Dr. Lee: We’re busy but in good shape

Concerns remain with pain sedatives, ventilators

This is the seventh 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: What worries you the most this week when by most accounts we are now in the middle of the pandemic surge?

JARONE LEE: Two things come to mind.  The first is the supply of medications we use in the ICUs.  These include drugs to sedate patients, as well as pain medications and medications to increase the blood pressure when it is too low.  We are well beyond our standard ICU volume here at MGH, across our system and state.  Similarly, because of COVID, there are more patients in ICUs across America than ever before.  All these patients need continuous sedating, pain, and blood pressure medications to keep them stable.  The demand for these drugs is extremely high.

Speaking with our pharmacy folks here that track our demand and supply, they tell me that this shortage is because of both increased demand and supply chain concerns related to manufacturing and transportation.  While we have enough right now, the sustained need of our COVID patients over upcoming weeks gives us worry.

The second issue is related to ventilators.  The current public focus is on the expensive machinery part of this issue.  However, what is less appreciated and equally important is that each ventilator requires an array of supplies to operate.  These items include supplies to connect the patient to the machine, filters to filter out the virus, cords to connect to our monitoring system, and many other accessories.  These items are also in short supply and becoming increasingly difficult to find and source.  If we run out of these items, then the ventilators become as useful as a very expensive paper weight.  Also, as we put new ventilators into use, we have a growing concern that it isn’t just about having sufficient amounts of these accessories, but also having the correct type.

HATTIS: By the numbers, what do things look today at MGH and across Partners?

LEE: Officially, this morning our hospitals report 449 COVID-19 confirmed and suspect cases, with 161 in our ICUs. Last week, COVID patients represented about 40 percent of our inpatient beds at MGH; now it is around 45 percent.  The numbers are also at steady levels throughout the Partners system.

The good news is that by both internal and external models, we are not going to surge beyond our capacity to offer beds, ICU care, and ventilators to both COVID and non-COVID patients.  The bad news is that we are expecting to stay at a sustained and high level of very sick patients for a while, possibly many weeks.  Even though we are at the peak or plateau, the patients that require hospitalization and ICU care could take another two weeks before presenting to the hospital.  So even though there are less new cases now, at the hospital we are expecting to continue to see more cases for a while.  We will continue to be very busy in the hospitals until this is over.

We could also see an increased demand for hospital and ICU beds in the upcoming week with this issue of missing patients.  What I mean is that many people are probably delaying care that they should have received earlier.  For example, patients that are slowing decompensating from their health disease, lung disease, or diabetes are not coming into the hospitals right now.  They are all getting sicker at home and will need treatment eventually, but they will most likely be sicker than if they came in earlier.  This could mean longer hospitalizations, possibly more ICU level care.  I will say that I’ve seen this phenomenon during my federal deployments to disaster zones.  People delay care because the health care infrastructure in a disaster zone is out of order.  Once my team can go in and set up a field hospital and start seeing patients, the patients are typically sicker because of this delay in care.

HATTIS: MGH is generally viewed as a white patient institution when you look at the usual race and ethnicity demographics of your hospitalized patients.  But with COVID -19 bringing in higher numbers of Latino patients as compared to their usual proportion of MGH inpatients, has that made the hospital feel different?

LEE: While we are used to having many patients in our hospitals who do not speak English as their first language, we now have a disproportionate number of patients that speak only Spanish.  We have been able to meet this demand.  Beyond our standard interpreter services, we have a lot of Spanish-speaking clinicians that are volunteering their time to help us communicate with patients and families.  For us on the front lines that do not speak Spanish, having a clinical translator has been amazingly helpful.

Beyond just translating, they have been able to do a deeper dive with the families as our clinician volunteers understand the disease and the medical care. This surge of Hispanic patients has made us feel good about how we not only take care of patients from all over the world, but also how we act as a community safety net for communities like Chelsea.

There are many other Massachusetts communities that are disproportionately affected by COVID-19 in similar ways to Chelsea.  Hospitals like Lawrence General or Signature Brockton Hospital are independent hospitals without the network like we have here within MassGeneral Brigham.  My worry is that if the surge and plateau continue, who will help these smaller, less-resourced community hospitals.  Who will back them up?

Similarly, outbreaks have been reported in rural parts of our country, particularly in the Midwest in meatpacking plants.  Often the people that work in these facilities are poor and underserved immigrants with many of them non-English speaking. As these outbreaks are in rural areas, health care infrastructure like ICU beds and doctors are in short supply.  Many areas had no ICU beds. We will need to find a way to help these folks if the surge continues and hits them.

HATTIS: What is of interest on the clinical side affecting COVID patients right now?

LEE: Beyond the issues we talked about previously, two other clinical issues are kidney failure and clotting issues. We have noticed that many critically-ill COVID-19 patients develop kidney failure.  These patients end up on kidney dialysis with us.  We hope that the need for dialysis is short-term.  If we use our experience from other critically-ill patients before COVID-19, we know that a majority of the patients that need kidney dialysis in the ICU will not need it long-term if they survive.  Unfortunately, we also know that if a patient requires kidney dialysis when critically-ill, their chances of death increases substantially.  Here at the Mass General and at the Brigham, we have sufficient dialysis resources.  We have had to transfer a few patients from our community hospitals for dialysis as their capabilities were maxed out.

We’re also seeing blood clotting with our very ill COVID-19 patients. We treat it with blood thinners such as heparin.  Our clinical challenge is to see if it is safe to start an anticoagulant on a COVID-19 patient with a clot.  Unfortunately, many of these patients are also bleeding while they are clotting.  We call this disseminated intravascular coagulopathy, or DIC, and it can be a very serious condition.

HATTIS: A lot in the news this past week about crisis standards of care, their revision and whether we may even need these now?

LEE: Let me start with the good news based on our modeling. It appears at our hospital and across our system we will not need to activate crisis standards of care.  We have enough beds, ventilators, and other resources now and expect not to get to a point where we must ration care.

And while I can’t of course assess what is happening at every hospital in our state, it seems that the same should be true at other facilities, at least here in Boston.  I say that based both on the case trajectory as well as the fact that, for the first time in my memory, hospitals are really communicating and collaborating with each other to share resources.   So that no single hospital will fall behind and have to active its crisis standards, people are talking daily. Already we have transferred patients to reduce over-burdened hospitals and have shared ventilators between hospitals across systems.  One recent specific example is that Boston Children’s Hospital has loaned their ICU ventilators to three hospitals in Boston, including us.  I hope both the discussions and the sharing continue long after this pandemic is behind us.

As for the content of the state’s crisis standards of care,  I am glad that the state has modified its policy in a way that seems to be less prejudicial against certain communities, especially communities of color in terms of how chronic illnesses impact the calculation of someone’s priority score.

Finally, it is worth noting that there has been a lot of discussion about the fact that at MGH, being a care giver does not add priority points for being prioritized to get life-sustaining treatment during crisis standards of care.   This differs from the state recommendation and what is being adopted at other hospitals, to my understanding.  For good reason, this has concerned some people here. However, I personally understand the reasoning as it relates to issues of social equity and so I accept that policy decision.

HATTIS: I have heard that another area of controversy at MGH and at Partners relates to issues connected to compensation.   Specifically, I heard some number of staff thought that it was wrong of the Partners administrators to not add some sort of hazard pay for certain job categories across the system.  Others, including a number of residents in particular, have asked that all Partners employees be paid at least $32 per hour, given that they are running the risk of infection. What are your thoughts on this?

LEE: On these two topics, my personal belief is that they are extremely important topics to discuss.  I also know and feel the sentiment that as front-line workers we feel the real danger when taking care of infected patients.  We all have stories of friends and family affected by COVID-19, many severely.  We all worry about bringing it home. I also know that additional compensation doesn’t seem to be the answer.  Instead, I think that the resources – largely financial – should be put into keeping us safe and mitigating our risk of contracting COVID as much as possible.  My personal feeling is that our hospital and system has and is doing that.  They have provided us with extensive resources beyond what I have heard offered at other hospitals.  Our leadership has ensured an adequate supply of PPE, paid hotel rooms, and created many other resources, including psychiatric resources, to protect us.  They have also spent these resources so we would not need to deal with the moral distress of not having enough ventilators and equipment when taking care of our patients.  As front-line clinicians, my sense is that many of us would want the resources to be put into where they are needed most – treating patients and maximally protecting ourselves.

On the wage issue, my belief is that this crisis has uncovered underlying societal issues that were already there previously.  I acknowledge that there is a need for a living wage for not just our staff, but everyone, including many of our patients.  Perhaps this is something to fully air and discuss once this crisis is over.

 HATTIS: What’s up with your son this past week?

LEE: Happy to end our conversations with a small story about our 5-year-old from the last week.  I worked from home and was on a number of Zoom calls this week.  Of course, our 5-year-old joined a few of these unintentionally.  He would run into to the room where I am taking the call and yell “daddy.”  Many of the folks on my call all said “wait, that is my name.”

 

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: Preparing for the surge

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

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
Dr. Lee: At MGH patients don’t die alone

Surge still manageable for Dr. Lee