Upon completion of medical school, new graduates raise their hands and swear to uphold a number of professional & ethical standards. This Hippocratic oath constitutes a way of life as they recite in unison, “In purity and according to divine law, I will carry out my life & my art.” As all healthcare workers care for patients amidst this pandemic, they sacrifice, advocate, and inspire.
Q & A TODAY
ALLYSON, an emergency medicine doctor in Virginia
ED, a surgeon in DC
SAMANTHA, an internist in Oregon
ALLYSON
Q: How has your ER been during this pandemic?
COVID-19 has changed every facet of care in my emergency department, from the way patients are initially triaged to our visitor policy. Our department has needed to be flexible and innovative as we discover new things about the virus and the best way to keep our patients and clinical staff safe in this new environment.
Before COVID, patients arriving by car queued in one line to await the registration process. It was not uncommon to have a line twenty feet deep out the door. Now, our patients enter a medical tent outside our entrance where nurses first place masks on them and evaluate their complaints. If the complaint includes any symptoms that indicate the patient may be infected with COVID, the nurse assigns a certain letter sticker. All other complaints receive a different letter to indicate their initial risk assessment for COVID is low. We have divided the waiting room into two areas; one for any possible COVID complaint and the other for our low risk patients in order to establish a physical division between the two. In well-appearing patients that might have the virus, but who have stable blood pressure, heart rate, and temperature (what we call your vital signs in medicine), we may even attempt to discharge this cohort home after an x-ray or COVID test to minimize their exposure in the department.
Any patient that needs more in depth evaluation will be brought back to a room. Ideally, these patients are placed in a negative pressure room. This means there is a ventilation system that generates pressure lower than that of the surroundings to allow air to flow into the isolation room, but also to prevent contaminated air from escaping the room. Unfortunately, not every room in the ED has this capability. One of the new things I have needed to adjust my mentality to is not just rushing into the room as soon as the patient arrives. Before entering, I have to take the time to put on PPE--or personal protective equipment. This includes a paper gown, an n95 mask, a face shield, double gloves, shoe covers, goggles, and a scrub cap which covers my hair.
We try to enter the room as a team-myself, the nurse, and a tech to minimize the number of times we are opening and closing the door. Once in the room, we establish how sick this patient is. What is the likelihood we will need to place the patient on a ventilator? A patient is placed on a monitor to check their oxygenation which gives us an idea if this patient requires oxygen by a tube that sits just under their nose or something more invasive like a ventilator. An IV is placed, blood is drawn and sent to the lab, an EKG (or picture of the heart) may be done at that time. One of the trademarks of emergency medicine is being able to provide an airway if the patient is not able to breathe on their own for any reason. Patients who have COVID often require intubation (a breathing tube placed in the airway) so that they can be hooked up to a ventilator.
My residency trained me to intubate patients in all scenarios--traumas, heart attacks, you name it. However, we have taken the lessons learned in Italy, Spain, and China that the intubation procedure itself generates a significant amount of virus particles spread into the air, thereby placing doctors and nurses at increased risk. For this reason, our hospital created an intubation team composed of anesthesiologists who come to the ED and wear PAPR's ( a powered air purifying respirator) to do the intubation for any patient that may need one. Patients who have COVID require significant resources in their care--supplies, PPE, and simply manpower to name a few.
One of the most difficult aspects of caring for these patients is the inability to deliver the "human touch" or what we call the art of medicine. Patients can no longer see my facial expressions, my smile hidden behind my mask, or the concern in my eyes, which is diminished by my goggles. Even the ability to simply communicate is hampered by patients trying to hear my voice, unable to read what my lips are saying against the increased hum of activity in the room. Most recently, we have implemented the use of iPads with the goal of improving communication, while limiting our direct exposure in the room. But, ultimately, these patients are alone.
Our policy, like most nationwide, is that we cannot allow any visitors in the room with the patient due to the level of contagion. Most of my interaction with a patient's family is now over telephone, whereas previously they were bedside. These are hard conversations to have over the phone--I listen to spouses, children, and siblings agonize over end of life decisions if these patients have not already specified what they want in an advanced directive. During one of my shifts, I had seven patients transition to hospice care based on their poor prognosis and what their family felt was most compassionate for their loved one. Needless to say, my shifts are exhausting and are filled with many patients who present with very similar symptoms and necessitate the same level of care. This has been a challenge to emergency physicians as we become increasingly myopic to the diagnosis of COVID. Trained to be detectives and to put symptoms together to reveal a diagnosis, our natural instinct has become it must be COVID.
I try not to anchor on the virus and miss other critical pathology that could mimic the virus' symptoms. Chest pain, shortness of breath, and cough are all symptoms of heart attacks, heart failure, blood clots in the lung, to name a few, that we cannot afford to miss. Ironically, you may have heard hospitals are cutting staff and shortening the clinical hours we typically work. This is very true as we have seen a dramatic drop in ED visits for abdominal pain, chest pain, and dizziness as patients are simply staying home or using virtual appointments to address their medical issues. At this time, our hospital is unable to proceed with elective surgical cases due to government mandates to contain the virus; this has had a significant impact on its profitability. As a result, many nurses and doctors are being furloughed, leading to another level of stress in an already chaotic environment.
People ask me if I am scared. Initially, I was fearful, but this is what I have trained for and what I do makes a difference (and what a heck of a lesson I am teaching my children that no book learning would ever do justice). I am not scared now; I am grateful. I am grateful to the community at large that has made sure I have not missed a meal, whether it be breakfast from Anita's, lunch from Jersey Mike's, or dinner from True Food. I am grateful to my school community--bottles of wine, loaves of homemade bread, masks, and even toilet paper that have appeared on my doorstep. I am grateful for the emails, calls, texts, and memes that are sent to me daily from friends I have not heard from in years. I am grateful I am able to get up in the morning and go to my job and be there for a patient who may take their last breath while I hold their hand when their family cannot. Emergency medicine doctors are often referred to as the "cowboys" or "MacGyvers" of medicine--we will take a ventilator and figure out how to make it serve two patients or even four. Give me a rubber band or a piece of dental floss and I'll get that ring that's been stuck on your finger for two years off in five minutes. We will still be the cowboys, COVID has just made it a bit harder.
Q: What types of precautions do you take to prevent yourself & your family from being exposed?
Prior to COVID, I did not really think twice about my exposure or my family's to anything dangerous. There was a brief time when we were all a little overwhelmed by the possibility of contracting the Ebola virus, but this was short-lived as the level of contagion was far lower because it was spread via sweat and blood during the late stages of the disease. With COVID, my risk is certainly substantially increased and by extension my family's as well. When I arrive for my shifts now, I wear lay clothes to work and change into hospital-issued scrubs in the ED. All of the physicians have essentially stopped wearing their white coats, jewelry, or even a sweatshirt that could harbor the virus. My hair is covered at all times by a scrub cap. I probably wash my hands over a 100 times during the shift and disinfect my respirator, goggles, stethoscope, and face shield every time I leave a patient's room. We have all placed our cell phones inside of a ziploc bag that can be discarded after we leave our shift. Before I leave the hospital, I change back into my lay clothes and disinfect everything once more--this includes my phone, my ID badge, any other items I may have with me. Once I reach my car, I place these items in the trunk along with the shoes I wear in the hospital. When I arrive at home, I use Clorox bleach wipes on every surface in the car that I have touched. I enter my house through the basement, shower and wash my hair. I have actually been using a hospital-issued cleansing agent that people typically use prior to surgeries. I bleach wipe all the handles, faucets, and anything I touched as I entered the basement. I gather my clothes and immediately go to the laundry room and wash them in a specific laundry sanitizer and drop my phone in our UV sanitizer machine. It is only at that point that I feel comfortable seeing my family. Some of my colleagues have chosen more extreme measures and have moved out of their homes. But, I feel the protocols I have implemented are sufficient to protect me and my family, at least for now. I try not to take my work home with me--certainly humor, long walks, this close-knit time with my family, and a daily dose of Vitamin C will keep me grounded and whole.
ED
Q: I know COVID-19 has affected you not only professionally but personally as well. Can you tell us about that?
Recovering from having COVID-19 was definitely a long and difficult process. But now that I have recovered, I am excited to be back at work helping patients as well as associates cope with the illness. I also plan to donate my plasma as soon as I am able to in the hopes that it can help even one patient. Without a doubt, it is a difficult process unlike anything we have experienced in the past. But I am confident that we as a society will get through this and be stronger in the end.
Q: What positive changes have you seen from when this started in DC until now?
I am really heartened by how everyone has really unified in fighting this disease. People on the front line-nurses, grocery store employees, pharmacists, police officers and all the others who are working tirelessly- have put their own lives at risk on a daily basis to help society continue to function as best as possible. I have also been impressed by how people in general have really abided by the stay at home and social distancing orders. Everyone is committed to the same goal which is to prevent the spread of COVID-19 and keep each other safe and healthy. Q: Some research is showing that 50 percent of Chinese healthcare workers who dealt with COVID-19 are exhibiting symptoms of depression, anxiety, insomnia. Moving forward, as we get through this pandemic, how do we deal with the wellness of our frontline workers?
This is a great question and very difficult to answer. Without question many of our frontline heroes will experience symptoms such as you described due to the daily stress of coping with fears for their own personal health as well as caring for the overwhelming numbers of COVID positive patients. I think we need to remember that as we come out of this crisis, many on the frontline will need to share their experiences and emotions, and we will need to have wellness programs in place to help them.
SAMANTHA
Q: I know the testing, which was a problem early on, is improving. Can you tell us about the testing in your system?
Yes that’s definitely the case. As of last night, we have been given the green light to test anyone who has any symptoms of COVID. This is real advancement from a few weeks ago when we could only test those fitting certain limited criteria. My health system has been quite nimble and fluid from the beginning, resulting in sometimes head-spinning and hourly protocol changes to follow the most current guidelines. This has culminated in three drive-thru testing sites being erected throughout the Willamette Valley within less than a week. We are able to place lab orders and have patients drive up in usually less than 10 minutes from registration to testing. Thankfully, we have full PPE for all involved.
In addition to making sure that our hospital staff had what they needed to do their jobs, primary care doctors were rapidly converted to telehealth so that we could continue to care for patients with suspected and diagnosed COVID and those without. We were provided workable guidelines for testing and monitoring COVID suspected and positive patients at home and have dedicated care coordinators that call those patients daily to check on them.
Q: I know the west coast was on the front end of this experience in our country. What can we learn from the experience there? We definitely feel grateful and lucky to live where we live especially during a pandemic. Knowing that there is regional coordination between Oregon, Washington, and California provides a higher sense of safety. It is a model that will hopefully be adopted throughout the country as it has been in regions of the East Coast. I think these common sense decisions are what will ultimately carry us forward. As a specific example, there was an immediate relationship built between our smaller hospital and a larger hospital lab in Washington state to process our COVID tests. This has now shifted more locally, but that relationship was key in facilitating some of our earlier diagnoses.
Sacrifice, advocacy, and inspiration....all in a day of the life of a doc.
To all healthcare workers everywhere, thank you for all you are doing!
Send this to the healthcare workers you want to thank in your life.
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