A report from the frontlines at MGH

‘We are very worried on the ICU side’

DR. JARONE LEE, a physician at Massachusetts General Hospital working on the frontlines of the COVID-19 pandemic, is very worried as predictions of infection rates run as high as 60 percent worldwide.

“I am a critical care doctor so I do see the sickest folks. We are very worried on the ICU side,” he said on the Codcast with Paul Hattis of Tufts University Medical School and John McDonough of Harvard’s TH Chan School of Public Health. (The interview was taped Friday afternoon.)

“At this point, we’re worried about the worst-case scenario, hoping for the best.,” Lee said.  “On the ICU side, if it gets to the point of Italy or some other places we’ve heard about in the world, we do not have the capacity to take care of that many patients. I believe that’s true probably for the US health system in general. We don’t have enough ventilators or ICU beds.”

Lee said government officials are urging the public to practice good personal hygiene and social distancing measures to slow the spread of the disease and reduce the number of cases per day so the health care system doesn’t get overwhelmed. Lee, however, cautions that the situation will get worse before it gets better.

“We are all worried that the cases are already there, and patients are going to get sicker,” Lee said. “The incubation is so long, somewhere between two to 14 days before some folks even show symptoms. We also know from some of the data out of other places that the sicker ones usually present later, somewhere between 8 to 9 to 10 days after having symptoms. So it’s sort of a late presentation. We’re at the upslope of the curve.”

Hattis cited one health analyst who says eastern Massachusetts has a total of 600 intensive care unit (ICU) beds, which are typically occupied 75 percent of the time. He said that doesn’t leave a lot of margin for a huge influx of COVID-19 patients.

Lee said hospitals are also establishing standards of care for times when staff and equipment are in short supply. In Italy, he said, there’s been a lot of “moral distress” by frontline staff having to choose who will receive care and who won’t. “This moral stress in many ways is not fully preventable, but we can definitely curtail it a lot with the correct system so we don’t have a bedside clinician making  impossible decisions,” he said.

McDonough said testing for the virus appears to be the big fail so far, with not enough tests being conducted. (Testing was lagging as of Friday, but appears to be picking up.)

Lee agreed.  “I’m not an expert on the testing, but I feel like it is a big problem. We don’t have enough tests to test everyone that we probably should and want,” he said. “If we had access to more tests, we would be testing more folks, including our own staff if they’re potentially exposed and everything else. If there’s anything we can do to increase the number of tests that would be ideal.”

Lee said Massachusetts General is working on its own test, which should be available soon. Several private testing companies have also won approval to do their own COVID-19 tests. Once more testing is done, officials in Massachusetts may get a better picture of the size of the problem.

“It’s in some ways good and bad news. The bad news is we’re probably not testing enough so there’s probably a lot of folks who are positive that we do not know about,” Lee said. “But at the same time we also know a lot of folks are probably asymptomatic or mildly symptomatic and it doesn’t really cause them any issues. And because we don’t have the true number of folks who are really infected, I think a lot of these reports of mortality and everything else are probably higher than they really are.”

One problem with COVID-19 is that the symptoms take so long to develop that people can be spreading the disease without really knowing it.

“That is what is so unique about this one. It is the common cold virus, the coronavirus, so most folks might not even know they have it or just have the sniffles or low grade fever. It’s not them that we’re concerned about. It’s the folks who are at high risk for complications – mostly the elderly with comorbidities, with other diseases. … These are the folks who really get devastated by the flu and corona.”

Lee said Massachusetts General is planning for a surge of patients, trying to figure out how to expand its ICU space, leverage resources across the hospital, and protect hospital staff from being infected. He said roughly 20 percent of health care workers ended up being infected in China, a percentage that dropped to 10 percent in Italy.

“That shows us that health care workers, first responders, are very high risk,” he said. “What we do have now is we have the time. We’re actively planning and working on teaching everyone the proper way of using their ppe, their personal protective equipment, and different ways of taking it off and putting it on.”

Lee said the workforce bench at Massachusetts General is deep right now but everyone is worried. He said infection isn’t the only concern in keeping staffing levels up. “One thing we are encountering, and this is personal, too, is that my son’s school just closed. So child care is a big issue. We have a lot of two physician families here. Everyone is trying to figure that out,” he said.

McDonough wanted to know how Lee, an Asian-American physician, feels about references to COVID-19 as the Wuhan or Chinese virus. Lee said his colleagues are all respectful, but he nevertheless tries to stifle coughs or sneezes (he has allergies) when he rides the subway to work because he fears people look at him differently.

“I haven’t quite noticed that personally, but I have heard multiple personal accounts of things that happened,” he said. “I do very much worry that folks are thinking that this is the Chinese virus, the Wuhan virus. I’ve heard other names for it, of course. We definitely do need to think of this and talk about it not as a Chinese virus in any way. This is a coronavirus that’s affecting the whole world and we’re all in it together. It did come from China from what we can tell, but they’re also big victims in this as well.”