“In A Pandemic, There Are No Emergencies”

For nearly eight billion people, what was supposed to have been a temporary way of life to combat a public health crisis has slowly become “the new normal.” In just a short time, the coronavirus (COVID-19) has torn through major cities, tourist towns, and impoverished communities, quickly finding its way to almost every part of the world. In turn, healthcare workers have had to adapt at a breathtaking pace.

Hospitals and clinics now operate under the assumption that every patient could potentially be infected with COVID-19. Processes are being modified or rewritten to ensure the safety of not just patients, but also of essential medical personnel. Most hospitals require temperature checks, oxygen stats testing, and an N95 mask. These changes, coupled with an unfamiliarity with the virus, have resulted in a different training experience for students and residents.

HOSPITALS CONTEND WITH RESOURCES AND STAFFING SHORTAGES

Dr. Shayna Popkin pictured wearing her personal protective equipment.

After the World Health Organization declared a worldwide pandemic, almost all teaching hospitals and preceptors made the decision to pull students from their rotations or externships. As frustrating as this was for the students, hospitals and clinics had to consider both a dwindling supply of personal protective equipment (PPE) and the extreme danger the virus also poses for young people, a fact that has become increasingly evident as the pandemic continues. Though it was initially reported that the most severe symptoms were seen in individuals over the age of 65, young people are also likely to deteriorate quickly.

“You essentially watch them almost die,” said Shayna Popkin, DO ‘19, during a webinar hosted by RVUCOM alumni in May. “This could be my cousin or someone in my family. Once you see it, it’s not hard to stay home. We have no students at my hospital right now because it’s not worth a student’s life.” In the time since the webinar took place, hospitals are now preparing for new interns to arrive and preparing to re-open for elective procedures, understanding that COVID-19 will be a part of the “new normal” for months or years to come. Of course, depending on the severity of new waves or how society responds, that could once again change.

While student doctors and physician assistant students have been removed from externships and rotations, residents have found themselves in the unusual situation of learning about a disease alongside their attending physicians. Dr. Popkin, a psychiatry resident at George Washington University, explained that normally she would have presented a diagnosis to her attending physician followed by a differential, but now she and the attending must formulate both.

During the Emergency Department portion of her residency, Dr. Popkin also encountered an additional obstacle: a lack of specialty consults. In an effort to limit their exposure to COVID-19, most physicians have scaled back their services, making an exception only when a patient is in critical condition. This means that physicians specializing in emergency medicine must now diagnose and treat patients with illnesses and injuries outside of their specialty.

Dr. Kashyap Kaul also serves as the Resident Medical Director for Northern Valley EMS and LVHN-MedEvac.

Kashyap Kaul, DO ‘18, an Emergency Medicine resident at Lehigh Valley Health Network, has experienced a similar lack of staffing, but for a different reason. “Half of our [Intensive Care Unit] team was taken out due to exposure to a positive patient,” he said during the webinar. “Another team had a patient test negative twice, then test positive later, leading to the team being quarantined.” Dr. Kaul suspects the patient was exposed to COVID-19 at the hospital.

In addition to the lack of testing, “the tests [themselves] are not great,” Dr. Kaul said, a sentiment echoed by healthcare workers nationwide. Many times, he explained, patients have tested negative while currently infected or asymptomatic or when retested after a positive result. In short, the tests are faulty, perhaps as a result of being mishandled in transit. As physicians, Drs. Kaul and Popkin must rely primarily on their own diagnosis rather than the tests themselves.

WHAT DOES IMMUNITY LOOK LIKE IN THE FACE OF THE UNKNOWN?

The unprecedented societal disruption caused by COVID-19 has placed an additional burden on physicians and scientists to understand and contain the virus expeditiously. But the unknowns surrounding the virus weigh heavily on them. “Once it’s there, you can normalize it. But waiting and not knowing, that is hard. It’s a lot of ‘what ifs’,” said Dr. Popkin.

Back in May, when the webinar was hosted, it was not known what the reinfection rate was or whether the virus was latent in the system. Physicians could not understand why some individuals did not recover fully and/or tested positive for COVID-19 more than 50 days out. Immunity has also been shrouded in the unknown, and physicians are hoping that current ongoing clinical trials and research will shed light on how some individuals develop robust antibodies and others do not. One guess is that those who recover from being exposed to high concentrations of viral particles—the kind that leads to a more severe immune system response requiring a ventilator—have increased antibody production leading to longer immunity. This, however, has not yet been confirmed or disproven by peer-reviewed studies.

Initially, those older adults were determined to be the most vulnerable, because of the severity of their symptoms. However, adults and children have also presented with multiple vascular issues, explained Dr. Kaul, including elevated D-dimer—when the blood becomes more hyper-coagulable—strokes, blood clots, and Pernio, the inflammatory disease that leads to “COVID Toes”.

Another rare inflammatory disease, Kawasaki’s Disease, which causes the blood vessels to become inflamed or swollen throughout the body, has emerged as a concern for children, along with Pediatric Multisystem Inflammatory Syndrome, which presents symptoms of Kawasaki’s, as well as severe abdominal pain, diarrhea, and high fevers. “Although clinically we are seeing a small amount of COVID-19 positive children present like this, we do not have the research or data to understand why it is affecting them so.” Adults have also displayed these inflammatory symptoms. 

PATIENT CARE CHANGES IN RESPONSE TO COVID-19

As unknowns persist, hospital beds fill to capacity, and wards are converted to treat COVID-19 patients, ER physicians like Dr. Kaul must contend with a new reality: “There are no emergencies in a pandemic.” In one instance, a patient’s blood pressure began to crash after being brought into Dr. Kaul’s emergency room. Before they could treat the patient, physicians and nurses had to stop to don PPE. In a pandemic, the safety of healthcare workers is of the utmost importance, and any patient who is admitted in for any reason is assumed to have COVID-19 unless proven otherwise. In this case, the patient ended up coding.

This is not the norm. “If someone is coding, everyone would immediately run in to start chest compressions,” Dr. Popkin explained further. “Now we have to be protected even if that delays care by 30 to 45 seconds. If the patient needs CPR, this will not happen until the healthcare team is in correct PPE, including a Powered Air Purifying Respirator (PAPR) for a patient who needs to be intubated.” 

Essentially, doctors have had to adjust their philosophy. Under normal circumstances, a physician prioritizes patient care above all. “While this is still the case,” said Dr. Popkin, “we also have to think about what is best for the providers, what is best for other patients, what is the best use of resources, and what is best for public health.” This shift in philosophy means delaying care to don PPE, reconsidering CPR (which leads to rib fractures) for elderly patients with multiple medical comorbidities, or conserving ventilators for those with a higher chance of recovery. “These are not normal decisions that we are usually expected to make as residents. [While battling this pandemic], we have had to ensure we keep our mind set on patient care but also on public health and what is best for the community. It makes one think in an existential way as opposed to just a medical way.”

HOSPITALS STRUGGLE TO STAY OPEN

Lauded as heroes on the frontlines, physicians in the United States are also part of a healthcare system that is not fully prepared to grapple with the coronavirus’ volatile nature and rare, but devastating patient outcomes. Medicine is not a recession-proof industry and, since March, hospitals have been stretched thin by the cancellation of elective procedures.

Today, most hospitals have transitioned to treating only urgent or emergent cases, such as a herniated disk that could cause nerve damage or a disk herniation compressing the spinal cord that could lead to immediate nerve damage. A knee replacement due to pain, however, would not be treated. As the pandemic persists, physicians and staff continue to be placed at great risk of contracting it, and hospitals need to prepare for an increase of Worker’s Compensations.  

Dr. Popkin coming home to her German Shepherd.

AT THE END OF THE DAY

Hospitals are also at the point where multiple “non-essential” staff, such as physical therapists, transporters, lab technicians, and even nurses, have been laid off or forced to reduce work hours. “From what I know, almost everywhere has a hiring freeze, and salaries will not have their normal pay bump due to inflation,” said Dr. Popkin. However, residents across the country have been protected and will still receive their annual raises.

Throughout all of this, some doctors and hospital staff are treating patients without the emotional support they need to weather the long hours and endless shifts. Due to their constant risk of exposure, many physicians and hospital staff have had to quarantine from family and loved ones, often for long periods of time.

“The best thing I can possibly do for my mental health is that, when I leave the hospital, I leave the hospital,” said Dr. Popkin. “Take your mind away from the codes and the intubations you’ve seen.” Another way Dr. Popkin manages her stress is by limiting how much she reads up on the virus to combat what has become known as “COVID fatigue,” while purposely absorbing herself in more trivial activities like Instagram. “You can become so involved in it that you don’t realize how much it’s affecting you.”  

Being a physician on the frontlines means an increased level of maturity. “I feel like I’m carrying a heavier weight on my shoulders than just an intern” Dr. Popkin concluded. “Working through a pandemic these last few months has matured [my fellow residents and I] as physicians.”  

On Monday, September 21st, Drs. Shayna Popkin and Kashyap Kaul will be joining a group of RVU alums for a panel discussion on what it is like to be a resident during a pandemic. For more details about the event, go to the RVU Facebook page here.

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