Advanced Journal of Emergency medicine
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Ethical Issues in Responding to the COVID-19 Pandemic; A Narrative Review
Get PDFAt present, the biggest challenge to health and economic systems around the world is the emergence of COVID-19 pandemic. Several ethical questions have been raised at the macro-, meso- and micro-levels with respect to proper management and control of this pandemic. The most important factor in creating fear and public anxiety and disturbances of social functions is the fatalities caused by the epidemic by an unknown pathogen in most countries. Decisions for epidemic control measures are made among many uncertainties, and prioritize public health over individual rights. People's trust and compliance with recommendations play a decisive role in public actions. Therefore, during an epidemic, necessities such as adherence to the values of honesty, respect, human dignity, solidarity, justice, reciprocity, transparency, and responsiveness in the response system need to be considered. The major ethical considerations in macro and micro levels of decision-making responding to the COVID-19 will be reviewed in this paper. Ethical dilemmas arise in different domains of a pandemic such as restriction on freedom of movement, individual’s refusal of preventive or therapeutic interventions, health care workers’ rights and duty to care, the allocation of scarce resources, off-label use of diagnostic and therapeutic measures and research. The purpose of this article is to pay attention to ethical principles in solving these challenges and does not necessarily respond to all ethical problems; however, it draws the reader's attention and moral sensitivity to the issues raised in this area
Bracing the Emergency Department for the COVID-19 Era
Get PDFThe COVID-19 pandemic in a matter of few months has wreaked havoc across the globe. However as per the WHO, the worst may not be over yet and COVID-19 is going to stay with us for a long time. The coronavirus is highly contagious, and in the current scenario containment measures in the form of lockdowns and curfew may only be useful in transiently flattening the curve and not disease elimination. The absence of an effective vaccine and/or treatment, means that morbidity and mortality associated with COVID-19 is going to increase in the foreseeable future. For the emergency physicians (EPs) working on the frontlines, the battle may have just begun. Any patient coming to emergency room (ER), with COVID-19 related symptoms or otherwise, could be a potential source for the spread of coronavirus infection in the hospital. With most of the ER’s being overcrowded, the place itself will act as amplifier which could lead to a catastrophe. Ever since the beginning of this pandemic, our focus has completely shifted to only COVID-19 related symptoms which is proving detrimental for the other non-COVID emergencies. We hereby put forth certain possible solutions which may be useful for the smooth functioning of our emergency departments (EDs)
Six min Walk Test as a Criterion for going to the Hospital in Suspected COVID-19 Patients; Is it Practical, Safe and Scientifically Justified?
Get PDFThe current outbreak of the novel coronavirus SARS‐CoV‐2 (COVID-19) has rapidly spread worldwide, which greatly endangers the global health and economy. Due to vast limitations in hospital resources, some countries have encountered serious problems for fair access to hospital beds. An interesting letter in this journal recommended 6-minute walk test (6MWT) as a proper clinical test to determine the necessity for going to the hospital in patients with suspected COVID-19. 6MWT is a field exercise test in which, patient should walk for 6 minutes as far as possible. It is usually used to compare pre- and post-treatment conditions in many pulmonary and cardiac disorders or to estimate functional status of individuals with some pulmonary and cardiovascular diseases. This test may be applied as a predictor of morbidity and mortality in these patients. Although the idea of finding an applicable and feasible clinical test to do at home is valuable by itself, but in our opinion, there are great concerns to use 6MWT for this purpose. Here, we will discuss about some serious concerns about the practical, judicious and scientifically justified use of this test in patients with suspected COVID-19
Fighting COVID-19: What Are the Available Options?
Get PDFSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the novel coronavirus, and its infection, coronavirus disease 2019 (COVID-19), have quickly become a worldwide threat. It is essential for clinicians to learn about this pandemic to manage patients. Among different aspects of the condition, is the treatment of this disease. Unfortunately, currently there is no effective treatment option that can be supported by evidence-based medicine. This review analyzes information from literature on treatments
A Letter on “Induced Demand after Implementing the Health Reform Plan in Selected Emergency Departments Affiliated to Isfahan University of Medical Sciences: a Cross-Sectional Study”
No full textDear Editor in Chief
Advanced Journal of Emergency Medicine
I am writing you to point to an error in the article written by Shahverdi et al. entitled "Induced Demand after Implementing the Health Reform Plan in Selected Emergency Departments Affiliated to Isfahan University of Medical Sciences: a Cross-Sectional Study", which was published in your Journal.
Variables have been proposed to increase the chance of induced demand on both patient and supplier (physicians, service providers and etc.) parts. For example, on the supply-side: "physicians' income, physician/population ratio, price of services, payment methods, consultation time per visit or service, type and size of hospital, and etc." and on the demand-side "patients' insurance coverage and etc.". The study aimed to assess the induced demand after implementing the health reform plan (HRP) in the selected emergency departments, but the findings focus on calculating the percentage of changes in services provided before and after HRP; and it has not been shown that the studied factors have led to induced demand. So, the calculated increases might be due to uncertainty. Furthermore, based on the statistics presented in table1, there is an increase of about 65% in radiographic images, from 0.02 (in 2012-13) to 0.33 (in 2015-2016) image/person, and the mean difference is 0.13. It seems that, there is a miscalculation. The mean difference should be 0.013, and so the increased amount will be 0.033
Sex Differences in Risk Factors Profile and Angiographic Pattern of the Patients Undergoing Coronary Angiography
Get PDFIntroduction: Coronary artery disease (CAD) is a costly problem and its presentations and risk factors may differ by sex. Objective: This study aimed to evaluate the risk factors profile and angiographic pattern of the patients undergoing coronary angiography, according to their gender. Methods: This cross-sectional study was conducted on 741 patients who were referred for coronary angiography from March to August 2018 at Imam Ali cardiovascular center, western Iran. Using a checklist, we collected the demographic, clinical, biochemical, and lab parameters and angiographic findings in these patients. Also, differences between groups were compared using Chi-square and independent t-tests. Results: Women were different from men in terms of the prevalence of hypertension (71.7% vs. 45.3%), diabetes mellitus (34.9% vs. 17.8%), and hypercholesterolemia (26.4% vs. 17.1%). Whereas, men were more likely to be smoker (28.7% vs. 0%) and obese (42.09±16.68 vs. 29.12±4.72). Total Cholesterol and Triglycerides were higher in women compared to men, which were statistically significant. Glucose plasma was significantly higher in women compared to men (p=0.01). Both atherogenic (low-density lipoprotein (LDL)) and protective (high-density lipoprotein (HDL)) cholesterol were higher in women than men. Women were more likely to take antiplatelet (i.e. Aspirin) and antihypertensive therapies (i.e. beta-Blocker, angiotensin receptor blockers (ARBs), and angiotensin converting enzyme (ACE) inhibitors) than men. Also, it was shown that, Men were more likely to have two-vessel disease (p=0.041) and three-vessel disease (P=0.013) compared to women. Disease in the right coronary artery (RCA) (28.9% vs. 14.4%), circumflex (LCx) (26.0% vs. 15.3%), and left anterior descending (LAD) (37.8% vs. 26.4%) was more plausible to occur in men compared to women (p≤0.05). Conclusion: Access and use of health care programs are needed to control CAD risk factors. The findings of the current study showed the significance of gender in the extent of coronary artery blockages
Factors Affecting Emergency Medical Technicians’ On-Scene Decision-Making in Emergency Situations: A Qualitative Study
Get PDFIntroduction: To save lives and reduce the disability and death of the patients, emergency medical technicians (EMTs) must make timely decisions in complex and, sometimes, life-threatening situations. Since the pre-hospital decision-making is a continuous and important process. Objective: The present study aims to identify the factors affecting EMTs’ on-scene decision-making in emergency situations. Methods: A qualitative approach using in-depth semi-structured interviews and field observations was employed to explore the factors influencing EMTs’ on-scene decision-making in emergency situations. Purposeful sampling was performed with 19 participants including 12 EMTs, 3 dispatchers, 3 medical directions physicians and one EMS manager as a policy maker. Interviews were conducted from October 2018 to March 2018 and the data were analyzed using Graneheim and Lundman’s content analysis approach. Results: Eight categories and 18 sub-categories emerged to describe the factors effective in emergency medical technicians’ on-scene decision-making. they were cultural context (community’s culture and organizational culture), interactions (malingering, threat and violence and considerations), competencies (acquisitive and intrinsic); personal feeling (positive feeling and negative feeling), authority (structural and in processing), education (public and professional), special conditions (patient’s clinical situation, weather conditions, mission’s time and mission’s location), and organizational resource (facility and equipment, and human resources). Conclusions: To facilitate EMTs’ on-scene decision-making, it is recommended to clarify the EMTs’ responsibilities, promote the community’s culture, modify people’s expectations, police monitoring and control and value the star of logo on EMTs' uniform. The EMTs’ on-scene decision-making process should also be explored
Corticosteroids Administration Following COVID-19-induced Acute Respiratory Distress Syndrome. Is it harmful or Life-saving?
Get PDFUntil now, April 22, 2020, Covid-19 has been confirmed in 2471136 patients and 203 countries and territories with mortality rate over 169000 patients. Right now, there is no definite cure for it and developing treatments including vaccines and antiviral compounds are under evaluations for efficacy. Covid-19 infection can be mild, severe, or even critical. The symptoms may range from fever (the most common symptom), chills, fatigue and cough to decreased arterial oxygen saturation, changes in respiratory rate and dyspnea. The dyspnea in critically patients is more severe. In severe cases, respiratory failure, acute respiratory distress syndrome (ARDS) and septic shock have been reported. Septic shock is also associated with hypoxia and acidosis. ARDS is the most important cause of death in this group of patients. This feature of the disease may be caused by various factors, including inflammatory mediators and cytokine storm. The computed tomography (CT) imaging findings have shown that the lung with ARDS has a ground-glass appearance, in which white fluid-filled patches are seen inside the lung. The fluid inside these patches has a jelly state. Pathological samples obtained from lung tissue also indicate pulmonary damage, obvious destruction of pneumocytes and formation of a hyaluronan membrane, which more emphasized on ARDS occurrence. Cytokine storm caused by Covid-19 infection is a severe immune response. The occurrence of cytokine storm can lead to severe tissue damages. Pre-inflammatory factors are involved in this process and one of them is interleukin 6 (IL-6) which affects different cells. IL-6 performs various functions such as regulating body temperature, increasing the production of acute phase protein and differentiation of B cells. On the other hand, the production of interleukin 1 (IL-1) as an inflammatory mediator will be increased during cytokine storm, as well. IL-1 can cause fever and stimulating the production of hyaluronan which has been seen in fibrosis. Based on studies on SARS-CoV, rapid spread and proliferation of the virus as a result of delayed interferon-1 production and subsequent rapid accumulation of macrophages and monocytes may also be involved in tissue destructions and a similar mechanism might be seen in Covid-19 infection. When there is no proper immune system response, the virus causes extensive tissue damages, especially to organs where ACE2 is most commonly seen, such as the lungs. Therefore, since the lungs are damaged, efforts should be focused on suppressing the inflammation, managing the symptoms and theoretically any compounds that may help this inflammation subside could play an important role in reducing the incidence of ARDS and consequently the mortality rate. The use of corticosteroids in different phases of ARDS has been inconsistent with conflicting results. Corticosteroids exert their anti-inflammatory effects by regulating the signaling pathways on the membrane and inside the cells, stopping pre-inflammatory gene-related processes (genes responsible for producing pre-inflammatory factors). Furthermore, they are able to increase the production of anti-inflammatory mediators such as interleukin 10 (IL-10). Corticosteroids have been investigated in some clinical protocols for evaluation of their effectiveness in reducing inflammatory responses and cytokine storm. According to the guideline of World Health Organization (WHO), systemic corticosteroids should not be routinely used in viral pneumonia except in clinical trials. However, WHO has recommended that these compounds can be used in exacerbations of asthma and COPD, and septic shock, considering each patient's condition and assessing the benefits and risks. This guideline further states that the use of corticosteroids in similar conditions such as influenza may lead to secondary super infections and increase mortality rate. But in another study on SARS-CoV, the use of corticosteroids was associated with improvement in time to survival in severe patients and decrease in mortality rate. Delayed viral clearance is another concern. In a study on patients with MERS-CoV, the use of corticosteroids did not make a significant difference in mortality rate. However, its association with a delay in viral clearance from the lungs of patients was reported. Side effects are another limiting factors for use of corticosteroids in patients with Covid-19. A similar study in patients with SARS-CoV showed that use of higher doses of corticosteroids in such conditions could cause a corticosteroid-induced diabetes, with 36.3% of patients experiencing such complication. The guideline of Surviving Sepsis Campaign for the management of patients with Covid-19 has recommended the use of corticosteroids under the following conditions: 1) in patients with Covid-19 who are suffering from septic shock, the use of corticosteroids (low-dose) are preferred over not using it. The guideline notes that there is no difference in mortality rate and side effects. However, there is weak recommendation that using corticosteroids in these conditions can reduce the time of resolution of shock and ICU and hospital length of staying; 2) In cytokine storm, if the patient has not yet developed ARDS, corticosteroids are recommended in ways other than routine procedures, and if ARDS occurred, the use of these compounds is recommended over not using them. Lesser need of oxygen, improved radiographic findings and reduced length of staying in ICU and hospital are some of the advantages that this guideline has referred to. However, there is just a week recommendation over the use of these compounds in this guideline. Based on what has been discussed, it could be concluded that the use of corticosteroids in the current situation should be limited, since there are no significant benefits over their effectiveness. On the other hand, there is a risk in prolongation of viral clearance and secondary infections and mortality rate. The use of these compounds should be limited to clinical trials to further evaluate their effectiveness in this new found disease. The clinical conditions of patients should be carefully evaluated throughout the studies and close monitoring should be performed while discontinuing these drugs
Why COVID-19?
Get PDFCOVID-19 is a highly contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an enveloped positive stranded RNA virus and the third member of the family Coronaviridae which has emerged as a zoonotic infection. The predecessor of this new pathogen caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle East Respiratory Syndrome (MERS) in 2012. Although corona viruses have been known since 1960’s, their familiar species were human pathogens and caused common cold and seasonal flu. SARS-CoV-2 is easily transmitted via respiratory secretions of an infected person, with a reproductive number (the average number of cases to which a single infected person will transmit the virus) of 1.4-2.5. Covid-19 has been estimated to have a case fatality rate of around 3%. As of today, asymptomatic transmission is assumed to be possible during the incubation period, which usually ranges from 2-14 days. The source of infection, animal host, and reservoir are currently unknown. In late December 2019, an outbreak of COVID-19 was reported from Wuhan city, China. The disease soon spread outside China borders and became rapidly prevalent all around the world. The pandemic announcement was officially made by World Health Organization (WHO) on 11 March 2020. Today COVID-19 has affected more than 212 countries and has made billions of people to be quarantined in their houses. Up to now, almost 1500000 confirmed cases of COVID-19 have been reported globally and the death toll has been declared to be 86000. In Iran, we are also facing this unprecedented global public health emergency, with about 65000 confirmed cases and 3993 deaths. This pandemic is beyond an expanding contagious disease and has influenced different features of life. Its enormous social, political, and specifically economic impacts all around the world are undeniable. In low- and middle-income countries this can potentially lead to a huge spike in poverty and collapse. Many vulnerable families have lost their income and access to the essential needs. Education systems have collapsed in many regions. The long-term effect of this global crisis has reduced economic growth even in developed countries. Economic effects of COVID-19 are estimated with dramatic variations. Orlik et al in Bloomberg hypothesized this cost to be $2.7 trillion. The political consequences are even harder to predict but quite significant and devastating, like the heated discussion, criticism and accusation flowing between the leaders of different countries. Since the pandemic is not yet over, the global influence will carry on to happen and make situation even more complicated. While the outbreak is evolving rapidly, health care systems across the world are actively fighting against the new virus. They have encountered many new challenges. Public health measures (such as active case finding, prompt isolation of cases and contacts tracing) to contain the spread of the disease in the society as well as provision of care for the unpredictably high number of people who are infected with the virus have stretched the healthcare system beyond its capacity. At the same time, protecting health care providers’ safety, which often requires provision of sufficient supplies of personal protective equipment, has definitely challenged the system. Societal demand for discovery of a definitive treatment and vaccine has also added to the complexity of the situation that the health care systems are facing. Studies about COVID-19 are increasingly being performed and published; many of them have not yet been fully reviewed and criticized by the academic community. Practitioners often find it difficult to find, appraise and apply the information they need amid the turbulence of their clinical practice. Furthermore, there are still many questions to be answered. The most efficient method for personal protection, methods of viral transmission, most accurate diagnostic approaches, and effective treatment options are yet to be determined. This special issue of the Advanced Journal of Emergency Medicine plans to specifically focus on COVID-19 by gathering the relevant scientific information available. We hope that by publishing high quality papers, this journal can provide its readers with further required information. Appropriate management of patients suffering COVID-19 as well as controlling this pandemic are our ultimate aspirations. We encourage further researches in this field by all scientists and physicians all across the world to be able to eradicate COVID-19 as soon as possible
Generalist versus Abdominal Subspecialist Radiologist Interpretations of Abdominopelvic Computed Tomography Performed on Patients with Abdominal Pain and its Impact on the Therapeutic Approach
Get PDFIntroduction: Abdominal pain is one of the most common patient complaints in the emergency department (ED) and abdominopelvic computed tomography (ACT) scan plays an important role in evaluation of these patients. Objective: The aim of this study was to determine the differences between interpretations by generalist radiologists and abdominal subspecialist radiologists regarding the abdominopelvic computed tomography (ACT) of patients who were admitted to the Emergency Department (ED) and to investigate its effect on the patients’ therapeutic approach. Methods: The records of 16452 patients who were admitted to the emergency department with complaint of abdominal pain between January 2015 and April 2017 were reviewed, retrospectively. Out of these patients, 245 (1.5%) underwent ACT for differential diagnosis and among them, 137 (0.8%) patients had their ACT reports evaluated by generalist radiologists in 45 minutes and by abdominal subspecialist radiologist 8–12 hours later and were included in the study. Patients were divided into three groups according to the effect of ACT reports on the performed treatment. Group 1: no effect on planned treatment, group 2: minor effect on planned treatment, which did not result in a change in the treatment process and group 3: major effect on planned treatment approach, which resulted in a change in the treatment process. These changes included at least one of the two criteria: changing the indication of surgery from emergency surgery to elective surgery and/or discharge of the patient from the ED, when actually hospitalization was required. Results: Out of the 137 patients, 87 (63.5%) were male, 50 (36.5%) were female and the patients’ mean age was 56 (27-93) years. There were 117 (85.4%) patients in group 1, 15 (10.9%) patients in group 2, and 5 (3.7%) patients in group 3. We determined minor inconsistency between the reports in group 2 and major inconsistency in group 3. Patients in group 3 suffered from delayed surgical intervention due to inconsistency of the CT reports resulting in prolonged hospital stay and increased morbidity. In 17 patients (four patients in Group 1 and 13 patients in Group 2) treatment plan was changed due to CT results; and while surgical treatment was planned for them prior to CT scan, they were discharged with medical treatment after that and overtreatment was prevented. Conclusion: Contribution of abdominal radiologists to evaluation of ACT images in the ED would reduce the inconsistency in ACT reports and prevent the patients from receiving insufficient treatment or overtreatment