On the COVID Wards
I was “activated” to duty on the inpatient COVID surge teams last week. I was worried, not only because it’s been a decade since I’ve been in charge of an inpatient service, but more so because SARS-CoV-2 is a new virus, and COVID19* is a new disease. How do we manage these patients? No one truly knows what works and what doesn’t. There’s no textbooks. There’s a relative handful of research studies, many with messy methods. It’s hard to conduct quality research during a pandemic; As a result, it’s hard to know how to interpret the data.
But my hospital sure as hell is trying. In addition to a bunch of unbelievably expedited clinical trials of our own, our peeps have reviewed and synthesized every damn piece of published research on COVID19 there is, creating an entire online library of concise, practical guidance for docs like me. The days leading up to my first shift were spent reading, reading, reading, as well as attending online orientation ZOOM calls featuring busy slides and loads of logistical details.
The day before I was to start, I went to the hospital to spend the morning orienting to the inpatient electronic medical record and getting familiar with all the work flow craziness. So much has changed, even from last month. There are no visitors allowed to the hospital at all, and to get in, you have to display your ID badge and your daily “COVID PASS”. This is an app on your phone with a short list of symptoms like “Have you had a fever/chills/cough/diarrhea/new congestion that is not allergies/ loss of sense of smell?” every single employee of our sprawling campus has to check “NO” and flash their “CLEARED FOR WORK” screen to the security guards. Then we all get a squirt of house-made hand sanitizer and a clean surgical mask. Because no visitors are allowed, everyone you see is a colleague: A lot a lot of determined-looking people wearing scrubs and Danskos, some with white coats, occasionally suits.
So much of the hospital has been converted to COVID19 care: We had almost 500 patients with confirmed or suspected infection at last update. Even the pediatric ICU is caring for adult COVID19 patients. I spent the morning orienting on a large unit that used to care for every manner of medical problem, but now it’s all COVID19 patients, every single one. And every time any staff member enters a patient room, they have to don all the layers: An N95 mask and plastic eye protection (we get one of each per day), and a disposable paper gown and gloves (these are discarded after each patient encounter). I learned that the way the teams evaluate patients has had to change to preserve our precious PPE, and to lower the risk of getting infected. First, we have instructions to “bundle” orders as much as possible, so that nurses don’t have to go in and out of rooms more often than is absolutely necessary. When doctors are rounding, the ideal is that only one team member goes into the room to actually see the patient, and only once a day. “It’s better if your resident goes into the room, and then you just call the patient later on their bedside phone,” they explained to me. I learned how to get the patient bedside phone number to print out on my list, along with other now-essential info: How much oxygen the patient was on, and the dates and results of their most recent three SARS-CoV-2 swabs.
I learned where to get my N95 mask for the day– they’re kept in a locked cabinet over the nursing supervisor’s desk– and how to recirculate it: We all have to write our name, hospital, the unit location, and a special location code in black Sharpie– it has to be a black Sharpie– across the front of the mask. At the end of the shift, it goes into a big bin with a gazillion others. Then they’re collected and decontaminated in a special process involving hydrogen peroxide. Afterwards, all the masks are inspected and individually packaged in boxes that look just like hamburger boxes, and shipped back to the units, where they get stored anywhere there’s room, which on our floor was the visitor lounge. After all, there’s no visitors, anymore.
And between patients, if you’re just charting or whatever and you need a break from the suffocating pressure of the N95 mask (they ARE tight!), or a place to rest your plastic glasses, you place it all in a paper dish that looks just like a French fry box, but you only get one, so you write your name on that with the Sharpie, too. That’s how people refer to them- your hamburger box and your French fry dish! (And you can wear your hospital-issued surgical mask to rest your face.) Your phone has to go into a Ziplock baggie, and yes, it still works.
There’s more, much more newly necessary weirdness. After a few hours, I felt like I had the hang of all the things I could possibly get the hang of, thanked my colleagues, and left the unit.
On a whim, I swung by the unit where I was going to be working, over on White 7, which used to be a surgical unit:
The doctor I was taking over for had said to call her for signout, but I just showed up instead. As we chatted, she realized that I spoke Spanish. “Can you help us with a patient care issue that’s come up?” she asked. “We need a translator, and in this case it might be better if it’s someone in person.”
I was happy to help of course, and so I got myself an N95, donned all the PPE, and went into the room with the team. I ended up getting pulled into this kind of complicated situation, which I figured was good because then when I started the next day, I would know what was going on. Which I thought would help make the first morning go smoothly.
Which it didn’t. Overnight, we got a transfer from the ICU, a patient with a lot of complex medical issues, who was still pretty sick. We spent a good chunk of the morning with that one patient, and our team was almost late for mid-morning rounds with the head nurse and case managers. Kudos to the excellent residents, both third years, one in psychiatry and one in neurology: They had learned their patients well and rounds went fine. They never missed a beat.
And that’s kind of how the rest of this week went. We kept ourselves one step ahead, learning the patients, and asking for help when we needed it. The hospitalist team and the infectious disease specialists had put together a network of backup support and resource pagers, and we called on them plenty. They were always there for us, never judging, always practical. I never magically transformed into a COVID19 expert, but I figured if I couldn’t be an amazing teaching attending who had all the answers, I could at least emphasize the basics. In the case of this illness, it’s communication and compassion.
Communication because patients are alone, their family members aren’t allowed to visit, at all, and we can’t talk to them in person. So we want to make absolutely sure that we always call family, every day. We’ll even call multiple family members, just to make sure they all know about any changes and plans. We’re kind of insane about this actually, because it’s just so important. The saddest are the patients who have no one to call. This is common, more than one would want to think.
Communication between team members is critical, too. Our hospital uses this in-house app called Voalte where everyone on the unit can text each other: Admins, nurses, doctors, housekeeping. We coordinate rounds and orders with the nurses this way, who are all awesome, BTW. When our patients have complications and other specialists are involved, we’re also able to arrange ZOOM case conferences with them. For one meeting, seven experts from all across the hospital got on a ZOOM call on short notice to discuss some puzzling findings in a very sick patient. We talked through what it might mean, came up with a list of possibilities and a plan, right then and there in real time, altogether. It was incredible, and honestly, I’m not sure it would have worked out pre-COVID19.
Compassion means reassuring people, because they’re often terrified. Being alone with no chance of family or friends to be with them makes it even worse. Compassion also means really trying to understand the patient’s perspective and get a grasp of their beliefs, because it can help their treatment. Many of our Latino patients are Catholic, and so I make it a point to ask about their faith. People can be visibly moved by this. We consult our Chaplaincy service a lot (they’ll call the patients and pray with them on the phone), and when it seems right, I’ll even pray with patients myself, quick little blessings, really. People brighten, and even seem strengthened by simple prayer. And that may be all psychological, but if it helps, it helps.
By the end of twelve hours every day, everything aches. My head, my heart, my feet. My last day of this first block, Saturday, I was so tired and distracted that I walked the half-mile to my usual parking lot, only to get there and realize it was a weekend and I’d parked in the garage right next to the hospital… Luckily, I love walking outside in the fresh air.
Once I’m home, no one is allowed near me until I’ve showered. I strip off everything, wrap it in a ball, and drop it straight in the laundry, then run for the tub. Shampoo and soap, a lot of it. Heck, I even wash out the insides of my nostrils. Only when I’m totally clean, then the kids can hug me, and they do.
*COVID19 stands for Coronavirus Disease of 2019, BTW