Hey guys, just a brief introduction. I am board certified emergency medicine physician who currently works in the San Antonio area. The last several weeks I have been fielding questions from friends and family and I am looking to pass along recommendations regarding utilizing the emergency department during a pandemic.
Here are a few questions I have received.
"Hey my family member has a fever and a cough, should we be taking him to the ER? And if we do go, what should we expect?"
- While I cannot comment on individual cases, my recommendation in general is if your main concern is that you or your family has CV, you should preferably be staying home and self quarantine unless you are having significant issues with breathing or other severe symptoms. This recommendation does not change even if you have significant exposure history. You can call your PCP and see if they are able to do private lab testing; however, this testing is still limited and it is up to the discretion of your physician. Turn around time for these private lab tests is 3-4 days at the moment, so you will still need to self-quarantine while awaiting results. Several Texas cities will be opening drive-thru testing centers which will hopefully be an option in the very near future.
- The goal is that we do not inundate our ERs with patients at a time when we need all the space and supplies we can get.
- If you do happen to go to the ER, our current clinical pathway for patients where there is even a slight concern for CV in a well appearing patient that will not require hospitalization is a chest x-ray and influenza testing (we are still in the middle of flu season), along with any other diagnostics the treating physician deems necessary. It is still much more likely for you to have another virus or even bacterial pneumonia over CV. This is our pathway even if you have significant exposure history but are clearly well enough to go home. Our recommendation in these cases will typically be to self-quarantine for 14 days and should be provided a work note for that time period with the caveat to return immediately if symptoms significantly worsen.
- If we believe you will be hospitalized, then our current clinical pathway is to start with the chest x-ray and influenza testing. If those are negative, add on a respiratory viral panel (which includes things like rhinovirus, influenza, adenovirus, non-novel coronavirus, etc.) and a CT of the chest to evaluate for ground glass opacities which are common with any type of viral pneumonia. If after that there are no clear alternative diagnoses to explain your symptoms and there is enough concern based on the treating physicians discretion, samples will be sent off for CV testing which currently take ~48hrs to result.
"What are the signs and symptoms that should worry us enough to come into an ER?"
- Everyone has a different threshold for worry, so it is difficult to give blanket statements. Also, my recommendations are addressing specifically CV/other respiratory infections and not other medical emergencies. People typically freak out about the "height" of their fever. Fever alone, even 103-105, is not concerning by itself. What we care more about in the ER is what other symptoms you are having and what is causing the fever. Coughing is very typical of all respiratory viruses and again, alone, should not be much cause for concern.
- The main things we are worried about is your respiratory, mental, and cardiovascular status. Things you should be looking out for is significant shortness of breath. One sign of this is tachypnea (fast breathing). Where I personally really start getting concerned are in those breathing over 24x/minute (but mainly if it just looks like they are breathing very fast). Other signs that are very concerning include having difficulty walking up stairs due to exhaustion, or difficulty even walking around normally, or use of accessory respiratory muscles like significant abdominal breathing, intercostal muscle use (muscles between the ribs), and utilizing muscles in the neck to assist in breathing. Additionally, if someone is experiencing what appears to be a respiratory viral syndrome begins to have confusion, you have difficulty arousing them, or have very slowed mentation (taking long periods to answer questions), these are potential signs of low oxygen levels or diminished blood flow to brain and are indications to immediately go to an ER. Other signs can include severe fatigue, as well. Not just the "I don't feel like getting out of bed", but the "I literally can't (or barely can) get out of bed because I am too weak".
Some additional tips
- Try to avoid going to the ER if you believe something can clearly wait. This obviously is the case even in times without a pandemic, but are even more important now so that you limit your exposure to possible + cases. I'm not talking about waiting if you have severe chest pain or abdominal pain that isn't going away, or some other issue that clearly needs to be evaluated immediately. What I am talking about is things like concern for broken toes (typically just requires buddy taping and sometimes a walking boot), having high blood pressure without any symptoms, or an uncomplicated abscess, or simple cellulitis, or a mild rash, or symptoms that have been going on for more than a week or two. Basically things that can wait a day or two until you can get in to see your doctor, or things that can be handled at an urgent care.
- Please do not have more than one person join you to the ER. We are currently not allowing more than one visitor per patient. This is to limit the number of individuals that might be exposed if a CV+ positive patient comes through.
- Please do not be upset with us if we do not perform testing for CV. We have strict clinical pathways to limit the number of unnecessary tests that are sent to the health department. In mild cases, treatment would essentially be the same as with any other virus, regardless. Please follow the recommendations of self-quarantine, as well.
Let me know if any of you all have any additional questions.
Here are a few questions I have received.
"Hey my family member has a fever and a cough, should we be taking him to the ER? And if we do go, what should we expect?"
- While I cannot comment on individual cases, my recommendation in general is if your main concern is that you or your family has CV, you should preferably be staying home and self quarantine unless you are having significant issues with breathing or other severe symptoms. This recommendation does not change even if you have significant exposure history. You can call your PCP and see if they are able to do private lab testing; however, this testing is still limited and it is up to the discretion of your physician. Turn around time for these private lab tests is 3-4 days at the moment, so you will still need to self-quarantine while awaiting results. Several Texas cities will be opening drive-thru testing centers which will hopefully be an option in the very near future.
- The goal is that we do not inundate our ERs with patients at a time when we need all the space and supplies we can get.
- If you do happen to go to the ER, our current clinical pathway for patients where there is even a slight concern for CV in a well appearing patient that will not require hospitalization is a chest x-ray and influenza testing (we are still in the middle of flu season), along with any other diagnostics the treating physician deems necessary. It is still much more likely for you to have another virus or even bacterial pneumonia over CV. This is our pathway even if you have significant exposure history but are clearly well enough to go home. Our recommendation in these cases will typically be to self-quarantine for 14 days and should be provided a work note for that time period with the caveat to return immediately if symptoms significantly worsen.
- If we believe you will be hospitalized, then our current clinical pathway is to start with the chest x-ray and influenza testing. If those are negative, add on a respiratory viral panel (which includes things like rhinovirus, influenza, adenovirus, non-novel coronavirus, etc.) and a CT of the chest to evaluate for ground glass opacities which are common with any type of viral pneumonia. If after that there are no clear alternative diagnoses to explain your symptoms and there is enough concern based on the treating physicians discretion, samples will be sent off for CV testing which currently take ~48hrs to result.
"What are the signs and symptoms that should worry us enough to come into an ER?"
- Everyone has a different threshold for worry, so it is difficult to give blanket statements. Also, my recommendations are addressing specifically CV/other respiratory infections and not other medical emergencies. People typically freak out about the "height" of their fever. Fever alone, even 103-105, is not concerning by itself. What we care more about in the ER is what other symptoms you are having and what is causing the fever. Coughing is very typical of all respiratory viruses and again, alone, should not be much cause for concern.
- The main things we are worried about is your respiratory, mental, and cardiovascular status. Things you should be looking out for is significant shortness of breath. One sign of this is tachypnea (fast breathing). Where I personally really start getting concerned are in those breathing over 24x/minute (but mainly if it just looks like they are breathing very fast). Other signs that are very concerning include having difficulty walking up stairs due to exhaustion, or difficulty even walking around normally, or use of accessory respiratory muscles like significant abdominal breathing, intercostal muscle use (muscles between the ribs), and utilizing muscles in the neck to assist in breathing. Additionally, if someone is experiencing what appears to be a respiratory viral syndrome begins to have confusion, you have difficulty arousing them, or have very slowed mentation (taking long periods to answer questions), these are potential signs of low oxygen levels or diminished blood flow to brain and are indications to immediately go to an ER. Other signs can include severe fatigue, as well. Not just the "I don't feel like getting out of bed", but the "I literally can't (or barely can) get out of bed because I am too weak".
Some additional tips
- Try to avoid going to the ER if you believe something can clearly wait. This obviously is the case even in times without a pandemic, but are even more important now so that you limit your exposure to possible + cases. I'm not talking about waiting if you have severe chest pain or abdominal pain that isn't going away, or some other issue that clearly needs to be evaluated immediately. What I am talking about is things like concern for broken toes (typically just requires buddy taping and sometimes a walking boot), having high blood pressure without any symptoms, or an uncomplicated abscess, or simple cellulitis, or a mild rash, or symptoms that have been going on for more than a week or two. Basically things that can wait a day or two until you can get in to see your doctor, or things that can be handled at an urgent care.
- Please do not have more than one person join you to the ER. We are currently not allowing more than one visitor per patient. This is to limit the number of individuals that might be exposed if a CV+ positive patient comes through.
- Please do not be upset with us if we do not perform testing for CV. We have strict clinical pathways to limit the number of unnecessary tests that are sent to the health department. In mild cases, treatment would essentially be the same as with any other virus, regardless. Please follow the recommendations of self-quarantine, as well.
Let me know if any of you all have any additional questions.
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