COVID-19 is all I can think about these days. It feels as though it is taking over the world. While the majority of cases have been in urban centres, based on the global trajectory this will not remain the case for long.

My thoughts have been especially drawn to the dilemmas that I worry rural physicians will face in the days to come. Although I know there are countless other challenges that will be encountered, two of the overarching issues that I’ve been dwelling on are the scarcity of resources in rural communities and the moral injury that will result from being the gatekeepers of said scarce resources.

Scarcity of resources comes in infinite layers to this situation. In our rural communities, healthcare providers themselves are already a scarce resource. Should our rural physicians and nurses become exposed to or infected with COVID-19 and need to self-isolate, this creates a scarcity of our most essential resource – healthcare manpower.

In addition to this, rural hospitals are not built with pandemics in mind, and so most are not equipped with negative pressure rooms or even basic partitions within emergency departments to prevent mass exposure to a COVID-19+ patient. If we face an influx of COVID-19+ patients certain hospitals risk major outbreaks which may require mass quarantine.

In our rural communities within BC and across Canada, physicians often have limited access to very few (or no) ICU beds and ventilators. In Italy, even well-equipped urban physicians have been faced with an unimaginably devastating situation in which they must turn away previously healthy individuals over age 65 for ICU-level care, as ICU and ventilator capacity has been far overwhelmed. I worry that this problem will only be compounded in our rural communities.

When rural physicians have patients requiring ICU-level care, we rely on transfer to centres with higher levels of care. In reality, COVID-19 means that it may be impossible to find an ICU bed available for transfer. If rural physicians cannot find a bed or ventilator for their critically ill patients, the devastating question may then become, “to intubate or not to intubate”?

This then leads to our next issue—moral injury. Physicians across the country may be faced with the same heartbreaking situation as our Italian counterparts.

To quote Wendy Dean, “moral injury occurs when we perpetrate, bear witness to or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first.”

Imagine this. You are working in a rural community in which you have lived for over a decade. You are working in the emergency department when your neighbor presents to care with severe dyspnea and cough which has been worsening over a week prior to acutely worsening this morning. Based on the history (and based on the pandemic!) you realize that your neighbor likely has COVID-19 and best practice requires intubation to reduce aerosolization and because respiratory failure is predicted. You get on the phone with the Patient Transfer Network to try to arrange transport to an ICU. PTN informs you that there are no available ICU beds anywhere in the country, let alone in the province. No one in your hospital has ICU-level training. You are faced with the devastating prospect of either intubating your neighbor and attempting to bag them for hours or days as you wait hopefully for the prospect of an opening bed, thereby taking limited resources (including yourself) away from other patients that will be requiring your attention, or telling your neighbor and their family that there is nothing further that you can do aside from supportive care and hoping for the best.

Even writing about this fictitious scenario breaks my heart. How can we, as human beings, bear the weight of such a decision and expect to escape unscathed? I don’t have an answer for this. COVID-19 is coming, and with it will come physical, emotional, and psychological exhaustion of our healthcare providers as they are faced with impossible tasks in the days to come.

Now, more than ever, we must come together to support each other and our communities during this time of uncertainty and hardship.

Do you have any suggestions about how rural physicians can cope with the challenges ahead of us? Any suggestions on how to better prepare clinics and emergency departments? Any words of wisdom or resources to share on how to cope with this unprecedented stress and its toll on our psychological wellbeing?

Please comment below to share – we are all in this together, and even some kind and encouraging words can go a long way.

Image source: www.coronavirus.maryland.gov

            You are invited to participate in a study about how your quality of life has been impacted by the COVID-19 pandemic. The study is called Clinicians' quality of life and moral injury during the COVID-19 pandemic (H20-01237).

We are asking you to participate in this 10-minute survey, and you may choose to be entered into a draw for one of five $100 Amazon gift cards.

Your email address was obtained by our research team by reaching out to key clinical and leadership figures at your health institution. We are also asking you to forward this survey to your spouse/partner (if applicable) to seek their participation. We also want their perspective of having a loved one work during the pandemic. We’re also hoping you can share this survey widely with your colleagues in medicine, nursing, physician assistants, respiratory therapists and paramedics at your institution. The link to the survey is below.

Thank you very much your participation in this survey, and assisting with this important study.

Sincerely,

David Barbic MD MSc FRCP(C)
Clinical Assistant Professor; Scientist
Department of Emergency Medicine; Centre for Health Evaluation Outcomes Sciences
University of British Columbia; St Paul’s Hospital
Vancouver, BC, Canada

https://ubc.ca1.qualtrics.com/jfe/form/SV_0ND4mEkktlmVAxv

There's emergency evidence that for patients who can be discharged home from the ED with COVID-19, we should be advising them to consider purchasing a home fingertip pulse oximeter to check their saturation BID or TID. Pulse oximetry has some limitations: too much motion, nail polish, etc, However it's a valuable tool to help keep our patients safe and get them to return to the ED if their saturation levels drop (<93%).

https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14053

Importantly, smartphone and smartwatch technology is too inaccurate at this time to recommend use, and not all pulse oximeters are created equal. Even if it's marketed as "FDA approved", doesn't mean it's accurate.

Two reliable fingertip pulse oximeters with ISO level accuracy and precision are the Contec CMS 50DL and the Beijing Choice C20.

https://pubmed.ncbi.nlm.nih.gov/27089002/

Researchers at Washington University in St Louis analyzed 154 000 Veterans Affairs (generally whiter and 90% male, median age ~63) patients who survived Covid in 2020, and compared them to 2 cohorts of nearly 11 million patients.

The 1-year rate of excess major cardiovascular events (acute coronary syndrome, stroke, heart failure, cardiac arrest, atrial fibrillation) was 45 per 1000 patients. Over this short time frame, it appears as though Covid-19 is a major independent new risk factor for cardiovascular disease.

It is unclear whether the mechanism is direct myocyte damage, viral persistence, inflammatory response, thrombotic issues, vascular endothelial damage, or any other mechanism or combination thereof.

While this will need to be replicated in other groups, over different time frames, and with vaccinated patients, it may be reasonable to inquire about prior Covid infection when assessing patients for potential cardiovascular concerns.

READ FULL ARTICLE

What do you think of these findings?

Best, Frank.

In the spring of 2020 Interior health advised that CPR was an AGMP and that PPE + N95 masks were required before CPR could be started.  This from an April 2020 update.

https://www.interiorhealth.ca/YourEnvironment/CommunicableDiseaseControl/covid19/IH-PH-COV-368%20Memo_Code%20Blue%20Response%20Principles_08Apr2020.pdf

This is also confirmed by the BCCDCs protocol

http://www.bccdc.ca/Health-Info-Site/Documents/COVID_Adult_CPR_Protocol.pdf

however looking at the Canadian  Heart and Stroke foundation guideline for CPR:

https://na94.salesforce.com/sfc/p/#A0000000BYzI/a/2K000000Uwfs/WVEuMt5NrCJiwkMIQovXBzyXpoxH1VKIsMuyYZFkJoc

for health care providers if you suspect COVID then of course don PPE/N95, but what about in the community or on the street if you do not know the risk/ COVID status of the person?  do you start CPR?