COVID-19; Reflecting on a Globalized Response

COVID-19; Reflecting on a Globalized Response

As I write this is, it has been 200 days since the first reports in China came out regarding an unspecified viral illness in Wuhan, China. What is now the pandemic of COVID-19 has spread around the world, and in history books and our collective memory, the year 2020 will forever be closely associated with this virus. There have been nearly 14 million confirmed cases around the world and nearly 600,000 known deaths from COVID-19. Some countries have done incredibly well with containment measures, while others continue to see case counts grow every day.

It has been fascinating to see how the outbreak has had different impacts in communities around the world, including how local and global responses have efficiently controlled or been unable to contain this novel public health problem. Prevention and mitigation strategies continue to form the foundation of public health management of this outbreak. The capacity for any country or locality to provide the most invasive supportive care is widely variable, and even when it is available mechanical ventilation is certainly not a panacea as COVID-19 case-survival rates in those being mechanically ventilated have been low (from 14% to 25%).

At the core of the variable outcomes seems to be a mix of sociological issues: a mix of personal beliefs, geography, politics, socio-economics and health infrastructure which lead to vastly different outcomes around the globe.

The accumulation of more epidemiological data over the past 200 days has improved our collective understanding of the COVID-19 virus, as today we have improved models and a better understanding of the rates of asymptomatic carriers (estimated at 40%) and mortality rates (1.4%-15.4%). Yet still, uncertainties and local variability (even within countries) have made an accurate calculation of the COVID-19 basic reproductive number (R0; the number of people who are infected by a single disease carrier) difficult. In the early stage of the outbreak in Wuhan, R0 calculation ranged from 1.4-5.7, and some have suggested that instead of single R0 value, modellers should consider using ongoing contact tracing to gain a better range of transmissibility values.

We have seen how prevention strategies such as hand-washing, face-masking, and physical distancing can impact local and disseminated disease spread. While many communities have come together through a collective approach to lock-downs and universal masking measures, other localities have struggled to get adequate levels of citizen compliance. Others have struggled with obtaining testing supplies. Certain political systems allow for streamlined and unified directives while others have made it difficult to provide adequate centralized coordination.

As the COVID-19 pandemic has spread to almost every country in the world, outbreaks are smoldering in much of the global south. While the United States continues to see rising numbers of cases with numerous states confronting ongoing daily record high incident cases, other countries such as Brazil are seeing similar upward trends. At the global level, the curve of daily incident cases seemed to have “flattened” and held steady through much of April and into May with aggressive seemingly worldwide measures. However, since the last days of May, global incident cases have been again steadily increasing. This is likely due to a variety of reasons but is linked, at least in part, to efforts to reopen economies and return to pre-pandemic routines and lifestyles.

covid-19 daily cases
Source: Johns Hopkins University Coronavirus Resource Center https://coronavirus.jhu.edu/map.html, accessed July 17, 2020

As an American citizen and a physician with training in public health, it has been both interesting and frustrating to see the how some countries (including my own) have had deficiencies in dealing with testing and basic prevention (such as mandatory universal masking). While I don’t want to engage in political rhetoric or cast blame in any one place, I do think it is instructive to point out that in the United States (or anywhere else for that matter) the sociological factors of personal preferences and autonomy, geography, and local politics have had an overwhelming influence in determining the progress of the pandemic.

Quarantining has always been a unique problem that sits at the intersection of personal autonomy and communal wellbeing, and is implemented and respected by citizens in different ways around the world. It would seem, at least anecdotally, that cultures with an emphasis on personal independence and autonomous choice have had greater difficulty with containment or in obtaining high levels of compliance with masking and distancing measures, even when compared to other localities with similar socio-economic situations.

These sociological factors are key to responding to and managing any epidemic health concern. We have come to see that in our globalized world, our ability and desire to work together towards a common goal, even at the cost of personal sacrifice, will determine our ability to control both the COVID-19 pandemic and the next health crisis of the future.

Public health education and communication, it would seem, is at the crux to getting collective buy-in and global participation.

Unfortunately, as with so many things these days, such issues can be easily politicized and cause fractured and disparate approaches to response. In our globalized world, this coronavirus outbreak is unlikely to be the last public health crisis we must face as a worldwide community.

As thoughts turn towards what is to come, from vaccine development and distribution to numerous long-term economic impacts, we are not nearing the end of this outbreak yet.

The incidence curve is growing, and there is much work left to be done. My hope is that as we move into the second half of 2020, our global community can continue to find ways to improve communication and coordination in order to come together to approach and control this pandemic collectively. The fate of this outbreak, and likely the next, hangs in the balance.

Cite this article as: J. Austin Lee, USA, "COVID-19; Reflecting on a Globalized Response," in International Emergency Medicine Education Project, August 3, 2020, https://iem-student.org/2020/08/03/covid-19-reflecting-on-a-globalized-response/, date accessed: December 4, 2021

COVID-19 Clinical Readiness Course For Medical Students

COVID-19 clinical readiness course

Dear students,

We are pleased to open our fourth course for you; iEM/Lecturio – COVID-19 Clinal Readiness Course.

As we did in the EMCC course, we collaborated with Lecturio to provide you an excellent course to improve your knowledge in the clinical applications in COVID-19 cases.

The interactive course content is prepared by Lecturio’s expert educators Dr. Eisha Chopra, Dr. Julie Rice, Dr. Daniel Sweiden, Dr. Julianna Jung from John Hopkins University, Department of Emergency Medicine. Assessments of the course were prepared by Dr. Arif Alper Cevik from United Arab Emirates University, College of Medicine and Health Sciences.

One more time, we thank Lecturio for their amazing resources and support to our social responsibility initiative to help medical students in need during these challenging times.

As a part of our social responsibility initiative, iem-course.org will continue to provide free open online courses related to emergency medicine. We hope our courses help you to continue your education during these difficult times.

Please send us your feedback or requests about courses.

We are here to help you.

Best regards.

Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

iEM Course is a social responsibility initiative of iEM Education Project

Course Length

This course requires 2-4 hours of study time. The course content will be available for 7 days after the enrolment.

Who can get benefit from this course?

  • Junior and senior medical students (course specifically designed for these groups)
  • Interns/Junior emergency medicine residents/registrars

Certificate

The candidates who successfully pass final summative assessment of the course will be provided course completion certificate.

Other Free Online Courses

Cite this article as: Arif Alper Cevik, "COVID-19 Clinical Readiness Course For Medical Students," in International Emergency Medicine Education Project, June 26, 2020, https://iem-student.org/2020/06/26/covid-19-clinical-readiness-course/, date accessed: December 4, 2021

3D Video Laryngoscopes

Laryngoscopy can be described as endoscopy of the larynx, which used to facilitate tracheal intubation during general anesthesia or cardiopulmonary resuscitation. For decades, direct laryngoscopy has been the standard technique for tracheal intubation. But today, there are two main types of laryngoscopy: direct and indirect. Indirect laryngoscopy means the provider visualizes the patient’s vocal cords without having a direct line of sight. Indirect Laryngoscopy includes video laryngoscopes, fiberoptic bronchoscopes, and optically-enhanced laryngoscopes. Video laryngoscopy introduced in recent years and it aims to overcome the limitations of direct laryngoscopy by using a camera attached to the laryngoscope. While it has clear advantages over direct laryngoscopy, video laryngoscopy still has a high cost of investment. It remains a rare commodity for Emergency Medicine clinics, especially in resource-limited settings.

While the COVID-19 pandemic was affecting the world, the people who were under the most significant risk were healthcare workers. We know that the risk of transmission of the disease is quite high, especially when performing high-risk medical procedures such as endotracheal intubation. It is a known fact that personal protective equipment such as masks or face shields are very important in protection. But it is even more important to stay physically away from the patient whenever possible. When intubating a patient, video laryngoscopy has a clear advantage in terms of eliminating the need to approach the patient’s head and trying to have a direct line of sight.

Video laryngoscopy devices are expensive. But, if you think about the essential components of it, you can easily realize that it doesn’t have to be this way. You need a blade, a camera system, a display, and a way to attach the blade and the camera system. While laryngoscopy blades are essential for Emergency clinics anyway, I can safely assume every Emergency clinic has them. A camera system and a display are also both fairly cheap and easy to obtain for most of the places on earth. Find those three and voila! You have a cheap video laryngoscope (In this post, I will not elaborate on the technique of combining a normal blade with a video camera).

For those who want to go to the next level, there are some ways of making your very own prettier video laryngoscopy devices. You just need a 3D printer, but luckily it is possible to find 3D printers in many cities these days.

So here we go.

Umay

The pandemic paved the way for innovation in many ways. Numerous doctors from all over the world rolled up their sleeves to develop new medical devices. Yasemin Özdamar, an Emergency Medicine specialist from Turkey, designed 3D-printable video laryngoscope blades named “Umay” (possibly an allusion to Orkhon inscriptions) in pediatric and adult forms based on normal laryngoscope blades.

The printing files of these blades can be downloaded for free in formats suitable for printing with PLA material, which is frequently used in 3D printers, and PA12, which is preferred for more professional printing. You can download the files here: Pediatric – Adult.

AirAngel

AirAngel is a not-for-profit tutorial center dedicated to making video laryngoscopes accessible in under-resourced nations. You can purchase the blade or video laryngoscopy devices from their website with a fairly low price of US$100-180. You can also get the file of the blade for free and 3D print it yourself. Its design is really similar to a D blade. You can head to AirAngel’s website and grab the printing file now.

Here is an example tutorial for AirAngel:

In our tests (in Turkey), the cost of printing one blade approximately 50 Turkish Liras (roughly equal to US$7 with today’s exchange rates). We also bought a “Borescope USB Camera” with a camera head outer diameter of 5.5mm from our local internet store for approximately US$13 (A similar product from Amazon). So, the cost was US$20 in total, which is cheaper than AirAngel’s offer, and a lot cheaper than a conventional video laryngoscope. We have attached the camera to the blade using special parts on them and connected the camera to a phone. And under a minute, a video laryngoscope was born.

Please note: The intended purpose of these designs is to be used as a training tool. They do not replace any medical-grade video laryngoscope systems. They are not in any way approved medical device designs, nor have they been reviewed by the FDA or any other organization. Be aware that many plastics vary in strength, heat resistance, and chemical resistance. The strength and durability of the blade will vary depending on what you print it with. Harmful and life-threatening complications may occur if pieces break in the airway.

Cite this article as: Ibrahim Sarbay, Turkey, "3D Video Laryngoscopes," in International Emergency Medicine Education Project, May 4, 2020, https://iem-student.org/2020/05/04/3d-video-laryngoscopes/, date accessed: December 4, 2021

COVID-19 vs Influenza: A Diagnostic Dilemma

covid 19 vs influenza

During the last two months, the world experienced an outbreak of what was known to be an unknown yet contagious virus, The Coronavirus, namely COVID-19. News circulated about the virus being spread in China, and the number of people affected increased daily. While there was panic in China, other parts of the world were alert and anticipating a few occurrences, but definitely not as much as the situation is today.

Eventually, as the numbers increased, number of hospital staff who started wearing masks and taking necessary precautions increased, anticipating the arrival of the disease into their regions, until a few days later, there was news of the virus being spread to different countries, new cases emerging from different parts of the world, the case fatality rate rising, infection control rules became stricter and this was the start of what has lead the COVID-19 to be announced as a pandemic by the World Health Organization.

While researches are being conducted, treatments are being tested, one of the biggest dilemmas physicians are facing, is to differentiate between Coronavirus and Flu caused by Influenza virus. The latter being a more known and common cause of flu during the winter months.

When news of the coronavirus created alarm in the general public, there was an influx of patients in the Emergency Departments all around the world, most of them being travelers with flu symptoms and airport staff. Since little was known about the virus then, standard infection control protocols were applied as a general rule until a diagnosis and the severity of illness was sought.This created another issue, could this be seasonal flu, or was it Corona? The decision was harder amongst people in extremes of age. When the disease had just been discovered, testing and results took time and little was known, unlike what the situation is today where countries such as South Korea are offering drive-through tests, with results within 24 hours.

This added to the importance of knowing the differences and similarities between the two to provide adequate management and treatment.

Similarities

  1. Transmitted by contact, droplets and fomites.
  2. Both require precautions such as good hand and respiratory hygiene
  3. Both cause mild to severe respiratory illness
  4. People are commonly affected in winter

Differences

  1. Influenza virus has additional symptoms such as muscle aches and fatigue whereas COVID-19 can present with diarrhea
  2. Influenza has a shorter incubation period as compared to COVID-19 (2-14 days)
  3. According to current data, children, women and elderly are more affected by influenza, whereas COVID-19 causes more severe illness in the elderly and those who are immunocompromised and those suffering from underlying medical conditions
  4. COVID-19 is being known to have a higher mortality rate as compared to influenza
  5. Annual vaccines and antiviral agents are effective against influenza, and there is currently no proven treatment for COVID-19
  6. People who have flu caused by influenza are most contagious in the first 3-4 days after contacting the illness

Overview of the COVID- 19

It belongs to the family of Coronaviruses, which may cause illness in animals or humans. In humans, several coronaviruses are known to cause respiratory infections ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). COVID-19 is the newest type discovered in Wuhan, China, in December 2019.

Method of transmission: is respiratory droplets from the nose or mouth of a person who is infected by the virus (coughs/sneezes within 1 meter).
Incubation period: 1-14 days

Symptoms, Diagnosis and Treatment

The most common symptoms of COVID-19 are fever, tiredness, and dry cough. Some patients may have aches and pains, nasal congestion, runny nose, sore throat, or diarrhea. Around 1 out of every six people who get COVID-19 becomes seriously ill and develops difficulty breathing.

Diagnosis: Nasopharyngeal swab, sputum culture
Chest Xray and CT: Bilateral chest infiltrates, consolidation (pneumonia)
Treatment: Symptomatic until a proven treatment is discovered.

Prevention

The four essential steps:
W – wash hands
A – avoid physical contact and public places
S – sterilize and sanitize regularly
H – hygiene is essential.

Cover your nose or mouth with your bent elbow or tissue while sneezing and dispose of the used tissue immediately.

Wear a mask when you have symptoms of flu to prevent spreading the illness.

Cite this article as: Sumaiya Hafiz, UAE, "COVID-19 vs Influenza: A Diagnostic Dilemma," in International Emergency Medicine Education Project, March 25, 2020, https://iem-student.org/2020/03/25/covid-19-vs-influenza/, date accessed: December 4, 2021

References