An Emergency Medicine Physician Speaks Candidly on COVID-19 Pressures

April 3, 2020
The pressures on healthcare providers these days are mounting and coming from many different areas. One ED physician paints the picture of the COVID-19 impact.

Across the country, physicians on the front lines are dealing with an unprecedented healthcare crisis. Not only are hospitals dealing with surges of COVID-19 patients—with the worst perhaps yet to come—but clinicians, nurses and other healthcare professionals are struggling with inadequate COVID-19 testing, a lack of necessary medical supplies, and not enough precautions in place to protect them.

These challenges have been widely reported in the past several weeks, and more recently, a survey from  Doximity, a professional medical network with more than 70 million U.S. physicians connected—with help from Harvard Medical School and RAND Corporation researchers—affirms what the public was already hearing—that clinicians on the front lines do not feel they are well-equipped enough to treat COVID-19 patients.

Amit Phull, M.D., an emergency medicine physician based in Chicago, and affiliated with Northwestern Memorial Hospital, recently spoke to Healthcare Innovation Managing Editor Rajiv Leventhal about the current moment in this public health crisis, the most pressing challenges physicians are facing as it relates to COVID-19, and more. Dr. Phull is also the vice president of strategy and insights at Doximity. Below are excerpts of that discussion.

What is the COVID-19 situation like for you, at this very moment? Can you paint the picture for readers?

It’s been a multi-faceted approach where folks from many specialties are getting involved, and folks throughout the hospital system are getting involved since you have to deal with two simultaneous problems. The first of those being the current day’s affairs, so you need to [make sure] that the ED and all the critical care units that have been spun [off] are adequately staffed and can handle the influx of patients directly in front of you.

In tandem with that, you need a bunch of folks focusing on not just tomorrow, but the week ensuing, because most models are showing that it will be a few weeks before overall health system capacity is overwhelmed. Both of these things are happening at the same time. In my ED, we have reshuffled a lot of the care spaces inside; we have a quick triage set up where folks coming in with respiratory complaints are triaged relative to the severity of their complaint.

We have a few of these negative pressure rooms in our EDs and, preferentially, when we have enough time to ensure it, we do procedures on COVID-suspicious/confirmed patients in those rooms. In these rooms, there’s a reduced risk of transmission [due to] the airflow. And then we reshuffle some of the remainder ED staff to accommodate the “normal” traffic you see day-to-day in the ED in a large city.

At the health system and city levels, it’s about trying to stay a day ahead. If we fill an ICU [room] today, that means we start building [another one] for tomorrow. At the city level, they are doing the same. I practice in Chicago, and McCormick place is in the midst of being converted into a very large field hospital. So all of this is an attempt to prepare us for what the models [project] is coming, while also dealing with what’s coming on a day-to-day basis.

Speaking of the models, when is the patient surge expected to peak in your region?

There are multiple models out there, with some being leveraged from the experience in Washington State, and then others being [developed] at the federal level. Our organization has done a great job keeping open-minded communication. We have [frequent] disaster preparedness updates and guidelines, and process updates if anything of substance has changed.

I think [the organization] is using an aggregate approach where they are taking input from a variety of different models and trying to find the most reliable [information] as everything is constantly changing. It looks like New York might still be a few weeks out from the peak, and we are somewhat time-delayed relative to New York. We do have the benefit of learning from their experience, and we are also predicting that it’s a few weeks out from the true peak, but that data does that change day-to-day.

What are the most pressing issues you’re dealing with right now as an emergency medicine physician?

The testing and supply [challenges] roll up into a [broader] category, and there’s still a certain degree of confusion around that. My organization has done a good job of communicating, but when things change, it’s very difficult to be in real time and up-to-date on the most recent changes, and then communicate those changes. There are shortages of protective equipment all over the place., and I don’t think that is isolated to any large metropolitan area. The health system, understandably so, is not stocked to deal with this kind of surge. Ideally, over time, we will be able to produce an uptick in manufacturing and distribution to help close that gap.

Prior to this [pandemic], on a normal day in the ED, I would [need] an N95 mask only for highly-infectious patients, but my instructions in those normal times would be to change my mask in between patients. And I would have no qualms in doing so because there were no constraints on the supply chain. I think what created confusion among providers on the front lines was that as opposed to recognizing the reality of the shortage and flexing our resources to meet it, in this instance, the guidelines actually changed. That leads to confusion because it’s a departure from your particular practice pattern.

Most [healthcare organizations] are trying to make do with what they have. There are “extended use” protocols where you are basically instructed to take the mask that you’d change a lot more frequently in normal times and extend that across the entirety of your shift. You are seeing testimonials of people using the same masks for days, if not weeks, so people are taking it upon themselves to try and sanitize them in order to maintain at least a perception of a confidence that you are adequately protected. I think that misgiving at the provider level just adds to the stress of dealing with an already stressful situation.

The reality is that there will be more patients than there is space to take care of those patients. So one thing that is beginning to evolve into a more serious consideration is what do we do with our other patients? Healthcare systems, especially those in large metropolitan areas, generally speaking do not run day-to-day with a lot of excess space baked into the cake; they run pretty close to capacity. So when this kind of extraneous variable shows up, it’s really difficult to manage just your baseline disease incidents such as heart attacks, strokes, and appendicitis—all the things that might bring you to a hospital anyway. That health system essentially has to be run in parallel with the coronavirus “health system” that’s being spun off in real time.

Has all of this led to a fear of organizations being understaffed due to a lack of healthy healthcare professionals?

That reality plays itself out differently in different places, even within a given city or town. It depends what staffing mix at a health system or even singular hospital has at its disposal.  Analogizing it to team sports, you are only as good as your bench. So you need to have a deep bench to draw upon in these types of instances. One of the realities we often forget that’s being brought to the forefront now is that healthcare providers are people, too. They get sick, they often have their own health conditions, often are caretakers of others back at home, and all these potential exposures they might run into at their “day jobs” have significant ramifications for them and their families.

One of the interesting debates I have seen evolve across different channels is, what are reasonable expectations of the healthcare workforce? A doctor has certain obligations in society, but he or she is not necessarily a solider. They may or may not have signed up for putting their entire family at risk when they pursued a career in medicine. So, individuals have to make those personal decisions as to what level of risk they are willing to accommodate for just going to work in the morning. For those that unfortunately do fall ill, we have to be prepared to have people swap in for them.

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