Tag Archives: coronavirus

Resident Perspective: My Biggest Fear

This is the continuation of a series of journal entries depicting what it’s like to be a part of the COVID pandemic from the medicine resident perspective.

Monday, April 6th

Aside from the very real concerns over lack of personal protective equipment (PPE), ICU beds, and ventilators, I believe that the biggest cause for anxiety among healthcare professionals is not having answers. Traditionally, the public has turned to physicians during public health scares as they purportedly know how to approach all ailments. This virus is demonstrating that given all of our progress in the medical field from state-of-the-art imaging modalities to treatments utilizing personal genetic properties, we still can’t answer many basic questions about this new disease.

Philadelphia has a geographic advantage over many other regions in relation to the viral spread. We have an up-close view of the damage that the virus has wrought in New York without having nearly the number of cases or hospital burden at this time. The delay it takes for the virus to move westward globally and down I-95 not only allows us to stock up on PPE, prepare the hospitals, and practice social distancing, it also gives us the opportunity to analyze the studies that have come out of places like China and Italy. Although hospital beds in Philadelphia are now filling up with COVID-19 patients, it’s the barrage of images in the media of trashbag-wearing nurses, overflooded hallways and pleas from staff urging more supplies or more assistance that make this even more terrifying. The answers to our questions will come, but during the quarantine when each day feels like a week, data collection isn’t necessarily the issue — interpreting the data is.

As the pandemic ramps up in our region, the ever-present fear of not knowing which patients entering the hospital with upper respiratory infection symptoms are positive is anxiety-producing, not only because these patients can become sick quickly, but because it’s easy to let your guard down. When you know your patient is infected you know to be extra cautious. Also, determining whom to test prior to admission, given the tests’ continued scarcity, remains an issue, even as our own institutions’ guidelines continuously evolve.

In an ideal world we’d screen everyone and it would be an accurate test. However, right now we cannot screen everyone and we know the test has a high rate of false-negatives. Let’s say we do identify a COVID-19 patient through testing but who doesn’t require hospitalization. Our guideline for duration of self-isolation is just a recommendation as we simply don’t know if they are still infectious post-isolation. We can’t even tell patients that tested positive whether or not they are susceptible to getting re-infected, and if it will return in autumn; we can only posit given what we know about other viruses in these situations. Lastly, we don’t even have a proven treatment plan, only what experts surmise is the best approach given the information we have. Hydroxychloroquine, among many other proposed treatments, is still in the nascent stages of evaluation but the public wants answers quickly. This is not typically how the peer-review process works in academia as it often takes months to years to evaluate therapies. In this case public expectations need to be grounded to a reality in which even when expedited, implementation of new practices moves at a seemingly-glacial pace.

Residents get daily updates regarding our own institutional policies as well as new relevant findings that could be practice-changing. It’s amazing seeing the sausage being made, but it’s also terrifying because the Attendings and veteran physicians that we as trainees look to for answers are now looking to each other for answers and opening the floor to all ideas.

The good news is that while we don’t have the answers yet (and we may never have all the answers), we can take comfort in knowing that we are in the golden age of data- and knowledge-sharing. Pooling the resources of physicians, epidemiologists, researchers, and statisticians internationally has allowed us to make great strides in our understanding of COVID-19 in a relatively short time, and work toward mitigating our greatest fear – the unknown.

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Resident Perspective

I was encouraged by my wife to keep a journal for thoughts and feelings surrounding the developing coronavirus pandemic because I may be able to offer a unique perspective as a resident in medicine who is also a new parent and attempting to overcome fear of the unknown and what’s to come. I will try to update as frequently as I am able.

Monday March 23rd 2020

I found out that the Attending Physician I had been working with all last week and who was coughing during rounds was getting tested for coronavirus last night in the emergency department. I can convince myself I’m having symptoms of fatigue, sore throat and maybe a headache but I’ve also been working in the hospital for almost four weeks straight and this could just be general exhaustion mixed with a touch of seasonal allergies. I try not to think about it too much.

I haven’t been wearing any masks or other personal protective equipment around the hospital yet. At this point I feel like we are still in the nascent stages of the impending unknown so wearing a mask right now seems premature. The practice isn’t mandatory but I see more and more random staff in the hallways with facemasks on, many of whom aren’t clinicians which is a greater indication that I should probably get on board. Every now and then I’ll check a supply closet or outside a patient’s room to see what the surgical mask inventory is like. There are constant rumors floating around that, like the N95 facemasks, other equipment will be locked up and parsed out by a charge nurse on an “as needed basis”. If a run-on-the-banks situation were to occur, I want to make sure I hit the sweet spot where I don’t contribute too much to the hysteria but ensure I’ve got a mask without having to fight for scraps. I’ll continue to assess the situation.

Meanwhile, I observe more PAPRs (Powered Air-Purifying Respirator—special protective equipment) next to rooms on the wards, awaiting their donning by newly trained hands. They’ll be used for all COVID patients but since there aren’t any confirmed as of yet in our hospital, the purpose is to be used by all COVID “rule-outs” for now–those that are being tested and don’t have results back. We have a three to five day turnaround for test results right now, meaning we simply don’t know if the virus is already in our presence. The increasing numbers of PAPRs seen daily act as a surrogate for the proximity of the disease to Philadelphia and as a gauge for the level of concern amongst residents.

Over the last several days quite literally every discussion between residents in the hospital is about the coronavirus. Either discussing potential treatments; rumors as to what’s going on in China, Italy, or New York; sending memes or chatting about our trepidation and general anxiety that has gripped the entire hospital. Even when seeing my patients, every TV seems to be tuned into the news, all of which are giving up-to-the-minute global figures alternating between death tolls and economic indices. Patients ask questions for which I don’t have answers. No families or visitors are allowed in the premises. No students or “non-essential personnel” permitted to the hospital. Residents are instructed to follow social distancing protocols and there are to be no gatherings of more than five.

I went to a stroke alert today at a patient’s room for a patient that I wasn’t directly taking care of, I just happened to be nearby. The patient was in a designated “rule-out” room meaning all personnel involved need to treat the patient with extreme caution, and to limit those in contact with the patient to only those “essential.” Two nurses and a tech were in the cramped room already while the neurology resident was outside the room, not wanting to unnecessarily expose herself, miming the actions for a neurologic exam to one of the nurses. She gave instructions through the patient’s door window and into a speakerphone in a patient’s room a mere 4 or 5 feet away. The nurse and the tech cautiously proceeded to ask the patient to perform the maneuvers coached by the neurologist. It was an odd scene as clearly the patient could hear the instructions from the hallway through the door as well as the speakerphone but was polite enough to not mention that to the nurse directly in front of him. The nurse dutifully relayed the commands, “can you follow my finger with your eyes and keep your head still?” and the patient dutifully followed them. It would be funny if it weren’t so bizarre. Turns out he wasn’t having a stroke but it was good to have the opportunity to work out kinks regarding the protocol for patient emergencies. Residents are instructed to make note of instances in which normal protocols can’t be followed given the extra necessary precautions we now have to take. No doubt there will be plenty.

The hospital is both quiet but buzzing lately. Most of the services only have a few patients on each team and I walk down the wards and can find four-five-six! rooms in a row without any occupants. I’ve never seen more than two consecutive empty beds during my years here. The hospital policy is to discharge as many patients as possible with the impending influx of COVID cases to come. No elective surgeries and if you don’t absolutely need to be hospitalized you’d be safer at home. The atmosphere was akin to the episode of Game of Thrones just prior to the final battle in the last season. Nervous and anxious, we have no overflowing wine to keep us preoccupied and stumbling about. The morale is low and the silence in the hallways and in the former resident-gathering areas from our lounge to the cafeteria forces it to reverberate. Philadelphia has the temporary advantage of being able to watch from the shore as the tidal wave from China picks up steam as it makes its way across Europe, to New York City and crashing down I-95.

That night at home I continued to mentally scan my body for any possible symptoms. I hardly ever get sick so I don’t know if I’m short of breath at the top of the stairs because I’m out of shape or because I have a deadly infection. Best to push it to the back of my mind as there’s nothing I can do about it at this moment.

Bedtime routine completed. I get a text message at 10:00pm from a co-worker saying that the Attending I had been working with came back positive for coronavirus.

Image from Getty Images.

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