Our internal ER COVID testing data is divided up between symptomatic and asymptomatic patients. It’s the ordering physician’s decision about whether a patient is symptomatic or not but generally symptoms could include fever, cough, trouble breathing, chest pain, etc…As docs, we’re generally fairly consistent in our decision making though with our experience a year into this, some of our decisions are different now than a year ago. With that said, comparing numbers of the past few months is probably reasonable. Last week saw the highest number of positive cases and highest positivity rate among our “symptomatic patients” since late January. This represents about half as many new positive cases as we were seeing during the winter surge but noticeably more patients during a shift such that the docs have taken notice this week. We actually talked about it during a shift the other day. The other piece, which is kind of interesting, is the lack of new cases identified in our “asymptomatic” screening. These patients include those being admitted for non-COVID related issues as well as those where we don’t think COVID is playing a role but want to double check. I don’t typically dive into the weeds in these posts about this category but our positivity rate among these patients was <2% last week which is probably the lowest it’s ever been. We also went 5 days in a row without a positive case among this group of patients. Despite this, our overall hospital positivity rate (that is predominantly made up of non-COVID outpatient/pre-op testing) is also the highest it’s been in over 6 weeks. Our total ED volume has been up a bit the last 2 weeks and that resulted in us testing more people than we have since mid-January as well. All of this together tells me that we are not done with COVID. We have also seen a slight increase in the amount of COVID patients that are hospitalized right now. Consistent with this, our COVID isolation patients that we track in the ER are up a bit as well. At least from a supply point of view, we’re in relatively good shape. We have plenty of PPE (though I still wear a single use N-95 for my whole shift), tests, and medications.
With that said, the hospital continues to work to get back to a sense of normalcy. We have seen this gradually over the last few weeks. About 2 weeks ago, employees were no longer required to go through the daily temperature check in order to get into the hospital. That was actually pretty nice from my point of view as it allowed me to use non-patient entrances to enter the emergency department more directly. Additionally, based on CDC guidelines, we will not mandate that employees quarantine after an accidental exposure to a COVID patient if the employee is vaccinated and asymptomatic. We all have masks on with all patient encounters, but it is possible that somebody has a patient encounter without eye protection with a “negative patient “only to have the patient develop COVID symptoms and test positive a day or two later. Not quarantining vaccinated employees actually encourages others to get the vaccine while maintaining our workforce to care for the patients. The other big change is based on the fact that nursing home patients are now generally vaccinated and we’re not seeing outbreaks from the nursing homes. For the past year, if you came from a nursing home, even if you tested negative for COVID, we kept you in our COVID isolation status. This is hard on the patient, their visitors, and our staff. We are now able to identify vaccinated patients, and if their screening test is negative, unless the patient is symptomatic, they will not be considered a PUI, a person under investigation. (We do have testing strategies in place for their hospitalization) These are positive changes from my point of view and helping us get back to a normal hospital environment which benefits patients and their family members.
Most ER docs are much more comfortable in scrubs than a tie. I wore a tie yesterday for the first time in a long time and perhaps only the 2nd or 3rd time in the past 13 months. My nursing leadership team is putting together a trauma educational conference next week and we are prerecording lectures. I participated on a panel where we discussed burnout, compassion fatigue, and vicarious trauma. This was an interesting opportunity to learn something and also have a discussion about how patient care can impacts us as healthcare workers. But the bigger story about mental health is the impact the COVID has had on society. The American Psychological Association (APA) released a study showing that the majority of Americans, 61%, experienced undesired weight changes since the pandemic started. Approximately 42% of respondents said they gained more weight over the past year than they intended. The average amount of weight gain, for those who gained weight, was 29 pounds with a median of 15 pounds. 10% of people gained more than 50 pounds. Such significant weight gains can certainly have downstream health implications. Approximately 18% of Americans said they lost more weight than they intended to, with the average amount of weight loss being 26 pounds. I have watched several doctors and friends consciously diet and exercise to reduce their weight this year, so not all weight loss is bad. (I had a bunch of friends buy Peloton’s over the past year and while I do not get the craze, they certainly love it.) The APA study also looked at alcohol intake. The majority of essential workers such as healthcare workers and law enforcement, said they relied on unhealthy habits to get through the pandemic. This includes an increase in alcohol intake. About 30% of people report that their mental health has taken a toll over the past year. As an emergency physician, taking care of psychiatric patients is a daily part of the job. We see all ages and all forms of mental illness including depression, suicidality, and psychosis. We have seen many patients throughout the pandemic who have had depression, suicidality, and psychosis as a result of isolation, increased stress, feeling disillusioned, and/or fear. I cannot help but think that many patients would never have had a psychiatric issue in their lifetime had it not been for the circumstances of the pandemic as the cause. It is really hard to see depressed and suicidal teenagers as well as psychotic young adults who have been productive in their careers come to the emergency department. Most of these people are brought by family and friends who recognizes something is very wrong; however, some people cause such disruption in their workplace or school environment, they are brought by the police. I am always glad that they make their way into the emergency department so we can start them on getting the help they need. As vaccinations help us get back to normal, I think the mental health impact of COVID will persist. We will need to look out for each other and have mental health awareness of those in our circle of family and close friends. COVID has made our daily existence very challenging and confusing for many people. We should not be beating ourselves up for that. If you need help, please reach out and get it. It’s good that many people are recognizing the benefits of therapy and turning to it as a solution. In the same APA study, essential workers were twice as likely to have received treatment from a mental health professional, 34% to 12%, as nonessential workers. This is part of dealing with what we’re all going through and it is important to reflect on your own mental health and seek help if you believe you need it.
I have been asked by several people to discuss why vaccinated people need to continue to wear masks. The answer is relatively complicated and has to do with the prevalence of COVID in the community, the variants and their impact on infectivity and virulence, the possibility of asymptomatic spread by vaccinated persons, and the duration of our immunity from the vaccine. The primary goal right now is to reduce the number of new positive cases that occur each week. It is this number that defines the prevalence of the disease in our community. As this number decreases from 50 cases per 100,000 population to 10 per 100,000 population and all the way down to less than 1 per 100,000 population, the likelihood of being exposed any time we go out decreases. It is this rate, along with testing positivity rate, that the public health officials are following closely to determine when we can stop wearing masks and go back to life as we know it before the pandemic. While vaccination significantly drops the likelihood that you can get COVID, it does not eliminate it down to 0. At this point in the pandemic, we still need to continue to do everything possible to prevent spread of the virus. That includes wearing a mask as recommended by the CDC if you’re out in public or in large group situations or around vulnerable populations even if you are vaccinated. The more the virus spreads, the more variants will be produced. Many of these variants will be benign. However, as we’ve seen, some of them will increase the ability of the virus to make people sick as well as potentially lead to more severe disease. The vaccines generally have less effectiveness against preventing transmission of the variants. Fortunately, the vaccines are still very good at preventing severe illness that leads to hospitalization or death from the variants. We also know from studies that the Moderna and AstraZeneca vaccine both reduce asymptomatic COVID infections compared to unvaccinated people. However, again, they do not reduce it to 0. Therefore, vaccinated people can be carriers and transmit the virus. We also do not know how long the immunity will last for, though this issue likely will not impact us for at least several more months. With that said, wearing mask in many situations is critical to prevent transmission and trying to prevent the development of new and more virulent variants. Over the rest of the year, as more adults and ultimately children get vaccinated, the prevalence of coronavirus will decrease in the community. The vaccine will drop our annual risk of getting sick by up to 95%. The critical numbers of getting life back to normal will again be the number of cases per 100,000 population per week. For the time being, we all owe it to each other to follow the CDC recommendation and do everything we can to prevent transmission. It really is a race to get people vaccinated as quickly as possible while we all maintain vigilance with the necessary mitigation strategies and patience.
It’s very rare that anyone I need to impress comes to my office for an in-person meeting these days. My office remains a bit of locker room. The attached picture is a little snapshot of the corner of my desk at work. I have my surgical caps, goggles, hand sanitizer, N-95s, plastic baggies, and snacks. Pretty much all the essentials of battling a pandemic in the ER.
Science matters. Wear a mask. Practice physical distancing.