COVID-19 Tips and Insights

9 April 2020 | Eric Levi | COVID-19 - The PMFA Journal

COVID19 affects everyone

Posted on 01/04/2020 by Eric Levi

Here’s a report from the Center for Disease Control and Prevention looking at the first 4000+ COVID positive patients in the United States: www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6912e2-H.pdf

There are two graphs in that article that concern me. This is the first one:

This tells me clearly that people of all age groups get admitted to hospitals. In fact, the big hospital admission burden is in the group between ages 20-74. This is important as we prepare for the incoming surge of patients. Many young people will require hospitalisation. Your youthfulness does not protect you from becoming ill enough that you need to be admitted to the hospital. Hospitalisations are expensive and labour intensive. We need to work hard at preventing these admissions. Community priority: social distancing to prevent spread and admission to hospitals. We can’t just use the number of ventilators as a measure of readiness. We need to look at the big picture of bed management across the service. Let’s dump that myth suggesting that COVID19 is an elderly person’s disease. No. It affects all age groups.

The second table is this:

It’s proving what we have heard from China , South Korea, Italy and the UK. Mortality rate goes up with age. In the oldest group of 85 and above, it appears that there is a case fatality rate of 10-27%. Now that’s a very high mortality risk. It’s critical that we have a frank discussion with patients and their families regarding advanced care plans even before entering the ICU.

Stay the course, friends. We’re all in this together.

Aerosol Generating Procedures in the COVID era

Posted on 28/03/2020 by EricLevi

THIS IS NOT A POLICY, PROTOCOL OR GUIDELINE. THIS IS A THOUGHT PRIMER. I AM NOT A PUBLIC HEALTH PHYSICIAN OR AN INFECTIOUS DISEASES PHYSICIAN. THESE ARE THINGS YOU SHOULD THINK ABOUT WITH YOUR TEAM WHEREVER YOU ARE IN THE WORLD. THESE ARE FOR AEROSOL GENERATING PROCEDURES. OTHER PROCEDURES FOLLOW STANDARD LOCAL PROTOCOLS.

You will be treating a COVID positive patient. Think about the safety of any aerosol generating procedure in this new COVID era. Modifications need to be made to mitigate the risks of spreading the virus. We need to protect the patient and healthcare staff.

What do we know?

The upper respiratory tract (the nose, nasopharynx, mouth, oropharynx, larynx, trachea and bronchi) are areas with high viral load. Evidence suggest that viral load in the nose and nasopharynx of non-symptomatic carriers are as high as those with symptoms. A patient could have no symptoms and yet carry the same amount of virus in the nose, and oral secretions. Data from China and Europe suggests that ENT surgeons have been unexpectedly hit hard with high numbers falling ill and some have died due to the virus. Studies have shown that tracheobronchial secretions carry the highest concentration of virus and followed by mucous and saliva. In some patients the virus can be detected in saliva weeks after the symptom onset. The virus has not been detected in urine or breastmilk.

What does this mean?

If you are an anaesthetist, ENT surgeon, Head & Neck surgeon, dental, maxillofacial surgeon, respiratory physician or anyone else doing procedures in the airway mucosa, you must modify your procedures based on COVID risks. Any procedures involving the nose, oral cavity and airway pose a risk of dissemination of virus. Any general anaesthetic involving bag and masking, ventilation, intubation, supraglottic airway device, nasal surgery (rhinoplasty, septoplasty sinus surgery, adenoidectomy), oral surgery (maxillofacial, dental, tonsillectomy) and airway interventions (bronchoscopy, laryngoscopy) etc are all high risk aerosol generating procedures (AGPs).

What must we do?

Risk assess the patient. Can we get a COVID status on the patient? If we cannot get a COVID test pre-procedure, assess the risk based on history and examination (contact with positive COVID, travel history, etc.). Some institutions may afford you the luxury of doing two tests 48 hours apart to confirm the status. This is not possible in all places.
Risk assess the procedure and modify accordingly. Can we delay the procedure? Do we have other alternatives? Can we modify the surgical approaches? Can we use a different technique or tool to reduce the aerosolisation?

What if we have to proceed with the procedure?

Modify and mitigate the risks as a team. Communicate. Communicate. Communicate.

Consider 3 possible levels of risk:

These are suggestions. You need to check your local area guidelines.

GREEN: standard precaution for negative COVID patients and non-aerosol generating procedure. Surgical mask, eye cover, & gloves for a non-ENT procedure. Eg. Neck dissection, thyroidectomy, etc.
YELLOW: for AGPs with negative COVID or very low suspicion of COVID. N95 mask, face shield, long sleeve gowns and gloves. Eg. for mastoidectomy, FESS or tonsillectomy. Should intubation fall into this category?
RED: for COVID positive AGPs. PAPRs and the maximal PPE available at your institution. Eg. an urgent FESS in a COVID positive patient.

This diagram is from the Canadian Society of Otolaryngology Head & Neck Surgery. THIS MAY NOT BE POSSIBLE IN EVERY PART OF THE WORLD.

Pre-operative considerations

Mask on the patient. Isolation. Reduce staff contact. One family member, one staff, reduce movements. Reduce exposure to other patients. Do not wait at holding bay or waiting room. Bring patient from emergency or ward direct to operating theatre.

Induction

Standard precautions. Assess level of risk Green, Yellow or Red. Reduce staff contact. Bag and mask, intubate under plastic drape. Seal the airway. Consider avoiding high flow oxygen, CPAP, Laryngeal mask etc. CHECK WITH YOUR LOCAL ANAESTHESIA TEAM.

Procedure

Modify techniques. Can you operate under a plastic drape? Any mucosal specimens (eg. sinus debris, tonsils etc, need to be placed in a sealed container immediately). Pictures of modifications to surgical techniques below. Modify your technique accordingly so as to mitigate the risks to the staff in theatre. Reduce personnel present. Add suction device. Negative pressure theatre. Check theatre airflow. Meticulous PPE. Buddy up so someone is always catching you and checking on you. CHECK YOUR LOCAL AREA GUIDELINES.

Modification to oral surgery under a plastic drape.

Emergence & Recovery

Wake the patient in theatre. Avoid coughing in recovery. Mask on patient. Go to an isolated area in recovery. One staff member to recover. Then straight to the ward. ASSESS RISK AND DISCUSS WITH YOUR LOCAL AREA TEAMS.

Turnover

Time to allow clean up and air circulation in theatre. Wipe down everything based on levels of risk.

Closure

Communicate, Communicate, Communicate. In my experience, every single time I ask the team to do a COVID run or simulation, new gaps in knowledge and practice are identified and resolved. Morale and teamwork are strengthened.

Practise it. This is our new normal for the next few months.

REMEMBER TO WORK WITH YOUR LOCAL AUTHORITIES WHO ARE BALANCING INDIVIDUAL NEEDS, PUBLIC HEALTH NEEDS AND THE REALITY OF FINITE RESOURCES.

ENT Surgeons and the COVID19 Pandemic

Posted on 22/03/2020 by EricLevi

Key findings from literature as of today:

ENT surgeons are at higher risk and have higher rates of contracting the virus SARS-CoV2.
Thought to be due to high virus load in nose, nasopharynx and oropharynx, even in asymptomatic carriers hence we may be examining and operating on asymptomatic patients with high viral load.
Airway procedures are aerosol-producing activities therefore placing staff at risk (nasoendoscopies, cautery, even oral examinations). Delay if possible.
Urgent need for protection with N95 masks, gowns and gloves in clinic. We should ask authorities to provide ENT clinics with them.
Any airway intervention, in particular but not limited to sinonasal surgeries, adenotonsillectomies and laryngobronchoscopies should be delayed if clinically appropriate. Severe, urgent, cancer, critical airway cases may go ahead on a case by case basis and intraoperative risk reduction strategies should be employed (masks during intubation, reduce personnel in theatre, N95 masks, smoke suction, etc.)
Testing is still limited in Australia and at this stage we cannot screen everyone for COVID19.
Ultimately we should screen all patients pre clinic or pre op but that’s not possible yet.
Please be reasonable and be cautious. There are still many patients requiring emergent and urgent ENT services. This does not mean we stop all ENT services. Please be supportive of your emergency colleagues. Wear a full PPE gear. Here’s a snapshot of ASOHNS recommendations. Full statement linked below.

Data is limited and imperfect. We are in a pandemic. Time to use whatever limited data we have to inform practice. Time to learn, support and not criticise colleagues.
Look out for anosmia. See this. Could be a red herring, could be true. Don’t know yet but be aware.

Resources to support the above statements:

Interview with Dr Jason Chan on managing ENT Services during Pandemic in Hong Kong. Excellent.
https://edhub.ama-assn.org/jn-learning/audio-player/
18326041?utm_source=twitter&utm_medium=social
_jamaoto&utm_campaign=article
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News of China Experience with higher number ENT Surgeons infected.
https://www.bloomberg.com/amp/news/articles/
2020-03-17/europe-s-doctors-getting-sick-like
-in-wuhan-chinese-doctors-say?__twitter_impression=true
Paper on nasal viral load. Just as high in asymptomatic patient.
https://www.nejm.org/doi/full/10.1056/NEJMc2001737
Paper on asymptomatic carriers.
https://link.springer.com/content/
pdf/10.1007/s11427-020-1661-4.pdf
Fever and cough are most common symptoms. But asymptomatic period really uncertain.
https://www.nejm.org/doi/full/
10.1056/NEJMoa2002032
ENT UK RECOMMENDATIONS
https://www.entuk.org/entuk
-guidelines-changes-ent-during-covid-19
ENT UK general guidance.
https://www.entuk.org/
guidance-ent-during-covid-19-pandemic
American Academy Recommendations. Specific mention of high virus carrier rate in the nose, nasopharynx and oropharynx.
https://www.entnet.org/content/
academy-supports-cms-offers-specific-nasal-policy
Reliable personal sources have also reported the following: transsphenoidal pituitary case in Wuhan infecting 14 health care workers. One ENT surgeon in the UK has died, 2 intubated and 1 on ECMO.
COVID19 repository of papers, guidelines etc collated by Australian Crit Care clinicians.
https://www.covid19repository.com/about/
Australian Society of Otolaryngology Head & Neck Surgery recommendations.
http://www.asohns.org.au/about-us/
news-and-announcements/latest-news?article=78
British Laryngological Society President.
http://www.britishlaryngological.org/
news/message-bla-president-covid-19
SkyNews on 2 intubated ENT Surgeons in the UK.
https://news.sky.com/story/coronavirus-two-nhs-medics
-on-ventilators-after-contracting-covid-19-from-patients-11961531
Suggested modifications to Sinus surgeries. Pre and post op concerns discussed. 12 minute lecture.
https://youtu.be/ZEQPVnt7II8
American Academy update recommendations 23 March 2020.
http://msg.entnet.org/q/1tgWzg1impN6Y2lbIZSAurCZ/wv
Be kind. Be kind. Be kind. This is an unprecedented Medical Emergency. We need to give every staff member the support that they need. This is the new normal for the next 3 months at least.

Life in a Pandemic

Posted on 15/03/2020 by EricLevi

Brace. Brace. Brace.

The next couple of weeks and months will be tough for all of us. There is no need for panic or hysteria but there is need to prepare. The flu pandemic in 1918 tore through the globe and killed somewhere between 20-50 million people. At that time, world travels were not as common as today, but the virus still managed to spread through the planet. Today we have the ability and the opportunity to alter the progress of this pandemic. We have the ability to cope with the severity of illness thanks to medical advances and we are able to coordinate the community response through communication and connectedness. Your personal act today has social repercussions to those in your community.

There are many great websites, articles and information out there which I have listed at the end of this article. I am going to focus on what we can do in the next few weeks. Time is of the essence.

COVID-19 is the disease name for a severe respiratory illness caused by the virus SARS-CoV2. On 31 Dec 2019, the World Health Organisation (WHO) received the first report of a pneumonia of unknown cause from Wuhan, China. The outbreak was declared a Public Health Emergency of International Concern on 30 January 2020. On 11 February 2020, WHO announced a name for the new coronavirus disease: COVID-19. On 11 of March, The WHO says “we are deeply concerned both by the alarming levels of spread and severity, and by the alarming levels of inaction. We have therefore made the assessment that COVID-19 can be characterized as a pandemic.” The WHO is worried about our lack of action.

The virus spreads rapidly through droplet and contact surfaces. Symptoms become obvious a couple of days later. The COVID-19 test takes time. Many are not tested as there are some limitations to access (cost in some countries) or resources (not enough testing kits). We don’t know a lot about this virus because it is novel. We have not seen this virus before. We have no immunity to it. We have no vaccines for it. All we know based on what we see happening in China, South Korea, Japan and Italy is that the virus causes a respiratory illness. Eighty percent of patients get a mild form while the rest get a severe form and the severity is strongly associated with advanced age (up to 8% mortality in those above 80 years old) and comorbidities (diabetes, hypertension and chronic illness).

Containment lines have been broken. The virus has entered multiple countries. The case rates in each of these countries are skyrocketing. It is not just the flu. It is a lot worse. South Korea, which has reported the lowest coronavirus death rates, has a COVID-19 death rate more than eight times higher than that of the flu. We are rapidly realising that inaction may mean death. The modelling and projections I am seeing is very concerning.

What can we do now?

Mitigate the spread. Slow the spread. Flatten the curve. The hospital system and health services can only cope with a fixed amount of resources. If we had a massive spike of COVID-19 cases, the hospitals will not be able to cope with the tsunami. There will be many deaths. But if we spread out the same number of cases over a longer period of time, the hospital will be better able to handle the wave. This is flattening the curve.

Practical steps:

Wash your hands. Do not steal alcohol hand sanitiser from hospitals or healthcare facilities. They need them! Soap and water for 20 seconds has been shown to be effective against the virus. Wash your hands as regularly as you possibly can.
Hand sanitiser with at least 60% alcohol is good but in short supply.
Do not touch your face. The virus enters through nose, mouth and eyes.
Reduce physical contact with others. Less than 15minutes face to face. Less than two hours in the same room. Keep a distance. No handshakes. Wave.
Cough into your elbow. But don’t do an elbow handshake after that!
Do not touch public surfaces and properties (door handles, lift buttons, etc). Use a wipe, tissue, etc.
Wipe surfaces with alcohol, detergents, soap and water.
Avoid crowded places.
Close down big meetings.
Work from home if possible.
Stay at home.
Only do essential activities: essential work, health, finance, groceries, supplies, etc. No retail, shopping, amusement parks, etc.
Essentially quarantine yourself as much as you possibly can.

What do we do if we are in lock down like Italy?

There will be various levels of “lock down”. Essential services will continue to run, so do not worry, stockpile or hoard necessary items.

Look after each other. Phone calls, FaceTime, WhatsApp, texts, email, social media. Social Distancing does not mean Social Isolation. With all the communication tools we have today we must continue to be engaged with each other.

Keep yourself mentally and physically healthy. Read books, meditate, write. Walk around the neighbourhood with your family. Talk on the phone more with people you have not spoken to due to your busyness.

Be kind and pay attention especially to those in the edges of your community. Do the grocery for the elderly family member. Provide practical help for single parents who have to stay home. Cook extra food for someone who can’t afford food as their work is closed down.

Do not overwhelm the health services with things that can wait. The health system needs to cope with COVID-19 tsunami. Attention and resources to non-urgents need to be devoted to COVID-19 cases. Do not overwhelm the front line clinicians (GP, Emergency, Respiratory units, Infectious Diseases, ICU etc.) One exhausted or ill doctor, nurse, clerk, physio, etc mean that some patients may not get the care they need.

If you’re an “Upstairs Clinician”, please support your front line “Downstairs” colleagues. You know what I mean. Watch out for burnout and exhaustion. There will be many emotionally challenging decisions that have to be made during this time. One ED, ICU, Respiratory Physician, or nurse is probably worth 10 ENT surgeons in this pandemic (personal value opinion!)

Listen to your leaders. Not a time to argue over non-essential matters.

Learn from China, Hong Kong, Taiwan, Singapore, Japan, Italy.

Be kind.

We will get through this together. We can flatten the curve together and reduce the mortality rate from this pandemic.

Some helpful sites below. (I married an Infectious Diseases Specialist. I read what she reads. Thanks dear.)

Global Daily Update from WHO
https://www.who.int/…/novel-coronavirus-2…/situation-reports

Global Stats
https://www.worldometers.info/coronavirus/

Australian stats
https://www.covid19data.com.au

Local (Victoria) Daily Update from Chief Health Officer
https://www.dhhs.vic.gov.au/coronavirus-covid-19-daily-update

Local (Victoria) Info for the public
https://www.dhhs.vic.gov.au/coronavirus

Coronavirus in children
https://theconversation.com/worried-about-your-child

Coronavirus explained to kids by Nanogirl (NZ)
https://www.youtube.com/watch?v=OPsY-jLqaXM

My favourite public health promotion video from this hilarious Italian Nonna
https://www.youtube.com/watch?v=mk8UvAvE4iQ

Practical Guide to self-isolation/quarantine
https://www.gps-can.com.au/covid19-basics/a-guide

COMMENTS ARE WELCOME