Dear Decaturish – Medical director at Emory Decatur Hospital speaks outMatthew Hogan, MD
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This letter was received on March 22.
I am the medical director at Emory Decatur Hospital. I am directly involved in caring for COVID-19 patients as well as planning, organizing, and managing our hospital’s response efforts.
I decided to work from home today. In the interest of social distancing, and considering I am currently non-essential personnel, I emailed and texted my group and told them I wouldn’t be coming in. It was a difficult decision. Morale is arguably more valuable than PPE right now and showing my face could mean the difference between hope and despair. It’s not that I have some special personality quirk that brightens a room, and my wife will tell anyone within earshot that my OCD can often deflate a balloon, but I’m the medical director, and seeing the captain aboard the ship can provide calm in rough waters.
But it’s more important right now that I decrease the risk I present to the community and hospital.
“That’s a good thing since you’re so incompetent,” I can hear my friend Dan crack before giving me a look of true concern. I have a lot of friends that think they’re funnier than Dave Chappelle, none more than Dan, but while he’s quick with a put-down, he’s even quicker with a hug.
That’s the problem these days. Hugs are now taboo, even borderline illegal. Proximity kills, and the benefits of me staying inside and avoiding the hospital right now outweigh the risks to my team’s strength and resolve. I’m 42 years old, and it’s more likely than not that I will make it through this even if I become infected, but that’s not the point of my quarantine. The point is that my presence puts others at risk including my colleagues and the already vulnerable patients fighting for their lives.
All this will change on Monday, anyway. After a weekend of what I can only imagine will be broken, inadequate sleep, I will walk through those guarded doors at 6 a.m. and take over as the primary lead on the COVID 19 service. My enemy then will no longer be the drain on team resolve that my absence creates, but the drain on supplies that my presence does.
A week ago, we had only seven patients under investigation (PUIs). Today, we have fifty. That number will continue to climb as the days go on and the pandemic escalates inside our criminally unprepared country. We were given no strategic guidelines and had to formulate our approach on the fly. Our stock was not supplemented, and we are already running low on PPE a week or two in. Chuck Noland had a better plan and more supplies when his Fed Ex plane crashed on an uninhabited island in the movie “Castaway.” Tom Hanks, who played Chuck Noland and was recently diagnosed with COVID himself, would probably agree.
To get a sense of the scope of the problem, let me break the process of seeing a PUI down to its core elements. Let me also say that there is disagreement in the medical community about some of these details, but I’ll get to that later.
Each of the PUIs requires DICE (Droplet Isolation, Contact and Eye) precautions, and that includes a surgical mask, goggles or a face shield, a gown and gloves. ACE precautions (Airborne, Contact, Eye) are similar but require a special N-95 mask and only need to be used during procedures that increase the risk of aerosolization of the COVID virus, like intubations. Masks and eye protection may be worn continuously between patient rooms on the same unit but must be changed when moving from patient room to nursing station or between different units, and gowns and gloves must be doffed after every patient.
It’s relatively easy for a doctor to go from room to room when rounding, limiting the need to stray off of one unit or to the nursing station and therefore conserving masks and eye protection. Nurses, however, have a much more difficult workflow, moving from patient room to nursing station more frequently than patient room to patient room as they gather and administer meds, take vital signs, and address new patient concerns. And while doctors can sometimes get away with one visit a day, nurses are in and out of each patient’s room up to ten times per twelve-hour shift. Add to this the support staff including food services, image technicians, and therapists, and in one day a patient’s room could be entered thirty times. This says nothing of the need for patients to be transported off the unit to get dialysis or a CT scan and what those units have to do to provide adequate isolation.
Every day, hospitals do battle with an untold number of microscopic boogeymen, and we regularly exercise DICE and ACE precautions to decrease the spread of plagues like MRSA, clostridium difficile, and tuberculosis to name a few. We have supplies of the necessary protective equipment to battle these pathogens but on a much smaller scale. On a typical day, we may have thirty patients on some form of isolation, so our hospital orders supplies based on about 200 patient days a week. Right now we have fifty PUIs and that number will only get worse. Add to this the fact that test results have been hideously delayed due to inadequate supplies of swabs and properly equipped labs, and you have a growing number of PUIs who don’t have the virus but must remain isolated until we know for sure. You don’t have to sit under apple trees to be able to calculate how fast our supplies will disappear.
I’m something of a minimalistic doctor already. I try to utilize the least amount of resources I can to obtain the same results. It’s good for both a patient’s care and a patient’s bill. Now, however, I’m forced to rethink my strategy entirely. I bought googles that I can reuse after cleaning, and I will round room to room to save on masks, but there is little I can do about the gowns and gloves, and nurses gotta do what nurses gotta do.
Over the past week, I’ve spent a large swath of time in zoom meetings and conference calls, educating and being educated on workflow and process change with respect to our new common enemy. I’ve also used that time to educate my staff, posting regular updates on detection, isolation, and treatment over email and on our office boards. A large focus has been on conservation, highlighting CDC and WHO recommendations on procedures and equipment. Unfortunately, misinformation spreads faster than fact, gaining momentum on fake news superhighways like Facebook and Twitter, fanning the flames of fear that pose as the most dangerous threat to our purpose.
There has been distrust. With information gleaned from sources spanning the world, there are bound to be contradictions. In China and Italy, studies have shown that the virus may remain airborne longer than we originally thought, yet the WHO and CDC continue to recommend DICE over ACE on most interactions with PUIs. Anecdotal reports from China have also indicated that regular mask use amongst the public may have tempered the spread, yet the CDC and WHO continue to press that not only are masks unnecessary for routine use unless interacting with a PUI, but that routine use could actually lead to increased spread of the disease due to improper placement, handling, and disposal.
The CDC and WHO are not wrong. They may not be right either. It’s too early to know for sure, and therefore understandable that people would choose to believe the more alarming information in order to adequately protect themselves. But that strategy completely ignores a fundamental principle of wartime—rationing. I get that it’s hard. Hell, I can’t even get my kids to stop eating all the Nutella. But none of us know how long this is going to go on for.
The WHO and CDC certainly have a duty to the truth, but they also have a duty to protect the public for as long as possible, and that means acknowledging that our existing supplies are limited, and until we ramp up production to meet demand, we need to do everything we can to make it last. Since the evidence on how exactly the virus spreads is not yet clear, it means that we have to save our N-95s for our most vulnerable providers in the emergency rooms and ICUs as they intubate dying patients. We have to stop wearing masks in public or when evaluating non-PUIs in the hospital so we can save them for our providers caring directly for the infected. We must endure some personal risk in order to protect those who are in the most danger.
There has been theft. On a nearly daily basis, critical boxes of gloves, masks, and gowns disappear, swiped from door and wall hangs when nobody is watching. We’ve been forced to lock down our most critical supplies, creating a state of heightened suspicion inside a building where trust saves lives. Misinformation leads to panic, and panic leads to a dissolution of the social norms that keep a functional society in place.
But it’s not just misinformation. The projections for how long we’ll need to remain socially distant are disheartening. One of the most forgiving estimates I’ve read is eight weeks, and I can’t imagine how my wife and kids will refrain from murdering me if COVID doesn’t. But in the end, we’ll be fine. Not many would consider me lucky when I’m about to put it all on the line, but I certainly do. I have a job that will keep paying me in a time when this country will likely see record unemployment.
Without work, bank accounts will dwindle, and before long we’ll reach a point where a lot of people won’t know how they’ll pay their bills or feed their children. I’ve heard rumblings of a military state, and the national guard is already rolling, preparing to squash the thefts, looting, and riots that will ignite first in our most vulnerable communities and then spread like wildfire as the nosediving economy swallows us from the bottom up.
Now is the time to create jobs. This is certainly not my area of expertise, but I refuse to believe that we don’t have the fortitude or ingenuity to reimagine our positions and make ventilators instead of cars or ship test kits instead of furniture. At the hospital alone, we need scribes to type notes for doctors spread thin, calm voices to call discharged patients about their test results, and transporters to move an increasingly sick population to safe beds on isolated units. We’re also going to need more doctors and nurses to replace those felled by the virus or fear itself.
There have already been resignations. A few were a long time coming but some came straight from the blindside. At a time when unity provides strength, nothing can crack a foundation faster than removing a brick. Our supplies aren’t just the materials that make up our PPE, they’re also the healthcare professionals who we depend on to occupy the front lines. As the number of PUIs grows exponentially, as my friends on the front line get sick themselves, some critically, our surge capacity will only hold if we remain resolute in the face of uncertainty. If we stay we fight for as long as we can, realizing that we all have a heavy personal risk. We all have an elderly mother at home, a sick husband undergoing chemotherapy, a spouse who is also on the front lines. We all have children who need parents.
The hospital right now provides the most unobstructed view of the fork in the road that we have now come upon. We must choose to move forth alone or in unity. One is easier, but it will lead to a squandering of our supplies, a blow to our troops, and a collapse of our safety. The other is harder, and while it will not stop the inevitable loss of life that we currently have no immunity against, it will keep us unified, intact, and able to recover.
I implore anyone who reads this to stay the fight. Stay inside until it’s safe to come out. Trust the institutions that guide us and follow their recommendations. Refrain from the trappings of fear. Find a way to contribute. Create a job. Make masks and gowns and tests kits. Help your neighbor or your cleaning lady. Spread the word not the panic. And most importantly, stick together. We won’t survive if we don’t.
– Matthew Hogan, MD
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