Director’s Corner: 12 Months of COVID

Reflecting on a year of uncertainty.

As COVID-19 crept into our ERs in early 2020, my wife and I returned from the grocery store on March 13 in preparation for Maryland’s lockdown.  After some wine, I made a Facebook post called an “Update from the Giant,” which included the store being low on anything I would want to eat, but did have plenty of fruits and vegetables.

Minutes later, since I really thought the ER was about to get inundated with patients who wanted testing (and recall, there was none to be had), I thought I would put out a PSA style post about avoiding the ER for routine non-emergent matters. I titled it “Report from the Frontline of the ER.” It totaled 185 words (this column averages 2,000) and was meant for my immediate friends. Here is part of it:

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“Coronavirus is in the community. I’m very happy schools are closed. Please practice social distancing and regular hand washing. People you know will get this. Most will be fine. Go to the ER if you are sick enough to need emergency care. But don’t go to get tested. Assume you have it and stay home for two weeks and distance yourself from your family members.” I was asked to make it public and it got some shares, but it was far from viral.

I continued with weekly “Friday Night Updates from the ER” essentially every Friday since March 13.  They picked up traction, shares and I figured out how to allow followers. After about a month, I got an email from one of the hospital VPs and I was pretty sure I would be fired or they would issue a cease and desist order.  No such thing. They wanted me to know they were there to help.  I have since generated some pretty loyal readers and have had people reach out to ask questions from all over the country.

If I was smarter and more tech savvy, I would have figured out a way to monetize it. At the request of the EP Monthly editorial board and as a way to reflect on the time since the pandemic started, here are snippets of the posts from last spring. While I have plenty of meeting minutes covering the big picture at work, these posts are more personal and help me appreciate how far we’ve come.

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March 20, 2020

I finished med school in 1994 and started residency at Hopkins in the middle of the AIDS crisis. I’ve lived through multiple healthcare crises and have seen nothing like this. Pretty much every senior administrator and clinician in my hospital is planning for these patients from 7 a.m. to 6 p.m. every day.

I typically spend five hours with my chief medical officer a month. Today I was in five hours of meetings with him. No one at the hospital level is planning for this like it’s the flu… I know there’s lots of ER docs running very low on PPE and all of us are figuring out how to get multiple uses out of one-time use items. There’s “ideally” and then there’s “reality.” I thought that only happened in third world countries.

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March 28, 2020

I don’t remember ever considering the risk to my health if I became a doctor when I was a pre-med in college. I never checked a box when I applied to medical school that I was willing to take health risks to care for my patients. With that said, I’ve accepted a lot of risks through the years. The risk of becoming HIV positive after getting stuck with a needle when the patient had HIV. Several times. I’ve wrestled with patients who were attacking others and I’ve had my life threatened by people who could legit kill me too many times to remember.

I’ve skipped putting on PPE to catch a baby so it didn’t hit the floor and to intubate someone who had so much pus from TB on his vocal cords that I was sure I would have a positive PPD after that case because my face was about one foot from his mouth. When seconds counted, he lived. It seemed like the worst case scenario back then was that I wouldn’t be able to drink alcohol for six months while I took meds for treatment. Even with HIV needle sticks in an era when all HIV patients died, no one really considered dying…

My biggest fear is someone from our ED gets critically ill (people are already exposed and/or sick) or dies. It’s a real possibility. While everyone is a little anxious and afraid, everyone also dons and doffs (gets in PPE, takes off PPE) without question. If anything, people realize we’re bathing in COVID and everyone is good with that. No germaphobe works in an ER. We do our job and take care of the sick.

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April 2, 2020

The patient acuity is crazy high.  We all went into emergency medicine to take care of the critically ill.  But holy cow.  We’re used to about 5% to 10% critically-ill but now it’s 50%.  The job is entirely different.  There is a lot of COVID out there.  It occurs in all age groups.  Many people will die… The stress and anxiety among HCW is high. We’re only a few weeks into an illness that may last months or even a year.  It’s like a marathon that has no clear ending at this point.

April 10, 2020

There are no ER or ICU doctors in any city seeing pandemic levels of COVID that has ever seen anything like this before. This is no joke or flu.  It’s not a political conspiracy.  It’s doctors and nurses doing their jobs with a lot of critically ill patients.  Its patients dying in the ER.  Its patients dying in the hospital. 

It’s horrendous pneumonias and patients who quickly decompensate… Many of us are uncomfortable with the analogy to war and I don’t feel like I’m in a war and people are shooting at me.  I can’t imagine the stress of combat. I’m doing what I’ve done tens of thousands of times.  The difference in my job comes when I walk out of the room and Doff my PPE….

It’s amazing how the medical community has come together to share information.  I’ve never been a big fan of Dr. Google, but whether it’s a listserv through ACEP, a Facebook group for EM docs or COVID, Twitter, podcasts, emails or something else online, the amount of medical knowledge that has been transferred from experts to novices in managing this is unheard of. Even our standard online peer reviewed references could never have kept up with the pace of information that was learned and distributed. Six weeks ago, we knew almost nothing about COVID.  Now, most ER docs are experts.

April 24, 2020

I think as a clinician you have to assume every patient has COVID.  In reality, about 50% of our patients are considered high risk and about 40% of them test positive.  There are clearly more intubations (about three times more each week compared to pre-COVID) and more deaths in the ED than pre-COVID as well. Young adults make up a good portion of our hospitalized patients.

May 1, 2020

This week started off very sad.  You may have seen the news Monday. An emergency physician medical director, like myself, committed suicide.  I didn’t know her and don’t know anything about her case, but it hurts anytime a doc — particularly one whose career appears to mirror mine — takes their own life. As ER docs, we all have stories we tell at cocktail parties for a laugh and each of us has cases that are too heart wrenching to ever talk about.

I cannot imagine the PTSD that the doctors and nurses who are working through this pandemic, particularly in NYC, with a rocketing increasing frequency of death, not to mention the added weight and stress of making decisions about who you care for next while consciously not performing critical interventions on someone else that may lead to their death.  I am sure that my experience in Arlington (VA) is not as bad as NYC.  

May 8, 2020

WE NEED MORE TIME.  The supply chain for PPE is still ridiculously messed up.  We still have PPE but my sense is we’re years away from going back to one-time use for our one-time use N95 masks. Having been around US Hospitals since 1986, it’s just so shocking to me that we’re reusing one-time use equipment. Remdesivir and convalescent plasma (from recovered patients with antibodies) may work, but we need more research (as well research on other medications). 

We also need more plasma from recovered patients (contact the American Red Cross or go to the VHC website to donate). Vaccine trials are in the works and may be ready later this year (scientists are setting records in how quickly a vaccine is developed and brought to market) but it’s not there yet.

May 15, 2020

Intubation and conspiracy theorists: Let me just say it, the conspiracy theorists drive me crazy and I don’t have time to debunk every YouTube video out there. COVID is real.  I have no alternative motives for how I take care of patients…..I’ve seen people say we’re intubating too early or doing it for more money.  Just crazy.  Early on, we did avoid non-invasive measures that we have previously used for a variety of reasons. 

One was the risk of COVID to the caregivers (we are safer if the patient is intubated) and protecting staff is critical so we can continue to take care of patients.  Second, we were watching people crash quickly and then stay intubated for prolonged periods of time, so the early algorithms recommended early intubation since it seemed inevitable, and this would decrease the risk of death when they were crashing and really unstable. 

This disease is new to every doctor so the guidelines and treatment recommendations changed on a regular basis in the early days (way back in March—note the sarcasm). We now have a lot more experience with the disease and have gone back to using our non-invasive methods.  We’re more comfortable in our belief that staff is safe in PPE during these high risk aerosolization procedures. However, when patients need intubation, it’s because it’s needed to keep them alive.  And never have I ever seen a doctor intubate a patient because we’d get more money for it.

May 29, 2020

I worked much of Memorial Day Weekend.  It was different than every other Memorial Day Weekend.  For starters, no Rolling Thunder this year.  I’ve met some really interesting people through the years who ended up in the ER as a result of Rolling Thunder.  That event definitely has some characters.  There were also no tourists last weekend.  One year, I took care of five teenagers who passed out watching the changing of the guard at Arlington National Cemetery.  And that was just over the course of one hour.  I love taking care of the tourists who come to town. 

June 5, 2020

“I can’t breathe” scares the crap out of me when a patient tells me that.  The A, B, Cs of emergency medicine are for airway, breathing and circulation, and there are a lot of reasons how people die when it starts with “I can’t breathe.” 

Aug. 7, 2020

I’m on vacation this week, which probably gave me a little too much time to be on social media.  The FDA, the US Surgeon General and the Yale School of Public Health all came out in support of the research showing that hydroxychloroquine (HCQ) is not effective against COVID yet there are plenty of non-scientists on Facebook advocating for it. Additionally, I got frustrated over people who think doctors are falsifying death certificates.

A GSW by suicide could be secondary to depression secondary to COVID 19 infection. I’ve not heard of that or seen that but theoretically it’s possible.  During one Facebook conversation I was in, a person admitted that COVID is very serious but his guess was that one in six of the reported COVID related deaths was not COVID.  No data to support that but just a guess about a conspiracy theory or doctors falsifying death certificates.

Sept. 11, 2020

In the early weeks of COVID, I generally followed up on patients I admitted.  It was the only way to see if they were positive or not (and assess my risk) and it gave me a good sense of the clinical course. As months went on, I now find out if they’re positive while they’re in the ER and while I’ll occasionally talk to the ICU docs to get follow up on some critically ill patients, most patients follow a similar course and go home.

I was doing some chart audits this morning and came across a patient I admitted last month. Nothing unusual about the case.  Middle aged guy (like me), a little overweight (like me), who had pneumonia, needed a bit of oxygen and got admitted for pneumonia. We saw a lot of this.

But then I saw his “status” as deceased on the EMR and that was like a kick in the gut. He got critically ill over his first week in the hospital, stayed alive a few more weeks, but ultimately died after a prolonged hospitalization. COVID is not over.  Although we have learned a ton over the last six months and have some reasonable treatment options, people are still dying and we’re still looking for better treatment options.

Oct. 23, 2020

As a country, we’ve now exceeded the 220,000 death mark for COVID cases.  I said this last summer when we hit 65,000, but it just amazes me how people have normalized this amount of death.  Maybe because the deaths are not occurring in your family, friend group or neighborhood, but they’re out there and if we don’t get better control of the recent uptick in cases, the virus will hit closer to home.  We’re at 70,000 new cases a day and 700+ deaths a day. Certainly, patient volumes are surging in hospitals around the country.

Locally, we’ve been very fortunate (likely as a result of really good mask compliance and distancing efforts), and remain in what’s been our status quo for the last couple of months with similar numbers of cases, hospitalized patients and percent positive rates.  Sure, it fluctuates a bit week to week, but in the grand scheme of things, we’re in much better shape than the spring, and better shape than the summer. We’re anticipating an uptick (maybe a surge) to start in the next few weeks.  We’re prepared and will keep a close eye on the data.

Nov. 27, 2020

The Rapid Abbott tests we have built our safety net around are in limited supply. I’ve heard rumors the government acquired large amounts of them for heavier hit areas and I’ve also heard that they had a manufacturing issue.  I don’t know what the reason is but I know that we, like a lot of hospitals where my friends and colleagues work, won’t be getting our usual weekly shipments, and therefore we are pivoting to other testing strategies.

The good news is that we’ve had some back up plans in the works for a bit, but it’s a change in how we do business.  Additionally, pipettes are apparently in real demand. You’ll remember pipettes from chemistry class.  The little things you squeeze to get liquid out of vial and move it to another vial. Apparently, we use hundreds and hundreds of these a week and there’s a shortage of these as well.

Dec. 11, 2020

Before we get into the vaccine news, I need to tell you that it’s been rough for healthcare workers.  We’re nine months into a pandemic — people are tired and emotionally drained.  We’re in a surge with record high numbers of cases and deaths across the US and everyone within the hospital community is feeling it.  Although it seems that the DMV is doing better than a lot of the country, we’re also seeing records set for new cases, deaths and hospitalizations.  Locally, hospitals are full or getting full.  EDs are pushed to capacity and beyond. 

I worked three shifts this past week. As a chair with administrative responsibilities, that’s more than usual for me, but still less than a full-time doc.  About 40% of the patients I saw had COVID.  Overall, about half of my patients required admission to the hospital, which is a much higher rate than normal. What was a bit different from the first surge is that I saw several patients who came in already knowing they had tested positive and were now sick enough to require the hospital.  COVID is so prevalent in our patients that I actually switched to wearing an N95 for the entire shift.  For most of this year, I was in the typical surgical mask and would put on an N95 as indicated.

Dec. 18, 2020

I’ve been asked by a lot of people if I’m getting the vaccine and the answer is YES. A couple of months ago my answer was that I wanted to see the data and hear what the experts had to say. Ultimately, as I consider the risk to benefit ratio, getting the vaccine was a no-brainer. 

I got my vaccine early Wednesday afternoon.  More than 48 hours later, I’m feeling pretty good.  My arm was a little sore starting about eight hours after the shot like any vaccine.  I took Advil in the morning and it was better. Because it fit my schedule best, I signed up for the first two hour window the hospital offered for vaccination. I guess I shouldn’t have been surprised at the long line of people who got there before me and before our time slot officially opened. 

I felt like I was waiting in line for a general admission concert (remember those?). It really was amazing and efficient.  They had six stations set up for vaccination.  After our vaccination, we were “observed” in our auditorium (physically distanced) for 15 minutes while the movie Elf was playing.  If not for the snowstorm on Wednesday, I would have been happy to hang out a bit longer and watch the movie, but it was a day off and I wasn’t scheduled to be in the hospital that day, so I left.

Spring 2021

It’s been fascinating to watch the scientific method play out in real time.  Look at convalescent plasma go from maybe, to useful, to not useful.  On the other hand, we now have some real data driven tools in our armamentarium, such as dexamethasone, tocilizumab and several vaccines. 

It’s unbelievable to me how much science has been accomplished in the past year, yet we still need to be cautious and practice science-based medicine.  We’ve also seen firsthand the importance of a strong public health system and the benefits of implementing mitigation strategies.

I hope that some of my story above is also your story.  It’s hard to remember all of the details and ugliness that the last 12-15 months have brought us. For me, the past year has been one of the most challenging yet rewarding times in my career.  We should all be amazingly proud of the work we’ve accomplished over the past year.  We’ve not only learned a new disease, we’ve also likely seen an improvement in the quality of the care that is delivered in our EDs, and we’ve overcome massive changes to our business model.

We will come out of this stronger than we went into it.  And I think it’s good to reflect on how far we’ve come.  Stay safe.