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
We see about 1350 patients a week in the ER. It’s varied tremendously over the pandemic, but the last few months have been pretty consistent. About 360 of those patients will get admitted overnight (they all get COVID tests). About 1% of our patients get transferred to another hospital each week. We do about 550-600 tests a week on ER patients. In early September, we had an 11% positivity rate. We’re now in the 6-7% range. Our asymptomatic patients account for about 450-500+ tests a week. The percent positivity rate of this group has gone from 9.5% to about 6% over the last 6 weeks. And then we have our symptomatic patients. These are generally people with fever, cough, shortness of breath, etc…where we are suspicious of COVID and/or an infectious etiology. Someone with asthma who is having shortness of breath and says it feels like their asthma attack, is likely not getting tested as a symptomatic patient, but it’s at the discretion of the ordering provider. The numbers are useful in the grand scheme of things but how we classify a test, doesn’t impact bedside care. Because the number of positives in the symptomatic category isn’t nearly as high as it was earlier in the year, the percentage can vary a lot even if the total number of cases isn’t so different week to week. With that said, the percent positivity of this grouping is also trending down, with a 6-week average of 19.5% and this past week being about 15%. The number of patients hospitalized with COVID remains similar to previous weeks.
Analysis by The Commonwealth Fund found that “if 80% of eligible people receive their booster dose…it would prevent about 90,000 deaths and more than 936,000 hospitalizations and prevent $56 billion in medical costs in the next six months compared with the baseline scenario.” But, “if booster vaccinations remain at their current pace, the researchers found, a potential COVID-19 winter surge could bring a peak of about 16,000 hospitalizations and 1,200 deaths per day by March.” COVID is not over yet but we do have ways to mitigate its impact. There’s also an opportunity reduce the risk of death by more routinely prescribing Paxlovid, particularly for people over the age of 50.
I’m pretty worried about what the ER will look like this winter. It’s always busier in the winter than the summer. Our weekly volume is currently higher than our pre-pandemic volume and we’re starting to see an increase in the numbers peds patients presenting with respiratory illnesses.
While a new bivalent booster is likely to benefit most people, a study published in The Lancet found that “hybrid immunity from prior omicron infection and at least two doses of COVID-19 vaccine provided the highest protection from omicron infection.” The researchers found “that omicron BA.1 primary infection was associated with greater protection against BA.2 infection (risk reduction = 72%; 95% CI, 65-78), and protection was increased further among those who had received two doses of mRNA vaccine (risk reduction = 96%; 95% CI, 95-96). Hybrid immunity from BA.1 infection plus two to three vaccine doses similarly increased the estimated effectiveness to 96% for longer than 5 months.” Keep in mind that immunity does not appear to last forever, so depending on when you had COVID and when you received your vaccines may matter.
With President Biden’s pardon of thousands of people who had Federal offenses for simple marijuana possession, weed was in the news a lot this week. For the record, I have to really concentrate to spell marijuana so if I’m typing, I usually use the word cannabis. I’d forgotten that cannabis is considered a Schedule 1 drug like heroin and LSD. Schedule 2 drugs include cocaine and PCP. I see plenty of drug related issues in the ER. Cannabis patients generally fall into two categories as ER patients. First, and most common, are those that have developed cyclical vomiting syndrome because of excessive, and usually long term, cannabis use. Cyclic vomiting syndrome is a very complicated illness with causes other than cannabis but is a painful illness with hours to days of excessive vomiting. Less common issues I see in the ER are patients who ingested too much of the active ingredient in cannabis typically through edibles. I’ve seen more teenagers and young adults for this recently. As an example, I had a teenager sent from school for acting “weird,” who was really high. He’d never had an edible before and ate too much. He sobered up over a few hours and went home with his mother. I’ve never seen someone die from cannabis like can happen with heroin or fentanyl. I’ve also never seen someone so high on cannabis that it took 4 police officers to subdue them, so they don’t hurt ER staff, like with PCP. Cannabis laws are changing, and I suspect will continue to do so at the state level (it’s on the ballot in Maryland next month). The Feds also need to look at how they classify cannabis.
I’m planning on getting my COVID booster and flu shot next week.
Coronavirus is not quite done with us yet.
Science matters. Get vaccinated (or your booster). Keep a mask handy.
Mike
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