thegenius

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Just had a string of night shifts at my ER in Northern California. It was thankfully quiet. Saw 1/hr. Each shift there were a few patients wondering if they had COVID-19.

The purpose of this post is to ask how all of you guys are thinking about medical decision making in this new world. Because how I'm handling respiratory complaints now is much different than how I did 6 months ago or even 3 months ago.

Here is one of my cases:
69 yo woman, healthy, remote history of follicular lymphoma in remission. Lives in Maine and arrived here in NorCal a few weeks ago to visit family. For the past 10 days has had a cough, and for the past 3 days subjective fever (or measured, I can't remember). She said "everybody in my family, children, grandchildren all have the same thing and they all got better. But I'm not." Some SOB. Some fatigue. These last two symptoms are not pronounced. Rest of ROS is basically negative.

PMH / PSH: As above
Meds: None
NKDA
No other pertinent family / social history, e.g. not a smoker

Vitals: Temp 98.2, HR 80, BP 150/70, RR 16, SpO2 94-97%
Pertinent exam: Unremarkable (no distress, can speak normally, she is wearing a mask, lungs are clear, she would cough a few times and it sounded productive, otherwise she does not appear ill).

So, normally I think most ER docs in this case, if we were not operating within the scope of COVID-19, would do either
1) no workup and d/c w/wo Abx
2) CXR and d/c w/wo Abx
3) CXR and BMP/CBC and d/c w/wo Abx
4) CXR, BMP/CBC, lactate, BCx and dispo w/wo Abx

I personally would have spent 3-5 minutes in the room, determined she is not sick, and then would probably do #2 above (CXR, CBC/BMP) and tell the patient you are either going home with or without antibiotics depending on those tests. But frankly there are any number of correct ways to handle this patient and the point of this thread is not to get angry at and tease people for their choice.

What I find now is that I'm not even entertaining working up routine respiratory patient complaints unless they have
1) many abnormal vital signs like RR > 24, SpO2 < 90%, hypotension. (I'm not even sure I care about isolated fever)
2) old and with many comorbidities.

Sometimes it's hard not to ignore. They might have several complaints like bloody diarrhea, cough, fever, or whatever.



So with my patient, I educated her as best as I could about COVID-19. I felt there was a low chance. She had symptoms for 10 days. (Plus I can't even test her for COVID-19.) Then we talked about what else she could have, like bacterial PNA, PE, etc. I decided at the end of the day to get a CXR as I felt if she had radiographic lobar PNA with 10 days of symptomology she could have bacterial PNA and would have given her Abx. I didn't even get labs. How would a WBC of 5, 10, or 15 change my mgmt?

Very interesting how it's becoming easier to safely discharge well-appearing patients with a markedly reduced (or no) workup.
 

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Not sure why the labs. If she has normal vitals and is clinically well-appearing a CBC, BMP and lactic aren't going to help you regardless (unless your hospital wants money).

I'd probably get a CXR to rule out pneumonia regardless. Either way she gets discharged.
 
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BoardingDoc

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Just had a string of night shifts at my ER in Northern California. It was thankfully quiet. Saw 1/hr. Each shift there were a few patients wondering if they had COVID-19.

The purpose of this post is to ask how all of you guys are thinking about medical decision making in this new world. Because how I'm handling respiratory complaints now is much different than how I did 6 months ago or even 3 months ago.

Here is one of my cases:
69 yo woman, healthy, remote history of follicular lymphoma in remission. Lives in Maine and arrived here in NorCal a few weeks ago to visit family. For the past 10 days has had a cough, and for the past 3 days subjective fever (or measured, I can't remember). She said "everybody in my family, children, grandchildren all have the same thing and they all got better. But I'm not." Some SOB. Some fatigue. These last two symptoms are not pronounced. Rest of ROS is basically negative.

PMH / PSH: As above
Meds: None
NKDA
No other pertinent family / social history, e.g. not a smoker

Vitals: Temp 98.2, HR 80, BP 150/70, RR 16, SpO2 94-97%
Pertinent exam: Unremarkable (no distress, can speak normally, she is wearing a mask, lungs are clear, she would cough a few times and it sounded productive, otherwise she does not appear ill).

So, normally I think most ER docs in this case, if we were not operating within the scope of COVID-19, would do either
1) no workup and d/c w/wo Abx
2) CXR and d/c w/wo Abx
3) CXR and BMP/CBC and d/c w/wo Abx
4) CXR, BMP/CBC, lactate, BCx and dispo w/wo Abx

I personally would have spent 3-5 minutes in the room, determined she is not sick, and then would probably do #2 above (CXR, CBC/BMP) and tell the patient you are either going home with or without antibiotics depending on those tests. But frankly there are any number of correct ways to handle this patient and the point of this thread is not to get angry at and tease people for their choice.

What I find now is that I'm not even entertaining working up routine respiratory patient complaints unless they have
1) many abnormal vital signs like RR > 24, SpO2 < 90%, hypotension. (I'm not even sure I care about isolated fever)
2) old and with many comorbidities.

Sometimes it's hard not to ignore. They might have several complaints like bloody diarrhea, cough, fever, or whatever.



So with my patient, I educated her as best as I could about COVID-19. I felt there was a low chance. She had symptoms for 10 days. (Plus I can't even test her for COVID-19.) Then we talked about what else she could have, like bacterial PNA, PE, etc. I decided at the end of the day to get a CXR as I felt if she had radiographic lobar PNA with 10 days of symptomology she could have bacterial PNA and would have given her Abx. I didn't even get labs. How would a WBC of 5, 10, or 15 change my mgmt?

Very interesting how it's becoming easier to safely discharge well-appearing patients with a markedly reduced (or no) workup.

She gets option 2 and goes home. I'm seeing increasing numbers of COVID-19 and unless you have respiratory distress/hypoxia, you go home. There's no reason to get labs. You get a CBC and see she has lymphopenia... what now? More suspicion for COVID-19? Now do you admit her? No, you send her home and give her good return instructions.
 
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thegenius

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Not sure why the labs. If she has normal vitals and is clinically well-appearing a CBC, BMP and lactic aren't going to help you regardless (unless your hospital wants money).

I'd probably get a CXR to rule out pneumonia regardless. Either way she gets discharged.

Yea well I'm just saying that if 100 ER doctors saw that same patient, you would get a spectrum of workups that span #1-4.
 

thegenius

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So what's interesting is that when you are in the middle of an epidemic that causes viral pneumonia, and someone comes in with symptoms of pneumonia, do you think they have a bacterial pneumonia or a viral pneumonia?

Because a CXR doesn't change mgmt of having a viral pnuemonia.

I struggled with this for some time.
 

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I am going to differ from what the others are saying.

Before this epidemic I would have done a CXR and discharged with or without abx depending on the results.

However, my COVID-19 anecdata says that even mild-moderate hypoxia is bad prognosis for deterioration on day 3-4. And it's a rapid, otherwise unexpected deterioration. But that's if she has that, as opposed to a regular viral URI.

So for a case as above I would do the following:

CXR: looking for typical bibasilar patchy infiltrates
CBC, BMP, CRP: we've been seeing normal WBC and elevated CRP (>50)
Abx: if CXR shows a consolidation, would treat for CAP
Dispo: if the CXR and labs paint the COVID-19 picture, and she is 94% on room air, I would admit. If she is closer to 98-100% on room air OR it's not looking likely I would discharge.
 
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ERCAT

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Super interesting that you post this because I am finding that my approach is also changing. I find that I am ordering less, usually just a chest x-ray, flu test, and rarely a COVID test and most patients just get discharged with instructions to isolate “like you do have COVID.” Normally a complaint of dyspnea triggers an automatic work up in my mind but with most of these patients... they get this simple work up and get discharged.

However, if significant tachycardia or if their oxygen is less than 94 percent, or if they’re 60 or older, or if they just straight up have severe symptoms, I am doing more than less.

I had a patient just like this today, similar age and history, and she had recently traveled and was on estrogen. She mentioned significant dyspnea, however, so that’s how she differed from your patient. I did feel she had a viral process but ultimately did a work up including an EKG, D-Dimer, and chest X-ray (she probably could have gone straight for CTA chest, but my suspicion for PE was low and thus I got a D-Dimer which was normal). I also tested for flu and COVID. I wouldn’t have gotten blood cultures or a lactic acid in my patient (or in your patient...curious, why would anyone with this presentation?) Her pulse ox remained 96-98 percent in room air even when I had the nurse ambulate (in her room, as much as she could) so she was discharged. I think with old patients or anyone with concerns of significant dyspnea (not just a “yes” on the ROS but significant enough to bring it up without being prompted - LOL) I will always check their sats with exertion before I discharge.
 

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I am going to differ from what the others are saying.

Before this epidemic I would have done a CXR and discharged with or without abx depending on the results.

However, my COVID-19 anecdata says that even mild-moderate hypoxia is bad prognosis for deterioration on day 3-4. And it's a rapid, otherwise unexpected deterioration. But that's if she has that, as opposed to a regular viral URI.

So for a case as above I would do the following:

CXR: looking for typical bibasilar patchy infiltrates
CBC, BMP, CRP: we've been seeing normal WBC and elevated CRP (>50)
Abx: if CXR shows a consolidation, would treat for CAP
Dispo: if the CXR and labs paint the COVID-19 picture, and she is 94% on room air, I would admit. If she is closer to 98-100% on room air OR it's not looking likely I would discharge.

All sounds reasonable except if I tried to admit a patient with a 94 percent oxygen saturation the hospitalist would give me the biggest lecture in the world and then refuse the admission.
 

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All sounds reasonable except if I tried to admit a patient with a 94 percent oxygen saturation the hospitalist would give me the biggest lecture in the world and then refuse the admission.

To be clear, the admission is not because she is 94% now, but because there's a good chance she suddenly decompensates and has full blown ARDS 3 days later. That seems to have been most people's experience in this pandemic. Your internists haven't been reading anything coming out of China or Italy? I don't have the most cooperative/forward thinking internal medicine department in the world, but it only takes a couple of bad cases for people to learn that this disease process is a bit different from what we are used to.
 
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Brigade4Radiant

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really for these patients we should be using the stroke robot and sending a lot home rather than wasting ppe.
 
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GeneralVeers

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I agree completely RE the "no touch MSE". Most of these people can be screened from the doorway using vitals, physical appearnance and +/- CXR. We aren't even testing for COVID any more on the ambulatory population so that's basically it as far as the workup.
 
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thegenius

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94% is borderline for me. I don't know what I would do.

Another option is to have the patient come back tomorrow for a recheck of their vital signs.

The other problem is that CXR findings are neither sensitive nor specific for COVID. We used to think bibasilar or multi-focal pneumonia more likely COVID. However I took care of the index case of community acquired COVID in the US and her CXR looked like:

image1.jpeg

It never occurred to me she had COVID, I gave her abx and admitted her. Was tubed sometime within 2-3 days.


How many times have you
- given pneumonia abx to a 60 yo person with fever 100.5, cough, WBC 16K with left shift and a normal CXR?
- suspected PNA, gotten a negative CXR, then gotten a CT for some reason which showed PNA (either focal or patches)?

Lastly...and I'm interested to hear your opinion:

Lets say in retrospect that an analysis of nationwide hospital records for people being admitted with "Pneumonia" from Feb 1 to May 31. They count 78,000 admissions. This is in the middle of a nationwide pandemic causing viral pneumonia. What percentage of these will end up being COVID-19? What percentage will be non-COVID-19?

I suspect it will be a high percentage of COVID-19.
 
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I agree completely RE the "no touch MSE". Most of these people can be screened from the doorway using vitals, physical appearnance and +/- CXR. We aren't even testing for COVID any more on the ambulatory population so that's basically it as far as the workup.

I really wish we could do this no touch MSE from the doorway... sigh
 
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I really wish we could do this no touch MSE from the doorway... sigh
Why can't you? Or rather, why do you need anyone's permission to do so? For charting, you can certainly get eight physical examination findings from the doorway without ever touching a patient.
 
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Why can't you? Or rather, why do you need anyone's permission to do so? For charting, you can certainly get eight physical examination findings from the doorway without ever touching a patient.

Can you and TooMuchResearch explain a bit or elaborate on what you are doing...
 

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I plan to start tonight on all respiratory or fever complaints. Honestly close contact with heart/lung exam makes almost no difference in treatment or disposition of patients, and will greatly reduce our risk.
 
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thegenius

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However, my COVID-19 anecdata says that even mild-moderate hypoxia is bad prognosis for deterioration on day 3-4. And it's a rapid, otherwise unexpected deterioration. But that's if she has that, as opposed to a regular viral URI.

So for a case as above I would do the following:

CXR: looking for typical bibasilar patchy infiltrates
CBC, BMP, CRP: we've been seeing normal WBC and elevated CRP (>50)
Abx: if CXR shows a consolidation, would treat for CAP
Dispo: if the CXR and labs paint the COVID-19 picture, and she is 94% on room air, I would admit. If she is closer to 98-100% on room air OR it's not looking likely I would discharge.

I think that's the challenge...at some point one needs to pull the trigger and admit someone.

People can have lobar pneumonia and have COVID-19
People can have sore throat and runny nose. I'm reading numerous reports of solely "URI" symptoms who are + COVID-19
A significant number of people have GI symptoms

This is potentially going to be tough
 
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I don't think we have enough beds to admit people for potential "unexpected deterioration". Technically that could be anyone who is non-toxic with normal vital signs.
 
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BoardingDoc

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Can you and TooMuchResearch explain a bit or elaborate on what you are doing...
Can you and TooMuchResearch explain a bit or elaborate on what you are doing...
General - alert
Head - NCAT
Eyes - lids appear normal
Pulm - no respiratory distress
Abd - ND
Skin - Dry
Neuro - no gross weakness
Psych - normal affect

If the patient has normal vital signs and has no respiratory distress but they're there for a respiratory complaint you can order whatever tests you think are necessary but there is literally no reason for you to actually go in the room.
 

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We're not really caring about proper billable charting for these either. The problem we're having at our tertiary site is our average age and comorbidities. The low risk people aren't abundant
Why can't you? Or rather, why do you need anyone's permission to do so? For charting, you can certainly get eight physical examination findings from the doorway without ever touching a patient.
 

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We're not really caring about proper billable charting for these either. The problem we're having at our tertiary site is our average age and comorbidities. The low risk people aren't abundant

I think the experience is really going to vary hospital to hospital. In my 6 hospital system, we have one site where the average age I see is > 70. At another, it's basically a glorified urgent care with most patients under 50. I think we've actually seen volume go down systemwide as people are (rightly) staying home.
 

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I don't think we have enough beds to admit people for potential "unexpected deterioration". Technically that could be anyone who is non-toxic with normal vital signs.

I totally agree, and I think it's tough too because what if this 69 year old ends up just having say rhinovirus or plain old CAP and ends up catching COVID while admitted? Maybe the safest place for high risk patients with no high risk features is far far away from the hospital after a very good conversation with patient and family? I don't know the answer, and I suspect there is no good answer.
 
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Away from the hospital is the right answer.
I totally agree, and I think it's tough too because what if this 69 year old ends up just having say rhinovirus or plain old CAP and ends up catching COVID while admitted? Maybe the safest place for high risk patients with no high risk features is far far away from the hospital after a very good conversation with patient and family? I don't know the answer, and I suspect there is no good answer.
 

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Away from the hospital is the right answer.

You're right. If we admit someone to the hospital who doesn't have COVID, they likely will once they get admitted. The old people with non-concerning vitals and exam should definitely be discharged home with quarantine and return precuations.
 
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gro2001

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I don't think we have enough beds to admit people for potential "unexpected deterioration". Technically that could be anyone who is non-toxic with normal vital signs.

Perhaps I was being unclear. What I am saying is that it seems COVID positive patients who have hypoxia deteriorate suddenly and profoundly on day 3-4.

I am not saying admit everyone who is non toxic because they could deteriorate. I am saying admit COVID patients who are hypoxic, even if that same degree of hypoxia would not warrant an admission with other disease processes. Or don't. Your experience may be different with this epidemic.
 

gro2001

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I think that's the challenge...at some point one needs to pull the trigger and admit someone.

People can have lobar pneumonia and have COVID-19
People can have sore throat and runny nose. I'm reading numerous reports of solely "URI" symptoms who are + COVID-19
A significant number of people have GI symptoms

This is potentially going to be tough

Yeah, to be clear: I am not saying admit all COVID patients. I am saying admit COVID patients who are hypoxic. Solely URI and COVID positive shouldn't be anywhere near the hospital. Hypoxic COVID patients should be admitted if at all possible.
 
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#1, VSS. CXR and abx. No red flags. I doubt COVID-19 is going to make us re-write textbooks on how we approach pt's for determination of "sick or not sick".
 

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Perhaps I was being unclear. What I am saying is that it seems COVID positive patients who have hypoxia deteriorate suddenly and profoundly on day 3-4.

I'm not sure COVID changes the equation. I'd admit anyone who's hypoxic regardless of cause if that isn't their baseline.
 
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One thing I don't understand is: WHY ARE SENIORS NOT HEEDING THE WARNINGS FROM OFFICIALS and STAYING THE HELL HOME?

Today:

84F, constipation x3 days. Fell 3 days ago, on percocet.
75M, fishhook to thumb, self-removed. "Does it look infected to you, doc?"
82F, chronic arthritis pain, worse today, but same pain as always.

Attention BOOMERS: There's a virus out there reaping the souls of the elderly and the weakened, and you decide to come to the ER for this nonsense? Okayyy.
 
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Here's my thought process on the dispo of these patients:

Admit if RA Sp02 </= 93%, increased wob, or ill appearing. OR old/chronic cardiopulmonary failure w/ increased respiratory symptoms (ie anything more than "I'm nervous about this china virus can you test me?")

On suspect cases, labs/imaging ONLY if planning on admitting based on clinical impression.

Honestly, I would argue that admitting observation due potential for decline (which, by far my number one rationale for admitting patients in daily practice) is public health malfeasance in the setting of a pandemic which is likely to result in resource-limited conditions.
 

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Attention BOOMERS: There's a virus out there reaping the souls of the elderly and the weakened, and you decide to come to the ER for this nonsense? Okayyy.

There's a reason our more seasoned nurses refer to this as "The Boomer Doomer".

I see these people out walking around in crowded grocery stores, Home Depot, or take-out restaurants.

On the plus (but possibly inappropriate) side we are going to save a lot on Medicare and SS spending after this is done.
 

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There's a reason our more seasoned nurses refer to this as "The Boomer Doomer".

I see these people out walking around in crowded grocery stores, Home Depot, or take-out restaurants.

On the plus (but possibly inappropriate) side we are going to save a lot on Medicare and SS spending after this is done.
It's like Confucius said,

"How many will die from virus, after fighting over TP in Costco?"
 
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We'll burn through a generation of Medicare funding riding vents for 3 weeks though
There's a reason our more seasoned nurses refer to this as "The Boomer Doomer".

I see these people out walking around in crowded grocery stores, Home Depot, or take-out restaurants.

On the plus (but possibly inappropriate) side we are going to save a lot on Medicare and SS spending after this is done.
 
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thegenius

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Unless the worst predictions come through and we end up like Italy having to pick and choose who gets the vent.

What would you do if there is a critically ill patient who needs to be tubed in 10 minutes and you have no ICU beds, no vents, and and your ER is holding 10 patients for transfer?
 

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What would you do if there is a critically ill patient who needs to be tubed in 10 minutes and you have no ICU beds, no vents, and and your ER is holding 10 patients for transfer?

Assuming no special equipment like those super high-flow nasal BIPAP things, then whatever is available. BIPAP, face mask, and nature takes it course. There's no other answer, unless I can find employees willing to stand their and bag an intubated patient indefinitely.
 

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Assuming no special equipment like those super high-flow nasal BIPAP things, then whatever is available. BIPAP, face mask, and nature takes it course. There's no other answer, unless I can find employees willing to stand their and bag an intubated patient indefinitely.

Funny you should say that...I was wondering other day how long it would take someone to develop a medical app for healthcare workers that is a timer set up to help someone bag a pt. It could tell you when to twist the PEEP dial, making bagging rhythmic, maybe even set it to music. Call it "Human VENT". You could even have protocols for weaning. Dumb it down so you could grab non medical personnel like transport or one of the environmental cleaning peeps that you could turn into a human vent once they all run out.
 

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So what about co-infection and using RPP/FLU swabs to 'rule people out'? That is what our health department was recommending for anyone with fever cough uri symptoms to do first and stop there, if it was positive. On EMRAP they said confection can be as high as 6%, so that's not very re-assuring....
 

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So what about co-infection and using RPP/FLU swabs to 'rule people out'? That is what our health department was recommending for anyone with fever cough uri symptoms to do first and stop there, if it was positive. On EMRAP they said confection can be as high as 6%, so that's not very re-assuring....

We've been told the hospital labs are running very low on "viral medium" and NOT to order FLU and RSV on anyone at the moment.
 
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thegenius

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So what about co-infection and using RPP/FLU swabs to 'rule people out'? That is what our health department was recommending for anyone with fever cough uri symptoms to do first and stop there, if it was positive. On EMRAP they said confection can be as high as 6%, so that's not very re-assuring....

I dunno. I work at Kaiser and they say that in about 1-2 weeks they will stop asking all people to order Flu because it's on the decline now, and once it gets low enough there is no reason to send it.
 

Brigade4Radiant

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So now we may be lifting restrictions on quarantine so now hospitals may be overrun.
EMTLA need to be suspended and we need protocols to determine who gets resources
 
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turkeyjerky

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So now we may be lifting restrictions on quarantine so now hospitals may be overrun.
EMTLA need to be suspended and we need protocols to determine who gets resources

Failing suspension of EMTALA, we need our hospitals to qualify triage nurses as capable of doing an MSE. Immediate dc for people not needing ED resources.

We also need med-mal protection during this time. We can't be wasting valuable resources on defensive practice and documentation.
 

Interpolfanclub

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I believe that you can only suspend a few parts of EMTALA. Even the federal gov can't suspend the whole act. I would personally be absolutely amazed if we get any protection at all. I continue to document defensively but have cut back on what I feel were a lot of the "customer service" tests. I speak as an MD practicing in an area with numerous covid cases. I doubt seriously whether anyone is thinking (besides us) about our legal risk during this crisis. I think several years from now there are going to be a flood of lawsuits alleging malpractice during this pandemic.
 
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GeneralVeers

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Failing suspension of EMTALA, we need our hospitals to qualify triage nurses as capable of doing an MSE. Immediate dc for people not needing ED resources.

I don't see an alternative to this. If the worst should happen and our hospitals end up over-capacity with critically-ill seniors, then the walking well will wait indefinitely to be seen by a doctor.
 
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TooMuchResearch

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I have a lot more people opting against testing for things I think are unlikely to yield useful results when I walk into the room masked and meticulously cleaning my hands and ask directly if they want tests I anticipate will be negative or if they'd rather just come back in 1-2 days if things get worse. CT scans, labs, chest pain obs - you name it, people are declining it.
I believe that you can only suspend a few parts of EMTALA. Even the federal gov can't suspend the whole act. I would personally be absolutely amazed if we get any protection at all. I continue to document defensively but have cut back on what I feel were a lot of the "customer service" tests. I speak as an MD practicing in an area with numerous covid cases. I doubt seriously whether anyone is thinking (besides us) about our legal risk during this crisis. I think several years from now there are going to be a flood of lawsuits alleging malpractice during this pandemic.
 
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Tiger26

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Thoughts for the group but I don't see much reason to get near them and am planning to call from outside the room through the door.

Auscultation in most cases is just theater for patient satisfaction and we can essentially get what we need with the history, a pulse ox and other vitals, visualization, and +/- CXR.

The only reason I see to go in the room is to intubate
 

thegenius

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Thoughts for the group but I don't see much reason to get near them and am planning to call from outside the room through the door.

Auscultation in most cases is just theater for patient satisfaction and we can essentially get what we need with the history, a pulse ox and other vitals, visualization, and +/- CXR.

The only reason I see to go in the room is to intubate

You may not be satisfying EMTALA.
You will need to find substantial evidence that a patient complaint of "Shortness of Breath" does not merit auscultating the lungs.
Otherwise you will lose.
 
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