I hope everyone had a great Thanksgiving. If you saw extended family and friends, I hope you did it safely—vaccinated, people stayed home if they were symptomatic, used OTC testing, etc… I worked the day shift which is usually marked by how early I see the first kitchen injury and what the total number of Thanksgiving related injuries ultimately tally. Those mandolin slicers usually result in a few ER visits but for whatever reason, I personally did not see any kitchen injuries.
What I did spend a lot of time dealing with were patients who came in during the night shift severely intoxicated and often with injuries, either as a result of falls or assaults. Every year, there is a college student who dies of alcohol poisoning and binge drinking hits the news cycle. And while binge drinking is more prevalent among college students than working adults, every ER sees patients on a daily patient who present with extremely high blood alcohol levels and/or complications related to alcohol use. From my point of view, I’d much rather have someone brought to the ER for evaluation because their friends/family are so concerned about their level of intoxication rather than leaving the person to sleep it off where they might stop breathing, choke on their own vomit, or try to walk and fall down a flight of stairs. With that said, the night before Thanksgiving is always a big party night and seeing an ER the morning after is living proof of what could go wrong when you party with your friends.
I wish I had done a better job of keeping a list of all the shortages we’ve had at the hospital since the beginning of the pandemic. And it’s not over yet. As an example of something where the hospital is regularly sourcing a variety of vendors, I find some amusement in watching our masks change. The color changes, the material in the loops that go over your ears varies, and even the metal clip that adjusts above the nose isn’t standard, etc…I definitely have my favorite brand but since they all work, I just laugh at it. Currently, we have a shortage of sterile gloves and splinting supplies. We shouldn’t run out as our supply management team is sourcing from other companies, but the shortages definitely require time and coordination from our management team, taking them away from other duties.
COVID cases continue to subtly increase in the ER and around the hospital. Our number of positive cases, percent positive rate, and ER patients who require COVID isolation has bumped a bit (again) week over week. Although much of the hospital returned to business as usual long ago, we haven’t let our guard down in the ER very much. While we don’t need a dedicated COVID section in the ER, we’re still routinely considering COVID in our differential diagnosis, wearing N95’s and goggles, and wiping down our workstations before shifts and wiping down our stethoscopes and personal items after shifts. This week marked a bit of a personal change for me, however. At the beginning of the pandemic, I switched to wearing scrubs on administrative days and put away my dress shirts. I also brought 2 pairs of shoes into work (1 for admin days and 1 for clinical shifts) so I wouldn’t have to be tracking COVID into and out of my house. For a variety of reasons, this week, I’ve generally returned to dress shirts on admin days and brought my dress shoes home so I can just wear them when I leave the house. COVID isn’t gone but my office looks less like a locker room.
Remdesivir has been a standard treatment for COVID patient requiring oxygen since early in the pandemic. There have been some randomized controlled studies that have shown benefit while others have not been as positive. A friend and colleague who runs an emergency medicine literature review blog called RebelEM recently posted a very thorough review and analysis of the The DisCoVeRy Trial which looked at 847 hospitalized COVID patients on a variety of primary and secondary outcomes, including the duration of hospitalization, the need for intubation, and mortality. This study found “no significant difference in the clinical status at days 15 and 29, time to hospital discharge, or 28-day all-cause mortality” comparing standard care to standard care + remdesivir. This study also showed that remdesivir does not appear to offer benefit to patients who have had symptoms for more than 7 days and at $3-5K for a 5 day treatment course, perhaps we have to be more careful about who is getting it.
Michigan has been in the news a lot as the Covid hot zone recently. I know I have a bunch of readers in Michigan, and I certainly feel for all of you over this holiday weekend. Michigan is running about 54% of the population fully vaccinated. Compare that to 59% of America, 64% of Virginia, and 67% of Maryland. (Maryland Govenor Larry Hogan is reporting that 88% of adults and 99.9% of seniors in Maryland have received at least one dose of vaccine. Way to go Maryland!) The state of Michigan has seen a steep rise in cases over the last 2 weeks. In Michigan, hospitalization numbers are up 46% over the last 2 weeks. Case numbers are up 78% over the last 2 weeks as well. A report from Spectrum Health, which operates 14 hospitals in Michigan, said that 86% of the 371 patients hospitalized were unvaccinated. This is also led to the need to expand ICU capacity.
The attached graphic is from the University of Michigan earlier this week. It’s easy to see the benefits of vaccination compared to no vaccination when it comes to patients who require hospitalization, require ICU care, and those who require mechanical ventilation. The graphic also highlights whether an individual patient has risk factors such as age greater than 65 or underlying lung disease. Getting vaccinated clearly reduces your risk of getting sick enough to require hospitalization. Across the country, pediatric cases have risen 32% from 2 weeks ago. Obviously, the vaccine will make a difference over time, but remember you are not fully vaccinated until 2 weeks after your second dose. Get your kids vaccinated now so they can be safer when the winter holidays roll around.
In a bit of irony, reported this week, there was a “summit” on COVID for physicians earlier this month in Florida to discuss alternative treatments for COVID (antivax, ivermectin, etc…). Among about 800 participants at the meeting, apparently 7 got COVID in the days following the meeting.
Finally, in the something to keep an eye on category…..there is a new variant (B.1.1.529) first identified in South Africa that has generated a lot of news the past 24 hours as cases in S. Africa have increased 10 fold compared to a few weeks ago. This new variant appears to have the most mutations (32) in the spike protein of any variant (delta had 9) and there is, of course, concern that it is more transmissible. Fortunately, it is detectable by our current PCR tests and at this point, it doesn’t appear to cause more severe illness. The World Health Organization met earlier today and officially named the variant Omicron and classified it a variant of concern. There will be more info on this variant in the coming weeks. Keep in mind that other variants have been discussed and then faded from the news cycle though getting the world vaccinated must remain a priority.
Science matters. Get vaccinated (or your booster). Wear a mask. We’re almost there.