With COVID surging again, Dr. Lee returns

Maybe we need a right to repair for hospital equipment

This is the 13th 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, a retired associate professor at the Tufts University Medical School who participates in CommonWealth’s Health or Consequences Codcast. The first 12 conversations took place during the initial COVID-19 surge, and now they are resuming again. Find links for past conversations at the end of the story.

PAUL HATTIS: Reported COVID-19 cases are now averaging between 1000-2000 per day for almost two weeks here in MA, and total case numbers across the US are the highest ever. What do you and your colleagues foresee with COVID over the next few months?

JARONE LEE: First, thank you for having me back. I was hoping that our last interview would be the last one we would need to have on COVID-19; unfortunately, it looks like we might be at the start of a new surge. Many reasons for this uptick in cases, but I do believe COVID-19 fatigue is a big part—letting our guard down. I feel it, I’m sure everyone does. As a reminder, hospitalizations and admissions to the ICU lag for weeks after the cases start going up.  We are likely at the start of this second surge and will realize the greatest fallout in the next few weeks to months.

I want to reiterate something from our last interview. I do believe that COVID is the “black swan” of our time for the United States. We have all seen the death and destruction from COVID now. It is still here and will be around for a good amount of time to come. The importance of wearing a mask, socially distancing, washing your hands, and staying safe is more important now than ever.

HATTIS: Gov. Charlie Baker attributes the case rise to primarily behavior of those under 30. Do you agree?

LEE: I do think it is a big part. Gov. Baker cited data earlier this week that 15 percent of new cases in April were among people under age 30, now it is 37 percent. There is a cohort of younger folks that are not taking COVID seriously by gathering together and not wearing masks. They are correct in that they are at low risk for complications if they contract COVID. However, their risk is not zero. We continue to see young patients debilitated by COVID, and some have complications, including strokes. Remember that this is an extremely contagious disease and it can spread when one is asymptomatic. These COVID-infected younger folks can easily transmit it to friends and family that are at high risk. I’ve seen way too many cases where an elderly family member contracted COVID from another family member.

Lastly, there are many young folks who are doing everything they can to stay safe, but still become COVID infected. Remember, there are many essential and frontline workers in this age group, and they must continue to work despite the risks. Included in this group include nurses working on the front lines of care delivery, who, according to data, have the highest rates of COVID infection of any job group.

HATTIS: On the hospital side, what is happening now with the high numbers and demographics of patients you are seeing at Massachusetts General and across your health care system?

LEE: It feels like a slow smolder. Some of our sites have higher numbers than others, such as Newton-Wellesley, mostly from a recent outbreak at a local long-term care facility. While the numbers of hospitalizations and ICU patients continues to stay low, I believe that we should closely watch the numbers of patients with COVID and influenza on the outpatient side. This includes the emergency department and urgent care patients that are seen, but not needing hospital level of care. For me, these patients quite possibly represent the canary in the coal mine, signaling that there very well could be sicker patients behind them that will require hospitalizations and ICU admissions in the weeks to come.

Dr. Jarone Lee of Massachusetts General Hospital.

HATTIS: If COVID numbers increase substantially, including with hospitalized patients, how will things work operationally at MGH in such an event?

LEE: Despite the lull in COVID cases here, full-scale planning continues. Our teams watch both internal and external COVID statistics closely as we plan for future surges. We are thinking about it in discrete phases where we would activate different tiers of surge capacity as needed. Much of the work right now is to put in place structures and systems that we can quickly activate when needed. Otherwise, unless required by the governor to shut down, we plan to continue to take care of all patients throughout a future surge.  Unfortunately, we did see the excess devastation from shutting down most non-COVID care during the first surge, where patients delayed care and ultimately presented much sicker than if they had come in earlier. Soon after our first COVID surge ended, our ICUs remained full — filled with sick, non-COVID patients. This trend continues today where our ICU volume is still higher than expected as a result from delayed care. Overall, we are confident that we will be able to take care of all patients regardless of if they have or do not have COVID.

HATTIS: Care-wise, what has been learned about how best to treat COVID patients that would make things different from before?

LEE: Some good news to report on this front. During the first surge, everything with these patients was clinically, logistically, and emotionally difficult. Recently I took care of a new, critically-ill patient with COVID to my ICU; it felt routine, like taking care of any other sick patient. This disease is less frightening now as we know much more than we did nine months ago. PPE, steroids and remdesivir work. There is a robust system of clinical trials offered for COVID-19 patients. With that said, the number of patients in our ICUs with COVID already feels uncomfortably high.

Additional good news includes the vaccine results from Pfizer. Of course, as a scientist I am always skeptical of early results. A lot can happen in the next few months as Pfizer collects more data—including safety data. I would not be surprised if the final numbers and results are much worse than the reported 90 percent effectiveness. Regardless, very good news.

On the outpatient side, the monoclonal antibody from Eli Lilly just got emergency use authorization approval for high-risk COVID patients that are not hospitalized. My initial thought is that this will become a nightmare in logistics and in ensuring equitable distribution. With over 130,000 new cases of COVID daily in the US and over 10 million already infected, how do we ensure equitable allocation with only 300,000 doses so far available?

HATTIS: If there is another surge of very sick patients, are you worried?

LEE: Yes. Think about the amount of PPE, equipment, drugs, and personnel needed to take care of just one patient with COVID-19. Every health care professional that enters the room will need gowns, gloves, and eye protection. A typical nurse must enter a room multiple times a day, and possibly multiple times an hour if a patient is in the ICU. So, overall, the same worries persist. Do we have enough PPE, ventilators, equipment, staffing? All of our resources will be stretched and stressed again with another surge.

Regarding ventilators, we learned from the first surge that not all types of ventilators work well for COVID-19 patients. For patients with COVID-19 that do require a ventilator, their lung disease is so profound that they really gain most from a specialized, high-end, ICU-level ventilator. We observed during the first surge that using other ventilators, such as transport and anesthesia ventilators, worked poorly. There are many reasons why these other ventilators failed, ranging from lack of humidification leading to clogging of the ventilator tubing to inadequate software for controlling certain machine parameters. From my understanding, many of the ventilators distributed by the federal Strategic National Stockpile and built by the Defense Production Act were these non-ICU, transport-type ventilators that are not adequate for COVID-19 patients.

Another concern I have is that many of our medical devices use proprietary supplies and software. This leads to a multitude of problems for us on the hospital side. First, if we run out of certain essential machine parts that are proprietary, the entire device may become useless unless the manufacturer can produce or fix it—that can take a lot of time. This almost occurred during the first surge, when we almost ran out of a proprietary connecting tube for one of our ventilator types. Second, the device manufacturers typically do not share their repair manuals, without which, we are not able to fix these devices ourselves. It feels as if we need some sort of hospital right to repair rules, applying not just to ventilators but to most, if not all, of our medical devices, everything from dialysis machines to monitors for vital signs. To me, the need to standardize supplies, software, and to be transparent about repairing seems essential and commonsense.

HATTIS: How are you doing personally?

LEE: I would be lying if I said I was not a little burned out from our first surge. A second surge will only compound this problem. As a health care community, we need to be more open about burnout and depression. The story of Dr. Lorna Breen comes to mind. I worked with her personally during my time as an emergency medicine physician in New York City. She was an amazing emergency physician that ended up committing suicide because of what she saw with COVID-19. I do believe that her story is the tip of the iceberg.

HATTIS: Catch us up on your family.

LEE: The first surge was very tough, especially for my wife. She had to balance working from home and managing Zoom classes for our son, while I was often away at the hospital. Unfortunately, the inevitability of this happening again feels very real right now as our COVID numbers in Boston continue to tick up.

But there’s always bright spots. One night recently, our 5-year old son asked us how we know COVID is real if we cannot see it. We explained to him that he should think of it like a fart, where even if you can’t see it, you still know it is there.

 

Earlier interviews 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

The black swan of our time