“Shared expectations lead to predictability.”
56. “Crisis level of care” when hospitals are overwhelmed
Q: What happens when the number of COVID-19 patients needing hospital-level care exceed the capacity of existing facilities?
A: When the number of patients exceeds a hospital’s ability to give routine levels of care, several tactics are used to expand the number of additional patients that can safely arrive. Patients in the emergency department who require in-patient care can be held for transfer to another facility. Under previous federal initiatives, many states have set up a state- or region-wide central clearinghouse that can identify the nearest bed and facilitate the transfer. The next level of “surge capacity” might be to stop elective, non-emergency surgeries to open existing beds for the emergency. After this, a hospital might locate unused space within the facility and set up additional areas with beds, equipment, personal protection equipment, and staff. Finally, as well publicized in New York, federal and other outside resources can be brought in to set up remote facilities in large open areas – tents in fields, enclosed exhibition halls or the US Navy’s hospital ships in nearby ports.
The question then becomes what happens if all these surge capacities do not match the increasing needs of overwhelming numbers of patients. The process of triage, or sorting and categorizing patients is then required. So far, no state has yet faced this crisis point. But indications lead to the possibility that one state, Arizona. may soon be there. During June, the governor has suspended following the CDC guidelines for “opening up” the economy in several separate controlled stages. In rapid succession, businesses are opening indoor restaurant seating, bars, beauty salons and barbershops. There are no state guidelines on social distancing or wearing cloth face coverings. Only recently, the governor decided to allow local communities to make separate decisions mandating use of masks. Testing was never adequately developed as a system, and people in long lines may now wait up to 6 hours before they can be tested – if at all. The number of tests available are quite limited. And it takes up to a week – or longer – for people to receive their test results. This, of course, makes contact tracing nearly impossible. Recent news reports have shown that many people, especially under the age of 40 are not wearing masks, even when locally required. The public views this disease as either “overblown” by the media, or as innocuous as the common cold. The daily new hospitalizations are exponentially increasing, and public health officials are projecting the state’s health care system will reach capacity early on July. There is no reporting that temporary federal or other resources to set up remote temporary hospital capacity is being considered.
When and if this happens in Arizona or any other state, some patients may not be given the customary standard of care they usually would, and decisions will be required on who will be denied. The American Medical Association has a well-established ethics section to guide such decisions. In its stated principles, “a physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Yet, “during public health emergencies like pandemics, this commitment of fidelity to the individual patient is counterbalanced by the need to protect the welfare of a population of patients.” Guidance is offered when allocating limited resources. Decisions should be based on “likelihood of benefit or to avoid premature death…” Each hospital has already developed ethical guidelines in detail, following these AMA guidelines.
But what does this mean? If a COVID-19 patient on a ventilator goes into cardiac arrest, CPR would normally be performed unless the patient has an authorized “do not resuscitate (DNR)” on file. Under crisis standard of care, CPR would not be considered at all. If a patient in a completely full ICU is pronounced dead, and two patients are in the emergency department waiting to be admitted, one will remain in the ED until another space is later opened. Several patients requiring a ventilator may be held aside in the ED without one, stressing the capacity of the ED to manage “routine” patients (trauma, cardiac care, etc.). Patients presenting by walking into the ED with difficulty breathing who otherwise might be admitted, will now be sent home with an order for oxygen. We may soon learn more about this crisis standard of care from actual reporting – we all hope this will never happen.
57. Methanol in hand sanitizer
Q: I found a supply of hand sanitizer using methanol instead of ethanol. Is this just as effective?
A: Everyone should check the label on their bottles of hand sanitizer! Many are sold as “No Germ” or “antibacterial.” Coronavirus-19 is a virus, and this requires a “viricide.” Antibiotics do not destroy virus particles. In addition, a company in Mexico: Eskbiochem SA de CV has distributed many products in the US listing the contents as “80% alcohol.” These include such product names “All-Clean”, “CleanCare”, “The Good Gel”, and “Saniderm.” These products contain methanol rather than ethanol as the primary ingredient. On June 17, the FDA advised consumers not to use these products. Methanol, otherwise known as “wood alcohol,” when ingested or absorbed through the skin, is toxic. The FDA further advises that anyone who has been using a methanol-based hand sanitizer should contact their physician to prevent adverse effects. Especially if ingested, methanol poisoning can lead to neurological problems including seizures, blurred vision, blindness, even coma and death.
58. “No-swab” saliva test
Q: Is the use of a swab the only way to get tested for coronavirys-19?
A: On Monday, June 22, the British government reported a clinical trial is underway for a weekly testing regime using a “no swab” saliva test. The goal is to make testing for the presence of coronavirus-19 less dependent on the availability of swabs, easier to administer and to provide more rapid results. Saliva test results usually are available in just 48 hours. One result of this study might be the availability of “at-home” testing kits. The test uses a different laboratory process, which promises to be more accurate. Developed by the British Firm Optigene, this is being tested by a group of 14,000 participants in the city of Southampton.
59. Social distancing effectiveness
Q. Just how effective is social distancing?
A: In June, an article in the British journal The Lancet reinforced and elaborated on the value of social distancing to prevent infections of coronavirus-19. The World Health Organization (WHO) reported that by keeping at least 1 meter (about 3 feet) away from others the risk is reduced of the virus spreading from the larger droplets that people spray out when they cough, sneeze and talk. In Switzerland, a study demonstrated that a distance of more than 1 meter reduces the risk of infection by 80%. This study also reported that the risk even then is greater when a larger number of droplets are expelled as when people sing or speak loudly. It has also been recognized that regardless of the distance, one’s risk increases when other factors are considered, including duration of any close proximity, the number of people in a given space, use of cloth face coverings, availability of air-exchanging ventilation, and if people talk quietly or loudly.
60. List of conditions indicating “Stay-at-home” is expanding
Q: I hear that more factors and medical conditions have been added to the original list indicating more people than before need to stay at home as the economy is re-opening. What are these?
A: Over time, increasing data and analysis is identifying several factors associated with poor outcomes for people who contact coronavirus-19. CDC on June 25 published an updated guideline identifying this.
With respect to age, 8 out of 10 people who died from COVID-19 were over the age of 65. The number of people hospitalized per 100,000 population over age 75 was 843; between ages 40-75, the rate was 319; under age 40 the rate was 35.
For people of any age, the risk of severe illness rises if there are underlying medical conditions. Newly identified medical conditions responsible for this now include:
Chronic kidney disease
COPD (a pulmonarydisease)
Immunocompromised state
Obesity
Serious cardiac conditions
Sickle cell disease
Type 2 diabetes
The following MAY present a greater risk:
Asthma
Cerebrovascular disease
Cystic fibrosis
Hypertension
Dementia
Liver disease
Pregnancy
Pulmonary fibrosis
Smoking
Thalassemia (a blood Disorder)
Type 1 diabetes
All people in these high-risk groups should continue to remain at home, if possible, as others participate in economic reopening through the recommended sequential phases. Strict use of social distancing, use of cloth face coverings and frequent hand washing or sanitizer use are all recommended when it is necessary for anyone to go out in public.
