Dr. Lee: Preparing for the surge

Concerns on staff, PPE, but testing improving

This is the third 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: In the week since we last spoke, describe in general terms what is going on right now in terms of COVID-19 illness at the MGH?

JARONE LEE: Overall, COVID-19 patient volume has been steadily increasing. It seemed to start last Friday with a rapid uptick in sicker and more cases. As of Wednesday, there were nearly 30 test-confirmed inpatients, with 12 of the confirmed in the ICU. There are also slightly over 100 patients who have not yet been confirmed by tests—but we suspect have COVID-19 disease. Several of these unconfirmed cases are in the intensive care unit now. The numbers continue to change and, depending on when and how the numbers are reported, they can be different at the hospital level and also what is reported by the Department of Public Health.

Our ICU patients come directly from the emergency department and also from regular hospital beds – people who were admitted to the hospital and then became increasingly ill, primarily with breathing problems.

HATTIS: Can you provide some numbers on ICU beds, ventilators, and what happens if a surge in cases occurs?

LEE: First, we regularly have about 150 or so ICU beds that can take adult patients and an ability to scale up more. We normally have 150 ventilators for those critical care beds—but can scale that number to 300 or so by accessing ones from the operating rooms and recovery and procedural units.

Some analysts are predicting the patient surge here in Boston will come in the first few weeks of April and, even though you hear or read about increased manufacturing efforts, those machines might not be available to hospitals for weeks or months. Without getting overly technical, if the demand for mechanical supports for breathing is greater than the supply of ventilators; we may need to become very nimble at using other breathing-supporting technologies such as high-flow nasal cannulas, BIPAP masks, or possibly splitting ventilators. All of these options are difficult at best and could potentially put us healthcare workers at increased risk of infection. In our medical community, there is a lot of discussion about how, when, and if we should use these modalities.

HATTIS: Anything you can say about age or sex distribution generally of COVID-19 patients in the ICU, and/or their history of underlying conditions?

LEE: As was the situation when we spoke a week ago, we are seeing people under age 60 in our ICUs who are seriously ill, some without underlying medical conditions.  While the bulk of patients are older with conditions that increase their risk of serious illness from COVID-19, similar to NYC we continue to see a younger population of patients that are extremely sick.  It is hard to say why. It might be that we have a higher rate of COVID-19 amongst younger folks or there are other factors at play. There is also a predominance of men who are seriously ill as compared to women.

HATTIS: I’ve heard about some drug treatment trials going on with remdesivir, and now an antimalarial combined with an antibiotic that President Trump has been talking a lot about.  How are you at MGH navigating between wanting to use untested treatments, that theoretically or anecdotally may be promising, versus waiting for the science?

LEE: We are a site for the remdesivir trial. Patients must consent to participate and then are randomly given the drug or a placebo. Patients in the trial are not necessarily all in the ICU. It is not clear whether this drug will be found to be beneficial or not. We are trying other medicines that are on the market for other medical problems. Trump has expressed hope about the combination of an antimalarial drug and an antibiotic. Unfortunately, this is still an experimental treatment and we do not know if it will be beneficial. There are many other drugs in the arsenal – also all unproven – that are being considered for patients with COVID-19. These include drugs to reduce the inflammatory system of the body, certain antibiotics, as well as specific anti-virals and anti-malarials. This use of approved drugs for non-approved uses is a decision left to the treatment team. When an ICU patient with COVID-19 begins deteriorating, we are apt to try everything we can to help. Decisions on using these drugs are not done in a vacuum, but instead are discussed by multiple experts at the bedside to be sure the hoped for benefit of the treatment outweighs any risks. These discussions happen multiple times a day on all of our COVID-19 patients.

HATTIS: How are things going in terms of frontline health care workers getting infected at MGH and having adequate numbers of staff?

LEE: At the moment, we have enough staff. Workforce is a constant source of stress and discussion. The Boston Globe reported that officially 41 staff members are out because they have tested positive. The difficult part is that we have a lot of staff also out with symptoms that are possibly from COVID-19, but most likely from their normal allergies. For example, one of my nurses normally has allergies and gets a runny nose. During this time of crisis, we are asking her to not work and get tested, which means she could be out for a few days and possibly more.  We also have clinicians that have underlying medical conditions that make them at high-risk of severe illness from COVID-19.  To protect them, we are actively moving them to other jobs and areas of the hospital. That reduces the pool of clinicians I have to staff my unit.

We are thinking about what happens in a few weeks when the patient surge is expected. We are developing a curriculum to teach ICU-level care to doctors and nurses who typically do not work in an ICU. This includes everything from the bedside medical care to how to safely transport and move patients with COVID-19.

HATTIS: Update us on personal protection equipment, or PPE, adequacy at the hospital?  Any adjustments in how equipment is being used in light of efforts to want to preserve supplies?

LEE: Partners is asking everyone—even non-patient care staff—to wear surgical face masks when working at the hospital. But even more worrisome than an insufficient number of regular surgical masks, we are worried about running out of the highly protective N95 masks. These N95s are what we use when we do high-risk procedures on our COVID-19 patients. Gowns and eye protection are also a worry. As much as we are concerned about insufficient PPE, we are in much better position than many other sites in the state and likely across the country.  A few weeks from now, I am most worried about the smaller, community-based hospitals and those not connected to larger health care systems. That is where the shortages are likely to be most acute.

HATTIS: Where is testing right now at MGH and the turnaround time?

LEE: Testing for corona is much improved since we last spoke. As reported in the media, between the state, private labs, and testing going on in hospitals, testing is much more available. Depending on which test we use, getting the results could take up to a week.

HATTIS: Anything else surprising that we have not talked about so far?

LEE: Let’s talk about something positive. At MGH, we are appreciative of the immense number of people that have reached out to offer their help and services. These are folks from all fields, from major tech companies to academic labs at MIT. Collectively, they all want to help and be part of the solution to our critical issues, such as N95 masks and ventilators. Just this week, we received a large supply of masks from the Boston Fire Department. I want to especially thank Fire Commissioner John Dempsey and Chief Jim Hoar.  This shows that we are all in this together.

HATTIS: In Wuhan, officials have claimed success in reducing infections in the community by having health care workers stay in hotels, and congregating initially diagnosed patients at field sites rather than at home. Any discussion going on about these things?

LEE: There is a lot of discussion around the dorm/hotel idea for health care workers.  The goal is to not only protect healthcare worker families, but reduce community spread by keeping us away from others. We will see whether or not we use these approaches here as well as infected patients who are not seriously ill.

HATTIS: How are you and your family holding up right now?

LEE: We’re holding up OK. Our son is learning the joys of remote classrooms. I was skeptical, but it is working better than expected. In addition to our own health, my colleagues and I worry about bringing the virus home to our loved ones.  Some of my colleagues have sent their families away. A few are living in more remote parts of their homes. All of us aggressively decontaminate ourselves before getting home. It is not easy.

 

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