As coronavirus spreads, doctors in the ER warn ‘the worst of it has not hit us yet’

Streets in cities and towns across the country are eerily quiet. Car traffic has dropped so substantially air pollution is abating. In many places, people are hunkered down indoors, trying to avoid contracting Covid-19.
But the true battle against the SARS-CoV-2 virus, which causes the disease, is playing out in hospitals that are currently — or will soon be — engulfed in an onslaught of patients struggling to breathe.
The tsunami has crashed over Seattle, parts of California, New Orleans, and New York City. In Boston and other places along the eastern seaboard, the full force of the wave hasn’t yet hit, but it’s clear it is coming soon.

Hospitals everywhere are surging their capacity, discharging any patients who can safely go home and attempting to conserve dwindling supplies of personal protective equipment, or PPE. Some are resorting to extraordinary measures — even going so far as to sanitize used N95 masks by baking them — to prevent health care workers from becoming Covid-19 patients themselves.

What does it look like to be on the front lines of that response — and what can we expect to happen in facilities across the country in the weeks to come?

STAT spoke with three clinicians about what is happening in U.S. hospitals: Megan Ranney, an emergency physician at Lifespan Health Systems in Providence, R.I.; Lakshman Swamy, an intensive care doctor at Boston University Medical Center and the VA Boston; and Craig Spencer, an ER physician and director of global health in emergency medicine at NewYork-Presbyterian/Columbia University Medical Center. Spencer has firsthand experience with devastating infectious diseases: He contracted Ebola in West Africa in 2014.
Their comments, compiled here, have been lightly edited for clarity and length.

On the current situation in hospitals:

Ranney: In Rhode Island, just like in emergency departments across the nation, we are seeing the number of cases double, and double, and double again. And that’s even with very limited testing. We are not running out of space at this point. We are really proactively setting up alternative facilities like tents to help us to take care of the increased numbers of patients that are coming in with Covid-like illnesses.
Swamy: We’re not rationing care. But the terrifying thing is that we see it over the horizon. Because the patients keep coming. We’re in Boston, we’re not in New York. We’re hearing terrifying stories from New York. … It’s the same as what we hear in Italy, what we heard in China.
Ranney: What hospitals in my region are seeing is that most patients can be cared for at home. But that’s a tough judgment for people to make on their own. We are, as a state and as a hospital system, working to set up alternative triage mechanisms to help keep people home if they can stay home without ever having to come to the hospital. Like telehealth, like self-triage programs, things like that.

“We are in the storm, but the worst of it has not hit us yet. And we absolutely see it coming.”

Lakshman Swaby, intensive care doctor in Boston

Swamy: We are in the storm, but the worst of it has not hit us yet. And we absolutely see it coming.
Spencer: I didn’t see a single patient with chest pain. Not a single person with abdominal pain. I’m worried about where those patients are. Where are all the regular patients? Where did they go? What the heck is happening with them? And who’s going to be thinking about the non-Covid mortality, the impact of Covid on non-Covid patients?

On how the disease presents:

Ranney: Most people are going to be OK with this disease. Most people get a really bad cough and get some body aches, but go on to recover within seven to 14 days. But there is a portion of people, and it’s unpredictable who those people are, who get really, really sick.
Swamy: When we have a unit full of critically ill patients who are often on ventilators and have medications running, the kind of attention that requires is immense on a moment-to-moment scale. The reason is our interventions are sometimes as dangerous as the disease. The ventilator isn’t something you can just set and forget. Once someone’s on a ventilator, there’s no margin for error. Especially with Covid.

On shortages of PPE and medical equipment:

Ranney: Almost all of our personal protective equipment is meant to be disposable. Instead, we are wearing procedural masks, surgical masks as long as we can. A week. Or two weeks if possible. We are reusing those N95 respirators between patients. So we take them off, we put them in a paper bag, and then we reuse them. These, of course, are all things that the CDC has recommended, so we’re [doing] what has become standard protocol. But it is not the way that this equipment is meant to be used. This does not feel normal. It feels scary. And it feels that there is a potential for error.
Spencer: There are a lot of places that are quite short. So reusing your N95 when you’re not supposed to be or at least it’s not recommended. Trying to find different ways to reuse them. Baking them in the oven, UV light, etc. This is all kind of novel and certainly not ideal. But it’s always better than the latest CDC recommendation of last resort: bandanas and scarves.
Swamy: There are non-invasive ventilation strategies, which can provide some amount of support for breathing and oxygenation, without needing a ventilator or a breathing tube. But the problem is that all of those things have some elevated risk of aerosolizing virus. If we had unlimited supply of protective equipment and if we had a better understanding of what this virus actually does in terms of aerosolizing, and if we had more negative pressure rooms, then we would be able to use more of these things. But right now we just can’t — because the worst thing we could do is spread the virus to more people.

On the rapidly evolving response:

Ranney: It’s almost impossible to wrap our brains around the degree to which our daily practice of medicine is shifting, truly day by day. The number of patients changes day by day. The protocols change day by day. The CDC’s recommendations change day by day. The treatment options change day by day. So at the same time we’re facing uncertainty about our own risk of getting ill, we’re also facing uncertainty about what the best current protocols are for assessing and taking care of these patients. Because there’s so little scientific evidence. And the patient volume is increasing so quickly.
Spencer: We’re learning on the job. There’s not one single resource that says: “Are you taking care of Covid patients? These are the 78 things that you absolutely need to know.” There’s just so much information and it changes every single day. I remember looking last week at the number of journal articles that had already come out. It was like 12,200. Even if I had the abstracts for all of those, I wouldn’t be able to keep up.

On the personal risk of caring for Covid-19 patients:

Ranney: I have more than a dozen of my physician friends across the country, not in my own hospital but in Massachusetts, in New York, in Washington, in California, who’ve been diagnosed with Covid-19 at this point. So I know that I’m high risk.
Swamy: Every time I go to the ICU I basically hug my family and take a picture of my kids. They don’t know, but in my mind, if I have an exposure, I don’t know if I’ll come home. I don’t know if I should. I don’t know where I’ll go. There’s just a lot of fear about that.

Ranney: I have friends who are doing things like recording videos for their kids just in case they get sick. My colleagues are scared.
Spencer: For me it’s eerily reminiscent of the West Africa Ebola outbreak in 2014-2015, the mental anguish and anxiety of taking care of patients. I’m seeing a lot of my colleagues figuring out how to manage that. It’s really hard for physicians to kind of be vulnerable and we all need to be a little bit vulnerable right now.
Ranney: I have children, I have parents, I have a spouse. We’re having daily discussions about whether I quarantine from them because obviously I’m getting exposed to people constantly in the emergency department. I’m also distancing myself from my parents, which they’re not happy about. But I just can’t risk they’re getting sick.
Swamy: The tension is really high. I think the biggest fears I have are that my family will get sick, that I’ll make my family sick, that I’ll bring it home. That I’ll get sick. If I get infected, what am I going to do? How am I going to keep my family healthy? I don’t have somewhere to go to quarantine myself away.
Ranney: This pandemic is going to change a generation of health care providers. It is going to change generations of health care providers.

As coronavirus spreads, doctors in the ER warn ‘the worst of it has not hit us yet’