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—The Holiday Edition–a day early on Thursday
From my first post on March 13, 2020—“Go to the ER if you are sick enough to need emergency care. But don’t go to get tested. Assume you have it and stay home for 2 weeks and distance yourself from your family (separate bedroom and bathroom if possible). Testing is still very limited and soon, it will be irrelevant as most with people with respiratory symptoms (fever, cough, shortness of breath) will have this. Protect the elderly as their chance of needing hospitalization or the ICU is much higher. ER’s and hospitals were at capacity to begin with. People wanting testing unnecessarily adds to capacity issues and forces us to use our limited supply of gowns and masks. Again, if you feel sick enough to need an ER, we are there for you.”
ER volume declined 40% as people really locked down and we never saw the massive spread we initially expected. Locking down to “flatten the curve” protected most hospitals. The surge of cases came, but not to extent we expected. We are now seeing the surge we anticipated back then and perhaps those sentences are more appropriate for January 2022.
ER’s are swamped. Our daily volume averaged 180 patients a day prior to the pandemic. We would swing from 165-205 but getting to 220+ was extraordinarily rare at my site. With the exception of Christmas, over the past week, our daily volume has been at 200+ patients a day with volumes of 250-265 the last 3 days in a row. I don’t have a written list of our top 10 volume days (which bums me out to admit that), but I’m pretty sure we had our top 3 this week. And every ER director I talk to is facing the same challenge. This is an extraordinary time for healthcare, and it’s led large hospital systems across the country to put out on their social media platforms that ER’s should not be used for routine testing and for minor illness right now. That’s additionally troubling as getting a test (anywhere) is extremely challenging and I’ve seen huge lines extend for over a block at my own local urgent care.
It’s crazy to me that almost 2 years into the pandemic, testing is still such a huge issue. It’s hard to find tests in pharmacies, it’s hard to schedule appointments for testing, and lines for other testing centers can take hours. While most patients coming to the ER are symptomatic, some probably wouldn’t come to the ER if they had better access to testing. While I understand the internal concern and fear to seek the ER if you think you have COVID, emergency care is extraordinarily expensive with legit space and staffing constraints. Coming to the ER for minor symptoms, covid exposure, or testing before you travel is not typically necessary or advisable.
Although Omicron appears less dangerous than Delta, last week our hospital inpatient COVID volume was 40% of our prior peak number. This week, it’s over 70%. Although the overall morbidity and mortality rates may be lower with Omicron across the population, the actual numbers of patients getting sick with COVID may exceed any hospital’s capacity to care for those requiring it. In the ER, we’ve set records when it comes to the numbers of patients we’ve diagnosed with COVID. COVID isolation orders have doubled in the past week and represents about half of our daily volume. Fortunately, the admission rate on these patients is about 15%. In previous surges, this number was 40%.
Consistent with all the other places you’ve seen case counts, we’ve had a 10-fold increase in the number of positive covid tests in our ER compared to 2 weeks ago. About 41% of our patients are testing positive –this is about a 60% positivity rate when looking at symptomatic patients (was 13% one month ago) and 25% positivity when screening patients (admissions, transfers, non-covid symptoms). This number was <1% a month ago. The number of tests we perform weekly has doubled from a month ago while the positive numbers have increased 30-fold (this was tricky math for me, but I think it’s right).
Keep an eye on booster shots for 12-15 year olds. Look out for an FDA announcement Monday.
The CDC has had a wild week. I’m not going to get into the reduction of the isolation criteria this week (down to 5 days from 10 days), but I do want to mention they revised the percentage of cases that Omicron makes up. Last week, they announced that Omicron had skyrocketed from 22% to 74% of the COVID cases in the US. This week the CDC is saying, oops, they got it wrong, and that Omicron is 58% while Delta is 41%. This is interesting but doesn’t change anything in the ER. My take is that we’re seeing Omicron as it’s much more infectious, hitting many vaccinated and boosted patients, and seems to present a little differently. I’m seeing lots of families get sick. I’m also seeing people with headaches who turn out to be COVID positive. We’re also not seeing as many of the severe pneumonias we saw previously, and not as many people require admission (this could possibly be related to vaccination and/or booster). I’m told from the ICU team that, although it’s small numbers at this point, they are seeing a higher percentage of people survive intubation/mechanical ventilation than in previous surges. The frontline instincts are that Omicron is here and not as severe as Delta. However, with massively increasing numbers of patients, the ER and hospital are the busiest they’ve been since the pandemic started. And people are still requiring hospitalization from COVID, and people continue to die.
Patients have all kinds of personalities. There are the “downplayers” –people who are literally dying and say they feel fine, while others are histrionic or dramatic—screaming about their pain or refusing to get on the exam stretcher themselves because they feel too sick. There are some you want to become friends with or get a drink, and of course, some are just jerks. But there’s often a moment of truth where patients just want to know if they’re going to die. I’ve seen this more and more with COVID. I had a boss who used to say that as ER docs, we were in the “reassurance business”—ruling out the life-threatening stuff to tell people they were fine. There’s some truth to that, more so 20+ years ago when 50% of our patients weren’t true emergencies. Our patients are even much sicker now than before the pandemic, so I find myself having the tougher conversations now more often than I used to. These conversations are about DNR, comfort care, chances of dying, life expectancy, and potential interventions. Let’s go back to that moment of truth conversation. One of the more surprising conversations I’ve had over and over with young, healthy, vaccinated patients diagnosed with COVID are when they say to me one of the following: “Am I going to die? I feel like I’m going to die? I can’t imagine how bad unvaccinated people feel because I feel awful.” And these are the patients I’m sending home. Even if Omicron isn’t as bad as Delta from a risk of severe illness/hospitalization/death perspective, I’m pretty sure it often makes many people feel really sick. And most people still would prefer to avoid that.
The Coronavirus is not done with us yet.
Science matters. Get vaccinated (or your booster). Wear a mask.
Mike
PS Happy 28th anniversary to my fantastic wife. From Dewey Beach, to having a family, to juggling professional careers, and now navigating a pandemic, there’s no one better to have as a co-pilot.
PPS. Pictures this week include me back in full PPE. Lots of it this week. Also, there is a clip from our main side tracking board from earlier this week. There’s a lot of positive COVID tests.
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