The black swan of our time

COVID causing cracks in health care system to widen

This is the twelfth 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 do you think of all the coverage of people around the country and around here who are not practicing social distancing?

JARONE LEE: Many of us are holding our breath right now after having seen and heard about the many people that were out during Memorial Day weekend.  We are worried that  people are not adequately distancing and wearing masks, which would make a second surge inevitable.  What we have learned is that this virus spreads quickly and is devastating to many.  From experience, we know that patients are arriving very ill somewhere between 3 days to 10 days after the start of symptoms.  This could mean that we might see a new increase in cases in about 2-3 weeks from now.  I hope not.

Remember, we are not only seeing sick patients who are older and chronically ill die of COVID-19. We are also seeing young, generally healthy people die as well.  Our units are still filled with many younger patients with COVID-19 that are still trying to get off mechanical ventilators.  And the risks are not confined to those not socially distancing.  During these past months, I’ve heard many sad stories from family members who regret how someone isolating at home still became ill and now is likely going to die because someone who was not distancing became infected and then brought it home to that now very sick person.

HATTIS: Can you predict when the next surge of hospital patients may occur?

LEE: That would be helpful.  Currently, we check the state’s daily case count and percent of positive tests. We also model our internal volumes and cases.  There is some interesting research on the horizon, however.  One is a study out of Yale that measured the viral load in raw sewage and found that virus concentrations in the sewage correlated with new cases in around a week and hospital admissions in three days.  If this turns out to work – the research hasn’t been peer-reviewed yet – it could potentially act as an early warning sign of a new surge.

HATTIS:  If a second surge arrives, what have you learned from the first one that might be helpful?

LEE: We are starting to plan for a second surge based on lessons learned.  We have a group of clinicians that are now able to ramp up and ramp down as needed.  The experience, knowledge, and muscle memory is there to quickly re-open surge ICUs.  Similarly, we have a new group of non-ICU nurses with a lot of ICU experience now.  They are seasoned after three months.  Some of them loved working with us in the ICUs and want to continue their tour of duty; others are ready to return to their original jobs.  Overall, the interaction of staff from different areas of the hospital has created a greater sense of community overall.

We still have an allotment of ventilators from the US Strategic National Stockpile.  These ventilators will need to be returned at some point and possibly redistributed by the federal government to other hot spots.  We are actively talking through scenarios and numbers to see how many and what type of ventilators we need for future surges.

Another big question for the future is how we maintain hospital operations for non-COVID patients during a second surge. During the first, we had to cancel all elective care.  I’m sure there will be a tiered response as we go forward.  We’re expecting a trickle of patients that come in regularly with COVID-19.  If that volume goes above a certain threshold, non-COVID care will need to be reduced and we will likely be back to implementing some sort of surge plan.

HATTIS: Any other health care system changes that have resulted from the COVID pandemic?

LEE: As for post-acute care, Boston Hope, the field hospital at the Boston Convention and Exhibition Center is now closing to new patients.  We learned how important it is to have a well-functioning post-acute component of care available that can accept COVID patients.  If there is another big surge, dealing with capacity issues at the hospital requires that we have a place to move patients to as they recover—emptying their bed here for the next wave of sick patients.

On the ambulatory side, it was striking how quickly we could increase a range of telehealth services to maintain access to care. Telehealth is a big win for patients as well as health providers.  Of course, nothing can fully replace in-person clinical visits for many medical needs, but for many aspects of care, telehealth services can reduce the burden to both patients and clinicians.  Telehealth allows a quick follow-up with a frail, elderly patient.  Patients who work multiple jobs can fit their doctor’s visit in more easily. I’ve even noticed that our administrative meetings are better attended these days because of video-conferencing.

HATTIS: What’s the status of COVID patients in the hospital now?

LEE: We continue to have fewer COVID patients and the ones remaining continue to be on the sicker side.  One sad clinical observation that we are now seeing is that a small cohort of patients are now in a stage where their lung injuries are probably irreversible.  There is very little we can offer these patients as the lungs do not recover.

We also have patients who have recovered their lung function but still need a ventilator because of muscular weakness and not because of direct injury to the lung itself.  These folks will need to move to a long-term care facility where they can regain their strength and hopefully come off the ventilator. A subset of these folks also has kidney damage and needs hemodialysis.  Unfortunately, patients requiring both a ventilator and hemodialysis typically have nowhere to go. Very few facilities can take care of patients that require both a ventilator and hemodialysis.  They often end up staying with us in the hospital for a prolonged time, typically many months.

HATTIS: Treatment options seem to be coming. Do you agree?

LEE: Every few days, there is something new that advances our knowledge.  A recent large study on the use of hydroxychloroquine found harm if used at large scale.  The remdesivir trial just was released and published and there is much speculation that remdesivir coupled with other drugs might have further benefit.  We are enrolling here for a trial looking at the combination of remdesivir and barictnib.  This is just one of multiple trials under way here, including other anti-virals and immunosuppressants.  We are also experimenting with high doses of inhaled nitric oxide to see if it has the dual effect of improving oxygen levels and killing the virus. The pace of research and publications on this disease has been amazing to watch.  I’m not sure if we will ever see this pace of knowledge discovery ever again.

HATTIS: How are patients who call their primary care doctor with symptoms of COVID-19 illness being managed right now?

LEE: The testing guidelines are dictated by the state and generally testing is offered patients with signs and symptoms of COVID-19, patients that need a procedure or admission to the hospital, and patients from high-risk communities.

HATTIS: How have hospital workers fared in terms of contracting the virus?

LEE: PPE in the hospital setting works.  If available and used properly, it can protect front line health care workers from acquiring infection.  Unlike estimates in Italy or New York City that perhaps 20 percent of hospital workers directly caring for COVID patients became infected, that percentage appears much lower here in Boston, or so it seems from talking to various colleagues.  There have been clinicians who have become severely affected, but we’ve  had success with PPE in hospitals because of how wicked careful we have been thus far in donning and doffing PPE.  A recent study by one of my colleagues found that front-line healthcare workers are 12 times more likely to get COVID-19 than the general community, but the risk would be much higher without adequate PPE.  Just like we are opening up society and taking more risks—my worry is that staff are getting tired and possibly at risk of letting their guard down.  PPE only works if we are meticulous not only about wearing it properly, but also in safely taking it off.  We must be as vigilant about PPE now as we were at the very beginning of this pandemic—that is key to our safety as front line workers.

HATTIS: We often talk about your personal life and experiences. Three months into the pandemic, how are you doing?

LEE: All I can say is I’m tired. We are all tired, physically, mentally and emotionally.  The hardest part of all this is watching the cracks in our health care system widen because of this crisis.  The cracks manifest along racial, ethnic, gender, and other lines. The COVID outbreak has clearly shown us that we have a long way to go towards building an inclusive and equal society.  In Boston, we continue to see how inequities of all sorts have led to certain communities getting hit harder by COVID-19 than others.  We now have an opportunity to rebuild and reorganize in a better way. I think we can do it.

HATTIS: This is going to be our last chat during this first phase of the COVID pandemic. Can you sum up in some way?

LEE: First, I want to thank you and CommonWealth for giving a front-line worker a voice over the last 13 weeks.  One of the biggest lessons to date is that we now know something like COVID-19 can happen.  This is the Black Swan of our time.  Massive death and destruction at this scale was something of movies and other countries, not something that happens here.  We now know that even in the US pandemic outbreaks can fundamentally change our way of life. On a happier note, another major lesson learned is that we are not completely powerless, and can hopefully beat things like this through thoughtful, collaborative efforts. This pandemic has brought hospitals and others together like never before.  Many resources were shared, including staff, ventilators, and other equipment. We helped each other out, which is something I hope we can build on in the future.

 

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

Dr. Lee: At MGH patients don’t die alone

Surge still manageable for Dr. Lee

Dr. Lee: We’re busy but in good shape

Dr. Lee says COVID-19 patient counts down

I’m seeing promising ventilator death data

At MGH, they worry about a second surge

Meet the Author

Paul A. Hattis

Associate professor, Tufts University Medical School
Fewer but sicker patients in the MGH ICUs