Session 1 Pre-Class Assignment: Comment on the provided HPIs
Session 1 Assignment: Consider discharge planning for this patient– what are the possible/likely outcomes and what elements need to considered to formulate a plan. Load MDCalc on your phone and use it to do the Calculated Creatinine Clearance for this patient – why is it important to do this on elderly patients, even if they have a normal Creatinine? Management of pelvic fractures – when is surgery required? What are the main elements of non-surgical management?
Discharge planning:
Important to ask the patient what she wants.
She is currently at mild cognitive impairment. Due to her injury, she will likely need to be discharged to a subacute rehab facility unless she can get reliable home physical therapy because she will need to be mobilized early and regularly and will need supervision and assistance when ambulating and her ADLs.
Following this, it would be reasonable to discharge her home since she seems to have no problems with adherence to her medications and claims to have a good support system through her church and the home aid she has. However, it is important to explain to her that, while memantine and donepezil may slow the progression of her dementia, her cognitive state will decline so that she needs help with ADLs so she will eventually have to consider a skilled nursing facility where she will be able to get the specialized 24 hour care she will need.
CrCl
Elderly patients have lower muscle mass, so their creatinine levels can appear normal even when the kidneys aren’t functioning normally. Additionally, elderly patients are typically on multiple of medications, so the provider needs to assess if they can tolerate them.
Management of pelvic fractures
The first step in management should be a FAST exam because you want to make sure there is no bleeding, as the pelvis is located in an area with a lot of vasculature
Surgery is more common with traumatic fractures than in atraumatic fractures like we have in the patient presented during this session.
If the FAST exam is positive for blood or they seem hemodynamically unstable:
Bind the pelvis with a pelvic binder or a sheet around the greater trochanters
Perform a diagnostic peritoneal aspirate
Session 2 Assignment: Review flattening the curve – what does it mean and why do we care about it? Compare how South Korea handled the outbreak with how NYS handled it? Herd immunity – what is it and is anyone reaching it?
Flattening the curve is a public health initiative to slow the rate of spread of COVID-19 and especially decrease the number of patients who will need medical care over time so that the max number of people who will need healthcare at any given time is low enough that the healthcare system can accommodate them all. The implication of “flattening the curve” also comes with increasing healthcare capacity and resources (“raising the line”).
We can flatten the curve through hand washing, social distancing, self-isolation , and frequently disinfecting commonly used surfaces.
This is an important concept because, as we saw here and everywhere (mention Italy), healthcare systems can become overwhelmed very quickly. There weren’t enough ventilators or even beds for everyone who got infected, leading to an overwhelmingly high loss of life such that funeral homes and crematoriums can’t keep up. Flattening the curve means that fewer people will be infected leading to less loss of life, and those who are infected and end up needing medical care will receive the appropriate care they need.
Looking at the NYS curve of new cases, flattening the curve seems to be working. (show the curve). Since the NYS PAUSE guidelines were implemented (March 22nd/23rd) , or rather since the couple of weeks since they were implemented because we have to take the incubation period of the virus (which is anywhere between 2 and 12/14 days but usually by 5 days), our curve effectively started to plateau and now we are experiencing a nice decline. During all this time NYS was accumulating more PPE, ventilators, and other necessities and setting up more places to care for the state’s patients like (act like you’re thinking) the SS comfort and the central park field hospital. As a result of these efforts and flattening the curve, we have been able to send ventilators and other materials to other states whose peaks came up later than ours.
I am also supposed to talk about South Korea’s response to covid-19 and how it was different from NYS’s response. To give some background, South Korea, like so many countries, experienced essentially an explosion of cases. But within a month they effectively flattened their curve and had very few new daily cases. For instance, on March 3rd they had over 850 new cases, but on May 5th they had 3 new cases. Of course, yesterday and for the past week or two they’ve seen a bit of an increase in their new daily cases with yesterday’s number at 29, which, in conjunction with the data from China, is sparking concerns for a second wave. What I think makes this really impressive about South Korea is actually how they did it. Because while we and almost every other country we have heard about in mainstream media more or less locked down, South Korea didn’t.
The biggest difference between South Koreas response and NYS’s apart from the way they responded in terms of no lockdown versus a lockdown, was the swiftness with which South Korea responded. It took NYS nearly a month to react by closing schools and putting the PAUSE order in effect and implement widespread testing. In South Korea, however, within a week of finding their first positive case, started mass producing and shipping testing kits to different parts of the country. They also isolated the source of the outbreak really early, which was one specific church congregation. We kind of had that with the upstate 1-mile radius situation for that town in Rochester, but it wasn’t as effective. Of course, we have to acknowledge that South Korea was hit with MERS 5 years ago, so they were kind of more prepared to treat this new virus as an emergency, whereas the US hadn’t actually experienced this kind of thing before.
Another thing South Korea did was that they opened over 600 testing centers and encouraged citizens to get tested early and frequently with as little contact as possible. What I thought was cool was the “phone booths” they set up (talk about it with the picture). Moreover, buildings in South Korea set up thermal image identifying cameras to find people with fevers and test them.
The other big thing is that South Korea started contact tracing immediately when they found positive cases. This works by basically retracing the patient’s steps, finding whoever they came in contact with, testing them, and having them self isolate. This is something the US and NYS have just begun to talk about and might have really helped sooner. South Korea eventually began to publicize this tracing because it obviously is really difficult to track every single person an infected patient has come in contact with. So it was more like “someone with the virus travelled on this bus at this time on this day” so people could see for themselves if they needed to be tested and isolate.
People were only ordered to quarantine if they tested positive or came into contact with someone who tested positive. South Koreans have also opted to forego privacy in favor of controlling the outbreak, which is a very different mindset than we have in New York. People there who test positive and are ordered to isolate are required by law to download an app to their phones that tracks if they leave the quarantine and can be fined up to $2,500 if they do.
So to recap:
South Korea developed testing early
Conducted mass testing
Early contact tracing
No restricting travel
Compromised privacy
NY took a while to catch up
Limited testing that eventually became so backed up because of lack of resources
Contact tracing not implemented
Lockdown
Privacy maintained
Herd immunity is essentially indirect protection from an illness for people who are not immune to the illness when a majority of the population is immune. Vaccines or prior infection are the big thing that cause herd immunity because they allow people to develop antibodies to prevent infection and therefore transmission.
At this point it is a bit early to think about herd immunity with COVID-19, nor is it really a great idea to consider without an actual vaccine that is an option because the other option for that is for most of the population to be infected. Given how dangerous this virus has proven to be, this isn’t a viable option.
The other thing to consider with herd immunity is the mutation rate of a virus. This is what the problem really is for influenza to create a vaccine and rely on herd immunity because it mutates so quickly. The current data show that COVID-19 is a relatively stable virus even though it has shown a bit of mutation, but that still means that a vaccine is still a viable option.
It is also too early to really think about the antibodies people are forming against this virus because a lot of the time the antibodies might not be long-lasting enough or they might not have a high enough level of antibodies. What needs to be done in this case is to first test for antibodies in people who have tested positive for COVID-19 (but ideally everyone) and then draw a titer periodically (3, 6, 12 months, etc.) to see if long-lasting immunity is possible.
https://abcnews.go.com/Health/flattening-coronavirus-curve-happening/story?id=70119118
https://gothamist.com/news/coronavirus-statistics-tracking-epidemic-new-york
https://www.nytimes.com/2020/03/23/world/asia/coronavirus-south-korea-flatten-curve.html
https://www.worldometers.info/coronavirus/country/south-korea/
Session 3 Assignment: One of the questions you are likely to be asked about by patients and perhaps friends and family is whether masks make a difference and whether they should wear one. Please look at the evidence for and against and decide what it shows with respect to:
- Usefulness of homemade cloth masks (are different types more/less effective?)
- Whether it makes a difference in likelihood of transmission for people to wear a mask when outdoors, in a closed environment (e.g. a subway or bus).
- Whether wearing a mask makes transmission in the home less? (infected pt. wearing mask vs. others wearing mask vs. all wearing masks)
- Whether countries where mask use is common have lower transmission rates/R0/fatality rates?
- Who is more protected by a cloth mask – the person wearing it or the contacts of the person wearing it.
As per recent research, all homemade cloth masks are at least a bit effective, but the data show that those made with cotton are most effective. Silk masks also appear to be quite effective, though less than cotton. Of course, higher thread counts and double layering in all masks result in greater efficacy. Cotton blends with chiffon, silk, and flannel appear to be even more effective than cotton alone. More important, though, seems to be the fit of the mask. If there is a gap in the mask, the efficacy is reduced quite significantly. In counseling a patient, I would recommend high threat count cotton-based masks that fit properly so there are no gaps in the mask.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7185834/pdf/nn0c03252.pdf
Since COVID-19 is transmitted through droplets, there is inherently more risk of transmission when in a closed environment like a subway or bus compared to an open outdoor space like a park. However, the droplets do stay in the air for up to three hours, so being in an open outdoor space doesn’t mean one is “safe” from the virus; everyone should still wear a mask and practice keeping a distance of at least 6 feet (ideally 12 feet based on recent reporting concerning how far the droplets move in the air from mainstream news outlets) from people they are not already quarantining with. Masks should definitely be worn in more enclosed spaces like bus or train because, unless capacity is significantly reduced, it is much harder to maintain that distance between people and the droplets can hang around longer due to poorer ventilation.
https://www.businessinsider.com/risk-of-coronavirus-transmission-lower-outdoors-evidence-2020-5
Home transmission is hard to avoid when one member of the household is infected since it is much harder to avoid contact with that person. The best way to minimize the chance of transmission is for everyone, the infected individual most importantly, to wear a mask. If the infected individual does not wear a mask and is spreading droplets without any sort of barrier while the uninfected individuals wear masks, the chances are high that the uninfected individuals will become infected. If the infected person is wearing a mask and the uninfected individuals are not wearing masks, the infected person’s particle spreading is greatly reduced. Ideally, everyone would wear a mask so that the infected person is not spreading droplets as widely and the uninfected individuals have some sort of barrier protection to lower the transmission rates almost completely.
The following graphic might be helpful to use with patients who might need a more visual representation:
(I could not find the source for this graphic and it isn’t included in the graphic itself, but this was the clearest/easiest to see of this type of representation I found)
https://jamanetwork.com/journals/jama/fullarticle/2764955
In areas where mask wearing is and has been the norm, like many countries in East Asia that dealt with MERS and SARS outbreaks years prior, there have been fewer transmission rates and fatalities. Moreover, these areas where 80% or more of the population wears masks are less likely to require shelter-in-place orders like we have experienced in the United States and can get the situation under control to the point where they are no longer in a state of emergency much faster than when little to no percent of the population practices wearing masks.
https://www.vanityfair.com/news/2020/05/masks-covid-19-infections-would-plummet-new-study-says
Wearing a mask, cloth or otherwise, protects others more than it protects the individual wearing it. This works because the mask prevents the spread of one’s own droplets, which is a really valuable concept when it comes to someone who is infected wearing the mask. Everyone, barring children under 2 years old, people with breathing problems that might be greatly exacerbated by a mask, and people who cannot adjust a mask on their own, should wear some type of mask or face covering outside in the interest of protecting themselves and others because asymptomatic individuals can still be infected without knowing it or presymptomatic.
https://patient.info/news-and-features/covid-19-do-you-need-to-wear-a-mask-to-avoid-coronavirus
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