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Ep. 45 - LiveWell Talk On...Emergency Care during COVID-19 (Dr. Ryan Sundermann & Dr. Ryan Dowden) April 27, 2020

Ep. 45 - LiveWell Talk On...Emergency Care during COVID-19

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Guest Hosts: Dr. Ryan Sundermann & Dr. Ryan Dowden, St. Luke's Emergency Department

Dr. Sundermann
This is LiveWell talk on emergency care during the COVID-19 epidemic. I'm Dr. Ryan St. Luke’s Hospital Emergency Room Medical Director.

Dr. Dowden
And I'm Dr. Ryan Dowden, physician in the ER at St. Luke’s.

Dr. Sundermann:
So today we're taking over Dr. Arnold's our chief medical officer's podcast to discuss what we're doing in St. Luke's emergency department to ensure your safety and ensure that you're getting the care that you need to get in the event that you're not feeling well. Because we've definitely seen a decrease in our volumes in the emergency department during this time, understandably because people are scared. They're afraid that they're going to contract something even by coming to the emergency department.

Dr. Dowden
Some of it's I think also that social distancing is maybe keeping people well or a less injured than the normal.

Dr. Sundermann
You're not going to work and smashing their fingers or falling off the roofs or even getting in a car accident on the way to work.

Dr. Dowden
Yeah, exactly. And not to mention that, you know, we're, taking measures to prevent spread of viruses. So, so I think it goes without saying that there's a decent chance that even the kids that we normally see with colds and flus and things aren't getting sick because of the same precautions. Their parents are taking social distancing for coronaviruses as well in the same social distancing works in the same way for the common cool virus, et cetera. But we certainly miss our patients and we definitely don't want to see people staying at home for symptoms that under normal circumstances they might not even bat an eye to come to the emergency department to get checked out for.

Dr. Sundermann:

I think we could definitely talk about some of the things that we've seen that would have been much way more severe because people didn't present early. One of the features is that people are trying to do the right thing. They're trying to make sure that sick people have access to the emergency room and they don't want to get sick. And if they, by coming to the same sort of health care facility, I mean, you see it in Hy-Vee or the other grocery stores, you know, you walked on the outs, you got to follow the directional errors, you've got to wear your mask and people are kind of, you know, they look at you sideways if you're not wearing a mask in there and you know, you'd wipe down your card. So naturally, if that's just from the grocery store, then think about coming to the hospital.

Dr. Dowden
Yeah, exactly. And I'm sure people have driven by and seen our shed out front in the ER and seen signs and maybe heard stories about how the processes are different. And of course that can potentially raise anxiety levels about coming in, is it safe? What's it going to be like, what do I expect when I get there? And, and you know, so I think that's a good thing. We're going to talk about some of this stuff and the steps we've taken.

Dr. Sundermann:
That's exactly the point though, is we've done all those things to keep people safe, you know, not only prevent the people with minimal symptoms from having to come into the emergency department, you know, they go, we have a shed. A lot of, you have seen a lot of tents out in the public. We actually have a shed because some of the strong winds we've had in the last month tried to blow our tent away and so we moved to a shed that’s pretty much locked down. 

Dr. Dowden
Maybe not a good idea to have a tent during April and May.

Dr. Sundermann:
Yeah. The worst place to be. Maybe Texas or Oklahoma. So we've, we've put those in place to keep, well people moving through without even having to come to the department. But we've also split the waiting room in half. And so we've got patients that if they come in with any respiratory symptoms and they can't go right back to the emergency department, they can go to our respiratory waiting room where they mask and their distance far apart so that they're outside the cough radius, which is the distance that droplets spread. But they're in a mask anyway. We put a mask on them if they're in a waiting room, but because of the low volumes we haven't even had to use our waiting rooms. And then we have a well-rated waiting room as well where if you have a sprained ankle or a cut or something you can go to that waiting room.
So we've split the waiting room in two, but are all of our rooms are private rooms. You're not sharing rooms. They're wiped down completely after every visit. And then if there is a respiratory patient, we even have what's called a negative pressure system where it basically pulls fresh air through so that nothing actually gets out of that room. So it's extremely safe. In fact, our rate of illness as healthcare providers in the emergency department, it's actually very, very, very low. And that's because of our protective equipment that we're using and what we're doing to keep the rooms clean and the people isolated.

Dowden
I think it's important to note the purpose of this recording isn't necessarily to talk about the signs and symptoms of coronavirus and the illness itself, but rather to talk about the precautions and everything that we have in place to keep all of our patients safe. And, and as the medical director Dr. Sundermann, you know, works a tremendous amount, but in March, he alone, he worked double the number of hours that he normally does in preparation for coronavirus. And, quite frankly, you know, the disease process itself is evolving. And even as doctors, we're getting new and updated information on the disease every day and best practices from around the country and so forth. And obviously we're, we're very focused on that, but ahead of time, when we look back now four, six weeks ago before social distancing started when we knew the disease was calming and that we weren't going to prepare for a surge, a big focus of the preparation at that point in the emergency department and in the hospital as a whole. It wasn't necessarily preparing for how we were going to actually take care of these patients. In other words, what medicines we were gong give them and what symptoms we were going to expect and what we're going to do. But rather the, the preparation was all in place to try to figure out how we were going to deal with this contagious disease and keep it from spreading to our healthcare workers and to the other uninfected patients. And so the majority of the work preparing for this was all done for that reason.

Sundermann
Know you saw the efforts and people were trying to get the protective equipment. You knowI was going out and buying mask and goggles and things like that just to make sure that we had enough. And you saw the public outpouring when then people are, you know, once people realized there was a potential for shortage, we had donations of N95 masks and things like that. Construction workers and even individuals would remodel their basement would drop off a stack of 20 masks. And you know, that was fantastic. And that was, the preparation that was required to get ready. And then we kind of were, we thought we were behind the curve and we were racing to get ready and then has been this kind of quiet, hopefully it's not the quiet before the storm, but it's definitely been a quiet.

But the problem is, is that what we've seen is because people have this fear or they're trying to distance themselves from the potential, the potential of infection, they're neglecting some of their other potential signs and symptoms that would lead them to normally come to the emergency department. You know, the guy who's been at home with chest pain for a week because he thinks I can just wait this out. Or the woman at home who's been, you know gaining significant amounts of weight and ankle swelling, not realizing that it's a heart failure that's progressing and she needs to see a cardiologist or one of us to kind of get that to those symptoms in order. And so by the time that people are presenting that disease is progressed much further than it normally would have.

Dowden
I think one of the things to point out here is as, as emergency physicians, when we advocate for our patients we always use this term prudent person and we want to make sure that everybody has access to care in the emergency department for symptoms that a prudent lay person would go and seek care for. And, we definitely don't want that to be any different during the coronavirus.

Sundermann
Explain what a  prudent lay person 

Dowden
A prudent lay person would be your average citizen who has average healthcare knowledge. If they have symptoms that they believe might be due to a, to a serious or life threatening condition, they would go and seek medical care. And we want that to happen during coronavirus. Just as it would happen at any other time. We definitely don't want people to delay their care or to be scared to come to the emergency department, or quite frankly, there's been a lot of the movement for you know, stay home to protect us, you know, stay home to protect your health care workers. We we're. We are very fortunate. And at St. Luke's and, and in Cedar Rapids we at this point don't lack for PPE and and we feel very safe and comfortable taking care of patients. 

Sundermann
Yeah. I remember when we first started going into rooms over a month ago with a mask on, you know, our patients weren't accustomed to not see our faces. But very, quickly, I'd walk in, I'd say something to the effect of, Hey, I'm sorry I have to wear this a face mask. It's just for your protection. And patients were instantly thankful and show their graduate. Oh no, thanks. I understand. You know, they very much understood that and now it's just part of the routine now. People, I think they'd be shocked if you didn't come in wearing a mask and goggles. And sometimes I'll kind of pull them out of my mask and just say, Hey, this is me what my face looks like cause I'm Ryan and et cetera. And you know that just to kind of set them at ease a bit, but to the same way you talk about like severe illness.

Well a good friend of mine, and I'm, you know, I won't say his name, but you know, if he hears this, I hopefully understand that. Right. He called me up and he said, Hey, I'm at the office and my hand looks terrible. I've got a shard from my raking, you know, everybody's at home doing yard work cause they don't know what else. You know, I've never seen so many people walking their dogs ever before, but you know, and so there walking their dogs doing yard work, but he gets a shard of his rake in his hand and things, I don't know if I want to go see anybody about this, but by the next day this thing looks terrible. And so he's got to come in and you know, if he were to come in the day before, it probably had been removing the shard and he got an infection. So it's even the little things that you gotta make sure you don't let get carried away. In times like this. And like I said, well, you know, you're safe if you come to the emergency room, we're here. 

Dowden
We'll keep you safe. I bet if you asked him, you know, if that would've happened last summer, would you even thought twice about going to the ER to urgent care or something?
Where did all of our patients go? Where are you? Where are they? We're especially concerned right now because, you know, anecdotally we feel like we're not seeing the same number of cases of appendicitis and heart failure and heart attacks and strokes that, that we normally do. I was actually just talking to one of our surgeons the other night. The surgeon had to come in to take care of a patient in the middle of the night. It wasn't an appendicitis case, but we started talking about a appendicitis and she said, you know, she, I can't remember ever having a call night where I didn't take care of at least one case of appendicitis. And she said, I don't think that I've taken care of an appendicitis case in the last six weeks. Wow. It's stories like that that make you think, gosh, I sure hope people aren't [inaudible],

Sundermann
But it also says something about what our daily routines are that make us susceptible to every, like just everything. Yeah. It's kind of indicative, you see the pictures of how less human activity impacts things and you look at a pictures of the air quality is just re Los Angeles even. And they show the smog count and it's almost like to zero.

Dowden
Oh yeah. All the pictures that you see of animals, you know, coming into cities...

Sundermann
Deer walking in subway lines and things like that. It's, you know, it's kind of crazy. It's the Chernobyl effect, you know, where the, and plants and animals eventually take it all back over and

Dowden
Well, you know certainly maybe aren't having appendicitis as much, maybe people aren't having other things that is happening, but there are lots of conditions that, that if caught and treated early, you know, will prevent much more severe illness. I can even give a couple of examples of things that I personally have seen. Even during this last stretch of shifts, I just worked in that, you know, simple things like a bladder infection being untreated and leading to a more severe kidney infection or a sore throat being untreated and leading to a more severe abscess in the throat that needed to be surgically drained and, I don't know whether either one of those cases would have been different during non coronavirus times, but those are examples of things that could potentially have gotten worse if, if the patient was reluctant to come in and seek care early for their illness during this time as opposed to  any other time.

Sundermann
 I think that is critical. We don't. One of the things we are doing a lot is studying the disease. And so there is a ton of information coming out of the epicenters, like New York and Washington and places like that. And so we see a lot of these kind of crazy presentations and in fact people will assume that this is a respiratory illness but in which it is. But it starts with some fairly benign symptoms. And what I do not want to do is scare people into coming in the emergency room. That's not my goal here. What I want to do is make sure that you're aware that it's not just cough and fever. It often starts with bad headache and body aches.
You know, we all get headaches. And so if you just think you have your traditional headache and you can manage it with Tylenol or Motrin or cetera and or whatever, do that by all means. But if you have an unusual headache or a headache that's unremitting or not going away, all right, and now gets accompanied by body aches and you just feel like this is particularly unusual. Those can be symptoms of COVID. In fact, 40 to 50% of people start off with non respiratory symptoms. So you have to pay attention to things like that. And well, there isn't a treatment for it yet. It is important that you identify it early.

Dowden
Well, and quite frankly, any one of those symptoms could be a symptom of another disease that just as serious or more serious than coronavirus. And, thinking to yourself, Oh, I know I'm not supposed to leave my house or go into the hospital if I might have coronavirus you know, it could be a mistake. You know, we, we have all the precautions in place to keep you from spreading the disease to the healthcare providers and other patients. And at this point I think the message needs to be look out for yourself first. If at any time you're not sure about the symptoms or you're worried or you think to yourself, you know, under normal circumstances, I would definitely be going to the ER for these symptoms. That's what we still want you to think. Because we definitely don't want people sitting at home and feeling that way.

Sundermann
And at a minimum, call your primary care provider. We have a nurse line, you can always call them. They have telemedicine visits available. And we have a respiratory clinic that if you call your primary care provider, they can get you in. If you think your symptoms aren't severe enough, by all means go there. In the middle of the night, they're not open. And so the thing is we, you know, we're 24/7, we never close. You know, we're here for you and you know, like whether it's headache, if it's a crazy headache, it could be COVID, but it could also be that something horrible that needs to get diagnosed quickly. But you just, again, that prudent lay-person use your own best judgment and if you feel like it's an emergency, trust your gut and come and see us and you know, we're going to keep you safe. You don't have to worry about keeping us safe cause we've got all that in place. And so

Dowden
We'll take care of you. We should go over one more time, just the steps that we've taken. So, the first, first and foremost, if you know, I think a lot of people have their own masks now and, and when they're leaving their house, they're typically wearing masks. But, if you don't have your own mask, we have masks to put on you. When, you arrive in the ER, we, you're going to be met by a, by a greeter and they're going to do a, just a basic review of your symptoms and kind of help disposition you either to the respiratory part of our ER or the non respiratory part of the ER.

Sundermann
Or you might go to the shed if you come in and you say, I've got a mild fever, cough, but I'm not short of breath and you have some kind of just basic symptoms and you want to be ruled out for COVID, we’ll, send you to our shed. And at that point we'll determine if you qualify for testing. Again, remember, because testing is limited there, you don't necessarily be tested if you don't meet criteria from the state perspective. We might just tell you to assume that you could have it and to shelter in place for two weeks and you have to be symptom free for at least 72 hours before you return activities out to outside the home. So again, I'll reiterate, even if we think that you could have it, not everybody qualifies for testing.

Sundermann
So if you come in, we send you over to our shed and you walk through and they say, yep, sounds like you might have it, go home, don't be offended. You know, we're limited by supply and also by state regulation, as do we test. There is some new stuff coming out with some of the more rapid testing, but we're kind of late to get a lot of that and here in Iowa because we haven't been the epicenter so that it's coming, but it's not prime time yet. So just understand that and have some patience. 

Dowden
So to back to your point. Yes. So the process is to show up and you get screened and then, we've got separate areas leading into the department. You know, some people might call it waiting rooms. Fortunately for us lately we haven't had a need to have anybody in the waiting room. And we hope to keep it that way, that the emergency department itself is geographically very large and, and we are separating respiratory cases from non respiratory cases to the extent possible.

Sundermann
We clean the rooms extremely well. In fact, that's been one of the issues is making sure we had enough of these, they call them PDI wipes that we wipe down every room, every that a patient leaves regardless of your symptoms. And if it is a respiratory patient, that room has actually left to kind of settle even for a period of time depending on the type of room we have before we even go in and clean it. So we're very prudent about, again, there's that word prudent again, but the we're very careful, careful about making sure that these rooms are cleaned to protect you as well as us.

Dowden
And there are lots of steps in process being implemented to prevent equipment use from being, you know, from the respiratory patients to non respiratory patients. You know, different processes for diagnostic tests x-rays and blood tests, EKG, things like that for patients with potential coronavirus symptoms and those who don't. And even at the end of the visit different processes for physically even exiting the department then we normally have in place. So from start to finish we have processes in place in order to keep everyone safe and to limit spread of the coronavirus in the emergency department

Sundermann
And we feel very good about it. I'll tell you what, we're probably close to the time that we have available to us. I will remind everybody that if you have some further topics that you'd like to discuss, whether it's a COVID-19 related or other health questions, even Dr. Arnold does this podcast regularly and he'd be more than happy to answer any of those questions. So if you want to shoot those questions to the following email stlukescr@unitypoint.org