‘We All Know That It’s Going to Get Worse’

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As the coronavirus crisis continues to worsen, health-care providers on the frontlines find themselves in a precarious position. They risk exposure on a daily basis as they care for the rising influx of COVID-19 patients, while struggling with shortages in protective gear, ventilators, and bed space. We talked to an ER doctor working at a major academic hospital in New York City about what she has seen in her emergency room, and her fears and hopes for the coming months.

We work in a very high-volume institution, and we [always] have really sick patients, so my colleagues are used to fast-paced, intense work. But this has amplified that even more. I work in the adult ER where we definitely have corona-positive patients. The trick is, you don’t know if they have it when you’re [first] seeing the patient, because the test doesn’t come back while they’re in the ER. This is nerve-wracking for a physician: When patients are coming in and they’re in respiratory distress and shouting they can’t breathe, we have to gown up and take a moment to protect ourselves, while we’re used to just jumping in and getting dirty with the patient.

When I was on my shift two days ago we had people rolling in in respiratory distress, saying they can’t breathe, and normally we’re ready to just help them. I kept having to remind my residents and my nurses to back off and go get their protective gear on. It’s just not in our nature. We had a patient the other day — and we’re not sure that it was COVID-19 — but he was really sick and coughing up and vomiting blood, and we had to intubate him. I was nervous. Even though I was in the gear, you still have the thought, “Okay, this could be the moment that I get infected.” It’s a weird feeling to have to think twice about approaching a patient.

I think most of us are anticipating getting COVID-19. I’ve had that conversation with almost all the attendings, and I have been told that I’ve been exposed already. Our biggest problem is that we don’t have the gear to protect ourselves. Sometimes we’re being told to reuse N95 masks, which should be used for any aerosolized procedure, including intubations. It’s completely ridiculous. You’re asking us to take care of a sick population. If we can’t even protect ourselves, then we’re going to get sick and there will be nobody to take care of them. One of our staff members already has COVID-19. I wish Trump and the federal government would help New York and start ramping up the production of N95s. The entire country should be ramping up production so your physicians can get ready for the storm we’re already in.

The patients we have are [often] sick to begin with because they have poor health. We have had one COVID-19 death that was a younger person, like mid-40s, but they were not in amazing shape. He had diabetes and was fairly obese. I haven’t been seeing a lot of young people who aren’t able to go home and quarantine themselves. Someone young and healthy had it, he was in his mid-30s, and he looked like a flu patient. I think he’ll be fine in a week or so. On the other hand, we have people who are already on immunosuppressants, or transplant patients, or renal disease patients, or oncology patients — those are the patients that come in with severe respiratory distress or sepsis.

I think it’s going to get a lot worse in terms of ERs getting overwhelmed and being able to appropriately isolate people. And when someone comes in with regular appendicitis, am I going to be sitting that person next to patients with COVID-19 and risk [them getting] sick?

Let’s say I’m concerned that a patient may have corona. I’d to admit them to an isolation bed. But the other night, there were no more isolation beds in the hospital. So then we were told by the hospital that these patients would be waiting in the ER with us, which is a big problem. If people keep coming in with no isolation beds, they’re going to be sitting in hallways. Our hospital is [considering] closing surgical operating rooms and using one of the smaller hospital campuses that has been closed as a COVID-19 hospital. But there’s nothing concrete, which makes me nervous.

The really frustrating part for emergency medicine doctors is that we’re also getting a lot of Monday morning quarterbacking. For instance, we had a patient the other day who couldn’t breathe and was screaming for help. She really needed an airway procedure. One of my colleagues wanted to put her on something called high flow, but it aerosolizes the virus so we decided we were going to intubate her instead. But then critical care [doctors] came downstairs and were upset that we intubated the patient because we have to save ventilators. They’re like, “Could you have tried to wait a bit and not intubated her as fast and just see how she did?” But if you have someone in front of you, who’s crashing, saying “I can’t breathe,” there’s no time to think and say, Oh, how many vents do I have?

We all know that it’s going to get worse. We’re very concerned that we’re going to have to start choosing who we’re going to treat and who we’re not. Our institution had a meeting with the hospitalist [the physician who oversees care for hospitalized patients] upstairs about being ready to have palliative care conversations. That’s usually what we do with cancer patients and chronically ill patients. The hospitalist I spoke to told me they’re preparing to have those conversations with a lot of COVID-19 patients and their families, because there’s not going to be enough support for them here.

If you’re young and healthy and having fever and chills and aches and are feeling under the weather, you should stay home and quarantine yourself. If you’re really feeling worried, you should call your primary care doctor and get their recommendation. Because those young people are going to be overwhelming our ERs. We don’t have the capacity to test every single human who comes in saying, “I want to be tested.”

When it first started, the infectious disease department had a handle on it, and they would email and say “patient so-and-so came back positive.” But I worked a shift two days ago and didn’t get that email, I just got a text from a resident who was nice enough to inform me that someone I’d intubated was positive. Now [the department] can’t even keep track of who’s positive and who’s not.

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‘We All Know That It’s Going to Get Worse’