May 4, 2020

Introduction: Emergency physicians rarely are involved in tube exchanges; I can’t remember the last time I had to do one. However, during the COVID19 surge, we found ourselves boarding intubated patients for days and even weeks as our ICUs were filled to the brim. With our ICU teams so busy, it became increasingly important for us to aid in critical care management where we could. Initially this was simply with lines and hemodynamic monitoring but, tube exchange became important. A number of our boarding patients developed considerable mucous plugging and tube obstruction that could not be cleared by suction. Reintubation with a fresh tube, while well within our scope, creates unnecessary risks - aerosol generation, increased provider exposure and possible harm to patient if intubation proves challenging. Tube exchange over a bougie seems to make a lot of sense.

Note: Due to the lack of experience most EM clinicians have with this procedure and the fact that it is a high-risk one, it may be best to consult anesthesia to help with the procedure if they are available. We acknowledge that this may not be possible if that service is stretched thin due to circumstances.

April 29, 2020

Needs Assessment: As the COVID19 pandemic continues to mount, hospitals will rapidly reach maximal capacity. As a result, patients are boarding longer in the ED and, new patients are waiting longer to be seen. This dynamic poses numerous threats to patients safety. While we are seeing a large number of patients with severe and critical COVID19 who require intense monitoring, therapy and even ICU resources, many patients are only in need of supplemental O2 while they deal with their symptoms. The ability to discharge patients home with O2 and proper follow up monitoring can help open up more beds in both the ED and the hospital in general allowing us to deliver the proper resources to patients who need them.

April 26, 2020

Background: Awake proning, or having patients lie on their stomachs, can help oxygenation by helping to recruit posterior portions of the lungs and by helping with perfusion to oxygenated lung segments. The literature around proning centers on intubated patients with adult respiratory distress syndrome in the ICU. However, there are increasing recommendations from front line clinicians and experts about the benefits of proning hypoxemic COVID19 patients who are awake in an effort to improve oxygenation and stave off intubation. While there may be physiologic reasoning, anecdotal experience and application of data from intubated patients, there is an absence of data specifically on COVID19 patients and proning. Fortunately, we now have some literature to look at:

April 22, 2020

Take Home Points
  • N95 masks ideally should be single use but in COVID19 times, safe reuse practices are critical.
  • The best approach to reuse is vaporized H2O2 and UV light decontamination with a total of 3 decon cycles prior to losing mask integrity.
  • A backup method of cycling between 4 masks is likely effective as SARS-CoV-2 cannot survive > 72 hours outside a human host in sufficient numbers to cause infection.
  • Ethanol soaks are effective in decontamination but destroy mask integrity and should not be use.
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