Objectives: Practices regarding anticoagulation use in coronavirus disease 2019 focus primarily on its efficacy in the critically ill without a clear understanding of when to begin anticoagulation. We sought to understand the association of preinfection daily oral anticoagulation use and the short-term mortality of patients hospitalized with coronavirus disease 2019. Design: Retrospective chart review. Setting: Large health system with high coronavirus disease 2019 prevalence. Patients: Patients 60 years or older admitted to the hospital with positive coronavirus disease 2019 polymerase chain reaction test. Interventions: We compared both those on warfarin and those on a direct oral anticoagulant prior to admission and throughout disease course with those who were never exposed to an oral anticoagulant. Results: Our primary outcome was inhospital mortality at 21 days from the first coronavirus disease 2019 test ordered. Patients in the direct oral anticoagulant group (n = 104) were found to have significantly lower 21-day all-cause in hospital mortality than patients in the control group (n = 894) both prior to adjustment (14.4% vs 23.8%; odds ratio, 0.57 [0.29–0.92]; p = 0.03) and after controlling for age, gender, and comorbidities (odds ratio, 0.44 [0.20–0.90]; p = 0.033). Patients on warfarin (n = 28) were found to have an elevated unadjusted mortality rate of 32% versus 23.8% in the control group (odds ratio, 1.51 [0.64–3.31]; p = 0.31). After adjustment, a reduction in mortality was observed but not found to be statistically significant (odds ratio, 0.29 [0.02–1.62]; p = 0.24). There was no statistical difference noted in the number of bleeding events in each group. Conclusions: In this retrospective cohort study evaluating oral anticoagulant use among patients with coronavirus disease 2019, we found that patients who are on daily oral anticoagulation at the time of infection and throughout their disease course had significantly lower risk of all-cause mortality at 21 days. Validation of these findings should be performed on population-based levels. While research regarding anticoagulation algorithms is ongoing, we believe these results support future randomized control trials to understand the efficacy and risk of the use of early oral anticoagulation.

IntroductiondAlthough bear attacks on humans are uncommon, the incidence has slowly risen as human populations increasingly encroach on wilderness habitat. In the Kingdom of Bhutan, Himalayan black bear attacks occur regularly. Bears preferentially attack the face, often causing injuries that require surgical airway management. We sought to determine how often patients injured by Himalayan black bears required airway management during initial resuscitation.MethodsdWe conducted a retrospective review of emergency department and admission records of the 3 referral hospitals in Bhutan. We identified all victims of bear attacks in Bhutan who received emergency airway management, including surgical airway management during the period from August 2013 to December 2017.ResultsdThere were 21 patients who were treated for injuries from bear attacks during the study period. Of these, 12 required emergency airway management. Three patients who required emergency airways (2 intubations, 1 surgical airway) were attacked near a regional referral hospital and received care at that hospital. The remaining 9 patients received care from the helicopter emergency medical services (HEMS) retrieval team (1 intubation, 8 surgical airways).ConclusionsdThe use of highly trained HEMS critical care retrieval teams may improve outcomes in critically injured patients who require time-critical airway management in remote areas. Countries such as Bhutan with populations far from emergency and critical care might benefit from the establishment of HEMS critical care retrieval services. HEMS teams providing care while retrieving patients from austere environments should be expert in emergency airway management.

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The population of the Kingdom of Bhutan is scattered in small villages throughout the eastern Himalaya. Infants born prematurely in villages have no access to neonatal intensive care until they are transported to the national referral hospital, a process that once took hours, if not days. After the introduction of a helicopter critical-care retrieval team, we were able to send a trained team to a remote location that successfully administered surfactant and initiated critical care to a premature, extreme low birth weight infant in severe respiratory distress in the first hour of life. Although the infant was in shock and in a near-arrest state at the time the team arrived, he made an excellent recovery after resuscitation by the team.