Dr. Lee: At MGH, patients don’t die alone
COVID-19 tests inaccurate 20-30% of time
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This is the fifth conversation between Dr. Jarone Lee, a frontline critical care and emergency physician at Massachusetts General Hospital and associate professor at Harvard Medical School, and Dr. Paul Hattis, an associate professor at the Tufts University Medical School who participates in CommonWealth’s Health or Consequences Codcast. Find links for past conversations at the end of the story.
PAUL HATTIS: Since last week when we spoke, please update what is happening in general terms at MGH as well as across the Partners Healthcare system with respect to COVID-19 illness?
JARONE LEE: At MGH and across the system our COVID-19 patient volume continues to increase. Similarly, the number of COVID patients requiring an admission to the ICU continues to uptick daily. At MGH, we are operating beyond our standard ICU capacity. We have multiple additional ICU spaces now open and taking new critically-ill COVID-19 patients. Just yesterday, we opened another area to start taking additional intubated COVID patients. Similarly, the community hospitals in our network have expanded beyond their standard ICU areas to take additional ICU patients. With this said, we do still have a lot of capacity to expand as the surge continues.
I know that there has been increased national focus on what is happening with African-American and Hispanic patients with this illness. At MGH we have noticed an increase in Hispanic patients with COVID-19. As previously reported, this is around four times higher than our typical inpatient volume of Hispanic patients.
This disease appears to disproportionately result in more serious disease in African-American and Hispanic populations. My opinion is that this is because of socio-economic and environmental factors affecting these populations that lead to higher prevalence of underlying conditions such as diabetes and hypertension that then predisposes COVID-19 infected patients to more serious illness.
HATTIS: Tell me a bit about some of the clinical issues in caring for COVID-19 patients that you are seeing in the ICU?
LEE: The majority of our ICU beds are now COVID-19 patients, practically all on ventilators. We have started using ventilators that we brought from our operating rooms to the ICUs. In such instances, these anesthesia ventilators require an anesthesiologist to run them instead of a respiratory therapist. We are preemptively using these ventilators now so that we can extend our overall supply, not because we are running out of ventilators. At this juncture, we still have the ability to open many more ICU beds with ventilators at MGH and across our system.
Clinically, the Acute Respiratory Distress Syndrome (ARDS) that develops in COVID-19 patients is atypical compared to other patients with such a diagnosis. Some COVID-19 patients with ARDS have lung mechanics that seem better than what we would expect from looking at their CAT scan and chest x-ray. Many of these very sick patients have profound challenges in maintaining adequate oxygen levels in their blood. To treat this, we sometimes flip these patients onto their stomachs (proning) to improve the oxygen levels in the blood. This works by using gravitational forces to help the oxygen that goes into the lungs to better match up with the blood flow, allowing for more oxygen to enter the bloodstream.
The other part of this disease is that patients are staying on the ventilator longer than our typical patients in the ICU that normally require mechanical ventilation. In many ways, the patients we are seeing are still early in the course of their disease; but we already have a few that have been with us for over two weeks on ventilator support. This is not different from experiences in other hot spots around the world.
Also, clinically, as has been reported from the literature, we are similarly seeing about 15 to 20 percent of ICU COVID-19 patients with injury to the heart function in addition to just lung injury.
LEE: As for survival, it is too early to provide meaningful statistics. I am hopeful, though, as we have had many success stories. Here at MGH, we have been successful in getting many patients off mechanical ventilation already and hopefully on their way to recovery. It appears that the short-term survival at MGH of COVID-19 patients needing ventilators seems higher than the numbers you cite.
HATTIS: With COVID-19 patients on vents, what can you say about staffing issues?
LEE: We have increased the total number of ICU beds we run and the sites where we locate them. With each new ICU unit that we open, we need a whole team to take care of the patients from respiratory therapists to nurses. As of now we do not have any capacity limits and we have all the staffing resources needed to continue to open new ICU beds—despite that over 200 MGH workers have been reported as being COVID-19 infected.
HATTIS: How do family member communications and interactions work with your COVID 19 ventilator patients?
LEE: From the ICU care perspective, one really can’t overstate how much this illness has changed how we interact with patients and families. One of the biggest emotional and professional stressors for us is that we cannot have families come in to see their sick loved ones. Typically, we have families visit regularly, but to control the spread of the virus we have a strict policy of no visitors at this time.
We do have an exception in that we would allow one visitor to come in if our patient is about to imminently pass away. We understand the paramount importance of how our dying patients and their families have a desire to have their loved one not pass away alone.
To help facilitate discussions and updates with families, we have been using video conferencing. In this day and age, video conferencing is quick to setup and allows families to connect with loved-ones even if they are not in the hospital. My team tries to do this regularly with our patients’ families.
Finally, I do believe that the psychological toll is greatest amongst our nurses as they are at the bedside with our patients the most. Once settled in the ICU, they are also the first line of contact with the distraught families.
HATTIS: What is happening with respect to serious illness care and end of life conversations at MGH and in the ICU?
LEE: This is an important question. I am aware that our primary care providers and others are having preparatory discussions about end-of-life treatment preferences, especially with older patients. Because of the pandemic, this conversation of what someone would want if they become critically ill is especially important now. And some patients do come to the ICU with orders that they do not want mechanical ventilation,
Ideally, I believe we should not have these serious illness discussions for the first time when a patient needs ICU care. As before COVID-19, many times in the ICU setting we have end-of-life-care preference conversations regularly with our patients and families. In this current situation, it is no different and personally I have found that many times after a discussion about invasive ventilation, many patients and family members choose to focus on quality of life and comfort
HATTIS: What’s the status of personal protective equipment, or PPE, and overall staffing to meet patient care needs
LEE: PPE remains adequate. We are very appreciative of all the efforts being made to supply us and the rest of the health care system. Starting soon, there is an FDA-approved machine that can decontaminate N95 masks for reuse. This will greatly help our supply.
HATTIS: What about testing, anything interesting there to note?
LEE: We still do prioritize testing of hospitalized patients. With multiple types of testing available, it is easier every week to get.
One thing worth commenting on is that the COVID-19 testing is not 100 percent accurate. What I mean is that a negative test result might not actually be negative. So if it is negative, there is a chance that you might still be infected but the test is falsely wrong, also known as a false negative. From reports, it seems like the test could have a false negative rate of around 20-30 percent. In other words, the test could miss 20-30 percent of cases.
This is why when we see a negative test in someone with all the signs and markers of COVID-19, we tend not to believe it. We also sometimes test a patient multiple times. Recently I had to put one of my patients on mechanical ventilation. He had two negative COVID tests already, but everything about him was that he had the disease. After intubation, I was able to get a better sample from his lungs and it showed that he was in fact positive.
HATTIS: What about staff personal protection efforts that are going on? What do you personally do?
LEE: This issue continues to be a big concern for us on the front lines. The gym behind MGH recently opened up to us if we want to shower before returning home after a shift. Personally, before leaving I change out of my dirty scrubs, replace them with a pair of new ones and then once I get home, I shower ASAP. I also try to put my clothes right into the hamper/wash. Everyone has come up with their own routines to avoid infecting themselves and their families. Multiple nurses have told me that when they get home, they put all their clothes immediately into a plastic bag before even entering their home, and then wash their clothes with a sanitize wash cycle after every shift.
HATTIS: A few weeks ago, we briefly discussed hotels for health care workers and congregate housing of people who are asymptomatic or mildly ill and positive. What’s MGH doing?
LEE: MGH and our hospitals in the system now offer paid hotel rooms for any healthcare worker after a shift.
HATTIS: The Baker administration and the nonprofit Partners in Health are trying to set up a 1,000-person organization to trace those exposed to patients who test positive to get them into isolation or tested. Any thoughts on that effort?
LEE: This approach is an important and key public health measure to reduce viral spread. While this is not my area of expertise, for me the big question is what will be the plan to isolate and quarantine identified cases and potentially infectious people. Would they require these people to leave their homes and reside in other housing? This seems like a big change in culture for us in America if implemented. From a pure public health standpoint, it does make sense.
HATTIS: How are you and your family holding up?
LEE: I’m focused on COVID-19 all the time these days. My colleagues and I regularly talk about how hard it is to think about other things especially as the number of cases continues to increase. Recently I had to intubate three patients that were about my age. I know that I’ve said this before, but we will not beat this disease in the hospitals and ICUs. This can only be beat through good public health measures to reduce community spread. As we know well, everyone is affected, including the young and healthy.
On a lighter note, we continue to work through the trials and tribulations of home schooling and remote learning. My son continues to ask if people on TV can hear him. The new thing is that we typically use one of our laptops for remote learning. Unfortunately, he gets very excited during these classes and has gotten close to destroying our precious laptop. As a result we just bought a separate tablet device dedicated to his remote learning – with an appropriate child-proof rubber case.
Previous conversations with Dr. Lee:
The Codcast: A report from the frontlines at MGH
Q&A with MGH doc Jarone Lee: We’re seeing patients of all ages
Dr. Lee: ICU units won’t beat this disease