#201: COVID Narratives: Stories from Physicians at the Front Lines

March 26, 2020 | By Justin Berk

What Providers Can Expect when COVID Hits Home

Listen as the pioneers of the COVID pandemic share their experiences taking care of some of the first COVID patients in the US. Our guests have a broad range of expertise and experiences. This episode features hospitalist Dr. Francisco Alvarez (University of California at San Francisco, @fnalvarez), Infectious Disease fellow Dr. Karolina Maciag (University of Washington, @KMaciag), Critical Care and Pulmonology Fellow Dr. David Furfaro (Columbia University, @david_furfaro) and intensivist and founder of onepagericu.com, Dr. Nick Mark (Seattle, WA).

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Credits

Written and Produced: Justin Berk MD MPH MBA

Cover Art: Kate Grant MBChB DipGUMed

Hosts: Justin Berk MD MPH MBA; Matthew Watto MD, FACP; Paul Williams MD, FACP   

Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Guest: Dr. Francisco Alvarez, Dr. Karolina Maciag, Dr. Dave Furfaro, Dr. Nick Mark

Time Stamps

• 00:00 Sponsor
• 00:20 Intro, disclaimer, guest bios and a bad pun
• 04:28 Francisco: Process leading up to first case
• 07:42 Karolina: The perspective of the consultant- calm in the storm
• 11:40 (Karolina) Seattle Flu Study as early warning
• 16:00 Dave: ICU patients
• 20:30 Nick: making decisions with a moving target
• 25:05 Sponsor
• 25:53 Francisco: data available on Twitter
• 28:00 Francisco: the role of generalist during the COVID pandemic
• 31:15 Karolina: on vulnerable populations during pandemic
• 38:26 Dave/Nick: how generalists should be preparing themselves
• 45:16 Avoiding aerosolized procedures / nebulizers
• 47:46 What was the big surprises
• 54:20 How do you address the anxiety
• 60:12 Plugs
• 64:20 Outro

COVID Front Line Pearls

1. The Seattle Flu Study first noticed patterns indicating the spread of respiratory virus.
2. Threshold to intubate is less as many of these patients decompensate from hypoxic respiratory failure very quickly
3. ICU challenges include providing established clinical care while protecting the team
4. Enormous data is being disseminated in non-traditional forms e.g. Twitter
5. Hospitalists may play a role in delivering critical care, but more importantly they can step up in hospital operations: discharging ED patients and coordinating effectively with ICU colleagues to escalate and de-escalate care
6. Vulnerable patients may be affected not just by the disease but the disruption in health delivery systems
7. It is important to remember from a patient’s perspective, COVID is an isolating disease

COVID Front Line Notes 

Early Lessons Learned

Francisco: 

“Getting patients early… let us set up systems in place.”

“Zero was set up in advance; we weren’t expecting them until they arrived. We set up things as we went.”

Karolina: 

“The main emotion that I was having during the early, and now evolving, stages of the epidemic was a real sense of pride and belonging to a community that is approaching this epidemic with knowledge, with empathy, and with calmness.”

“In the epicenter of the storm there was a calmness that our leadership was doing the right thing.”

“The front line trenches are the EMS staff, emergency department teams, ICU teams, and nursing teams.”

“[The care is becoming protocolized. In fact, when a COVID patient is admitted, the ID team is not always consulted routinely… Consulting on COVID is a small part of what we do. There are still Staphs and Streps and transplant patients getting ill.”

The Seattle Flu Study was one of the first times where we noticed patterns indicating the spread of respiratory virus. A NYTimes study showed how study leaders tried to warn the public.

Dave: 

“The ICU is a place of controlled chaos at baseline so there are times in the day, even with COVID, it just feels like good routine ICU care as usual. And in a lot of ways  that’s a really good thing. That means these patients are getting the care that they need to receive.”

The threshold to intubate is much less with COVID’s rapid progressive decompensation to hypoxic respiratory failure. There is less of the lag time seen with the flu and other viruses.

ICUs are still full every day: we still have GI bleeds and sepsis. Some of them turn out to be COVID positive. But some of the other challenges are just protecting providers: wearing PPE appropriately.

“There has been a surge of collaboration”. We’ve had a lot of involvement with ID… all other ICUs are pitching in. It’s been incredible to see how the preparations are being done.  It’s incredible to see how others come together. For example, starting at midnight, Facilities personnel were working with engineers to convert more and more rooms to negative pressure rooms overnight. 

Nick: 

“We deal with uncertainty a lot in the ICU. When we talk about COVID being a novel disease it is: but the illness it causes, ARDS, is very well known to us… [there is] a lot of familiarity here with maneuvers we are comfortable doing: controlled intubation, lung-protective ventilation, inhaled prostacyclins, neuromuscular blockers, proning people early. These strategies work.”

“The personal safety aspect is a new dimension and we’re told different things at different times.”

One of the coping strategies I used is to still down new knowledge down to one page.

Newest version of the #ICUonepager on management of #COVID; added more details and clarified the treatment section (several investigational therapies; steroids NOT recommended) v2.4 #FOAMcc #FOAMed #covid4MDs 🙏 to all who gave feedback; download PPT from https://t.co/a5nxKnr6Q9 pic.twitter.com/SpMTxufdrJ

— Nick Mark MD (@nickmmark) March 16, 2020

What Generalists Should Know

Francisco:

“It’s incredible to see the amount of data that has gone out and how quickly on non-traditional forms of dissemination  like social media.”  We published a paper on some of the first US COVID cases and by the time it was published; all of that information was already available on Twitter, which was a good thing.

The majority of patients will have mild or moderate disease. Some institutions are training their hospitalists on intubations, but the major role of generalists will be operations management: to help things run smoothly. One thing is working closely with our colleagues to clean out ED in an efficient manner and have a clear communication path with ICU colleagues for escalation and de-escalation of care. 

Karolina: 

The COVID-19 disease affects our most vulnerable populations, in unique ways. Chronically ill and disabled patients are having trouble getting routine care as it is delayed from the epidemic. They have to show courage just to come to the clinic.  One element that has not gotten enough traction is how it affects our transplant population who are already immunocompromised.

A comment someone said in the hospital: “this feels like the HIV epidemic all over again”  We have learned a lot about the pathophysiology of the disease and the pharmacology of treatment; but that comment re-humanized it.

Dave: 

There are two ways internists can prepare: excellent patient care and protecting yourself: 

Protect Yourself

• Learn how to “down and doff” personal protective equipment (PPE).    
  • Matt’s Note: The CDC offers a very comprehensive video.

• Think about the flow of the day. If you’re seeing a COVID patient, call the nurse and see what needs to be done. If the pump needs to be changed, learn how to help!
• Know about aerosolized procedures and how to minimize them. This includes use of HFNC, NIPPV, and nebulizers.

Excellent Patient Care

• Understand the disease course: the patients become hypoxemic rapidly and often have stiff lungs. Increased PEEP helps.
• Know your resources; plan when you need help. Know who you call (eg a senior anesthesia team) or other hospital resources to ensure optimal care delivery and protection.

Nick: 

There are four major steps: 1) Protect yourself and your team, 2) offer good proven ICU care, 3) think about clinical trial enrollment, and 4) remember compassion.

Remember Compasion. Think about what it’s like to be a patient with COVID in a room where family can’t visit. Everyone that comes in is wearing scary equipment and wants to spend as less time with you as possible.If you’re in the room you might as well spend another minute with them, hold their hand or provide comfort in some way.

Avoid nebulizers. Use spacers with MDI or avoid nebulizers and HFNC unless you have highly individualized reasons. 

• Karolina: Remember our standard high-value care and how (friend of the show and Things We Do For No Reason^TM expert), Dr. Lenny Feldman describes how MDIs are non-inferior (and perhaps superior) to nebulizer treatments in the hospital.

We’re still learning about risk. Data regarding health care workers may suggest they face a higher inoculum of virus and that could increase risk of more severity of disease. Remember to use PPE.

Surprises of the Pandemic

Nick:

The degree of innovation has been impressive. Nursing has found ways to move IV pumps into the hall or move the ventilator brain out of the room so changes can be made without exposure. This conserves PPE, reduces risk, saves time donning and doffing.

People have come together to be supportive. An example: medical students helping with groceries, baby-sitting, and supporting staff at risk.

Dave:

Changes in health care delivery: Telehealth is really sweeping into our clinics.

Teamwork. So many specialties are coming together and working together to address new problems.

Being open about daily anxieties. This is an unprecedented event that will have daily anxieties but we should all be open about this and help support each other and our team. “Sometimes I find the ICU is the most calm place, it’s controlled chaos there…rather than when I’m back home and listening to the news.”

Francisco:

With  housemates, we’ve had to have difficult conversations about boundaries regarding my taking care of COVID patients. This extra social element adds to a lot of psychosocial burden to all of us.

Nick: 

“One of the biggest challenges is that usually the stress of work goes away when I go home. But this has a chronic stress that we’ll talk about for years… I try to remind myself I’m here to wear masks, not tin foil hats. “ 

Plugs and Other Resources to Check Out

• COVID Communications Guide (scripted exchanges with potential responses)
• CardioNerds: Episode #20: COVID-19 in the ICU
• Facility works, patient care assistants and other heroes in the epidemic
• UW COVID Resource Site
• Learners and Students
• OnePagerICU.com

Links

1. The Seattle Flu Study research team helped identify first patterns of COVID in the US
2. A New York Times article highlighted the story of the Seattle Flu Study  was one of the first 
3. A published case series of the first 12 US COVID patients (Dr. Alvarez is a co-author)
4. The CDC offers a very comprehensive video for donning and doffing
5. A previous “Things We Do For No Reason^TM” article suggests MDIs are non-inferior to nebulizer treatments
6. COVID Communications Guide
7. CardioNerds: Episode #20: COVID-19 in the ICU
8. UW COVID Resource Site
9. OnePagerICU.com

Goal

Listeners will recall the perspectives of the first providers taking care of COVID patients and will be able to apply some of their insights to when the epidemic hits their region.

Learning objectives

After listening to this episode listeners will…  

1. Be familiar with the ICU and hospitalist challenges in taking care of COVID patients.
2. Describe how to learn new information and connect with others in the COVID community.
3. Recognize the social challenges associated with the epidemic for patients and providers.

Disclosures

Drs. Maciag, Mark, Alvarez, and Furfaro report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Alvarez, F, Maciag K, Furfaro D, Mark N, Berk, JB, Williams PN, Watto MF. “#201: COVID Narratives: Stories from Physicians at the Front Lines”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. March 26, 2020.