The Tip of the Spear: Emergency Medicine and Missouri’s Response to the COVID-19 Pandemic

Abstract

The COVID-19 pandemic provided the specialty of emergency medicine the opportunity to showcase what many knew all along: emergency physicians (EP) are well suited to deal with the unknown and can quickly adapt even with incomplete or limited information and resources. Emergency physicians in Missouri served in integral positions locally, nationally and internationally. Missouri EPs published numerous manuscripts on topics from basic science to clinical care. Device innovation also occurred with the development of protective devices for health care workers.

As we approach the three-year mark of the COVID-19 pandemic, the burden of clinical care still weighs heavily on EPs. Each wave of the pandemic has brought challenges and spurred EPs to innovate in new ways. As Michigan EP Brian Zink, MD once said “Anyone, Anything, Anytime”. These words correctly sum up emergency medicine. When others hesitated to care for COVID-19 patients, EPs stepped up despite uncertainty and risks to their own health. Emergency medicine has led the way and continues to innovate and push the envelope of emergency care.

Introduction

Each wave of the COVID-19 pandemic has and continues to present unique challenges. During the first wave in early 2020, uncertainty about an easily transmissible novel coronavirus combined with supply chain issues limiting access to personal protective equipment were significant obstacles to overcome. Innovation focused on synthesizing rapidly evolving data and creating solutions to safely manage patients with COVID-19 while protecting health care professionals.

The second wave in the summer of 2020 was marked by a lack of intensive care unit (ICU) beds to care for critically-ill COVID-19 and other patients. This scarcity magnified the sadly familiar concept of boarding patients in the Emergency Department (ED), a practice well-associated with increased morbidity and mortality. Up to the task and despite long and difficult days, EPs contributed some of the early research describing how to diagnose and manage suspected COVID-19, borne out of necessity due to patients boarding in the ED for hours to days.^{1, 2} The critical shortages of hospital staff across the United States during a new wave of the pandemic at the end of 2021 again demonstrated the fragility of the healthcare system. Once more, EPs adapted and overcame multiple barriers associated with limited resources.³ Lack of adequate COVID-19 testing capacity nationwide further compounded healthcare system issues such as staffing shortages. This led many mildly ill or asymptomatic but exposed patients to seek COVID-19 testing in EDs, further stretching an overcrowded system. Situated on the frontlines of healthcare, EPs have made invaluable contributions to COVID-19 pandemic response worldwide.

The specialty of emergency medicine has played a pivotal role in Missouri throughout the course of the pandemic. There are over 600 board-certified EPs in the state of Missouri. This number does not include the almost 200 EM residents who train at five sites across the state (Columbia, Joplin, Kansas City, and two in St. Louis). Emergency physicians not only serve as frontline clinicians within EDs but as emergency medical services directors, guiding urban and rural prehospital care throughout the state. Many of Missouri’s EPs are also national and international leaders in innovation, research and information dissemination.

Electronic Resources/Information Dissemination

Rapid communication to all health care personnel caring for COVID-19 patients was essential. In the early part of the pandemic, rarely did a day pass without the release of a new publication about COVID-19 transmission, management, or prognosis. In an unprecedented move, many non-peer reviewed or preliminary studies were uploaded to preprint repositories such as medRxiv.org in order for those on the frontlines to access the latest data. Unfortunately, lack of peer review opened opportunities for poorly designed studies with inaccurate conclusions to garner attention, leading to the dissemination of incorrect information that challenged the precepts of evidence-based medicine. Worse, this information was frequently discussed and further disseminated by news organizations.⁴

Early on, the American College of Emergency Physicians (ACEP) stepped up to help provide clinicians with guidelines to summarize and interpret the enormous amount of rapidly changing data. The ACEP COVID-19 Field Guide was released electronically in the spring of 2020. Harnessing the knowledge of its membership, this seventeen-chapter guide provided extensive information on the diagnosis and treatment of COVID-19 in both prehospital and ED settings [https://www.acep.org/corona/covid-19-field-guide/cover-page] Missouri emergency physicians authored chapters in the guide. This living on-line document was updated continuously through the summer of 2021. Contents were comprehensive and thoroughly vetted, including recommendations on home safety when returning from work, vaccinations, treatment, and personal well-being. As of February 2022, the ACEP COVID-19 Field Guide has received over 200,000 page views from over 60,000 unique visitors and is referenced by over 180 agencies. Not content to stop there, ACEP partnered with EvidenceCare to create the COVID-19 ED Management Tool⁵ (Figure 1)[https://www.acep.org/corona/COVID-19-alert/covid-19-articles/covid-19-ED-management-tool-now-available]. Missouri EPs, Christopher Sampson, MD and Christopher Carpenter, MD, MSC, participated in this work as part of a national coalition of expert physicians including representation from the NIH and Department of Veteran Affairs. This management tool provides an easy-to-use electronic algorithm to guide the diagnostic, prognostic, pharmacologic, and non-pharmacologic management approach to COVID-19 patients presenting to the ED stratified by disease severity and is updated monthly.

Figure 1.

Part of the American Colleges of Emergency Medicine/EvidenceCare Emergency Department Covid-19 Management Tool

In February 2022, Missouri EPs Phillip Mudd, MD, PhD, and Dr. Carpenter led the Society for Academic Emergency Medicine COVID-19 Education Task Force in the creation of the COVID-19 Provider Toolkit [https://www.saem.org/education/saem-online-academic-resources/covid-19-provider-toolkit] in response to the need for resources to guide conversations with ED patients about vaccination concerns, facemasks, and emerging COVID-19 therapeutics. This resource was made available by an unrestricted grant from GlaxoSmithKline and included both patient-facing and physician-facing videos, handouts, and hyperlinks for additional information available in English, Spanish, and German.

COVID-19 Extension for Community Healthcare Outcomes (ECHO) is another resource that has been made available to clinicians across Missouri [https://showmeecho.org/clinics/covid-19]. Breaking the mold, COVID-19 ECHO provides a video conferencing solution to link health care professionals across the state disseminating best practice learning through case based discussions. The expert hub panel consists of specialists (Infectious Disease, Community Health, Emergency Medicine) from all areas of the state. Since its inception in spring of 2020, the weekly video conference has seen over 100 attendees each session.

Barrier Devices

Given the early uncertainty regarding both mode and ease of transmission of SARS-CoV-2 to healthcare personnel and whether the virus could be aerosolized during emergency care, EM innovators began to work immediately on solutions to provide patient care safely. With many patients arriving in severe respiratory distress, endotracheal intubation was frequently performed early on. Considered an aerosol-generating procedure, ideas for use of barrier enclosures during endotracheal intubation surfaced quickly in an effort to protect healthcare personnel, some receiving publication.⁶ Cost was a concern with some devices produced at manufacturing sites closed down in the early phase of lockdown.

In Missouri, EP Adam Beckett, DO, created a low-cost barrier device easily adapted to prehospital and hospital settings.^7,8 Using readily-available supplies such as PVC pipes and auto warp, he created a box that could be placed over patients to contain aerosols generated during airway management and hopefully mitigate viral transmission in the ED. In Branson, Missouri, EPs led by Richard Blubaugh, DO created a barrier device, the SafER [https://safermedicalproducts.com] portable negative-pressure system, that could suction away exhaled respiratory aerosols, preventing their release into the healthcare environment (Figure 2).

Figure 2.

SafER Portable Negative Pressure System

Other innovations included reconfiguring pre-existing areas within the ED to provide COVID-19 care. One innovation used the hospital decontamination room as a COVID-19 cardiac arrest management area.⁹ Potentially infectious patients entered the ED decontamination room using an outside door; following treatment, the room could be rapidly disinfected. Given visitor limitations during the pandemic, this innovation also enabled family to remain close to their loved one during cardiopulmonary resuscitation.

Missouri EPs’ COVID-19 Original Research

The COVID-19 pandemic has led to a fountain of research from Missouri EM researchers, spanning from basic sciences to clinical care. A Missouri EP was part of a workgroup that reviewed the evidence and authored an Infectious Diseases Society of America guideline discussing health care personnel infection prevention.¹⁰ Clinical research by Missouri EPs have addressed stroke care and barriers to care among patients who inject drugs during the pandemic.^11,12 In addition, Missouri EPs provided some of the earliest evidence-based guidance around the diagnosis of COVID-19 based on history, physical examination, laboratory testing, and imaging along with a proposal for an acceptable criterion standard for COVID-19.² Missouri EPs also participated in a registry of 116 hospitals across 25 states to derive and validate a clinical prediction rule to diagnose COVID-19 using clinical data while awaiting confirmatory laboratory results.¹³ In addition, Missouri EPs with expertise in geriatric emergency medicine synthesized best practices for the management of COVID-19 in older adults, including two consensus conferences funded by the National Institute of Aging through the Geriatric Emergency Care Applied Research Network [https://gearnetwork.org/] as well as a series of webinars via the Geriatric Emergency Department Collaborative [https://gedcollaborative.com/].^14,15 Amidst the stresses of inadequate personal protective equipment supplies coupled with vaccine uncertainty, healthcare personnel wellness was also prioritized.¹⁶ Given early concerns regarding the transmissibility of SARS-CoV-2, clinical research by Missouri EPs also addressed personal protective equipment as well as its disinfection and reuse given limited supplies.^{17, 18}

Basic science manuscripts from Missouri EPs covered such diverse topics as pathogenesis, host immune response, kidney physiology, and biomarkers for disease severity and prognosis in COVID-19.^19–29 Other Missouri researchers evaluated potential therapeutics for COVID-19 including interleukin-6 receptor blockers and caspase inhibitors as well as factors differentiating COVID-19 from influenza.^{23, 30–34}

The rapid pace of COVID-19 research during the pandemic created demand for trustworthy evidence reviews and the implications for patients and clinicians.³⁵ One such resource was Brief-19 [www.brief19.com]. For more than a year, this website provided daily updates of COVID-19-related research and policy from EPs on the frontlines. Led by EP Jeremy Faust, MD, MS, of Harvard Medical School, the writing team included multiple Missouri EPs and a future Missouri EM resident. Under the leadership of Deputy Editor and Missouri EP Dr. Christopher Carpenter, Academic Emergency Medicine aggregated all articles published on COVID-19 by the journal in a readily-accessible web resource to streamline access for key stakeholders.³⁶

Summary

As Missouri approaches the three-year mark of the COVID-19 pandemic, the burden of clinical care still weighs heavily on EPs. Each wave of the pandemic has presented challenges and spurred EPs to innovate. Michigan EP Dr. Brian Zink’s words, “Anyone, Anything, Anytime,” continue to capture the essence of emergency medicine. When others hesitated to care for COVID-19 patients, EPs stepped up despite great uncertainty and risk to their own health. Emergency medicine has not only contributed around-the-clock clinical care during the pandemic, but also led research designed to contain, manage, and ultimately overcome the era of COVID-19.