An urgent dispatch from the COVID-19 front lines

We are physicians. We are experts at triaging and prioritizing action. Our decisions mean the difference between life and death. We regularly balance competing interests in the setting of constrained resources. We fight hard for our patients. Our job has been likened to “walking through minefields in clown shoes.” It breeds humility. If we make a bad decision, the unthinkable happens. And we are frequently reminded of the fragility of life. We have glimpsed the future of COVID-19 and are horrified. At this point, New York alone is outpacing Lombardia, and the U.S. is outpacing every Western country thus far. We aren’t waiting for the cavalry to ride in, because there isn’t one coming. It’s up to us.

Here’s what we should demand of our state and federal governments

Physicians, nurses, and hospitals have been working nonstop for weeks and know the tsunami is here. We should have acted long ago, but we cannot waste time arguing about what could’ve been done. We are in the now, and we are going to need your help. The prescription for ending this epidemic is: leadership, organization, creativity, hard work, and proven public health measures. We will need to draw on every resource to do this in the most efficient and effective manner so we can save lives, and everyone else can get back to their own.

It is critical to flatten the curve. If our ventilators run out, like the toilet paper did, many will die unnecessarily because of shortages. Survival for those who become critically ill is poor, despite every desperate measure we take. Our horror as health care workers on the front line is that we have little to offer patients to change the course of their disease. States can bend the curve and “buy time” with decisive leadership and action. Buying time means we can:

  • Create better, widely available tests to know who is infected
  • Acquire PPE to protect health care workers
  • Adjust our “business as usual” processes
  • Discover a new therapy that makes this disease an inconvenience and not a death sentence
  • Find a vaccine that is safe and effective
  • Reinstate our normal life-saving care for those who are not infected

So, yes, it is incredibly important that everyone stays home now to buy us time and save lives.  But it isn’t enough. What we do with this time purchased at great expense really matters. We are at a crossroads, and the government decisions will determine the path we will take. The task may seem impossible, but it is NOT impossible. It will take unprecedented coordination and effort, but we are fortunate to have roadmaps laid out for us by Singapore and South Korea, democratic nations that are winning the war on COVID-19. South Korea’s daily case count is declining. As of March 23rd, there were more cases of COVID-19 diagnosed in New York City alone than the entire country of Korea. Singapore has lived with this for months longer than we have, yet life goes on, and they have not shut down schools. Their strategy and coordinated efforts have paid off. What it requires, however, is decisive and strong leadership along with the humility to recognize that this is neither “business as usual” nor “disaster as usual.” We cannot be Italy – we will fail.

Here are the immediate steps that governments should take:

Shelter in place. We must limit all nonessential contact to reduce the spread of the virus. This cannot last forever but it will be important to implement the strategies we need.

Strategic planning and organization. We should employ and leverage every resource available in our state to fight this. A team of non-medical professionals, working in parallel to our health systems, state and universities, should be established to offload work and support the state’s COVID-19 response. Best practices and treatment breakthroughs should be distributed widely among the health care community. While the hospitals and physicians are working and preparing, this group should start now working to assist in the following ways:

  • Determine a strategic plan and framework for prioritizing needs, opportunities, barriers, and communications
  • Work with the state and federal leadership to overcome regulatory barriers to implementing interventions quickly
  • Identify and implement initiatives that must be done at the state level and cannot be accomplished by individual health systems alone
  • Identify and communicate best practices across the state to every overburdened hospital system
  • Coordinate partnerships with the many corporations willing and poised to make a huge impact
  • Develop and deploy technology (or workers from other industries) that can make traditional public health measures, such as contact tracing and isolation, scalable

Control hospital hot spots. Hospitals are a major source of spread for COVID-19. If patients decompensate, they tend to do so on day 7 or 8. Patients should only come to the hospital if they need services that cannot be rendered in another location. Hotels, nursing homes, conference facilities, concert venues could be repurposed to house patients who cannot care for themselves at home. We should follow Singapore and Hong Kong, who set up trailer parks and dorms along with home delivery services to those in quarantine. Patients can be monitored via telemedicine for changes in respiratory rate or oxygen saturation to indicate if they need more intensive medical care. If this occurs, they can be taken to dedicated COVID-19 hospitals, where the risk to health care workers is concentrated, and there are no other patients who will become infected by nosocomial spread.

A current issue facing hospitals is the EMTALA law that states no patient can be turned away from the hospital.  Emergency physicians fully support this law, but in this case, it creates a challenge because patients cannot be directed to a designated “COVID-19 hospital” but instead must be fully assessed at whichever hospital they present to first, thus increasing and distributing the risk of health care worker exposure to COVID-19 at additional sites.

The following policies can help containment:

  • Changes to hospital policies, processes, and organization to focus on containment
  • Create regulatory guidance instructing patients, EMS and health systems to allow known COVID-19 patients to be sent preferentially to COVID-19 hospitals where care can be cohorted, reducing risk other patients and health care workers
  • Build or repurpose alternative housing for COVID-19 positive patients who do not need critical care and the homeless who need quarantine
  • Build telemedicine services to support home care and identify patients who need to be hospitalized
  • Coordinate hospitals at a state level, to allow for isolation of COVID-19 positive patients in the most efficient manner, limit risk and nosocomial spread

Protect health care workers.  Even with appropriate PPE usage, American physicians and nurses have already died. Health care workers need to be appropriately protected to conserve this vital workforce, but also to snuff out the pandemic. In Italy, nearly 1 in 10 of those infected are health care workers. Health care worker infection is a driving force in the spread. It is unethical to expect health care workers to martyr themselves without proper protection. And that means appropriate PPE as well as changes to the “business as usual” processes. The crisis standard of care is triggered by the need for containment, not by volume surges. We can accomplish this with changes to our operations. In the SARS response in Taiwan, utilizing best practices for isolation and triage dramatically reduced health care worker and patient infections. In the 18 hospitals implementing these best practices, zero health care workers and only two patients developed nosocomial SARS infection. In contrast, in the 33 control hospitals, 115 HWSs, and 203 patients developed SARS. Health care workers do not need to die to provide care. If they do, it is a failure of leadership, not knowledge or technology.

Deploy federal disaster assistance. FEMA is an expert in disaster management and communications. The National Guard could be directed to provide boots-on-the-ground assistance. Among the many ways they could help:

  • Deploy to hospitals and serve as “dofficers” to watch health care workers as they doff (take off) their PPE to be sure they are not self-contaminating during this most critical step
  • Assist in rapid deployment of video intercom technology
  • Set up tent triage to contain and limit the spread of infection
  • Create community COVID-19 housing in a hotel or other location
  • Assist in performing mass screening and testing
  • Perform contact screening per Department of Health protocols

Expand proven public health measures:  The lack of testing has been catastrophic because traditional public health surveillance and case tracking measures have not been available. It is nearly impossible to screen for this virus, given that infected patients can be minimally symptomatic with a diverse array of symptoms. As soon as testing comes available, either PCR or antibody testing, it should be ramped up and deployed as quickly as possible. We will need to change our normal business practices and make this testing widely available.  We need a method to track and communicate results to patients and the department of public health.   Singapore and South Korea perform  “contact tracing” on COVID-19 positive patients and isolate individuals who are at high risk of contracting the virus.  Dr. Tedros Ghebreyesus, the World Health Organization’s director-general, gives this advice: “Find, isolate, test and treat every case, and trace every contact.”

The U.S. is on the verge of becoming the new epicenter for this pandemic.  Medicine is only one small tool in this war. Society must do their part.  All of our lives will depend on it.

Amy Cho, Mark Pappadakis, and Theresa Tassey are emergency physicians. Sunny Jha is an anesthesiologist.

Image credit: Shutterstock.com

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