March 15, 2020
Everyone – Thank you so much for your work these past few weeks. If you have questions, please just reach out.
Given the rapidly evolving response to COVID19, it can be challenging to stay current. Below are the most critical updates from NYP and GME.
Please see the COVID19 Updates page for additional information and resources
NYP COVID19 TRAVEL GUIDANCE AND FAQs
NYP COVID19 CLINICAL BULLETIN #5
- Reminder: Do not send SARS-COV-2 testing on patients that have a + respiratory pathogen panel. As of information across the globe and epidemiologic studies done in the US, there is very little (like less than 0.05%) chance of concomitant COVID-19 in patients with another viral illness. We do want to be able to test folks with negative RPPs requiring admission so we must preserve our supplies. If there are any questions on specific cases, please reach out to our Infection Control/Epi colleagues to get their advice on testing. Document that conversation and order/don’t order as instructed.
- New, non-ED Staff working in ED: effective tomorrow we will seen an influx of non-ED RNs and PAs to help work in the ED. We will be rapidly in-servicing them on basic low acuity workflows tomorrow am.
- Goggles and surgical masks should be worn in every patient encounter: goggles are available at WC from Peters office; at LM from Brenna’s office.
- WC OBGYN service is dropping the GA for OB triage evaluations to 14 weeks starting tomorrow, March 16th. More to come on LMH workflow.
- At both LMH and WC, effective tomorrow, Suicidal Ideation cases can be cohorted 4:1
- WCMC ED Tent opens tomorrow: we will see ADULT LRTI infectious POIs formerly seen in Area D. Area D will be used as an admitted holding area and will not be staffed by an MD. B Hall West will continue to be used for ESI 4&5 cases.
- WC ADULT Ortho Consult Update: Due to COVID-related extreme shortage of HSS staff, please see list below, cases to discharge without ortho consults. The ortho residents are, as always, willing to look at any imaging and make a determination as well to help the ED. Dave Bodnar is working with HSS to work on a process to send these below cases directly after HSS w a medical screening exam.
- Outpatient Management of Orthopedic Injuries:
- Clavicle fractures
- Upper extremity fractures (unless neurovascular symptoms or needing immediate surgical intervention or dislocated joint requiring reduction) This includes proximal humerus fractures, humerus fractures, radial head fractures, forearm fractures, distal radius fractures (including displaced) Can be placed in appropriate slab splint, or sling with close Ortho outpatient followup (meaning w/in 24-48 hours.)
- Hand fractures
- Simple hand lacs/nailbed/avulsions-place xeroform and gauze (pictures can be sent through mobile heartbeat for ortho evaluation)
- Lower extremity injuries: Patella fractures; Quad tendon/patella tendon ruptures; Achilles tendon ruptures; Foot fractures; Ankle fractures not needing a reduction (excluding bimal, trimal)
- HSS post op patients
- All medical students are officially no longer in the clinical space in the ED (or anywhere in the hospital). This is true for LMH and WC.
- ADULT Schedule changes: Community para-telemedicine and the ED/Ortho Sports Medicine clinic led by Dr. Ahmed have been canceled. Please continue to review the schedule as updates are happening multiple times a day. As discussed yesterday, under Rahul’s guidance, due to the number of providers out on medical leave, Robbys is making major modifications to the schedule for the remainder of March. Our priority is to have safest, leanest clinical schedule to generate the most robust sick call and available staffing for surges.
- Fomites & Clothes: Lots of questions and concerns about clothing and laundering; in IP&Cs opinion these are not significant concerns from a COVID-19 transmission perspective. I do think it’s important to remind people that COVID-19/SARS-CoV-2 transmits differently than Ebola. Ebola transmits through heavily contaminated bodily fluids so transmission through contaminated surfaces/clothing etc was important. There is no evidence that COVID-19 is transmitting via contaminated clothing or other fomites.
- Updated NYC DOH description of COVID-19 patients in NYC. We have had 2 deaths in NYS. One of those deaths was an elderly woman with underlying lung disease. Please see attached. 58% of cases are male. Community spread (non-travel) is most common form.
- ADULT – who to admit: There are a lot of questions coming up on who to admit. The most common type of ADULT patient we are seeing is: +symptoms, +CXR, negative RPP. Very low suspicion to admit these ADULT patients, unless there was extenuating circumstances.
- CTs are NOT of value to further characterize positive findings found on CXR
- CTs MAY be of value to evaluate a patient with LRTI symptoms with a clear CXR
- Please see this description of patients from colleagues in Italy. Marisol Nardi, one of our LMH nocturnist, sent this to us, describing 5 types of patients they are seeing in Italy. They are using CT sparingly due to infection control issues and the length of time terminal cleaning takes. Clues to COVID-19 outside of symptoms and chest xray: leukopenia (particularly lymphopenia), hypoxia on ABG, respiratory alkalosis on blood gas, elevated ESR. A lot of information mentioned by Dr. Nardi is confirmed by the most recent articles in JAMA, NEJM, etc.
- Coronavirus, the 5 types of ADULT patients with COVID-19.
- Doctors from the hospitals of the Lodi province in Italy, in collaboration with Chinese colleagues were able to identified 5 types of patients with COVID-19. Their characteristics, which determines a different management, were explained in a video-conference by Dr Stefano Paglia, the Chair of the Emergency Department of Lodi and Codogno, the red zone in Lombardy, Italy.
- Type 1: Patient with fever, without respiratory symptoms, with no hypoxia on ABG and negative CXR. These patients are tested for COVID-19 if considered at risk based on standard criteria of contact with known COVID-19 infected person. These patients can be discharged if saturation does not drop with ambulation. This may constitute the majority of patients that present to the ER in the pre-epidemic stage.
- Type 2: Patient with fever, infiltrates on CXR and/or hypoxia on ABG. These patients should be hospitalized since they can potentially deteriorate quickly. These patients are not dischargeable and are 20 times more common than critically ill patients.
- Type 3: Patient with frank hypoxia on ABG, in addition to fever and multiple infiltrates on CXR. These patients require step-down level or care.
- Type 4: Patient with pre-ARDS. These patients require positive pressure ventilation. In Italy they are using CPAP.
- Type 5: Patients with pure ARDS. In two Chinese epidemiologic studies published in The Lancet, ARDS was found in 17% of the cases included in those studies. Dr Paglia indicated that this condition is typical of men between the ages of 35-70. These patients often present with SpO2 of 35-40%, and appeared less sick compared to their data/numbers. These patients often require intubation.
- Most patient with COVID-19 have leukopenia, respiratory alkalosis on ABG, interstitial infiltrates on CXR. Dr Paglia stressed that CT scans is not fundamental and it can be risky, given the patient transportation needs.
- The current state of our blood supply at NYP/WC is good. However, we want you to encourage your teams to pay careful attention to transfusion guidelines and indications over the next few weeks to ensure we can appropriately conserve the blood supply. Platelets will most likely be affected the most, then RBCs.
Dr. Nick Gavin: Milstein to Allen Transfer
PPOC will begin identifying patients who are appropriate for admission to the Allen Hospital based on the attached clinical exclusion criteria. We are seeking to revamp this process as it will offload work from the Milstein Hospitalist team, help with Milstein ED crowding, and enhance quality of care for this cohort of patients.
When the PPOC nurses identify patients, they will be reaching out to the clinical team. During the day, when available, the care coordinators will be communicating with patients, but overnight, it will be the physicians and physician assistants caring for patients who will be responsible for approaching the patient about admission to the Allen.
The most important thing to express to patients is that the median wait for a Milstein bed has recently been 25 hours. This means that 50% of patients actually wait longer than that. When initiated, the transport to the Allen floor bed should be completed within 3 hours. Other key messaging is that Columbia Doctors follow patients at the Allen and patients typically have a better experience at the Allen Hospital.
Please see attached for the full process map, some ideas for scripting as you approach patients, and for the formal clinical exclusion criteria.
Thanks and please provide any and all feedback as this commences.
Dr. Lorna Breen: Followup Orders
We have confirmed that routine cultures and final imaging reads will automatically go into the NP follow up basket and we do not need to place follow up orders for them any longer.
While we appreciate the carefulness of those who have been doing so, the NPs have shared that it actually increases their work load as each result has two follow up orders that need to be checked.
Hopefully this new work flow will be more efficient for all. Please let us know if you have any questions, concerns or points of clarification.
From Dr. Ken Wong: Orienting off-service rotators
From Dr. Annie Katz: Joint Commission Visit
From Dr. Michael Stern: Age Adjusted D-dimer
Please do not use the age-adjusted d-dimer algorithm for determining appropriate management of PE risk in the elderly population. In the JAMA 2014 study (Righini et al), the fixed d-dimer level of 500ug/L, which is subtracted from the calculated age-adjusted cutoff (age X 10), is not the same threshold number that we use in our d-dimer assays at the Cornell campus. Therefore, extrapolation of the study’s data results to our practice is not accurate and therefore not appropriate. There has already been a case of a missed PE in an elderly patient after using this age adjusted d-dimer threshold with our assay.
From Dr. Dave Bodnar: Ortho Survey
We are constantly trying to improve our interaction with consult services. As such, we are hoping to get your feedback specifically on Orthopedic consults at Cornell. They have been attempting to improve their response to our consults, so it would be very helpful if you could please take a few minutes to answer the questions on this survey to gauge its effectiveness. The survey should take less than 5 minutes.
From Dr. Sara Murphy: ICU/CCU consults
MCB Message of the Month
From Rachel Sullivan, LCSW: Victim Intervention Program Social Worker
Due to new NYS Laws, it is now more important than ever that all sexual assault patients are offered private, individual time with a volunteer Advocate BEFORE any part of SAFE care begins, and again throughout SAFE care.
The Advocate role is only privileged/confidential at certain times, as long as there is no third party present during a conversation.
Advocates have now been instructed to meet with SAFE patients ALONE and FIRST, in order to fully explain their role and the limits to their privileged role. They will not be obtaining a history from patients.Any time a third party is present (ex. a SAFE, a nurse, a SW, a friend, etc.) conversations are no longer confidential and Advocates can then be considered a witness, meaning they can be subpoenaed by the court system.
All sexual assault survivors will be provided with the NYS Survivors Bill of Rights in the form of a packet. This packet will be given to patients first by a Social Worker, before leaving the room for an Advocate to then meet with the patient alone. (See below for case flow).
We are asking all SAFEs and ED staff to accommodate the Advocates’ REQUIREMENT to meet with patients alone. SAFEs should wait until the Advocate has already met the patient before beginning their interview and SAFEs should leave Advocates alone with patients again BEFORE beginning exam/evidence collection.
Please let me know if you have any questions or would like to discuss this further.
Thank you all so much for your attention to this so that we can ensure that all survivors’ rights are being upheld.
SAFE Cases Guide (will be located on Algorithms Page located on nypem.net drop down menu)
Shout out to everyone for all their hard work during this incredibly hard time. Thank you for supporting each other and our patients each shift. The dedication is appreciated!
Upcoming Residency Events
- March 18th – Intern Bowling Retreat (postponed at this time)
- April 1st – PGY2 Retreat (postponed)
- May 27th – 8 hr Theme and PGY4 Research Day
- May 28th – Residency Retreat
- June 3rd – Graduation at the Central Park Boathouse
- MedHub hours must be logged!
- Please fill-in your resident profile on nypem.net. It’s a great way to highlight your interests and things you’ve done during residency. https://nypem.net/meet-our-residents/
- Remember– Away Electives require an application submitted 112 days in advance, while NYP electives are a minimum of 56 days. Instructions located here.
- Check out this career guide from the Academy for Women in Academic Emergency Medicine https://issuu.com/saemonline/docs/saem_awaem_toolkit
- Please be wise on social media use and don’t risk patients’ trust in the medical profession.
- Give time and action-specific instructions in the discharge papers. “See your primary doctor soon” is much less informative than “See your primary doctor in the next four days, but return to the E.R. if your abdominal pain worsens or persists.”
- Get disability insurance before graduating residency. Here’s one resource to start.
- Educate yourself on potential job contract issues. Here’s one article and another EM specific book.
- If a job requires your residency malpractice insurance history, email email@example.com & firstname.lastname@example.org to obtain the relevant documents.
- Remember to complete your EMS ride-alongs! You need 10 4-hour sessions to graduate!
- Take a look at Dr. Mulcare’s timeline for the job hunt.
- Checkout SAEM’s 2019 academic career guide and their fellowship/ career roadmaps.
- Here’s an article on EMS fellowship opportunities.
- < 4 months to leading notifications! Start thinking big picture, and what you’d decide from the foot of the bed. Create a mini-curriculum for yourself of resuscitation-related podcasts, EM:RAP episodes, etc.
- If you have money to save after NYC costs and student loan repayment, consider putting it into NYP’s 403(b) or an IRA. The “Roth” option is likely better when you’re a resident.
- Scroll down to 3. Publications and Educational Initiatives for some good EM resources! Or check out this centralization of other EM resources including podcasts, books, apps and Qbanks.
- Do you take public transportation sometimes to work? Do you want to save 30% of that amount in tax savings over the next three years? Take 15min to enroll in NYP’s Commuter Transit program.
Chief on Call
- Please call and do not text/ email so we can address issues promptly.
- If you do not hear back within 10 minutes, then call any of the other chiefs.