As the COVID-19 pandemic unfolds, the UMHS Endeavour is putting the spotlight on UMHS grads who are working on the front lines in hospitals. UMHS 2018 grad Dr. Jordan Stav, an Emergency Medicine Resident at Ascension Macomb-Oakland Hospital in Michigan, shares his chilling and sobering account from the ER.
Dr. Stav spoke to the UMHS Endeavour with the proviso that he is not an infectious disease expert and is only sharing from his own experience.
The Front Lines of COVID-19
What’s it like working as a doctor now on the front lines of COVID-19, in a busy hospital emergency room?
“There is a lot of confusion and chaos, which leads to higher amounts of stress,” Dr. Stav said. “The policies set at the government level are lacking and reactive, as opposed to proactive. Most hospital systems are following similar protocols, but it is unknown at this time if they are effective. Many top leaders in the hospital and elsewhere are attempting to approach this pandemic from different perspectives and address the constantly changing challenges. Residents are being pulled from all non-essential rotations and being placed into areas of need (ICU, floor, ER, triage).”
“Surgical and specialty residents are being greatly affected in that many cannot scrub into procedures and are being asked to help in the four aforementioned areas of the hospital,” Dr. Stav said. “From a learning standpoint, it is action at all times, as if you are in a disaster or war zone. You are wearing PPE almost everywhere. Even into rooms where the patient does not currently have symptoms, because they still may develop them; which has occurred many times now. Your patient that came in for leg pain may be intubated in two days and found to have bilateral ground glass opacities on a CT scan. “
What do doctors need to know right now?
“There are more questions than answers at this time,” he said. “However, there is tons of learning, procedures, and effective helpful medicine to go around. The number-one rule is to protect yourself. If you are performing an invasive procedure on a PUI (person or patient under investigation) or confirmed COVID patient, then wear your CAPR or PAPR. You need to be healthy to help your patients. It is scary right now, but this is what caring for the truly sick looks like. Tons of learning still.”
The crisis has forced Dr. Stav to learn never-before-needed expertise. “I was taught how to have four patients hooked up to a single ventilator, which is a skill that is becoming increasingly likely that we’ll have to utilize in the future.”
What adjustments and precautions has he made in the workplace during this crisis?
“PPE on all patient encounters. N95 and goggles or shields with suspected patients. CAPR or PAPR with invasive procedures. No cavalier medicine. Treat every patient as if they may be exposed or a carrier. We have had multiple attendings and residents furloughed for treating patients with completely unrelated chief complaints that were found to be COVID positive later in the hospital stay. Even if someone is crashing, you don your PPE first.”
Dr. Stav has been treating COVID-19 patients and has sound advice for anyone working in hospitals right now.
“I cannot count the amount of PUIs I have treated. I have cared for confirmed positives as well, but who knows the actual numbers due to the lack of testing. PPE, PPE, PPE. Last night, I intubated a PUI patient in the ICU. As mentioned before, you don’t do anything without protecting yourself, even in rapidly progressing and unstable situations. Use viral filters if NPPV and/or intubation is necessary. Do not wear your own scrubs. I go into the surgical locker room, change into the hospital scrubs before every shift. Before I leave or after any invasive procedure, regardless of PPE, I change scrubs. I use the purple or blue top wipes on my shoes after shift. I do not wear my hospital shoes at home or anywhere else. I always put a small glove on my stethoscope if I have to auscultate anyone and after leaving the room, I use foam on my hands and stethoscope. Additionally, I always wipe down my dragon microphone, computer, and desk surface before each shift and sometimes in middle of each shift. If this sounds excessive, good. I would much rather be overly cautious than regretful.”
Doctors should look for certain symptoms that may indicate a patient must be tested for COVID-19. Dr. Stav said anyone who has a cough, fever, shortness of breath, diarrhea and vomiting might need a COVID-19 test.
“First, we test for strep, influenza, and a respiratory virus panel, “he said. “There is an estimated <2% chance of having a COVID co-infection with any of those bugs we test for. Additionally, if someone has a compelling history and any of the symptoms listed.”
“Regardless of symptoms, we do not currently test unless the patient is likely to require critical care, but that will likely change in the near future.”
Why is Need for COVID-19 Testing So Urgent?
“The virus is now community spread in my area, so screening for travel is useless,” Dr. Stav said. “The problem is the amount of testing available and turnaround times. At this time, many are not getting tested still. While unfortunate, the general public needs to understand social distancing and even self-quarantine is the best practice if they have URI symptoms. At this time, we are only testing those that we are admitting, and we are only admitting for profound hypoxia or significant comorbidities. That being said, policies are updating every hour and by the time I’m done answering this question will have changed. It is possible that, hopefully, greater, more far reaching testing will start be performed shortly; however, at this point, that is not the case.”
“With greater testing capabilities we can specifically isolate positives, but as of right now, everyone must act as if they are exposed and a carrier.”
New York, Seattle and other large cities are thinking about building temporary hospitals in hotels and convention centers, as well as possibly bringing in naval hospital ships, to treat emergency patients. Dr. Stav said he is not certain such measures are being considered just yet in metro area Detroit.
“If a hospital is large enough, it probably isn’t a horrible idea to dedicate a wing to COVID and PUI patients. As for building new facilities or using Carnival cruise ships and the like; the need to isolate patients is important. This, though, does not help alleviate the lack of staffing and supplies. Can’t have a hospital without ventilators, masks, doctors, and nurses. If someone can figure that part out, that could go a long way.”
In the interim, he said federal and state government are “absolutely” correct in pushing for mass production of ventilators, PPE (masks, etc.), sanitizers and other medical equipment.
Do all patients with confirmed or suspected COVID-19 need to be admitted to the hospital?
“No,” he said. “The vast majority of the public will end up getting this virus by most estimates. The vast majority of those who do get infected will have mild symptoms. Just because it is COVID doesn’t mean they have to be in the hospital. Use good clinical judgment as you would with any heart failure, COPD, or pneumonia patients. Those that are hypoxic and have comorbidities should likely be admitted. That being said, the data is evolving daily, as is the list of what qualifies as a significant comorbidity for this disease. Obesity seems to be a big problem. Diabetes is a huge problem. Both linked with worse morbidity and mortality. Asthma seems to be a large factor. As well as CAD and HTN. Follow your algorithms, but be a good clinician. As residents and students, you will not be making these final admit vs d/c decisions, but your voice can be heard if you know your information and argue a case intelligently. That being said, as a resident you will be in charge of deciding who needs to be intubated on the floor or in the ICU if no attending is present. Aim for an oxygen saturation greater that 88% on HiOx, or if you have to use a non-rebreather, put a mask over the patient and where aerosol PPE due to it being an open system. Once on the vent, practice ARDSnet strategies and attempt to maintain saturation >88%.”
Dr. Stav said he does not know how long COVID-19 patients requiring hospitalization need to be stay in a facility before being discharged.
“The answer, quite morbidly, is until they get better or pass away,” he said. “If they can breathe on room air and not be hypoxic, then they are probably good to go, but stay in self-quarantine. Unfortunately, we are seeing some patients improve on the ventilator and then after being extubated for 24 hours, code with no warning. So, caution is urged. Because we are attempting to keep the mildly symptomatic out of the hospital due to the strain on the system, if someone is getting admitted they are already truly ill and therefore their time to d/c will be longer regardless of their hospital course. More data will emerge the further we get into this. However, at this point this is a big question mark.”
Dr. Stav discussed current supportive treatments for COVID-19 patients with serious complications like respiratory failure, septic shock and organ failure.
“Extremely complicated and simple at the same time,” he said. “Those with Acute Hypoxic Respiratory failure are placed on a ventilator for two reasons in COVID: 1. These patients have decent chance of going into ARDS (Acute Respiratory Distress Syndrome); therefore, we need to control their PEEP and FiO2 effectively. 2.This closes their respiratory circuit and prevents them from aerosolizing the virus in the room the same way BiPAP or a nebulizer treatment would. Shock is complicated on these patients. Because of the likelihood to develop ARDS, we are hesitant to administer large fluid boluses.”
Certain medications are dangerous, and it is too early to talk about potential drug treatments right now. Dr. Stav said he believes NSAIDS (Advil and other forms of ibuoprofen) are controversial at this point and may have poorer outcomes, so he would use Tylenol over NSAIDS, but there is no definitive evidence one way or the other right now.
“We are also finding steroids to be potentially harmful,” he said. Many studies are looking into anti-viral and anti-malarial agents, which may demonstrate some relief, but there are no true results as of today. I know the pharmaceutical company TEVA just donated thousands of anti-malaria pills to US hospitals in anticipation of these being helpful. Some studies suggest Azithromycin can be beneficial. However, all these studies have been anecdotal to this point”.
He has specific advice for people with milder cases of COVID-19. What are some ways they are being treated?
“Rest, quarantine, Tylenol, hydration. Treat it like a regular URI. Just don’t use steroids; for whatever reason, these have demonstrated an increase in Relative Risk in developing severe symptoms. If you have a cough, cold, fever, n/v, diarrhea; stay home, unless you feel you cannot breathe.”
What Else do Medical Students Need to Know?
“This is a scary, but exciting time to be involved in the healthcare system,” Dr. Stav said. “This is not the fight we wanted, but it is exactly what we signed up for; to treat and protect the public. We will leave our training knowing everything there is to know about pandemic, respiratory viruses, treating the critically ill, and hospital operations by the time this wave of COVID passes. It will make us better doctors and leaders. We will have a much greater impact on policy development and we will be far more prepared for the next time this happens. It is exhausting, both physically and emotionally right now in our hospitals; but we’ll pull through. Especially those of us from Caribbean schools that already know how to persevere and come out on top. I hope everyone stays safe and uses this time wisely. Good luck.”
Dr. Stav said anyone with questions may email him and he will answer back as soon as possible.
COVID-19 Online Resources Recommended by Dr. Stav
The UMHS Endeavour and UMHS website will be updated in the coming days as news of the pandemic unfolds.
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