Dr. Daniel Asher, a 2017 UMHS graduate, completed a Family Medicine residency recently at Piedmont Medical Center in Columbus, GA and will return to the same facility in the fall as a hospitalist. Over the past few months, Dr. Asher has treated countless COVID-19 patients as the pandemic has unfolded in Georgia and nationwide.
In the latest installment of our UMHS Alumni On the Front Line series, we spoke to Dr. Asher about what it has been like working in a hospital during this unprecedented time. We discussed everything from dealing with the early cases of COVID-19 and an overwhelmed Emergency Room and ICU to making necessary adjustments and the emotional drain of losing patients, treatments that didn’t work and ones that do, the promise of a vaccine and more.
Dr. Daniel Asher. Photo: Courtesy of Dr. Asher.
What’s It Like Being a Doctor On the Front Lines of COVID-19?
For Dr. Asher, originally from Baltimore, MD, working as a Family Medicine resident during the onset of the COVID-19 pandemic was a challenge that he, like most doctors, was not prepared to handle. In a telephone interview with the UMHS Endeavour, Dr. Asher discussed the day-to-day challenges of working in a hospital on the front lines the past few months.
“It’s definitely been novel and unpredictable. Guidelines for this disease have been changing daily and so we really don’t know exactly how to treat and respond to this,” he said. “Usually we’re trained to treat sick people but it’s very unusual to be caring for our own [healthcare workers], that being nurses who get sick and also doctors who get sick so it’s a lot of novel experiences, very different and this puts everyone very much on edge.”
Fortunately, Piedmont Medical Center did not have a PPE shortage, unlike many healthcare facilities.
“Luckily for us, we didn’t get that PPE shortage [others had] as we were slow on the first wave. We are a regional hospital so we get patients from about a 200-mile radius and we have a lot of people coming from the really hard-hit areas. We have been blessed to have had a lot of companies and individuals donating PPE. Obviously as this pandemic continues, a PPE shortage is something we definitely will have to take into consideration. Our program specifically was able to come up with our own stash of PPE. We have stopped allowing visitors to come to the hospital in an attempt to limit the spread. At our hospital, the intensivist [a board-certified physician who provides special care for critically ill patients] and the anesthesiologists are the only people qualified to manage the critically ill COVID-19 patients, especially those who require intubations and chest tubes. Initially, resident interaction with COVID patients was limited. As the numbers have increased dramatically in the past few months, the hospital and residency program has had no choice but to utilize the residents as much as possible.”
Losing so many patients in a short time period was extremely difficult for Dr. Asher and the hospital staff.
“Losing any patient is going to be a difficult scenario but unfortunately with COVID-19, it is very much unpredictable,” Dr. Asher said. “One minute you have a patient who comes in requiring minimal oxygen and then literally 30 minutes later the patient crashes and requires oxygen support via mechanical ventilation. There is just no telling how fast it is going to happen.”
Dr. Asher recalled one particularly stressful shift.
“I can tell you a specific scenario I had that kind of hit me a little bit harder. I was on my night shift as the head third-year resident. There were two rapid responses back to back called on the COVID floor and there was only one Intensivist. Unfortunately, the intensivist was already tangled up with a patient downstairs that required a chest tube. I found myself being the first physician present to the first room. The patient stopped breathing and subsequently coded (heart stopped beating) and so ACLS was initiated. This patient needed to be intubated and the only people who were qualified to intubate a COVID patient (intensivist and anesthesiologist) were not present. I watched this patient go from hypoxic [a deficiency in the amount of oxygen reaching body tissues] to anoxic in a matter of minutes and I couldn’t do a thing about it. Oxygenating with an AMBU (Artificial Manual Breathing Unit) bag was prohibited as it is thought to aerosolize the virus and potentially spread it to everyone in the room.”
“I literally just stood there and watched this patient go. No matter how many compressions you do, the patient still needs oxygen so he went from hypoxic to anoxic in no time and I couldn’t do anything. This scenario was one of the first deaths of COVID-19 in our hospital and we learned a lot from it. They started teaching us third-year [residents] how to manage difficult airways. What was also difficult to process is the fact that we can’t have visitors in the hospital. As a result, these patients basically die alone, in our hands, without family members around to say good-bye.”
Symptoms of COVID-19: What Doctors Must Know
Besides the rising cases and alarming numbers of deaths, Dr. Asher has witnessed patients with many kinds of symptoms. What are some of the more prevalent symptoms?
“The most common things are cough, fever, sore throat, myalgias, anosmia [loss of smell]. We’ve also started to pick up on some gastrointestinal things like diarrhea and abdominal pain. Unfortunately, there are a lot of nonspecific things that very much mimic strep throat and the flu. In the more severe cases, patients present with shortness of breath, difficulty breathing, elevated heart and respiratory rate. Symptoms usually have a spontaneous onset. We are basically testing anyone who has a nonspecific fever, cough, and loss of smell for COVID.
In the early days of the pandemic back in March and April, getting a COVID-19 test often involved going to a hospital and waiting in a long line of often sick people in an outdoor tent just to get a swab test and waiting days to get a result. Now drive-through testing is standard and readily available in many states, and many doctors are ordering COVID-19 antibody tests along with regular blood work for patients, and one can get results much faster. Dr. Asher sees the increase in testing as a necessary step in controlling the virus.
“I think now we’re doing a much better job of testing,” he said. “We’re seeing a lot more people test positive. Specifically, at our hospital; they will call us. We’re doing a lot more telemedicine so if we know anyone who think they may have it, we have them call Piedmont Command Center which is kind of like the Piedmont hub and they’ll answer some questions and have the epidemiologist there answer some questions with the patient and they’ll deem whether or not the patient needs to be tested. A lot of random organizations here in town are putting together free COVID-19 testing like at the local high school so I think it’s a lot more available now than it was, which is good.”
There has been some debate over which COVID-19 tests are better, the nasal swab test or the antibody blood test. Are the nasal swab tests more accurate? It depends on certain factors.
“Whoever is doing the nasal swab test has to get a really good nasal swab and go really far back into the nasopharynx. The false negatives with swabs are a lot higher,” he said, noting that the antibody blood tests are a bit more “user friendly” for healthcare workers.
How Are COVID-19 Patients Treated?
When a patient is positive for COVID-19 and has symptoms and is actually admitted to a hospital, a number of steps are taken.
“Anybody that needs to be admitted [to hospital], every single one of them needs to have a large intravenous line. That was an initial issue we ran into early on in the pandemic. Normally a patient with pneumonia won’t necessarily require fluids or an IV. However, the unpredictable nature of COVID and the increased possibility of these patients coding, you definitely need a central line to administer pressors [used to treat hypotension in ICU patients] if warranted. A large IV line is also helpful when administering several different things at once. COVID patients are now getting fluids, antiviral, anticoagulants etc.”
Isolating patients is also crucial, and that can be difficult when the ICU is full. To work around this, Dr. Asher said his hospital opened a new wing at the hospital just for COVID patients.
“We have [a monitor] that is almost like a baby camera in every COVID room so nurses can watch from outside without them having to go in constantly. Definitely know your patients well and constantly check up on them, and obviously try your best not to expose yourself as much as possible so you’re going to have to really rely on your nurses."
What else do doctors and nurses need to do? “One, try not to expose yourself as much as possible. Everybody is sick until deemed otherwise, especially initially in the ER if the ED physician didn’t do a COVID-19 test, just go in there with your PPE regardless. We had an outbreak here in the hospital and we thought it was like a normal CHF [congestive heart failure] exacerbation. The patient was later on tested for COVID and tested positive. 15 nurses subsequently got exposed and sick and needed to quarantine at home. So, we’ve had to contend with things like that.”
Separating COVID-19 emergency patients from non-COVID-19 patients can also be tricky. At Piedmont Medical Center, staff try to separate patients if possible.
“But it’s an issue of whether it’s a true heart [issue] or heart issue plus COVID-19. A lot of them think it’s just a basic heart thing and all of a sudden, they test positive for COVID-19, too. They might be asymptomatic but still be able to pass it on.”
For now, the hospital has gradually started doing elective surgeries again. For all surgeries, patients must have a COVID-19 test as a precaution.
“They need to make sure whether they are COVID-19 positive or not and I think we did have a case where something like that happened where a patient had a ruptured ulcer or something like that and needed emergency surgery but they wouldn’t do it until the COVID-19 test came back. The patient did not die but surgery was definitely delayed so as not to needlessly expose others”
Dr. Asher in full PPE at work on the front lines. Photo: Courtesy of Dr. Asher.
COVID-19 Treatments & Discharge Guidelines
When someone is hospitalized with COVID-19, how long do they need to remain hospitalized?
“Basically, until they are asymptomatic or fever free for at least 72 hours and then they can go,” Dr. Asher said. “In the hospital, we are having the patients lie on their stomachs because for some reason that seems to be doing well for them. This is called proning. We’re giving them as much oxygen as needed. We definitely don’t discharge any patient who is still requiring oxygen. We also look at some laboratory levels too, we are able to see if some things are improving and that usually means they are close to discharge. Things like their liver function, LDH [lactate dehydrogenase], CRP [c-reactive protein, a protein made by your liver in response to an inflammation]. We are able to trend labs and see the progression of the disease and whether or not they are responding to our interventions. Once we see those things normalize and the patient is doing a lot better and is fever- free for 72 hours, that’s usually the discharging criteria.”
Current treatments that have helped COVID-19 patient include remdesivir (an antiviral drug originally used to treat Ebola) and the steroid Decadron (dexamethasone). The controversial treatment of hydroxychloroquine, an anti-malaria drug, and azithromycin, an antibiotic commonly by its brand name, Zithromax or “Z-Pack,” is no longer being given to COVID-19 patients. What went wrong with using the two drugs? Although some touted the drug combination as a “cure,” Dr. Asher said it turned out to be “quite the opposite.”
“Initially, we were treating patients with the hydroxychloroquine and the azithromycin,” he said. “Some of the issues we found initially were that a lot of people ran into liver failure because of the hydroxychloroquine and the two medications together, hydroxychloroquine and azithromycin, both those medications individually can cause fatal arrythmias [abnormal or irregular heartbeats]. Putting them together made it almost like tenfold and so we had a lot of patients die of fatal arrythmias out of nowhere and so we definitely stopped that early on.”
Two new treatments have shown promise.
“We have had a lot of success with the remdesivir and then there’s a new study that came out almost two or three weeks ago about using systemic Decadron [generic name is dexamethasone] which is a steroid. Very early on in the admission which has shown to improve mortality and is very contraindicatory to the whole idea of COVID-19 being an acute respiratory syndrome. For ARDS [acute respiratory distress syndrome] patients we don’t normally give steroids because often steroids have been proven to worsen mortality rates but for some reason with COVID-19, it has shown to improve mortality rates so that is another thing we are using.”
Dr. Asher said Decadron is often used to treat children with croup, a common lung infection in young children. “It’s been proven to also slow down and lessen the inflammatory response COVID-19 patients.”
Treating Patients with Milder Cases of COVID-19
Fortunately, not all patients with COVID-19 need to be hospitalized. Many can recover at home. Dr. Asher discussed the many ways milder cases are being treated.
“I’ve dealt with a lot of those,” he said. “[For milder cases], definitely keep a thermometer around and a mobile pulse oximeter machine. We tell our patients to monitor their temperature and oxygen saturation. If their oxygen saturation goes below 90 percent with exertion or 88 percent at rest, then we tell them to come into the ER. If their temperature is not being managed with Tylenol or an NSAID, things like that, those are reasons to come into the hospital. Otherwise, we tell them to stay as active as possible and if they are going outside [with a mask] do a brisk walk just to keep their lungs open and functioning. The majority of these people are grossly asymptomatic and will have a sudden minor complaint of a nonspecific cough or body aches. Patients with minor complaints can usually quarantine at home. Patients are usually retested once the symptoms and fever have resolved.
A protest against COVID-19 shelter-in-place orders in California in May 2020. Georgia and other states had similar protests, urging local governments to end lockdowns. Photo: Hu Nhu/Wikimedia Commons.
Did Ending Lockdowns Too Early Create COVID-19 Spikes?
There has been major media coverage about many states, including Georgia, ending lockdowns too early, and some say this has created many of the COVID-19 spikes currently happening in some states. How does this make Dr. Asher feel as a healthcare professional on the front lines?
“It’s kind of hard to say without being political but essentially you are seeing the top healthcare officials being undermined,” he said. “It is my opinion that decisions such as this should not be made without the consideration from our top healthcare officials. Initially it felt good because, for once, the world needed healthcare workers and we were the heroes. Now, it feels like our opinions no longer matter and we are having to suffer as a result of the increased spike.”
Many are pushing for states to stop lockdowns and open up more businesses because the economy has taken such a hit nationwide and so many people have lost jobs, but we also need to realize that the economy cannot do as well as we would like when the public is facing a pandemic
When it comes to a question of economy over health, Dr. Asher said, “The administration is literally picking or choosing money over lives.”
Why Wearing Masks & Social Distancing Matter
Much of the division in the U.S. is over how seriously people should take COVID-19 and necessary precautions like wearing masks in public places, social distancing and hand hygiene. What does Dr. Asher wish to say to people who refuse to wear masks and take precautions?
“Stop being selfish—that’s one of the best things they could do,” he said. “It’s not only for yourself but it’s to protect other people as well and at the very least just not be selfish and help protect somebody else from getting sick. If you don’t really care about your health, that’s fine but you’re walking around other people with more chronic diseases that if they were to get COVID-19 would not be as likely to have as good an outcome as they [younger] would have so I would say just don’t be selfish. If you don’t care about yourself getting COVID-19, then at least care about others. Care about your grandparents who would likely die from it if they got infected and listen to healthcare workers because we are the ones on the front lines who are having to deal with these patients day in and day out; we’re the ones who are taking care of family members that are dying alone. We’re the last people that they see. Do whatever the healthcare workers are doing. Most of us when we go out in public are still trying to protect ourselves. I had to take my eight-hour board exam with a mask on!”
As much as COVID-19 has been devastating from both an economic and health perspective, there have been some positive aspects.
“One thing I would say about this whole COVID-19 experience was the direct improvement in the world itself after we all quarantined,” he said. “Like in Venice, Italy, the waters cleared up after all the businesses and tourism shut down. It is humbling to see that. All the world needed to heal itself was for us to slow things down for a bit. I think it says a lot about the whole COVID-19 thing. Sometimes we just need to go back to our bare essentials, slow things down and just let the world heal itself. We need to pay more attention and put forth more focus on what really matters in life. That is our health, our family, our community and the world we live in.
COVID-19 & Children & Other Issues
COVID-19 has also created other health issues for patients because, as Dr. Asher pointed out, there is still much we do not yet know about the virus.
“One thing is it’s so unpredictable; there’s a lot of little nicks and crevices that this thing is showing up in,” he said. “We’re seeing a lot more strokes in COVID-19 patients because for some reason it turns the body into a very hyper coagulative state and we don’t know why. There are a lot more heart attacks associated with COVID-19. We are also seeing a disease state that mimics Kawasaki’s disease in more children who are positive for COVID-19.”
Kawasaki disease, according to the Mayo Clinic, is a disease that causes “swelling (inflammation) in the walls of medium-sized arteries throughout the body. It primarily affects children. The inflammation tends to affect the coronary arteries, which supply blood to the heart muscle.” It is also “sometimes called mucocutaneous lymph node syndrome because it also affects glands that swell during an infection (lymph nodes), skin, and the mucous membranes inside the mouth, nose and throat.:
It is quite alarming for doctors right now, especially since many schools plan to open soon in states with high numbers of COVID-19 cases.
“The most difficult thing about COVID-19 is we don’t really know what the heck kind of virus this is. We are seeing so many new things every day: A lot more strokes, a lot more heart attacks.”
There are other emerging diseases that are COVID-19-related that the medical community still knows little about, such as “COVID-19 toe” and rashes caused by COVID-19. A post on the Cleveland Clinic website quotes Dr. Humberto Choi, a pulmonologist, about possible explanation for the toe and rash symptoms that “like rashes, COVID-19 toes are just another way that the body can respond to a viral infection.”
Dr. Asher said he is not sure why some people experience such outlier symptoms from COVID-19, such as the strange rashes or “COVID-19 toes.”
“We have no explanation for it, especially when it’s associated COVID-19; we really have no explanation because we have no experience and very few reports coming out. It’s so novel and so new and unpredictable.”
Is America Prepared for the ‘Second Wave’?
There has been a lot of talk in the media about a “second wave” of COVID-19 in the fall or next winter, particularly top public health official Dr. Anthony Fauci. Should America face a second major wave of the virus, are we prepared?
“I think we’re definitely more educated and we’re a lot more hygienic,” Dr. Asher said. “I think basic hygiene has really played a part in this so more and more people are washing their hands which is crazy to believe that this is what it took to get there, but I would say we are a little more prepared.”
Dr. Fauci has said at many press conferences that he is “cautiously optimistic” there will be a COVID-19 vaccine in early 2021. Does Dr. Asher agree?
“Oh, yes. I’ve heard of one or two vaccines already out that they are testing on animals and now they are being tested in Africa. Hopefully by early next year we will have a vaccine in place.”
Already many anti-vaxxers have said they will not get the COVID-19 vaccine once it is approved.
“That’s a huge concern but we’ve had to deal with anti-vaxxers our entire lives.”
Is there proverbial light at the end of the tunnel for this pandemic?
“Yeah, I think so. We’re getting close. We need to remain united in the fight.”
New Position as Hospitalist
Dr. Asher is taking a well-deserved vacation off but will start his new position as the night-time hospitalist at Piedmont Medical Center on September 1, 2020.
What does a hospitalist do?
“A hospitalist is a licensed physician who practices exclusively in a hospital and treats/manages a large range of diseases. My job is to treat patients who are hospitalized due to a variety of illnesses. I have the ability to consult other physicians who specialize in a certain aspect of medicine to further help manage/treat my patient.” Dr. Asher said. “I specifically work with the residents at night and then we essentially just run the hospital, any code blues or rapid responses, we’re the rapid response team and code blue team. I do procedures, I do central lines, I do arterial lines, I do intubations, I guess just kind of run the hospital while everybody’s asleep.”
His final thoughts for current and prospective students at American and Caribbean medical schools about to enter hospitals?
“Maintain your basic hygiene, wash your hands, wear a mask as much as possible, and avoid getting sick. Avoid a pandemic. Treat every patient as if you were the last person they were going to see or as if they were one of your family members.”
(Top photo): Dr. Daniel Asher in PPE during a grueling shift working with COVID-19 patients. Photo: Courtesy of Dr. Asher.
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Scott is Director of Digital Content at UMHS and editor of the UMHS Endeavour blog. When he's not writing about UMHS students, faculty, events, public health, alumni and UMHS research, he writes and edits Broadway theater reviews for a website he publishes in New York City, StageZine.com.