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Let’s avoid collateral damage.

Patients who need resuscitation are being managed very differently because of Covid-19, something that is causing concern for emergency medicine specialists.

They fear that resuscitation efforts won’t meet the standard we are used to in emergency departments, so non-Covid-19 patients will become ‘collateral damage’.

“I understand that we need to protect health care workers but we need to be fully aware that this could put patients at greater risk,” Dr Keith Edwards an Emergency Physician in Sydney said.

“The most stark example is when a patient has a cardiac arrest in the emergency department. Staff need to put on full personal protective equipment (PPE) and this needs to be checked before we start resuscitation.

“This can cause a delay of at least 1-2 minutes.

“For example, if someone arrests in front of me in the emergency department in the hospital, under normal circumstances I would jump on them and start pumping on their chest straight away. But I won’t be able to do that. I will need to stop to gown up. Yet time, every minute to CPR, is critically important. Any delay in commencing it reduces the likelihood of the best outcome.”

“We are now also not able to use Non-invasive Ventilation in emergency departments. This is normally a widely used tool when dealing with patients who have acute respiratory distress caused by lung or heart disease.

“I have to either intubate them (insert a tube into the trachea), which is more risky and cumbersome, or decide to give substandard treatment.”

Covid-19 changes include:

  • Resuscitation must be done in full personal protective equipment (PPE) and this sometimes takes up to two minutes to put on – two minutes that could be crucial to saving a life.
  • Resuscitation must be done more slowly to avoid problems.
  • Those attending can’t actively use Bag-valve-mask (BVM) ventilation, a standard step in resuscitation because of the concern of spreading Covid-19 throughout the room.
  • They cannot use nasal prong oxygen to deliver oxygen into the body when someone has stopped breathing.
  • They must not have the ventilator turned on before connecting to the patient (the typical ED ventilator takes about 15 seconds to start up). This means the patient is not receiving oxygen for that extra time.

For more discussion on this, see the following article: https://www.mja.com.au/journal/2020/consensus-statement-safe-airway-society-principles-airway-management-and-tracheal#panel-article

Some hospitals have discussed the possibility of having someone gowned up in PPE and waiting.

“But this means you’ve got one person gowned up and waiting for that rare event. There are restrictions on what they can do when they’re gowned up and it also means that those gowns are wasted if nothing happens.” 

“We are not going to learn how to resolve these complexities before Covid-19 goes away. Yet the incidence of Covid-19 will increase.”

“We also have the problem of people avoiding coming to hospital with threatened heart complaints or other serious medical conditions, when we really know they should,” Dr Edwards said.

He said this is happening all over the world.

“I spoke to an Emergency physician colleague in The Netherlands who said she has seen two patients in the last week who came in in cardiogenic shock – as a result of a heart attack they had a few days before. They hadn’t come to hospital when they should have because of fear of Covid-19.”

These comments come at a time when the Australian Heart Foundation warns that people with heart disease are at a higher risk of dying from Covid-19 than others.

“International experience suggests older people and people with chronic health conditions, including cardiovascular disease, are at higher risk of dying from COVID-19 than other people,” Heart Foundation Group CEO, Adjunct Professor John Kelly, said.

“We urge people living with heart disease to take precautions to avoid infection with COVID-19, and to continue taking their medications as prescribed by their doctor,” Professor Kelly said.

For more information about protective measures and what to do if you are experiencing symptoms, follow the advice from the Department of Health or call the Coronavirus Health Information Line on 1800 020 080.

For the Heart Foundation’s statement on Covid-19 and increased risks if you have heart disease, go to: https://www.heartfoundation.org.au/your-heart/coronavirus-covid-19-and-cardiovascular-disease

For the Australasian College for Emergency Medicine’s statement, go to: https://acem.org.au/News/March-2020/ACEM-urges-community-not-to-neglect-urgent-medical

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