Facing Disaster During a COVID-19 Outbreak: What Emergency Medicine Experts Should Know?

AUTHORS

Meisam Moezzi 1 , Kambiz Masoumi 2 , Arash Forouzan 2 , Manda Poladzadeh 3 , Fakher Rahim ORCID 4 , *

1 Department of Emergency Medicine, Golestan Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

2 Department of Emergency Medicine, Imam Khomeini Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

3 Department of Emergency Medicine, Razi Hospital, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

4 Health Research Institute, Research Center of Thalassemia and Hemoglobinopathies, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran

How to Cite: Moezzi M , Masoumi K , Forouzan A , Poladzadeh M , Rahim F. Facing Disaster During a COVID-19 Outbreak: What Emergency Medicine Experts Should Know?, Jundishapur J Chronic Dis Care. 2021 ; 10(2):e114295. doi: 10.5812/jjcdc.114295.

ARTICLE INFORMATION

Jundishapur Journal of Chronic Disease Care: 10 (2); e114295
Published Online: May 1, 2021
Article Type: Review Article
Received: March 5, 2021
Revised: April 5, 2021
Accepted: April 5, 2021
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Abstract

Context: Since December 2019, the new coronavirus (COVID-19) has been identified as one of the significant challenges in the health systems of countries. Recently, the development and equipping of hospitals and medical centers have been considered as a priority, providing a variety of advanced services in the areas of diagnostic, therapeutic, and supportive services to patients. The present review aimed to shed light on the importance and crucial role of knowledge in the field of emergency medicine during the COVID-19 pandemic and to compare the local and international guidelines. Finally, in addition to the workplace and emergency practitioners’ acts, alongside the especial need to frequently disinfect with appropriate antiseptic materials, negative pressure ventilation should also be in the triage and emergency rooms. Besides, personal protection requirements should be sufficiently accessible, and emergency physicians should be trained to use them properly while adhering to safety principles. It is also recommended to use a cap, gown, appropriate mask, shield, and gloves during treatment, diagnostic and supportive measures, and practice frequent hand washing with antiseptic materials like alcohol solutions, as it reduces the risk of infection transmission. Moreover, it is imperative that nurses and physicians working in emergencies follow all safety principles at the end of the shift before entering their homes.

Conclusions: Ultimately, the final goal is to reduce the virus transmission through early detection, supportive, diagnostic, and therapeutic actions, and appropriate follow-up.

1. Context

Since December 2019, the new coronavirus (COVID-19) has been identified as one of the major challenges in the health systems of countries (1). Although information about previous outbreaks related to the coronavirus, including SARS and MERS, has mainly been identified, the very high pathogenicity of this virus has led to the large number of people affected in the short term. There are many unknown issues about the virus and its health consequences, including how the virus originated, the pathophysiology of the disease, the transmission, the pathogenesis, the treatment, the prevention, recovering, and the vaccination. However, it seems that what is most important is informing people in different communities to cut off the chain of virus transmission. All governmental and non-governmental organizations, especially health systems, are obliged to provide accurate information about the possible early symptoms and the need for referral of suspected individuals to health care centers to receive appropriate personal and social health care recommendations and to have direct control on all processes.

The Ministry of Health and Medical Education in Iran has established and institutionalized the referral and family physician network in rural and urban centers for many years under the supervision of the World Health Organization (WHO) (2). Although these systems have not shown their best performance for various reasons, they have been able to play an important role in promoting the health services of Iran. Recently, the development and equipping of hospitals and medical centers have been considered a priority, providing a variety of advanced services in the areas of diagnostic, therapeutic, and supportive services to patients. The present review aimed to shed light on the crucial role of knowledge in the field of emergency medicine during the COVID-19 pandemic and to compare the local and international guidelines

2. Evidence Acquisition

The aim of this study was to review strategies for the prevention and control of COVID-19 in emergency settings. Thus, PubMed, Scopus, ISI web of Sciences, Embase, and Cochrane central databases were systematically searched for related papers published from 2019 to 2021. Also, the guidelines of the Centers for Disease Control (CDC), Occupational Safety and Health Organization (OSHA), The National Institutes of Health (NHS), the American Association of Emergency Medicine (AAEM), and Iranian Society of Emergency Medicine (ISEM) were surveyed using a thematic search method.

2.1. Iranian Perspective

The field of emergency medicine has been launched in Iran since 2001 and has expanded throughout the country in recent years; thus, alongside training centers in many general and large hospitals, many hospitals in small towns have emergency medicine professionals (2). These medical staffs are considered as a primary or first-contact point of care for individuals requiring healthcare services; thus, they play a major role in reducing morbidity and mortality and faster assignment of the necessary care in emergencies. With the outbreak of COVID-19 in Iranian provinces and cities, emergency medicine specialists have come to the forefront of the disease exposure. Unfortunately, due to the recent industrial development of the country in recent years and the lack of compliance with specific standards in material purification, many environmental pollutants have polluted the air. Moreover, dust storms and respiratory crises caused by the first autumn rains in certain areas lead Iran's health system to plague by a host of respiratory illnesses in different seasons, especially the cold season. The high prevalence of colds, viral and bacterial respiratory infections, particularly in coincidence with infections caused by the influenza virus, have made the situation more difficult. The experience of the aforementioned crises in emergencies and health centers by general practitioners and emergency medicine, internal medicine, infectious disease, pulmonary, and the intensive care unit (ICU) specialists at the beginning of exposure to COVID-19 has caused many patients to be ignored and treatment and follow-up of patients be performed based on routine differential diagnoses flow diagrams and protocols (Figure 1) (3). This problem is more evident because many para-clinical signs and symptoms and findings are common in the differential diagnosis between COVID-19 and other community-acquired pneumonia symptoms, including lethargy, fatigue, fever, cough, shortness of breath, and diarrhea (4).

Figure 1. Diagnosis and management of community-acquired pneumonia (CAP) in the first 4 h. CXR, chest X-ray; DBP, diastolic blood pressure; SBP, systolic blood pressure.

2.2. Current Situation

Initially, some doctors involved in the diagnosis and treatment of patients developed signs and symptoms of COVID-19, which was followed by the public announcement of the positive cases of COVID-19 in the country, and immediately the country's health system was focused on the diagnosis, treatment, and protection of these patients, while also emphasizing on preventive measures. Unfortunately, since the early days of this epidemic in Iran, many physicians, especially emergency medicine specialists, due to the lack of familiarity with the disease signs, negligence in adherence to safety principles, and lack of awareness of patients being carriers, were affected with the disease requiring intensive care, and some died despite advanced supportive care.

Currently, the COVID-19 situation has evolved from a epidemic to a pandemic condition (5), and in addition to the policies and actions of major countries, especially in the field of emergency medicine, specialists and general practitioners working as front-line soldiers in dealing with potential patients must be healthy, safe, and energetic to provide the desired levels of care. Given the protocol provided by the Iranian Ministry of Health, the first step is to maintain the health of physicians and staff, and then to provide appropriate solutions for managing suspicious patients (Figure 2).

Figure 2. The flow diagram of admitting, evaluating, and transferring a suspected or infected COVID-19 patient by emergency medicine specialists (EMS); community-acquired pneumonia (CAP). CXR, chest x ray; DBP, diastolic blood pressure; SBP, systolic blood pressure.

2.3. The Crucial Role of Knowledge

The presence of experienced staff, including experienced and trained nurses, who will be in charge of triaging patients with qualified gowns, gloves, masks, face shields, and caps, is necessary to guide people to a specific pathway with the slightest suspicion of the disease (Figure 3).

Figure 3. Schematic view of the crucial role of awareness regarding the diagnosis, protection, and referral protocol of COVID-19

3. Discussion

The spread of COVID-19 disease has had many effects on economic and social activities around the world. Meanwhile, health care providers have to be present in their workplace and provide healthcare services to community members. Indeed, the global spread of this virus increases the likelihood of healthcare providers' involvement in medical procedures. During these procedures, the transmission of the virus is possible in three main ways, including airborne diffusion through the aerosols produced, diffusion through contact with the mucous membranes of the eye, nose, and mouth with saliva droplets, and diffusion from contaminated surfaces and medical instruments.

Thus, it is necessary to take some steps to face this clinical mega-crisis. First, it is imperative that all health centers, especially hospitals, activate crisis committees to properly monitor and manage all procedures for suspicious patients from the time of emergency arrival to hospital exit. This route includes triage, directing to emergency isolated units, resuscitation rooms, respiratory isolation units, special units, and recovering patients. Second, it is essential to separate and fully equip the triage area with negative pressure ventilation and proper temperature, and finally, frequently disinfect the emergency environment with suitable materials. Third, the next line of exposure is general practitioners or emergency medicine professionals whose job is history taking, physical examination, and supportive, therapeutic, and early diagnostic measures to stabilize the patient’s relative clinical condition.

Emergency physicians may perform transient invasive and noninvasive procedures to achieve these goals, including airway intubation, mechanical ventilation, cardiac massage, and respiratory ventilation, appropriate peripheral and central vascular catheters insertion, NG tube, or Foley bladder catheter insertion. All these responsibilities could lead to close contact with affected patients. Given the diverse range of clinical signs in patients with COVID-19, awareness, and preparation of these physicians is paramount.

4. Conclusions

In addition to emergency practitioners’ acts and the especial need to frequently disinfect the environment with appropriate antiseptic materials, negative pressure ventilation should also be in the triage and emergency rooms. Besides, personal protection requirements should be sufficiently accessible, and emergency physicians should be trained to use them properly and must adhere to safety principles. It is also recommended to use appropriate caps, gowns, masks, shields, and gloves during treatment, diagnostic and supportive measures, alongside frequent hand washing with antiseptic materials like alcohol solutions, as it reduces the risk of infection transmission. Moreover, it is imperative that nurses and physicians working in emergencies, at the end of the shift, follow all safety principles before entering their homes. Ultimately, the final goal is to reduce virus transmission, and perform early detection, supportive, diagnostic, and therapeutic actions, and do appropriate follow-up.

Footnotes

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  • Copyright © 2021, Jundishapur Journal of Chronic Disease Care. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
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