First in a series of reports from hospitals responding to the Covid-19 pandemic.
The doctor had treated patients in Liberia during the Ebola outbreak, in Saipan after a super typhoon, in the cholera-ravaged encampments of Haiti — and now she stood training a team for her next mission, this one in a carpeted Boston office overlooking a brick-oven pizza joint that was still serving pies.
“I don’t like to refer to Mass. General as a disaster setting, but this is a disaster we’re dealing with,” Lynn Black said, referring to the oncoming surge of Covid-19 cases at the Harvard teaching hospital.
Just four hours before, a few blocks away in a portrait-lined conference room, Massachusetts General Hospital’s incident commanders — the leaders who take the reins from the usual executives to get through an emergency — had pulled up a slide that illustrated what she meant. It depicted, in colored bars, the number of inpatients known to be infected with the new coronavirus over the past two weeks, as the in-house testing capacity ramped up from 20 or 30 samples a day to 400. On the morning of Saturday, March 14, there were three. By March 21, it was 15. By Monday the 23rd, there were 24 — and those were only the ones sick enough to have been admitted.
“We really are approaching the steep part of the curve,” said Paul Biddinger, director of the hospital’s center for disaster medicine and now the physician running the incident command team. He traced the slope with his finger. “We could probably all draw that freehand.”
That was why Black was now standing in a sports medicine clinic with a hodgepodge of medical professionals, including a vascular surgery nurse, a nurse practitioner from plastic surgery, a primary care physician who studies injection drug use, and a gastroenterologist with an interest in the effects of new-fangled cancer drugs on the gut, to name a few.
They had barely two hours to shape-shift into the pandemic-time equivalent of a family doctor’s office. Theirs was one transformation among many now playing out around the hospital and the world. At Mass. General, oncology units had become Covid units, and anesthesiology areas were being retrofitted for intensive care. In Connecticut, hospital beds were ready and waiting under the glaring lights and basketball hoops of a university gym. In Wuhan, China, hotels became wards for feverish, muscle-aching patients. Every instance was an exercise in medical improv, trying to turn a wild premise into a cogent scene.
Here, where physical therapists had watched the motions of injured athletes on the treadmill — “It literally looks like you walked into a Planet Fitness,” said Kaitlyn LeClair, a project manager helping to run the transition — the workers would use colored tape on the floor to figure out where to route different sorts of patients. They laughed nervously and shuffled their feet, taking it all in. It was Monday at 11:45 a.m.; the clinic was supposed to open at 2 that afternoon.
Officially, this sort of practice is known as RIC, for respiratory illness clinic, and it’s a place where patients can come to check if their sore throats are the result of the common cold, some other staple diagnosis, or Covid-19. There was already one testing site in the ambulance garage, with chairs taped six feet apart and 200 or 300 visitors coming through a day. The RIC provided a space to evaluate patients with milder symptoms but who were still potentially infectious.
It was initially set up within the hospital itself, taking over the digs of a women’s health clinic. But that spot provided too many avenues to and from other parts of the building; incident command didn’t want possible coronavirus-shedders to meander and expose workers elsewhere while heading in for a test. The hospital’s sports medicine clinic, in an office building a few blocks away, was perfect. There were even locker rooms, designed to funnel out the smell of sweat, which could be modified to whisk away air that might hold virus-carrying droplets. Over the past few days, builders had come in to erect temporary shiny white walls, like those that form the field office on a construction site, to distinguish staff-only zones. Now, it was moving day. And training day. And day 1 of patient visits.
“This is going to be a very infected area, and I want everybody to be safe,” said Black. She was wearing scrubs and a mask that puckered in and out with her every word. “There’s a difference when you practice in a setting like this. Our number one goal is patient care, and anyone who’s worked here at Mass. General — or anywhere else — as clinicians and care providers, when we see somebody who is in distress, we run toward them. That is visceral to who we are. We run to help them.”
She paused, looking up at the nurses and doctors and medical assistants leaning against the walls and the windows. “It is very challenging to say to you here,” she went on, “that if someone in the waiting room who is contaminated is having a seizure, you cannot run to them until you’ve donned your PPE.”
Donning personal protective equipment, it turns out, isn’t as quick or easy as it sounds. Just as the clinic itself was strictly divided up into areas that were clean and those that were at risk of being contaminated — a complex geography of potential infection — the same was true in miniature for each piece of PPE.
Slipping your head into a gown while you’re already wearing a mask meant smearing the inner surface of the gown — the one that would be against the worker’s clothes — over the outer surface of your mask. Instead, you had to rip apart the gown where it closed at the back of the neck, so you could simply put your arms straight into it, without involving your head. “The painful part is you’re going to need a buddy to get a little piece of tape and tape it for you,” he told the dozen or so assembled workers.
But as PPE supplies fluctuated with the surge in global demand, so had hospitals’ donning and doffing strategies. A few minutes later, the instructors revised that bit of advice. Ripping the neck fastening was the old way. Now, buddies or tape bits were no longer recommended.
The workers also got lessons in putting on their N95 respirators, more serious masks that they were only to use when performing procedures that could generate a fine spray of potentially infectious secretions. That includes swabbing the inside of a nostril to test for flu or coronavirus. “You’re not going to squeeze the bridge, you’re going to mold it like clay: press, press, press,” said Joann Pellegrino, a registered nurse, demonstrating how to flatten the crossbar of the mask over her nose and cheekbones.
In a way, Pellegrino was an old hand at coronavirus testing. She’d been one of the first nurses to staff the ambulance-garage site a few weeks ago. “It’s anxiety-provoking,” she said. “I think that’s normal that every day, with all the changes, that would only increase your anxiety. But you know, we just went with the flow.”
Over the weekend, she’d gone to see her granddaughters in suburban Wakefield. She hadn’t visited since she began working on coronavirus testing. “I’m not going near them,” she said. “I pulled up to their house, they were on the doorstep, and they left me food out front … meatballs and soup. They were sitting on the front step and I was down by the sidewalk.”
When one of the girls showed off being able to ride her bike without training wheels, Pellegrino began to cry. “It was kind of sad, but you do what you have to do,” she said.
What she and her colleagues had to do now was to put into practice everything they’d just heard about. There were four swabbing rooms — the carpets covered by clear taped-down plastic — where they could do rapid strep tests, nostril sampling to look for flu or Covid-19. In the normal exam rooms, they could take temperatures, feel lymph nodes, listen to lungs, but there was to be no tongue depressing, no looking in throats. As Black had said, “If somebody comes in and they meet criteria for strep throat and you’re not worried about an abscess, and they’re not doing temperature above 103.5, you don’t have to look in their throat.”
If somebody stopped breathing in the waiting room, because the clinic was not attached to the hospital, they were to call 911.
They would be operating at the deliberate pace of primary care with the knowledge that at any moment it might turn into an emergency, watching a crisis unfold exam by exam, test by test. It was a little after 1, and they still had some 45 minutes before the first patient might arrive. There shouldn’t be that many today, so they had time to settle in.
“Do we want to do a rehearsal?” said Michael Dougan, the gastroenterologist and immunology researcher. “I’m happy to be a pretend patient. We’re going to need providers and nurses.”
So he walked around to the patient entrance, where a makeshift wall had been put up as an intake booth. It had a window with holes drilled into it, and Dougan leaned his masked face in close. “I’m not feeling well, cough, cough,” he said.
He leaned closer, unable to hear what the person playing the receptionist was saying. “You’re going to have to shout for patients to hear,” he yelled.
Before the day was out, he’d swapped roles again, to care for the clinic’s first real patient.