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      Medical Students to the Rescue: Fighting COVID-19 with an Outpatient Pulse Oximetry Monitoring Protocol

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          Hospital surge capacity in a tertiary emergency referral centre during the COVID-19 outbreak in Italy

          The first person-to-person transmission of the 2019 novel coronavirus in Italy on 21 February 2020 led to an infection chain that represents one of the largest known COVID-19 outbreaks outside Asia. In northern Italy in particular, we rapidly experienced a critical care crisis due to a shortage of intensive care beds, as we expected according to data reported in China. Based on our experience of managing this surge, we produced this review to support other healthcare services in preparedness and training of hospitals during the current coronavirus outbreak. We had a dedicated task force that identified a response plan, which included: (1) establishment of dedicated, cohorted intensive care units for COVID-19-positive patients; (2) design of appropriate procedures for pre-triage, diagnosis and isolation of suspected and confirmed cases; and (3) training of all staff to work in the dedicated intensive care unit, in personal protective equipment usage and patient management. Hospital multidisciplinary and departmental collaboration was needed to work on all principles of surge capacity, including: space definition; supplies provision; staff recruitment; and ad hoc training. Dedicated protocols were applied where full isolation of spaces, staff and patients was implemented. Opening the unit and the whole hospital emergency process required the multidisciplinary, multi-level involvement of healthcare providers and hospital managers all working towards a common goal: patient care and hospital safety. Hospitals should be prepared to face severe disruptions to their routine and it is very likely that protocols and procedures might require re-discussion and updating on a daily basis.
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            COVID-19 and medical education

            The coronavirus disease 2019 (COVID-19) outbreak has rapidly transitioned into a worldwide pandemic. This development has had serious implications for public institutions and raises particular questions for medical schools. Frequent rotations between departments and hospitals make medical students potential vectors for COVID-19. Equally, as trainee doctors we stand to learn a tremendous amount and can contribute to the care of patients. More immediate concerns among medical students centre on the impact of COVID-19 on medical education. A substantial number of medical students are in the process of preparing for or undertaking assessments that require clinical exposure. The effect of COVID-19 on medical education could therefore be considerable. Several teaching hospitals in the UK have reported cases of COVID-19, with some hospitals suspending medical and observership students from attending clinical attachments. This suspension might extend to more hospitals as the COVID-19 pandemic continues to develop, which could lead to clinical medical students receiving reduced exposure in specific specialties, causing a detrimental effect to exam performance and competency as foundation year 1 doctors. The situation is more complex for some final year medical students who are in the process of sitting their final assessments. Some medical schools have reduced clinical exposure in the weeks coming up to their final exams to reduce the risk of contracting the virus. Many electives could also be cancelled because of the global prevalence of COVID-19. This situation would not only cause financial losses for students, but also lead to a missed opportunity of working in a health-care system outside of the UK. At this stage, it is difficult to predict what will happen, and most medical schools are following advice from Public Health England to determine how to proceed. Despite widespread panic and uncertainty, the medical community must ask itself what history has taught us about medical education during pandemics. To answer this question, we reflect on the effects of severe acute respiratory syndrome (SARS) on medical education in China at the turn of the century. 1 Some Chinese medical schools officially cancelled formal teaching on wards and their exams were delayed, hindering the education of medical students in the face of the newly emerging epidemic. 1 Similarly, in Canada, the impact of the SARS restrictions led to the cessation of clinical clerkships and electives for students for up to 6 weeks. 2 The Canadian national residency match felt the effect of these limitations, particularly because electives are one of the most crucial factors determining allocation. 1 Despite the challenges posed by the SARS epidemic, several resourceful initiatives were implemented, leading to progress in medical education. In one Chinese medical school, online problem-based learning techniques were implemented to complete the curricula; these methods proved incredibly popular, to the extent that they were applied in subsequent years. These impressive feats illuminate how even in times of distress, solace can always be found. We are waiting to see what ingenuities for medical education will emerge in the face of the COVID-19 pandemic. This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on March 27, 2020.
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              Caution against precaution: A case report on silent hypoxia in COVID-19

              Introduction Silent hypoxia is an entity that has been described in patients diagnosed with COVID-19. It is typically described as objective hypoxia in the absence of proportional respiratory distress. The physiological basis for this phenomenon is controversial, and its prognostic value is unclear. We present a case below, of a 66-year-old female presenting with severe hypoxia that was managed without mechanical ventilation. Presentation of case A 66 year old female with multiple comorbidities initially presented with a cough, fever and an oxygen saturation of 70% on room air in the absence of respiratory distress or altered mentation. She subsequently tested positive for COVID-19 and was admitted to the intensive care unit; received oxygen via high flow nasal cannula and continuous positive pressure mask. The patient remained in the intensive care unit for 40 days under close observation and exhibited multiple episodes of silent hypoxia on weaning oxygen. She was discharged on room air with an oxygen saturation >90% after 56 days. The patient was not intubated during her stay. Discussion and conclusion Clinicians face a clinical dilemma on whether to intubate a “silently hypoxemic” patient, who displays hypoxia out of proportion to clinical examination. The decision is confounded by a lack of clear evidence on whether the benefits of precautionary intubation outweighs the risks, especially in the current COVID-19 pandemic. A recent paradigm shift that recommends delaying intubation further displays the need for clearer analysis of the situation. Our case demonstrates a favorable outcome of the latter approach, yet emphasizes a case-by-case approach until clearer recommendations are available.

                Author and article information

                Telehealth and Medicine Today
                Partners in Digital Health
                29 December 2020
                : 5
                [1 ]Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA, USA
                [2 ]MD Candidate, Harvard Medical School, Boston, MA, USA
                [3 ]Harvard Medical Faculty Physicians, Beth Israel Deaconess Medical Center, Boston, MA, USA; Faculty, Harvard Medical School, Boston, MA, USA
                Author notes
                Corresponding Author: Oren Mechanic, Email: Oren.mechanic@ 123456gmail.com
                © 2020 Oren Mechanic

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, adapt, enhance this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial.

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