Friday Night Update from the ER in Arlington, VA: The “Tridemic” of “COVID, Respiratory Syncytial Virus (RSV), and Influenza all circulating at the same time”

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

Everyone has probably seen something about the potential “Tridemic.” That would be the combination of COVID, Respiratory Syncytial Virus (RSV), and Influenza all circulating at the same time. Without trying to be too dramatic, I think it could be real (or as real as any made up word can be). We’re being hit really hard with flu right now and seeing a lot of RSV, and of course, COVID isn’t going anywhere. The big questions will be how quickly things peak and how long the total surge lasts.

Let’s start with COVID. The hospital has 50% more COVID patient in it today than it did last Friday. The good news is that the total number isn’t bad and far below what we’ve had during COVID spikes, but it’s clearly higher than last week. In the ER, our total number of COVID positive patients that we diagnosed by testing was about twice as many as last week. We had about 50% more tests performed on patients categorized as “symptomatic” with about twice as many positives, which drove our percent positivity rate from 14-17% the last month to 19.5%. Overall, we performed about 20% more tests than the typical week in the last month) and had the highest percent positivity rate we’ve seen in a month.

I’m working on getting flu and RSV numbers. We’ve seen very little flu since COVID began. I’ve probably seen more flu cases this past week than in the last 2+ years combined. It’s almost all Influenza A. Locally, I’ve seen a report that there was an increase in the 30-50 year old age group diagnosed with flu, but personally, I’ve seen way more kids with flu in the ER this week than adults. A colleague of mine told me that she had 6 flu patients during her shift this week out her 24 total patients. I don’t think a quarter of the patients coming to the ER have the flu. Some of what we personally see during a shift is dictated by what shift we’re doing and what responsibilities we have. But none of us saw 6 flu patients in a week last winter—it was all COVID.

It’s uncommon that patients with the flu require admission. For the typical 20-30 year old who is in the ER because they feel bad or flu-like, I can usually diagnose the flu by asking if they feel like they’ve been run over by a truck. If the answer is yes, they likely have the flu. I had the flu over twenty years ago and thought I was going to die. It makes you feel that bad. I have gotten the flu shot every year since then (I didn’t get it prior to getting the flu) and not had it again. It’s not too late to get your flu shot. And while it may not completely prevent you from getting the flu, it will likely reduce the severity of your symptoms.

One other difference between now and pre pandemic is that prior to COVID, if you were young and healthy and I thought you had the flu, I didn’t test you for it. The prior generation of flu tests wasn’t great. If it was positive, we could confirm you had the flu but it was falsely negative 50% of the time. So if it came back negative, I still told you that you had the flu and that you should stay home from work, rest, take meds for your fevers and muscle aches, and drink lots of fluids. Now, we’re typically testing patients for COVID and flu, though much of the homecare continues to remain supportive (fluids, Tylenol, rest). The potential consequences of COVID do prompt us to try to diagnose it, even if it may not change our basic homecare recommendations (besides isolation). And since it’s a PCR test, it’s more accurate than prior flu tests we were using so we’re not getting the high false negative numbers.

I’m also working on getting RSV data. I’ve never felt compelled to track RSV cases before. It’s a common virus that most kids are get before they’re 2 (according to the CDC). Symptoms are usually mild, cold like, and resolve in 1-2 weeks. RSV can be serious, particularly for infants and older adults, or those with congenital heart or chronic lung disease. Staying hydrated and taking Tylenol for fevers usually does the trick. We don’t recommend cough medication for kids<6. We’ve always seen kids with it in the ER but the numbers have never overwhelmed the healthcare system. Sometimes, particularly in kids less than 2 or 3, we can see pretty significant breathing issues with RSV. Some of these kids will require the PICU (please see my post from last Friday). Area PICUs are quite full and getting patients transferred to tertiary care pediatric hospitals is already leading to longer delays this week than last week. This means patients will stay longer in the ER waiting for a bed to open up.

Here’s what you can do to help protect yourself and your family:

• Get your flu vaccine (and COVID booster)
• Wash your hands often with soap and water
• Try to avoid touching your face with unwashed hands
• Avoid close contact with people who are sick
• Stay home from work or school if you’re sick
• Cover your coughs and sneezes

While Dulles Airport continues to track potential Ebola patients, monkeypox is looking better. I believe Arlington County is reporting 64 monkeypox cases. Nationally, there’s been 20,000 cases but only 6 deaths. The highest number of new cases was in August, so we seem to be trending in the right direction.

I’m going to switch gears completely so bear with me. I had a patient with a DVT last Saturday. The overwhelming majority of DVT patients go home on a newish type of blood thinner called a Direct-Acting Oral Anticoagulant or DOAC). These are really game changing medications and have also allowed us to safely discharge a subset of patients with pulmonary emboli as well. There are a few possible options but pretty much everyone prescribes Eliquis or Xarelto (you’ve seen the ads for their use in atrial fibrillation on tv). So I discharged my patient on one of those meds only to get a call back from the patient a couple hours later saying the prescription required pre-authorization. There are few administrative perks of being an ER doc but one of them is that I don’t have to deal with pre-authorization. If I want a test, I can basically order it and it gets done. (Trust me—if we abuse the system, we’ll get feedback from the hospital so there are some controls and supervision in place) The majority of my prescriptions are for routine, and low cost, medications as well. But I did something during my shift last Saturday that I’ve never had to do in 25 years as an ER doc. I obtained pre-authorization for this med. I cannot understand why the insurance company would need a pre-auth for this med. You’re basically only using it for a few indications and if the patient couldn’t get it, she would need to return to the ER and quite possibly be admitted (at a much greater cost to the insurance company than giving her meds for a month). Doctor’s offices generally have staff that handle pre-authorization. This may be for medication or if they order a lot of tests like stress tests or MRIs. Again, we don’t do that in the ER and we’re not built for that. I didn’t have a case manager or anyone else to help me that day since it was a Saturday. But the patient needed the script, and I had a little bit of time.

I started with the pharmacy and worked my way to the company that managed her prescriptions. From there, I started to complete an online form only to get stopped because I had to upload a copy of either my actual medical license or my actual DEA certificate. Now on a normal workday, I could get those sent to me within an hour or so. But on a Saturday, there was zero chance I could get them and they’re not something we carry. So I called the tech support for the website or they gave me a number to reach a person to get a verbal pre-authorization (I can’t help but think how helpful that would have been when I first called the insurance company). The patient got the approval and then I called the pharmacy back to confirm they received the electronic approval and then I called the patient. The whole process took about 45 minutes. That’s about 2 patients worth of time who had to wait for other docs to see them. I don’t think I’ve ever publicly said anything negative about insurance companies despite their rising profits, passing higher costs on to customers, denials of payment for routine services that then require time and expense to appeal to finally get paid, etc….But this 45 minute experience seemed to sum up the craziness of the healthcare insurance industry.

Good luck to everyone participating in the Marine Corps Marathon this Sunday. I ran that race in 2009. VHC is the primary receiving hospital for patients that need an ER. Many thanks to Arlington EMS for the amazing work they do at the medical tents and on the streets taking care of the athletes and generally keeping them out of the ER.

On a happy note, the picture is of my dog. She’s a German Shepard mix we rescued form the Maryland SPCA 13 years ago and today is her 14th “birthday.” I wish she could live forever but we’re so grateful for the lifetime we’ve had with her.

Coronavirus is not quite done with us yet.

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

Mike