As the coronavirus situation currently stands (March 18th, 2020), I think I am lucky to be working at Sutherland Hospital, and especially to be working in the Emergency Department.

  • The “Shire” is a community with high levels of health literacy
  • Our population historically don’t like crossing bridges (!!), and there are no case clusters in our local area yet
  • these features mean that an epidemic affecting Sydney may well be less severe here (a “flatter” curve so to speak)
  • TSH is not a tertiary hospital, we are not receiving COVID patients transferred from other units
  • The flu clinic is being staffed by MOs from outside of ED
  • The coronavirus workload is being directed through the flu clinic not the ED
  • There is currently a decreased workload through ED as fewer “worried well” are presenting and we have cohorted respiratory patients in South Acute
  • The hospital is able to increase resources for sick respiratory patients by cancelling elective theatres, freeing up anaesthetic staff and surgeons to care for these patients, potentially utilising theatres , recovery, day stay unit, surgical wards and even pre-anaesthetic/surgery clinic environments for patient care.
    • Hopefully some of the “convalescent” care can be shifted to non-acute or private hospitals – we have many of these in our local area
    • International experience is that few patients (<5%) present to hospital in the ICU phase of their illness, those that need NIV or intubation have usually already admitted to hospital when they deteriorate
  • Overall, this may well mean that is not that different to “business as usual” in our ED! And even if it does, Emergency Physicians are flexible and adaptable and used to dealing with uncertainty!

There are treatments for COVID19 that are being tested

  • Anti retrovirals such as lopinavir/ritonavir reduce viral load and seem to reduce severity of illness if administered early (and as they are already used as PEP in HIV, I wonder if any high risk staff exposures could be given these meds??)
  • Anti- malarial chloroquine  (changes intracellular pH appear to stop viral replication; also used for malaria prophylaxis, so again potential as PEP)
  • These older drugs have known safety profiles so can be (and are being ) used NOW!
    • Multi-centre RCTs to provide us more info about efficacy of Rx in COVID 19 are already underway OS and in Australia
  • Anti-inflammatory tocilizumab may prevent some NIV patients from progressing to intubation

Likely changes to our usual practice:

  • There will be access block (especially for patients requiring NIV or ICU, regardless of COVID status)
  • We will need to wear PPE throughout our shifts – change into surgical scrubs, wear masks and gloves for all patients
  • We will need to exercise special precautions during aerosol generating procedures
    • We already have created a guideline to reduce risk to staff during intubation

Areas that cause me concern

  • High level of nursing homes and elderly patients in our area
    • Need RACFs to be sensible about who they transfer for acute hospital care; develop policies/guidelines to help in decision making
  • High demand for NIV and ICU beds may result in us needing to make difficult ethical/moral decisions
    • Putting public health concerns ahead of the patient directly in front of us is something we don’t usually have to do
    • We need clear policies/guidelines to help MOs in decision-making around not offering care to patients that would usually receive that level of care (e.g. LHD determined age and co-morbidity cut offs for NIV and ICU)