COVID-19 ‘war stories’ from the front lines

In early 2018, experts at the WHO coined the term “Disease X.” According to the WHO, Disease X “represents the knowledge that a serious international epidemic could be caused by a pathogen currently unknown to cause human disease.”

Now, many are pondering whether the COVID-19 pandemic could, in fact, be Disease X. Horror stories related to the pandemic abound, with personal protective equipment (PPE) in short supply and healthcare workers stressed to near-breaking points.

In the United States—a country with one of the most advanced healthcare systems in the world—healthcare workers have apparently resorted to what was once unthinkable. There are currently more than 240,000 confirmed cases of coronavirus in the United States, with nearly 6,000 deaths.

Anecdotal accounts paint a picture of physicians and other medical professionals using scarves/bandanas for masks, trash bags for gowns, and reusing N95 masks. 

Critics argue that the worst of these shortfalls could have been avoided if leaders in the federal government had acted more swiftly in the early days of the pandemic and hadn’t ignored or downplayed the looming danger. Better yet, plans should have been in place already to quickly and effectively respond to a “Disease X” type of emergency, with much greater stockpiles of medical supplies at the ready. 

But, that didn’t happen. As a consequence, state governors have aimed to fill the void in emergency leadership, while doctors and nurses in many hospitals scramble for masks, gowns, and ventilators. 

In a bid to better find out what’s really going on in the hospitals, MDLinx touched base with specialists on the front lines—valiant physicians and other healthcare workers who are putting their own well-being and that of their loved ones at risk to save the world.

Southern California

Hassan Bencheqroun, MD, is an intensivist at Desert Regional Medical Center in Palm Springs, CA, and an assistant professor at the University of California Riverside School of Medicine. He also practices in San Diego at Alvarado Hospital and Scripps Mercy Hospital in Chula Vista. California has about 11,000 confirmed cases of COVID-19 and more than 200 deaths. 

Although the hospitals where he practices are not in short supply of equipment, the staff is still very conscious not to waste. For example, when Dr. Bencheqroun sees a patient with COVID-19, he is careful to clean the masks and shields used with that particular patient for reuse during the same day. 

“We are extremely mindful of our protective equipment and supplies,” he said. “What we used to take for granted, we now value dearly. Even though there are more supplies [at our hospital], we don’t want to burn through them quickly in anticipation of the surge of patients sure to come. Moreover, we have no guarantee of if or when we will have more supplies.”

Dr. Bencheqroun noted not only the considerable human toll on patients but also the stress on all healthcare providers: “The focus is on the doctor when it is [really] a team effort. Everybody is looking out for the safety of everybody else. There’s a huge fear of us becoming the chain of transmission for the virus itself. It is a very fine balance between being extremely cautious in wanting to test everybody, but in doing that, utilizing scarce resources including appropriation of protective equipment, diagnostic tests, and so forth.”

He continued: “There is a palpable tension. Even when you catch your breath, you are on guard and have high adrenaline. This translates into our professional interactions, although we try to be compassionate and check on each other. Nevertheless, it’s tough.”

Caring for patients with COVID-19 comes with novel challenges, including the judgment call required when isolating a potential patient with the disease. 

“Each case is huge. It’s not easy. You feel the weight on your shoulders. ‘Am I overcalling it?’ But you’re constantly reminded that before a pandemic, everything is alarmist. And, after a pandemic, everything is woefully inadequate,” he mused. 

Specifically, calling a potential case of COVID-19 requires initiating a complex, resource-intensive mechanism. Potential COVID-19 cases require patient isolation in a negative-pressure room, use of copious quantities of valuable PPE, notification of staff, careful planning before exposure, consolidation of patient/staff exposure to imaging equipment, careful planning of phlebotomy, taking of vital signs, consolidation of drug administration, and more to minimize the times personnel enter the patient’s room.

“You wish to overcall it so you don’t miss cases, but that approach has consequences. It slows down our process. It makes you worry about sending for diagnostic tests, procedures, and central lines,” Dr. Bencheqroun said. “It’s a huge deal to send the COVID test. You don’t just send the test and wait. The patient is in the hospital, and they’re in contact with other people.”

Dr. Bencheqroun also noted the potential guilt of not calling a case of COVID-19 that later turns out to be the infection. Per Dr. Bencheqroun, over 50% of patients may present without fever but develop it later during their hospital stay. Asymptomatic patients carry the risk of sickening other patients and staff, with those staff who are potentially infected requiring a 14-day isolation, thus reducing the number of those able to help. He also lamented the incredible stories of sadness he’s heard, including accounts of ER colleagues in other hospitals requiring intubation after becoming infected.

According to Dr. Bencheqroun, the pandemic is likely much worse than what’s been let on by the media and government, as well as beliefs among the public consciousness. While he and his fellow colleagues stay up late at night doing more research on the virus to help the ill, after spending extreme hours seeing patients, he’s noticed others in his community holding social parties, which he finds “unconscionable” and direly irresponsible.

In part, he attributed any nonchalance about the virus to the nature of human perception. “I know that people process fear differently. Some people need to have the message repeated several times, with each time penetrating a level of the [consciousness] until they figure [it] out,” he said.

Even some of his colleagues in other fields fail to grasp the true gravity of the COVID-19 pandemic. Dr. Bencheqroun recalled being asked by another physician about what his day was like. He told her he spent part of it making funeral arrangements, sharing financial and password information with loved ones, and drafting a living will. It was only then that his colleague truly grasped the gravity of the current pandemic.

Following in the footsteps of medical schools in Italy, New York University, Columbia University, Rutgers University, Tufts University, Boston University, the University of Massachusetts and others plan to graduate medical students early to help care for patients with COVID-19. Although Dr. Bencheqroun can’t comment on any plans to graduate medical students early at the University of California Riverside School of Medicine, where he teaches, he does warn that caring for patients with this respiratory disease is remarkably nuanced and sometimes beyond the skill level of trainees like medical students and residents.

For instance, intubating a patient with COVID-19 entails the use of neuromuscular blockers for paralysis, and must be done by the most senior and skilled physician in the room to minimize time spent and enable troubleshooting in case of unforeseen circumstances. Moreover, residents may have different employment contracts than their attendings, and it’s unclear how becoming infected with the virus would impact issues such as pay, paid time off, medical care costs, and insurance copayments.

“As it stands right now, the hospital protocol calls for residents to avoid caring for COVID patients for their own good,” he reflected.

Dr. Bencheqroun summed up his views like this: “Special times call for special measures. But, in addition to challenges, we’ve heard inspiring stories of collaboration, selflessness and sacrifice, as well as the value of teamwork in the medical field. Doctors take solace from every story of recovery, and share clinical knowledge across the world.”

New York

Cases of COVID-19 in New York City—the epicenter of the US outbreak—have reached nearly 93,000 with about 2,400 deaths. A mid-level healthcare provider at Lenox Hill Hospital in Manhattan, who chooses to go by the pseudonym ElBey, describes the circumstances that healthcare workers have to endure during the pandemic. In recent weeks, he’s witnessed first-hand the ramp-up to the current crisis.

“This pandemic has evolved over time,” he said. “Before it became crisis mode, we felt things would happen. The first thing we noticed was the N95 masks, which used to be common, were all put under lock-and-key, probably about a month ago.”

Furthermore, he remarked that guidance regarding face-mask use wasn’t clear from the get-go. “Management didn’t get good guidance from the CDC,” he said. Specifically, it was unclear whether N95 masks were required for every patient unit.

Currently, although there is a paucity of PPE supplies at his hospital, things aren’t as bad as elsewhere. For now, every provider at Lenox Hill gets one N95 mask, which they cover in reusable surgical masks for patient encounters. Nevertheless, ElBey has heard the horror stories of other hospitals in the city, where healthcare workers were using garbage bags over their gowns.

“From last week on, there has been the greatest shortage of PPEs [at Lenox Hill],” he said.

At his hospital, attempts are being made to limit the spread of COVID-19, with staff stationed at entrances to take temperatures and ask about travel history. No elective or other surgeries are being performed at his hospital, and visitors are barred entrance.

Most worrisome, employee health services at his hospital are denying COVID-19 testing to employees showing symptoms like fever. Instead, they are directing employees to outside providers, including urgent-care centers, which are also reluctant to test. Alternatively, employees are sent to primary care providers, which lack testing altogether.

“On one side, they won’t test you in the hospital,” he said. “On the other side, they won’t test you in the urgent care [centers].” 

According to ElBey, you have to be desatting in your 90s or needing intubation to receive the test. “I don’t think they’re watching out for our best interest,” he said. ElBey conjectures that his hospital is reluctant to test providers for COVID-19 because they don’t want crucial staff out quarantined.

He thinks things will definitely get worse before they get better. “As of last Thursday, two mobile morgues showed up outside the hospital,” said ElBey. 

As for life in the Big Apple, ElBey noted that streets are deserted and subways are barren except for essential workers, the homeless, and those with mental illness. He estimates that about half of Gotham’s residents are wearing face masks—which for many are merely painter’s masks that confer no protection.

He saw people in crowds when the US Navy’s gigantic floating hospital, the USNS Comfort, docked at Pier 90. The hospital ship is serving patients who do not have COVID-19 to free up room in the city’s hospitals. He also knows that people are lining up to get tested at various points across the five boroughs, as well as Long Island, but he worries for the safety of those standing in line, as social distancing can be an issue here. He’s noticed that employees at Costco and Home Depot, at least, are trying to keep social-distancing norms.

Ohio

Yasir Tarabichi MD, MSCR, is an intensivist with The Metrohealth System in Cleveland, OH, and an assistant professor with Case Western Reserve University School of Medicine. He points out that, fortunately, his medical center is not as hard hit as others. Currently, there are about 2,900 confirmed cases of COVID-19 in Ohio and about 80 deaths. 

“We got lucky in Ohio. First, we had a little time to digest what was happening in Europe and on the coasts. And, secondly, our governor was quicker than others in issuing a ‘stay at home’ order,” said Dr. Tarabichi.

“As a result, we have been given the gift of time to prepare for the inevitable surge,” he explained. “What that means is aggressively accounting for and conserving personal protective equipment, and developing staffing and triage strategies before becoming overwhelmed. Much of this has been stressful, primarily because our hearts are with our colleagues in harder-hit states, and we wake up every day anticipating the tidal wave’s arrival in our own community.”

Dr. Tarabichi noted that he and fellow staff are already focused on repercussions of the pandemic:

“We are also overthinking everything—but at the end of the day, as healthcare systems and intensivists, we can't help but play out the worst-case scenarios in our minds. We have identified and appropriated all of the ventilators we can, but the fear is always loss of personnel. If a few healthcare providers get struck down, everyone has to work harder and is then at greater risk of becoming another casualty and therefore a greater burden on an already stretched system.”

Dr. Tarabichi stressed the importance of transparency in the midst of this health crisis. “Communication is always strained in a rushed, emergency situation. Bumps in plans always come up and pre-planned contingencies fall apart as a result. However, transparency can go a long way to overcome these hiccups, and we have at least that going for us in our institution. I don't think we are scared as much as we are anxiously anticipating the inevitable influx of critically sick patients,” he said.

On a more positive note, Dr. Tarabichi does see this pandemic as a learning experience for healthcare workers and institutions. “There is so much to learn from this seismic event. I think many doubted the power of social distancing in a pandemic or were reluctant to enforce it politically, but data will continue to pour out in its favor,” he noted.

This pandemic is teaching other hard-learned lessons, too: “The shortage of PPE is a tragedy borne from the efficiency of our healthcare systems, and we need to be much better prepared with reserves in tow for the next one.” 

He added, “Providers are now starting to understand the value and limitations of telehealth, by being forced to move the majority of our outpatient visits into the virtual world. Models of delivery will have to change.” 

Another lesson: “Regularly scheduled follow-ups for chronic conditions don’t make sense. Trigger-based virtual check-ins may be more timely and efficient. Not every inpatient consultation requires an in-person encounter—sometimes the answer is obvious enough to a consultant that a simple suggestion will do. The notion of what is essential and what is not in healthcare will be reassessed. Finally, everyone will begin to understand that the world, indeed, is more interconnected than they thought,” he concluded.

New Jersey

Lila, who chooses to be referred to by her first name for anonymity, is a critical care nurse at Robert Wood Johnson University Hospital Rahway in Rahway, NJ—only about 25 miles outside of New York City. The scene she describes is more akin to the backdrop of a sci-fi horror movie than that of a peaceful community hospital.

“It’s bad,” she said. “My hospital is small, but we’re having too many deaths. I’m worried. We should all be worried.” Lila does note that the patient population at her hospital skews older.

The state of New Jersey currently has more than 25,000 confirmed cases of COVID-19 with over 500 deaths. 

At the time she interviewed with MDLinx, one of her patients had just died—a 51-year-old woman—and among four critical care unit (CCU) nurse colleagues, six patients were dead. Moreover, five CCU nurses had fallen ill from COVID-19, along with two hospitalists. Lila also recounted heart-breaking accounts of colleagues infecting family members, including uncles, sons, and cousins—some of whom died.

Administrators at Lila’s hospital have instructed that every patient room gets two gowns for use by everyone—from certified nursing assistants cleaning feces to intensivists intubating (and potentially being doused in sputum). These supplies serve as fomites for transmission.  

“I’m worried about getting sick,” she said. “Luck has kept me from getting sick. We’re all at risk, I’m using the same PPE supplies and in the same environments as my coworkers who did get sick. We have the same duties. There is no difference between me and my colleagues,” she said. 

Nevertheless, the supply of PPEs at the hospital is highly guarded. Higher-ups have instructed CCU nurses, physicians, techs, and other staff that they receive only one N95 mask—to be used as long as possible. Although for now, healthcare providers are using new surgical masks to cover the N95 masks with every patient exposure, it’s unclear how long the supply of surgical masks will last. Rumor has it that the military will be bringing in more PPE, but Lila is unsure when this would happen, or whether it will at all.

Although staff has been instructed to wipe reused PPE down with bleach and antiviral wipes, there is no way to make sure that reused PPE is truly clean, according to Lila. Moreover, staff is asked to reuse booties for a week, which is another risk for COVID-19 transmission between patients and healthcare workers. 

She describes what she believes to be the most horrifying part of the situation, and what could be contributing to high case count in her area. “We are not being tested unless we’re febrile, and patients are not being tested unless they’re symptomatic. So, if I have it and I’m asymptomatic, technically I can be passing it on to any patient, friend, family member, and wouldn’t know. The asymptomatics are really the scary part. And, even negative test results can be false negatives. [Which is why] they should be testing people with negative results twice, but they’re not doing that either.”

According to Lila, the virus stays airborne for 3 hours, and even with a new gown or N95 mask, there is risk of transmission and infection. For now, she is grateful to receive new surgical masks and gloves.

Although strictest airborne precautions should be taken with COVID-19 patients, only droplet precautions are in place at the hospital—and worldwide—with Lila and other providers directly contacting the patients with nothing other than clean surgical masks and gloves, with everything else reused after cleaning. Additionally, negative-pressure rooms are in short supply, with engineers having to jerry-rig makeshift substitutes using windows. Of note, true negative-pressure rooms also have anterooms for changing. 

Lila recounted how she requisitioned a box of gowns from the supply closet and made it available to other CCU providers. This box won’t last forever, thus she also keeps garbage bags and a bottle of Lysol in her locker for use by colleagues, if/when needed.

“I’d rather use a garbage bag than reuse somebody’s gown,” she said. Again, staff is instructed to wipe down gowns for reuse with bleach and antiviral wipes, but there’s no way of knowing if things are truly sterilized, she said.

Like many young people, Lila lives at home with her parents. She worries every day about exposing her 69-year-old mother to the virus. To boot, although money is not the main concern in this crisis, she and others are receiving no hazard pay for their herculean efforts. Nevertheless, she’s understanding of the situation.

“I’m not angry,” she said. “I understand that [the hospital] is in a hard position because of shortages. But, they’re supervisors, and they have to figure it out. We are there to do a job, and we can only do what you help us to do. Fight for us; we don’t have a union! Please advocate for us like we nurses advocate for patients!”

We at MDLinx sincerely thank all the brave healthcare workers who are putting their lives at risk battling COVID-19. You are true heroes, and we commend you. We want to especially thank the healthcare providers who contributed to this story. By sharing your experiences, you educate and inform your colleagues in the United States and worldwide on how to keep safe and best serve patients during this time of consternation. If you’re a healthcare provider and want to share your story, please email us at support@usa.m3.com.