Ancillary Tests

Minimum: Rapid Malaria Testing (if febrile in malaria endemic region)

Better (Above +):

- 12-Lead ECG
- Rapid Flu Testing
- Rapid Dengue Testing
- I-STAT arterial blood gas or venous blood gas
- Ultrasound (cardiac and pulmonary)

Best (Above +):

- PA and LAT Chest Films
- Respiratory Pathogen Film Array (i.e. Biofire)
- COVID-19 PCR Testing
- Other laboratory testing listed DoD COVID19 Practice Management Guide

Identifying Patients at Risk for Deterioration:

- 1) Among patients with mild to moderate symptoms and normal resting pulse oximetry, the risk of deterioration is increased in those presenting with dyspnea, desaturation on exercise testing, and epidemiologic risk factors for severe disease (age over 50, cardiovascular disease, pulmonary disease, immunosuppressive medications). These patients should be monitored closely and considered for early evacuation.
- 2) Exercise (Walk) Test: Have the patient jog or walk in place for 3 minutes. Inability to complete the test or desaturation below SpO2 <94% confers a higher risk for clinical deterioration. This is a triage test used by several New York hospitals during the pandemic to help gauge the need for closer monitoring.

Consideration of Alternative Diagnoses

- 1) If a patient with symptoms possibly consistent with COVID-19 has known risk for or exposure to COVID-19, the patient should be managed as a PUI regardless of the differential diagnosis. This does not mean that alternative and/or comorbid diagnoses are impossible as COVID-19 patients can be co-infected with other pathogens.
- 2) Life threatening alternative diagnoses (e.g., pulmonary embolism, pneumothorax, acute myocardial infarction, etc.) should always be considered and managed according to standard practices for diagnosis and treatment.

Testing in Austere Locations

- 1) Most austere locations will be unable to test for COVID-19 using an approved polymerase chain reaction (PCR) assay. However, if testing does become available, the following should be considered:
- The false negative rate for COVID-19 PCR assay is likely to be significant enough to merit a minimum period of isolation (or quarantine) regardless of test result.
- Testing priority should be guided by the CDC priority for testing balanced against operational priorities. For example, a patient with mild symptoms and no risk factors for decompensation may not warrant immediate testing. However, if combatant command determines that the individual is mission critical, the testing may be considered a higher priority.
- 2) Given significant resource constraints in an austere environment (specifically the limited duration of oxygen supply, medication supply, and limited quantity of PPE) coordination for evacuation to the appropriate level of care should be initiated as soon as possible, even if the patient does not necessarily need urgent evacuation as it may take more than 24 hours to execute an evacuation mission. This underscores the importance for early evacuation coordination while simultaneously planning for prolonged care.
- 3) Appendix A describes a tiered Medical Condition (MedCon) flowchart developed for standardization of terminology across an area of responsibility (AOR) and between medical providers, medical planners, and operational leadership.