key: cord-0701006-z8k4xp03
authors: Bart, Nicole K.; Kearney, Katherine; Macdonald, Peter S.
title: Put on your own oxygen mask before helping others: mitigating healthcare worker risk from COVID‐19
date: 2020-07-12
journal: Intern Med J
DOI: 10.1111/imj.14897
sha: 27d4d550b9e709cbaa99a98f5aa3b8a5b1c7761f
doc_id: 701006
cord_uid: z8k4xp03

nan

As doctors, we have dealt with emergencies our entire careers. Every year during our training, we step out of our comfort zone and into new clinical challenges. It is not unusual to feel daunted or scared. In every single resuscitation attempt, advanced life support follows the same steps. We are trained that regardless of the situation, you fall back on your algorithms, and for a critical patient that means: airway, breathing, circulation and disability. We assess and reassess until the patient is better. We excel in an emergency because we respond with a calm demeanour that develops with years of training, dealing with the lesser known, and a drive for life-long learning.

We understand and can respond to an emergency, but there is no 'emergency' in a pandemic. In a pandemic, it is almost impossible to avoid completely the 'danger' in danger, response, send for help, airway, breathing, circulation, defibrillation (DRS ABCD) by virtue of the highly infectious nature of the disease. Although our training and skills will be vital in the coming months, what will prove more important will be taking the time to assess and mitigate risk.

In December 2019, a novel coronavirus was identified in Wuhan, China. 1 It was found to replicate in the upper respiratory tract with symptoms beginning on Days 5-10. By early 2020, the virus spread to 100 000 people in 100 countries, meeting the criteria for a global pandemic. According to the World Health Organization, cases are now 'accelerating', with over 4 million people infected worldwide by 11 May 2020.

Healthcare systems are struggling with the simple mathematics of supply and demand. Initial studies out of China suggest that 20% of the total infected will require medical care, with 14% having severe illness and 5% having critical illness. 2 Mortality is quoted at approximately 3% but is much higher in elderly and vulnerable populations. 3 The global health system is not equipped to manage the sheer volume of patients. Already in the United Kingdom, Italy, Iran and parts of the US triage systems have been enacted to inform decisions based on lack of resources. 4 With COVID-19 spreading exponentially and our hospital systems becoming inundated the risks to healthcare workers are also 'accelerating'. Healthcare workers have been casualties in this pandemic, where in Italy around 20% (n = 350) have contracted the virus and already 51 have died. 5, 6 Similarly, in China, up to 29% of the first COVID-19 infections were among healthcare workers. 7 With the increase in risk, there also appears to be a rationing of potentially life-saving equipment. In the United Kingdom, the protective gear of healthcare workers was downgraded. In the United States, doctors have been advised to wear a single mask for the duration of their shift and the gold-standard N95 masks have been abandoned apart from in front-line workers. The collective sense of duty is evidenced in the United Kingdom, where retired doctors have been conscripted despite being at higher risk of complications or even death from COVID-19.

We must learn quickly from the countries that have managed to mitigate risk for their healthcare workers. In Hong Kong, 8 Singapore and the second wave of doctors recruited in Wuhan the risk of transmission of COVID-19 to a healthcare worker is zero. 9 Danger mitigation strategies involved wearing masks at all times, meticulous hand washing, and disinfecting surfaces between patients. 8 Where possible separate teams and separate whole hospitals were used to prevent spread between COVID-19 positive and negative inpatients. That in some countries transmission to doctors is zero, while in others doctors are dying is a call to action.

In this pandemic, it is essential that we as a profession rely on our training, our ability to learn quickly and our calm communication skills. Yet before all of this, we have to remember the principles of basic first aid. First look for danger, and if the risk in a certain situation is unacceptable, mitigate the risk. Instead of relying on our innate reaction to self-sacrifice, we must elevate the importance of personal protection. More than ever, it is our clinical imperative to minimise danger to ourselves, and our colleagues in order to be well enough to look after our patients.

As a global society, there is a health incentive to look after clinicians, by ensuring adequate personal protective equipment and training, minimising community COVID-19 and asymptomatic carriers within the hospital setting and having a global response that minimises An urgent call to clinicians and researchers: 2020 acuity required when assessing and reporting laboratory abnormalities in COVID-19

The current outbreak of coronavirus 2019 (COVID-19) calls for actionable information to be published as soon as possible in the interest of public health. There is a surge in literature reviews and meta-analyses summarising the roles of routine laboratory markers in assessing disease severity and guiding treatment in COVID-19. A closer look at the literature reveals some shortcomings in the reporting and interpretation of laboratory results.

When discussing the management of liver injury in COVID-19, Zhang et al. provided a summary of patients with abnormal liver aminotransferases from several recent studies and discussed several possible mechanisms for liver injury. 1 Bangash et al. later reminded readers of the significance of the liver abnormalities reported in these studies, that, although the prevalence of elevated aminotransferases and bilirubin in patients faring worst was at least double that of others, clinically significant liver injury is uncommon (even when most severely ill patients are selected). 2 In addition, Bangash et al. noted that several studies have reported elevated levels of creatine kinase and lactate dehydrogenase or myoglobin.

Aminotransferase elevations do not necessarily arise from liver alone; COVID-19 infection might induce a myositis similar to that observed in severe influenza infections. 2 As study authors compare the significance of laboratory marker results between intensive care unit (ICU) and non-ICU groups, severe and less severe disease groups, or survivors and non-survivors, in addition to assessment of statistical significance of a marker between the two groups, the biological (and analytical) variation of the marker should be considered as well as the biological significance of the value difference.

A meta-analysis of four studies on the role of procalcitonin in patients with severe COVID-19 shows that increased procalcitonin values (above the normal reference limit) are associated with nearly fivefold higher risk of severe SARS-CoV-2 infection (odds ratio (OR), 4.76; 95% confidence interval (CI), 2.74-8.29). 3 A closer look at these four papers found that while Huang et al. used a reference limit of <0.1 ng/mL as normal, Guan et al. and Wang et al. used a different decision limit of ≥0.5 ng/mL as abnormal and Zhang et al. used a reference interval of 0-0.1 ng/mL. [4] [5] [6] [7] It would be more informative to know the analytical methods used and, provided there is no significant between-method biases, to consider a common reference interval; alternatively, the degree of

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention

Casefatality rate and characteristics of patients dying in relation to COVID-19 in Italy

Fair allocation of scarce medical resources in the time of Covid-19

COVID-19 and Italy: what next?

Elenco dei Medici caduti nel corso dell'epidemia di Covid-19. FNOMCeO

Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China

Escalating infection control response to the rapidly evolving epidemiology of the coronavirus disease 2019 (COVID-19) due to SARS-CoV-2 in Hong Kong

Keeping the coronavirus from infecting health care workers. The New Yorker 21