Last week, Joseph Underwood, MD, stood outside the door of a COVID-19 patient who needed to be intubated, and for a split second he felt the urge to avoid the chaotic and risky situation.
“You walk up to a room and there’s tons of signs on it saying ‘biohazard,’ and it’s scary,” notes Underwood, chair of the emergency trauma department at Hackensack University Medical Center (HUMC) in Bergen County, New Jersey. “You say to yourself, ‘Do I really want to go in there?’
“But then you look in the room and you say, ‘That could be my dad, my mom, my cousin, or my sister.’ So you go in.”
Underwood is one of thousands of providers across the country dealing with a nearly unfathomable and fast-moving health crisis. As the number of infected people in the United States climbs past 55,000, health care providers have become the equivalent of first responders who run toward danger while others run away. Already, scores of U.S. providers have been infected or quarantined.
These hospital workers carry the weight of multiple stresses they never could have imagined even a few weeks ago. In addition to fearing for their own safety, they often have too many patients and too little information about how to care for them. They are struggling to help growing numbers of patients who are increasingly sick and scared. And they worry that they could bring potentially deadly germs back home to their loved ones.
Meanwhile, there is no end or rest in sight for those on the front lines.
“We can cancel elective cases, we can do many clinic appointments via telemedicine, but the emergency department (ED) can’t be canceled,” notes Andra Blomkalns, MD, chair of the department of emergency medicine at Stanford Medicine. Blomkalns, who is trying to figure out what to do if half her staff needs to be out, says she can barely recall a time before the current outbreak.
“I feel like this isn’t just a virus, it’s a test,” she says. “It’s a test of our ability to be resilient and keep doing what needs to be done,” she adds. “It’s all COVID, all day, every day.”
As the number of U.S. COVID-19 infections spirals — in New York, for example, cases double every three days — providers are expected to deal with an overwhelming flood of patients, information, and logistical demands.
At UW Medicine in Seattle, an early epicenter of the outbreak, some staff members have been working 20-hour days trying to procure personal protective equipment (PPE) and find ways to make what they have last, such as bundling risky tasks to minimize PPE use.
“Washington was the tip of the outbreak,” says Timothy Dellit, MD, chief medical officer of UW Medicine. Based on what he has seen unfold in the weeks since, “I am worried that … the health care system in this country is going to be completely overwhelmed.”
One wave of the health care tsunami recently crashed down on staff at HUMC, which serves Bergen County, New Jersey, an area hard-hit by the epidemic. Within hours of word getting out that scientists there had developed a rapid-turnaround test, dozens of patients began flooding through the hospital’s doors.
If they were going to cope, the team there knew they would need to find appropriate spaces, equipment, processes, and personnel. At a quickly gathered meeting of key hospital staff, Underwood asked how long they thought it would take.
“They said, ‘We can be ready by tomorrow morning,’” he recalls. “I said, ‘You have two hours.’ And in 90 minutes we were up and running and taking care of patients.”
The effort called on everyone to dig deeper and respond faster than ever before, says Underwood. “It’s an example of [how] in a single moment the entire situation changes and you’re faced with something that could threaten your entire system.”
In fact, HUMC staff faced a new challenge just a couple of days later when sicker patients started showing up. “We have a lot of people on ventilators, and we are working to make sure we have enough supplies and equipment for the really, really sick folks,” says Underwood. “And now it’s something like Day 12. And the staff are doing incredible, courageous work, but they are getting tired, and we need to figure out how we are going to replenish and refresh them and make sure they stay healthy.”
Across the river from HUMC, David Buchholz, MD, is the senior founding medical director of primary care at Columbia University Irving Medical Center in New York City, where there have been more than 15,000 COVID-19 cases.
The flood of patients means he’s had to set up additional spaces, including a “cough and fever” unit fashioned out of a student health clinic on the university’s college campus. He’s also had to figure out how to keep patients from infecting one another, shuffle around providers to meet demands, and quickly train staff to handle new assignments. “Everything’s wild here,” he says, “absolutely wild.”
Meanwhile, staff everywhere are also scrambling to keep up with rapidly changing guidelines from government leaders and other experts. “I went to a meeting the other day, and the information I got had changed before I started my shift six hours later,” says Hans House, MD, an emergency medicine physician at the University of Iowa Hospitals and Clinics.
That’s why, when House gets home after a long day at work, he’s often up late at night searching for information. “This epidemic has consumed my life in every possible way.”
Facing physical dangers
During a recent nine-hour shift at George Washington University Hospital, Aisha Terry, MD, wore gloves, tight-fitting goggles, an N95 respiratory mask, and a hair cover the entire time. She was hot and uncomfortable and unable to drink or touch her mask for fear of contaminating it.
But, she says, “It’s all worth it if it limits my exposure.”
Other providers across the country aren’t as fortunate. “We are supposed to use one face shield for an entire shift and keep it in an envelope with our name,” explains House, who worries about supplies running out. “I’m buying my own masks from hardware stores,” he adds. “I’ve got to do something to stay safe.”
Among the many sudden changes in the lives of providers tackling the current crisis is an increasing and painful awareness of their own mortality.
“We sometimes act like doctors and nurses aren’t survivors of cancer, don’t have heart disease, and aren’t in immunocompromised states,” says Evan Berg, MD, vice chair of clinical operations for emergency medicine at Boston Medical Center. “But we are as human as anyone else.”
Blomkalns notes that, although she tested negative after exposure to a COVID-19 patient, she worries about her ED colleagues and spends time every day contacting co-workers who are out sick or awaiting test results. “Right now, I would consider all my providers potentially exposed,” she says.
And then providers have to deal with concerns about the safety of their own families.
“My colleague who tested positive was so upset,” notes Blomkalns. “He says, ‘I don’t care about myself much. I’ll get over this, but I brought this back to my home, my wife and children, and they’re the world to me.’”
Meanwhile, hospital workers across the country are figuring out makeshift ways to try to protect their families. “I’m taking every precaution I can think of,” says Terry. “I disrobe at my front door when I get home, carefully place my clothing in a bag, and immediately jump in the shower. I have a healthy respect for this disease. I know that anyone I come in contact with could be at risk.”
Helping horribly stressed patients
In addition to all the other ways providers’ lives have changed, they are also dealing with an increasingly stressed patient population.
“There is just so much anxiety and fear from everyone,” says Buchholz. “People often think that if they get COVID-19, they will die. We are spending so much of our time reassuring people.”
Sometimes, Blomkalns says, her ED patients want quicker care even though her staff are working as fast as they can.
“I know it’s pretty intimidating to be descended upon by a bunch of people in gowns, shields, masks, and gloves,” she says, and patients have a tough time waiting for test results that seem so weighty. “I try to start every conversation with, ‘I know this is tough, and I ask for your patience,’” she adds. “For the most part, people are being incredibly gracious and understanding.”
Meanwhile, certain vulnerable populations tug even more powerfully on providers’ already taut heartstrings.
“We’ve seen an increase in the number of patients in the ED reporting depression, anxiety, and even thoughts of suicide around COVID,” Terry points out. “If we’re anxious about it, certainly you can imagine that individuals at higher risk [of mental illness] are being affected. So services such as telepsychiatry and social work have been ramped up to address their needs.”
In Boston, Berg notes that his team treats many homeless patients in the ED and provides them with supports that extend beyond health care. “Our staff really worry about our homeless patients,” he says. “So that’s an additional layer of anxiety that everybody in the emergency department is dealing with.”
Of course, even “the worried well” can benefit from a few extra minutes if physicians have them to spare, notes Underwood.
“The other night I had a woman in her 60s and while I was taking her history she just stopped talking,” Underwood recalls. “I paused and said, ‘Is everything okay?’ but she didn’t answer. And then I saw her eyes welling up with tears. So I said, ‘You’re really scared.’ And she nodded. I just gave her a big hug.”
As for how they are making it through these tough times, providers often point to support from family and friends — and the inspiration of watching their colleagues work.
“It’s been amazing to see our workforce step up. We have retired faculty volunteering to come back,” says Dellit. “Some of our faculty went in and screened more than 100 residents in a long-term care facility because public health officials have been so overwhelmed,” he adds.
“This has all been very challenging,” he says, “but just to see that outpouring of effort and response from colleagues has been incredibly humbling and absolutely inspiring.”