Dr. Lee: ICU units won’t beat this disease

The keys are social distancing, good hygiene

This is the fourth conversation between Dr. Jarone Lee, a frontline critical care 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, describe in general terms what is now going on in terms of the number of patients with COVID-19 illness at the MGH and at Partners’ hospitals overall?

JARONE LEE: Volume of COVID-19 patients continues to steadily build. As of Thursday morning, we had 140 COVID-19 confirmed cases at MGH with 50 of those in the intensive care unit and the majority of these sickest patients on ventilators. We also have 105 others that we suspect of being infected and are in the process of being tested or awaiting results. Many of these are in the ICU as well.  On the ICU side where I am most involved, it’s filling steadily and now more than half of our ICU beds are filled with COVID-19 patients, the overwhelming majority of these on ventilators. COVID-19 patients on ventilators stay longer than most general ICU patients, with some with us for more than two weeks. We still have a lot of capacity to take more ICU patients. Even if we fill all of our standard ICU beds, we have plans to open up other areas of our hospital to continue to take critically-ill patients requiring an ICU bed. I am also moving ventilators around among Partners hospitals as needed to help those most affected by the crisis.  Across our system, we are seeing an increasing volume and high acuity of COVID-19 patients.

HATTIS: Has there been a need to do that so far—move ventilators around?

LEE: Yes, at three of our community hospitals in the system, they have had an influx of sufficiently sick COVID-19 patients who used up their main ventilators. While they all have additional ventilators as back-up; we thought it wise to augment them with additional ventilators.

HATTIS: When you look at the overall growth trends in hospitalization at the MGH and what you are observing both there and with some of the ICUs in the system, any view on whether the hospital case trajectory for COVID-19 illness in the Boston area will be more like New York City (spiking) or like Seattle (flatter growth)?

LEE: It is too early to tell. Of course, we are aware of the various projections where Boston will peak in 7 to 10 days. We will have to see if our efforts of social distancing and sacrifice are sufficient to reduce hospitalizations and mortality of the disease. Let’s hope it works. I want to underscore that the way to beat this is not intensive care units and hospitals, but good public health measures, such as socially distancing, good handwashing, and hygiene.

HATTIS: You mentioned that Partners’ community hospitals are very busy caring for increasing numbers of COVID-19 patients; in some ways, you suggest they are relatively more busy than you at MGH. Why is that?

LEE: We definitely have more patients at Brigham and Women’s and Mass General. However, we have to consider the local resources of each hospital. In absolute numbers they have much fewer ICU beds than we do. Even though, proportionately, their ICU-to-regular-bed ratio might be higher than ours, the vast size of Mass General or Brigham and Women’s allows for us to absorb the large local surges in cases. To my knowledge the increase in the COVID-19 patients at some of our community hospitals is not due to clusters at congregative living facilities, such as nursing homes. My best guess is that there is a general increase in COVID-19 illness and sickness from disease progression, but they are feeling it more at our smaller community hospitals because of less capacity than us at in Boston.

Interestingly, the two island hospitals seem busier than usual. As the media reported, this is probably because they have more people than expected living there during this time of year. With increased numbers, there is a higher chance of COVID-19 transmission, as well as all the other reasons people need medical care.

HATTIS: Anything worth noting about the patients you are seeing in the ICU?

LEE: As we have discussed previously, we’re seeing people of all ages but with a preponderance of older people and/or those with underlying medical conditions. Similar to other places that have experienced a surge in COVID-19 patients, we are seeing patients present very ill requiring ICU admissions early and late. Similar to the patients in China, some are presenting 7-9 days after start of illness, while many others are similar to the state of Washington and presenting 3 to 4 days after start of symptoms.

Also worth noting is that testing results at MGH are returning faster and faster, a great improvement from weeks ago.

HATTIS: What about staff and PPE needs at the present?

LEE: As of now, staffing is OK. We have to constantly reorganize schedules. For example, when someone is scheduled to work and has a small cough, we want to keep them away even if it is just their allergies. As such, they are usually out of work for a few days and we have to find coverage for them.

Additionally, we ask those at higher risk (older with co-morbidities) to forego caring for COVID-19 patients. For example, I have already had to move one of my nurse practitioners twice. We moved her to one of the other care units that did not have COVID-19 patients. Soon after, that unit filled with COVID-19 patients, and she now moved again to another clinical location.

HATTIS: How is PPE at the moment? Also, I have heard that some things like N95 masks are only available to purchase at prices such as $7.50 per mask—as compared to the usual 50 cents?

LEE: We are OK at the moment with PPE, although we always need more and are concerned that we will run out in the future if we do not have a steady supply. Funny that you mention pricing. Just this past week, I have received multiple random solicitations from sellers of N95 masks. They are quoting extraordinarily high prices. It really feels like price gouging to me and I worry about what will happen if this crisis continues and we continue to need PPE.  I especially worry about the less-resourced hospitals that are being quoted prices like that. For the record, I am not involved in purchasing for our hospital.

HATTIS: How is your family doing?

LEE: Thank goodness we are all still healthy, and my 5-year-old has surprisingly taken to online classes with his teachers and classmates. Funny thing is that because of this experience, he now asks if the person on TV can hear and see him! He actually does this now whenever there is someone talking on a screen. This pandemic is certainly bringing all sorts of surprises.

Previous conversations with Dr. Lee:

The Codcast: A report from the frontlines at MGH

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
Q&A with MGH doc Jarone Lee: We’re seeing patients of all ages

Dr. Lee: Preparing for the surge