U.S. hospitals are bracing for an onslaught of patients sickened by the new coronavirus, shoring up supplies, refining crisis plans, and putting on a brave face. But there’s another narrative at play: Many health workers feel left in the lurch.
STAT heard in recent days from dozens of frontline hospital employees, and depending on where they worked, they presented sharply different pictures of preparedness. There are those who believe their health systems are equipped to weather the coming storm. Others are less sure.
“For the hospitals, it depends on who is in charge — what camp your leadership is in,” an anesthesiologist on the East Coast, speaking on the condition of anonymity, told STAT. “There’s been the ‘just the flu’ contingent, and everyone else.”
Terry Adirim, a trained pediatric emergency physician who helps lead clinical care at Florida Atlantic University College of Medicine, agreed that there is “variability in preparedness” that has to do with hospital leadership. But the former senior Department of Defense and Homeland Security official added, “I think that comes because federal guidances haven’t been as strong as they could be.”
Delays in rolling out coronavirus tests mean it’s impossible to know how many people are infected, and how bad the epidemic will get. Knowing what to be ready for is difficult in these circumstances, and the level of preparedness appears to vary from state to state, city to city, hospital to hospital — and from individual to individual.
Some hospitals have engineered new protocols to triage ill patients — turning to tools like hotlines and telemedicine to advise those with mild illness on how to manage their symptoms. They have devised backup plans should intensive care units become overrun, including stopping elective surgeries and preparing to expand critical care into operating rooms.
But others are lagging.
Despite assurances from their hospitals’ leadership, many frontline workers are worried about emergency departments overrun, and too few life-support devices to go around. They’re afraid of protective supplies running low and of contracting the virus themselves — and passing it along to their loved ones. In China, 3,300 health workers were sickened by the virus, and 13 died.
Reports from the Seattle area, the epicenter of the U.S. outbreak, indicate that some of the city’s hospitals are nearly overwhelmed. One hospital’s note to staff, shared with New York Times columnist Nicholas Kristof, says the “local COVID-19 trajectory is likely to be similar to that of Northern Italy.” The hospital is down to a four-day supply of gloves.
“Our health care staff has been taking our N95 masks, because people are scared for their families,” said a resident physician in Philadelphia, one of the dozens of people who responded to STAT’s callout for health workers’ stories. “I’m worried about my parents, too.”
Hospital employees have uniformly been kept abreast of Covid-19 preparations through emails and web-based training modules. But there has been little in the way of in-person training on protocols for dealing with a virulent contagion. Although many first responders have been schooled in dealing with highly infectious diseases, other hospital employees are left wondering if they’ll be safe.
“This is unlike any other outbreak I’ve been involved with,” said Rainee Sinroll, a nurse in Missouri who worked through the H1N1 epidemic and has spoken extensively with other health workers in her region. “There’s absolutely no training and information to the staff that will be involved. And no message to the community that would lower cases, thereby allowing better care in our facilities.”
A surgical tech in New Mexico is expecting to see Covid-19 patients coming into her hospital, since the first cases were discovered in the state just a few days ago. But she’s deeply unhappy with the guidance from her hospital to date.
“Some of my colleagues and I feel let down,” said Alyssa Estrada, an instrument sterilization technician who says her hospital is already short-staffed. “If something happens, how are we going to keep our department running if we don’t have the manpower?”
There may be enough masks and gowns at her hospital, she said, but she’s already having difficulty getting sterilization equipment. Sanitation wipes, and sprays that get rid of biofilms — that is, slimy amalgamations of pathogens that reside on equipment — are in short supply.
“It’s kind of strange, because I feel like the city has been warning us more than the actual hospital has,” she said. “In the end, we’re all going to have to work together if this gets serious — and I feel like we all need to be more up-to-date on the information.”
Patients hospitalized with Covid-19 typically have pneumonia and difficulty breathing, which would require treatment with oxygen or, in severe cases, intubation and being hooked up to a ventilator. Physicians see these cases on a regular basis, but treating them in droves could overwhelm a hospital’s capacity.
“I’m concerned we won’t have enough epinephrine or albuterol — these are the bread and butter meds we use every day for pneumonias,” a pediatric ICU doctor in Chicago said.
The news reports from China, Iran, and Italy in particular has been sobering. Health workers in some places in Italy have had to choose which patient gets ventilator care, and which patient will not, according to reports from physicians there.
Many hospitals in the U.S. are already operating at high capacity. There are 45,000 ICU hospital beds and 160,000 ventilators nationwide — but, in the event of a moderate outbreak, about 200,000 Americans would need such intensive care. And that leaves out all the patients who might need lifesaving procedures, equipment, and medications for reasons other than coronavirus.
“It’s frightening, because for me as a doctor, I realize there is going to be a certain point where we’ll be forced to make decisions we’re not comfortable making,” the resident physician in Philadelphia said.
Though she’s received plenty of training in how to treat patients sickened by severe pneumonia, she said her medical education hasn’t involved making these heart-wrenching triage decisions.
“We’ve been so blessed by an excess of resources that we’ve never had to withdraw care from someone’s loved one because we need their ventilator for someone else,” she said. “But I’m scared of that happening.”
Many health systems say they are confident in their ability to tackle a surge of novel coronavirus cases.
Stanford University’s health system, for instance, has “redefined its triage process,” according to Sam Shen, a clinical associate professor of emergency medicine. It has set up a drive-through clinic for ill patients, in operation since Monday, that’s meant to test for coronavirus once tests are readily available. Severely ill patients will be directed immediately to negative-pressure rooms.
The university is also setting up tents in front of the emergency department entrance, to create an isolation space so patients with possible Covid-19 infections don’t need to enter the ER.
Mount Sinai Hospital in New York City has kicked off a telemedicine program, as have several other hospitals around the country. Like Stanford, the Manhattan health system has detailed triage plans — with tools to divert milder cases and bring the critical patients in for intensive care.
“I think we’re prepared,” said Jolion McGreevy, medical director of the Mount Sinai Hospital emergency department. “We have the resources, and it’s all being coordinated by a system command center that has high leadership.”
Large hospitals in many cities compete for patients, but the three major health systems in the Cleveland area — University Hospitals, Cleveland Clinic, and MetroHealth are absorbing the lessons taught by hard-hit cities like Wuhan in China and Bergamo in Italy.
“We have a trifecta approach in the city of Cleveland to mobilize joint resources for ambulatory care, mirroring what we’re seeing in other cities abroad,” said Robert Hughes, associate medical director of the department of emergency medicine at University Hospitals. “I’ve found that the collaborative spirit between the health systems in our city has been better for the community we serve.”
The fallout from the national dearth of Covid-19 testing kits looms, as well. Health workers who have fallen ill worry whether they have a cold, the flu, or the novel coronavirus — and most have no way of knowing the truth.
An East Coast emergency room physician who wished to remain anonymous has been ill for several weeks — with symptoms that appear, in her professional opinion, to be consistent with Covid-19. Although confirmed negative for the flu and other respiratory viral illnesses, the physician was denied coronavirus testing because there was no confirmed exposure to another patient ill with the disease.
“I’ve missed several weeks of work, unpaid, to avoid putting patients at risk,” the physician said. “I’m frustrated that I still can’t get tested to ensure I am safe to return to work.”
A certified nurse assistant in Alabama said that she, too, has been recently ill with a virus — and hasn’t had access to testing, despite working with a vulnerable population. The situation has been “very confusing, arbitrary, chaotic!” she said.
“No one among the CNA staff is talking about this in any meaningful way,” she said. “If the nurses are, I don’t know about it.”
In her hospital in Florida, Adirim has seen a disconnect in the attitudes of health workers glued to the news and others who have adopted a wait-and-watch outlook.
“I still hear other doctors in the hallways, saying this is just like the flu,” the East Coast anesthesiologist said. “Not everyone has been taking this as seriously as they should.”
Last month, she used her own money to buy goggles for herself and her husband — to protect against the virus, should it go airborne when patients are put on ventilators.
“If we hadn’t bought those goggles, we wouldn’t have anything,” she said.
In China and Italy, as health workers fell ill with Covid-19, health professionals from other specialties were trained to replace them. That very well might happen in the U.S., Adirim said.
When working with the Department of Homeland Security on prior epidemics, such as H1N1, Adirim’s team considered the possibility of health worker burnout or attrition — whether, under the threat of exhaustion or illness, employees would stop showing up at work.
But that hasn’t happened in Italy, or in China, nor during prior epidemics. The jury’s still out on the U.S. response, Adirim said, but she thinks that health workers will rise to the occasion and work tirelessly to combat the pandemic.
“I think those of us who go into health care fields understand that risk,” Adirim said.