccine to the current strains, logistically it may take too long. The flu vaccine is made by manufacturers and they are given permission by the FDA to align the vaccine with the expected strains. Currently, the COVID-vaccine, and adjustments to it, require clinical trials to show that adjustments to the vaccine worked better than previous versions. With time and experience, hopefully the manufacturers will be rapidly able to make adjustments to the circulating strains and the regulators will have enough trust that the manufacturers are doing the right thing.
Monkeypox is in Northern Virginia and Maryland. There are just a few cases and contact tracing is being investigated by the health department. Transmission generally occurs from skin to skin contact with people who have lesions. There is a vaccine and the government is starting to release vaccine from the strategic stockpile. 1200 doses have been given to people who had high risk exposures to monkeypox. With 550 cases spanning 30 countries, this is the largest monkeypox outbreak ever. The plan is to provide vaccine to people who had high risk exposure (needs to be administered within 4 days of exposure). There is also antiviral medicine for those who get sick. Most people recover within 2-4 weeks. The virus spreads through skin to skin contact when someone has a monkeypox lesion.
WARNING: For anyone who might be interested in what an ER doc might think about the Roe v Wade decision, please keep reading. If you’re only here for COVID, see you next Friday.
It’s been a week since the Roe v Wade decision. I apologize for not mentioning this last week as I needed some time to process the impact it would have on patients in the healthcare system and what we would see in the emergency department. I have always tried to keep politics out of these posts and will try to continue to do so here as well. Abortions have been going on for at least hundreds of years. Historians have documented abortions in America prior to the revolutionary war. I even came across an academic paper from 1979 published in Women’s Health that described abortion practices between 1600-1900 in America. Currently, there are about 500,000-600,000 abortions occurring annually in the US. These are done by professionals in healthcare facilities with generally very low complication rates. With the SCOTUS decision, about 58% of women of reproductive age will lose the right to abortion in their home state. Some women may have to travel hundreds of miles to another state to get an abortion. Other women will not be able to due to financial constraints, inability to get time off work, or not having adequate childcare. Make no mistake, outlawing abortion will have health consequences to individuals because abortions will continue to occur. They just won’t be done as safely.
Abortion is common. Studies show that approximately 25% of all women have had an abortion in their reproductive lifetime. Approximately 7% of US women have attempted a self-managed abortion (SMA), which could include taking self-sourced medications, using herbs, undergoing blunt abdominal trauma, or having instruments introduced into their intrauterine cavity. If you are an ER doc practicing in a state that outlaw’s abortions, it is likely you will start to see patients who have complications of this attempted SMA. SMA’s will present to the ER like miscarriages, which is something we see on a daily basis. About a third of pregnant women have vaginal bleeding in their first trimester and about half of them will go on to have a miscarriage. Miscarriages are common and may not need any intervention by a physician, though often are treated with surgery and/or medications. A small percentage of miscarriages can result in infections.
As I followed some of the potential abortion bills over the past year or so, I was just amazed at how ignorant some of the politicians were when it came to women’s health. Several laws included outlawing treatments of ectopic pregnancies. Ectopics are pregnancies that occur outside of the uterus and are not viable. 1 to 2% of all pregnancies are ectopic, typically occurring in a woman’s fallopian tubes. If untreated, these pregnancies will rupture, resulting in significant blood loss and ultimately death to the woman if untreated. Medicine has not evolved enough to remove the embryo from the tube and place it safely into the uterus. Ectopic pregnancies are either treated with medicines (Methotrexate) to dissolve the embryo or by surgery, which typically means removing the tube. Although this is currently not an issue around the DMV, I’ve seen several discussions on ER doc groups where ER docs had patients with ectopics and were consulting the hospital attorneys about how and when to intervene to stay within the law to save the life of someone with an ectopic pregnancy where the state outlaw’s treatment. That is just crazy to me.
Interestingly enough, there’s discussion about whether women of reproductive age with rheumatoid arthritis and lupus should even be allowed to continue on their prescribed methotrexate in states that don’t allow abortion. Methotrexate is used to treat ectopics and would prevent a fetus from developing. Lupus and RA are chronic medical conditions that can be challenging to manage. Why would we stop a medicine that is effective? Of course, with the SCOTUS decision, there is also discussion about outlawing Plan B (the morning after pill), IUDs, and less likely, traditional birth control pills. In-vitro fertilization (IVF) would also appear to be on the table for discussion.
Domestic abuse often gets worse for women during pregnancy. The American College of OBGYN estimates that about 1 out of every 6 women who are abused had abuse start during pregnancy. And the leading cause of death for pregnant women isn’t pregnancy related, it’s homicide, frequently killed by a partner. Homicide is twice as likely to be listed as the cause of death than bleeding or placental disorders, which are the typical pregnancy related causes of death. For black women in the US, pregnant women are nearly three times more likely to die by homicide than non-pregnant women.
The doctor-patient relationship is amazing and it’s a privilege to have patients (all of whom are essentially strangers to us) share secrets with us. While most ER patients do not have anything in their history they would be embarrassed to have their mother hear, many patients share events with us that they would not tell anyone else about. This could include abuse, depression and thoughts of hurting themselves, drug and alcohol use, and anything having to do with sex and bowel movements. We are here to not past judgment but rather to help people. Abortion is healthcare and the shared decision-making process that occurs between a patient and physician should not be interfered with by the court system. The AMA has restated its support for shared decision making, adopting a resolution that “opposes any effort to undermine the basic medical principle the clinical assessments such as the viability of the pregnancy and the safety of the pregnant person, or determinations to be made only by healthcare professionals with her patients.” Many other professional societies including the American College of OB/GYN and the American College of Emergency Physicians have released statements opposing the court’s decision because of the interference of the doctor-patient relationship.
July 4th is typically on the short list for the busiest nights of the year to work in the ER. Please have a safe holiday.
Coronavirus is not done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.