The Edge: Reflections On a Year of COVID

The Edge is a new monthly column from FlightBridgeED that features top EMS medical directors sharing current trends in critical care and prehospital medicine. In this installment Ritu Sahni, MD, associate medical director for FlightBridgeED's Podcast Division, reviews a year of COVID-19. 

We have recently passed a year of dealing with a worldwide pandemic that has impacted daily life in meaningful ways and had a tremendous impact on the emergency community. As we enter our second year of this pandemic, it is beneficial to reflect on the last year. How did it start? What have we learned? What impact will this have on our future? 

As I reviewed my 2020 calendar and had the opportunity to discuss things with some EMS friends, it became apparent there were some lessons learned—and feelings to unpack.¹ 

The Start of the Pandemic

The human brain has a tremendous capacity for adaptation and, frankly, looking past periods that were difficult or painful. Unfortunately the brain sometimes hides and stores those stressors, and they become apparent later. I had already forgotten the initial stress and events that occurred early. 

In early January the World Health Organization announced there was a mysterious pneumonialike illness in Wuhan, China that appeared to be caused by a new type of coronavirus. On January 8 the CDC issued a Health Alert Network (HAN) advisory about this new pneumonia and recommended screening patients for travel.² The HAN advisory had no advice for treatment because we had no idea what we were dealing with. At that time there were fewer than 100 cases noted, although there were likely many more in circulation. Early discussion and preparation really focused on one question: Will this be SARS 2.0 or burn itself out like other previous episodes? Obviously, neither was correct.

A lot of things changed on January 20, 2020, when the first U.S. case was identified.³ This individual had returned to the Seattle area after visiting family in Wuhan. He presented with a fever and cough for four days. The EMS community watched with some concern and began planning. However, as I look at my own calendar, I note travel at both the beginning and end of February. 

By the ESO Wave conference in late February, there was a lot of chatter. One of the presentations was by Eric Cooper, MD, EMS medical director for Snohomish County, Wash., who discussed his jurisdiction’s concerns around getting this patient transported. Concern was rising.

On February 28 Oregon announced its first case.⁴ In the Portland area we’d met that morning with public health to discuss an ongoing response, but it was still just a possibility. By the end of the day, everything had changed. I remember attending a friend’s birthday party that night at a local distillery and having a deep sense of foreboding—but also trying some new bourbons! 

The single most important fact about Oregon’s first case was this: This patient had no known link to an existing case. This was a case of community transmission—likely the hallmark of what made this blossom into a pandemic. SARS-CoV-2 could be transmitted in a manner that would be difficult to trace. Identification and isolation strategies alone—classic public health interventions—would not be an effective tool.

The Early Days

March 2020 seemed like the single longest month in many of our lives. EMS administrators and medical directors faced a pandemic in which nothing was known about transmission and there were no known treatments. The country watched as the fire seemed to ravage through nursing homes and then communities. Following that first case, the Seattle region next seemed to identify one of the first nursing home outbreaks. 

What did we learn from this? When the outbreak first started, it was really before we embraced an “every patient might have COVID” mentality. The first crews to take patients out of facilities were not in PPE. Even if the patient they were transporting was not infectious, they had likely been exposed. At one point a third of the local fire department had to be quarantined. This strain on the EMS system was one all of us wanted to avoid. Once COVID got into a firehouse or an agency, it could have major consequences.

In the meantime, a new tragedy started playing out in the media. We all watched as the emergency healthcare system in New York became rapidly overwhelmed. Hospitals became oversaturated, and deaths increased. This mirrored situations occurring throughout the world. 

The Evolution of Care

Initial care wasn’t necessarily focused on improving outcomes—we didn’t know how to do that yet. However, we did want to focus on protecting crews and preserving resources. During March the changes to PPE policies and clinical care were mind-numbing. Many agencies stopped using nebulizers or any form of aerosolizing procedures. We all experimented with and invented special drapes and plexiglass boxes for intubations. 

One key early intervention was probably wrong: We thought intubation early on would be better than using CPAP/NPPV. It provided a way to “close the circuit” and possibly prevent contamination. Additionally, these patients were so hypoxic, we thought this was the best method to manage them. Now we’ve learned these patients tolerate CPAP quite well, and it has become a hallmark of therapy. It may be time to look at all aerosolizing procedures again and resume business as usual in terms of therapy while maintaining PPE.

Unfortunately, medical therapy has continued to be somewhat disappointing. Early on we thought steroids were contraindicated. We were concerned systemic steroids would harm the body’s ability to fight viral replication. We now know the opposite. To date, in fact, dexamethasone is the only treatment that has been reliably shown to decrease mortality, especially in hospitalized patients.⁵ It appears the sequelae of COVID-19 infection are related to a massive inflammatory cascade referred to as cytokine storm, and it makes sense that powerful anti-inflammatories would prove effective.⁶ 

Several other treatments have been studied, including hydroxychloroquine, remdesivir, and monoclonal antibodies. While there was significant hope regarding these therapies, it appears they have no impact on mortality.^7,8 Of those, remdesivir has been approved because it seems it may shorten duration of illness, but the effect was much smaller in the final study than in the original preliminary report.⁹ 

Looking back at this, the longest year of my life, has proven to be interesting. Reflecting on what has happened and how things will change moving forward can only lead to better response for the next pandemic.  

References

1. FlightBridgeED. COVID: One. Year. Later. YouTube, 2021 Mar 19; www.youtube.com/watch?v=QGriVOplAGM.

2. Centers for Disease Control and Prevention. Outbreak of Pneumonia of Unknown Etiology (PUE) in Wuhan, China, 2020 Jan 8; https://emergency.cdc.gov/han/han00424.asp.

3. Holshue ML, DeBolt C, Lindquist S, et al. First Case of 2019 Novel Coronavirus in the United States. N Eng J Med, 2020 Mar 5; 382: 929–36.

4. Oregon Health Authority. Oregon announces first, presumptive case of novel coronavirus, 2020 Feb 28; www.oregon.gov/oha/ERD/Pages/Oregon-First-Presumptive-Case-Novel-Coronavirus.aspx.

5. RECOVERY Collaborative Group. Dexamethasone in Hospitalized Patients with Covid-19. N Eng J Med, 2021 Feb 25; 384: 693–704.

6. Fajgenbaum DC, June CH. Cytokine Storm. N Eng J Med, 2020 Dec 3; 383: 2,255–73.

7. ACTIV-3/TICO LY-CoV555 Study Group. A Neutralizing Monoclonal Antibody for Hospitalized Patients with Covid-19. N Eng J Med, 2021 Mar 11; 384: 905–14.

8. RECOVERY Collaborative Group. Effect of Hydroxychloroquine in Hospitalized Patients with Covid-19. N Eng J Med, 2020 Nov 19; 383: 2,030–40.

9. Beigel JH, Tomashek KM, Dodd LE, et al. Remdesivir for the Treatment of Covid-19 — Final Report. N Eng J Med, 2020 Nov 5; 383: 1,813–26.

Ritu Sahni, MD, MPH, FAEMS, is associate medical director of the Podcast Division and cohost of the SecondShift podcast for FlightBridgeED.