Thoughts from the COVID-19 front lines

I am an internal medicine physician directly taking care of patients admitted to the hospital who are COVID-19 positive or those who are being tested for COVID-19. Last week, my hospital created a special team dedicated to taking care of these patients. During that time, the hospital was eerily quiet: the ED no longer had patients lying in stretchers, and the inpatient medicine teams were carrying half of the patients they usually do. It was the calm before the storm, and honestly a refreshing break from the ins and outs of admitting and discharging.

On March 19th, the storm we had been anticipating arrived. The census on the COVID-19 team doubled overnight. The workload was unmanageable for me, the only physician overnight. For patient safety, the medicine leadership created a second COVID-19 team and added on a second physician overnight.

Many of the patients I am currently caring for (thankfully) have low suspicion of COVID-19, or if they do have COVID-19 (i.e., came in with the diagnosis or tested positive during the admission), do not need inpatient level of care. Some of these patients who have some symptoms overlapping with COVID-19 (e.g., fever, cough) have a remote history of treated cancer. Their oncologists are (rightly) terrified that they will decompensate and want their patients to be admitted and tested for COVID-19. I am not against testing people for COVID-19. In fact, I think everyone should be tested, especially health care workers who are young and asymptomatic. A study from South Korea, which screened a large proportion of their population, demonstrated that those aged 20-40 are likely to be asymptomatic carriers of the virus.

What I am against is admitting every single patient who needs to be ruled out for COVID-19 who don’t have inpatient level needs (e.g., no need for supplemental oxygen) because we are afraid they will decompensate. The decision behind which type of patient needs to be admitted comes from the whim of the ID doctor who is on call for the shift. As you can imagine, this doctor is getting hundreds of questions a day from other doctors all over the hospital about who should be tested for COVID-19. This doctor, therefore, has limited time to read about the patient in the EMR, let alone evaluate the patient in person. The ID doctors are the gatekeepers, and their jobs are critically important, but they are overburdened. You can ask two different ID doctors the same question, and they may give you completely different answers about whether the patient needs to be admitted.

Why the inconsistency in medical decision making? Our hospital and our healthcare system at large does not have an algorithm that we can reliably use to decide which of these patients are safe to go home and which of these patients need to be admitted to the hospital. As a counter-example, there are many well-established algorithms and criteria for urinary tract infections and pneumonias, based on evidence-based medicine and years of cumulative doctor experience. Because COVID-19 as a disease is so new, and because our country has been so ill-prepared for this pandemic, we do not have the knowledge nor the infrastructure to allocate the limited resources we have. We are quickly going to run out of hospital beds, PPE, and healthcare staff to take care of patients if we have no way to decide who is sick enough to require hospitalization.

The root of the problem is twofold: 1) Testing for COVID-19 isn’t widely available; and, 2) non-ID/internal medicine doctors (e.g., proceduralists and oncologists) are afraid that their patients will decompensate and/or that if they do a procedure on these patients, the providers themselves will get COVID-19. It is unclear if these physicians are afraid of dying from the disease (an OB/GYN colleague said she “didn’t sign up for this job to be exposed to a disease that has a 2 to 3 percent mortality rate”) or if they are afraid of spreading this to vulnerable patients.

I fall into the latter camp. As a future general internist, I feel that it’s my duty to take care of these patients. What I did not expect from this pandemic is to reassure other doctors and healthcare workers who do not have experience taking care of these patients. There is emerging literature on COVID-19 that is easily accessible to physicians and nurses, but some of them choose to make their medical decisions based on fear (e.g., pushing for unnecessary admissions that lead to overuse of PPE and hospital beds) instead of evidence. I also did not expect the divisiveness that this pandemic has brought within the healthcare community. There have been accusations by surgeons, anesthesiologists, and nursing colleagues that they were not told by other physicians that their patient was COVID-19 positive. Some do not trust the ability of ID doctors to make decisions about who requires testing. Some are even refusing to perform procedures or care for patients unless they are confirmed COVID-19 negative. In a time where collaboration is key among the different types of providers, there is a division that is preventing us from providing the best care for our patients. This realization makes me anxious, more anxious than the fact that we will soon run out of PPE and ventilators, or the high likelihood that I will unknowingly pass on COVID-19 to a patient.

The glimmer of hope through all of this is the kindness of others. The nurses in the ED who help me put together the plastic disposable stethoscopes so I can evaluate my patient. The patients who make jokes about my wonky face shield and N95 get-up. People who donate time, money, and food to those who don’t have the means to prepare for the pandemic. Those who practice social distancing. And most of all, my physician colleagues, nurses, janitors, phlebotomists, nursing assistants, PTs, pharmacists who are fighting every single day for their patients, despite the chaos and the risks. Thank you to everyone who is doing their part. Together, we can survive COVID-19.

The author is an anonymous physician.

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