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

The debate: "...have we reached a point where the readily available tests and scores in the ED provide “definitive” testing for most patients with chest pain, allowing final safe discharge? Does “Trop and go” provide a safe approach to those who have other negative tests in the ED, or might we be missing critical cardiac disease in this patient cohort?"

From a BC approach, we argue that a negative troponin result does NOT rule out serious coronary disease in all patients and propose the following strategy:

"Unstable patients, or those with an ischemic ECG, clear history of accelerating angina, or positive hs-cTn will warrant urgent referral. Those at clinically very low risk (younger with no cardiac risk factors) will benefit from rapid discharge and minimal specialty follow-up after a single normal ECG and negative hs-cTn.

However, the cohort of patients who do not fit into either category, including those with atypical or changing pain, an uncertain history including communication barriers, baseline ECG abnormalities, or mild hs-cTn elevations, may benefit from additional testing. In this group, patient goals and expectations, along with anticipated risks and benefits of testing, should be carefully clarified in an individualized manner."

Do you agree? How do you investigate suspected ACS in the high-sensitivity troponin era? What sort of follow-up barriers do you and your patients face?

Read the full debate.

https://cdn.nejm.org/pdf/Notable-Articles-of-2019.pdf

I work as part of an interdisciplinary team of family physicians and nurse practitioners delivering outreach primary care in rural and remote settings. Many of the communities we provide service to are at least 45 min from the closest rural hospital. There are no ALS paramedics.

I am looking to assemble a basic emergency kit to equip our providers with medications that can address immediate life threats. Medications I am considering include epinephrine, salbutamol, naloxone, glucose tab, ASA, nitro spray, dexamethasone, and TXA.

There are some additional medications that may be helpful to consider in this setting but warrant more consideration as they are restricted.

One example would be intramuscular midazolam for status epilepticus. Two examples of medication that have less life-saving implications but can be tremendously useful to facilitate transport are morphine and ketamine. All three medications are part of the B.C. EHS formulary. If used, these medications would be supplied by our standard pharmacy supplier, stored in locked Pelican cases, carried by the provider, and logged.

I am wondering what people’s thoughts are the stocking and use of these medications in a prehospital rural outreach setting by primary care providers.

- Are there medications you don’t think should be part of the list above?

- are there ones you would add

- what regulatory steps need to be taken to facilitate this

Thank you for your input,

James