Physicians brace for potential surge in COVID-19 cases
As health care workers begin to understand the scope of COVID-19 in their areas and how to respond to it, a new anxiety has set in: How long will the pandemic last?
“The biggest stress is not knowing where we’re going to go from here,” Manu Jain, MD, pulmonary and critical care specialist at Northwestern Memorial Hospital, told Healio Primary Care. “We as human beings can handle if we know how this is going to end — we can prepare for that. Not knowing how this is going to evolve and how we’re going to get back to any sense of normalcy is probably the most stressful part of this whole experience.”
Physicians on the front lines are often working long hours and caring for severely ill patients. Research published in JAMA Network Open showed high rates of depression (50.4%), anxiety (44.6%), insomnia (34%) and distress (71.5%) among health care workers in Wuhan, China, where the pandemic originated.
Jonathan A. Ripp, MD, MPH, chief wellness officer and senior associate dean for well-being and resilience at the Icahn School of Medicine at Mount Sinai, told Healio Primary Care that the concerns among employees at his health care system have evolved over the course of the pandemic. When the first cases emerged, the major stressors were about basic needs such as child care and personal safety, particularly given the nationwide shortage of masks and other personal protective equipment (PPE) for health care workers, he said.
These concerns have calmed over time, according to Steve Kefalas, MD, a physician and clinical instructor in the emergency department at Cedars Sinai Medical Center in Los Angeles.
“We seem to have settled into our new reality,” Kefalas told Healio Primary Care. “For the moment, we have enough masks, gloves, gowns and caps to protect ourselves. We seem to be hitting our stride, and I am feeling more comfortable with the hazards that lurk in our workplace.”
As more cases poured into EDs, Ripp said concerns shifted toward the possibility of running out of ventilators and other medical equipment. There was also uncertainty about redeployment. Physicians, nurses and other health care workers from departments that were essentially shut down or converted into telehealth services were reassigned to EDs and ICUs to help meet the increasing demand.
“People being brought from their usual comfort zones of where they practice means that they have to take care of types of patients that they either never had to take care of before or it’s been a dozen years,” Ripp said.
Even specialists who care for patients with respiratory distress daily were anxious about responding to COVID-19.
“We had read and heard about how things were happening in China, Italy and other parts of Europe, but it’s not the same as having patients that you’re directly taking care of,” said Jain, who works with a group of pulmonary intensivists. “It took us a week or two to get into more of a rhythm. We developed a sense of how to initially handle these folks, but things are being fine-tuned still.”
Jain said it appears that the number of new cases has plateaued in Chicago, but “there doesn’t seem to be an end in sight.”
“The question now is, at what point will things start to decrease and when can we start to look at getting back into our routine? At this point, that’s unknown,” he said. “When will we be able to rest a bit? And how long will it last?”
Predictions for the fall
Anne Schuchat, MD, principal deputy director of the CDC, said during a recent Q&A session with JAMA that it is hard to predict what will happen in the coming months. During the 2009 H1N1 pandemic, she said there was a wave of cases in the spring, followed by low-level disease transmission in the summer. More cases emerged as schools began to reopen in the fall. The virus “took off” earlier in regions where schools opened earlier, Schuchat said.
It is possible that delaying school openings or limiting attendance and activities like recesses and assemblies could help prevent or slow a new wave of COVID-19 cases in the fall, but nothing is certain, according to Schuchat.
“We really don’t know how this virus is going to behave,” she said. “What we need to do is take advantage of the lower-level transmission that we are starting to see in parts of the country to really up our game in terms of the individual responses.”
These responses include increasing testing capacity and contact tracing at the state and local levels, Schuchat said. In a recent survey of more than 750 primary care clinicians, 54% said they still lack PPE and full testing capabilities, and two-thirds said they believed that the country will open too early, complicating response efforts for the predicted second wave of infections.
“I worry that we may be lifting quarantine too soon,” Kefalas said. “The last thing we need is to recreate the challenges that New York had to endure, early in the pandemic. I have close friends who worked in New York City during the height of their surge. I see the weight they carry in their faces and on their shoulders. I feel for the doctors, like Dr. Lorna Breen, who took her own life after working in such an unforgiving environment.”
Schuchat said she is optimistic that lab testing capacity will increase in the coming weeks. The bigger concern, she said, is contact tracing, which will require more staffing and collaborations between public health officials, the federal government, universities and the private sector to incorporate apps and other technology that can improve the efficiency of contact tracing.
“If we do reduce transmission in the weeks ahead — before we head into fall — that increased testing, increased contact tracing, immediate isolation and quarantine of contacts can really help us keep rates low ... hopefully so that the health care capacity can be sufficient and that we can bide time until there are better treatments and until there is a vaccine,” Schuchat said.
Most of the U.S. population is still vulnerable to infection, she warned. Recent data show that only about 15% of the population in New York, including New York City — the epicenter of the outbreak in the U.S. — has been infected.
“I worry about the way we will ultimately get out of this as a society,” Kefalas said. “Will antibody testing be reliable enough to ensure immunity? Will we be able to test and track everyone we need to? Will a vaccine be developed soon enough? Will it be effective? Will the virus mutate year-to-year, much like the flu? These are all questions that will be answered in time. And I will move on to a new set of concerns, I’m sure.”
As cases begin to slow, Ripp said many physicians are starting to process the emotional toll of the pandemic.
“There’s a lot of grieving,” he said. “In our Mount Sinai health system, we’ve had several employee deaths at multiple levels ... Nobody has been untouched.”
Kefalas said deaths from COVID-19 serve as a reminder “of the fragility of life.”
“We have seen some gut-wrenching cases, where young and otherwise healthy people become very sick, very fast, in front of our eyes,” Kefalas said. “I spent a few minutes talking to one of my COVID-positive patients. I reminisced with him about my time in New York, and we had a few laughs during his short time in the ER. The next day he was in the ICU, and the following day he was intubated, and then placed on life-supporting ECMO.”
This patient sustained “multiple very grave complications and may never be the same again,” he added.
“COVID reminds us that we are all vulnerable — that life is short. That being said, I am honored to have the privilege of caring for people in their most vulnerable states,” Kefalas said. “I am reminded of my sense of purpose as a physician.”
In a Viewpoint published in JAMA, Ripp and colleagues wrote that it is essential for physicians and other health care workers to be able to perform their duties over an extended period given that surges of COVID-19 cases “could last weeks to months.”
“At the same time they cope with the societal shifts and emotional stressors faced by all people, health care professionals face greater risk for exposure, extreme workloads, moral dilemmas, and a rapidly evolving practice environment that differs greatly from what they are familiar with,” they wrote.
According to Ripp, the well-being of health care workers at Mount Sinai was a priority before the pandemic, and the infrastructure they put into place to support their employees is now helping them to effectively manage the COVID-19 crisis.
The infrastructure is based on three key areas: basic needs, communication and mental health support. Clinical constituent groups are embedded into various departments within the health care system to identify and address issues among employees.
When COVID-19 emerged, Ripp said the existing infrastructure helped uncover the needs of health care workers early in the pandemic. His wellness team expanded their efforts by collaborating with human resources, the employee assistance group, and the psychiatry and social work departments, among others, to launch a website “within a matter of days” to provide employees with information on resources such as PPE, food, transportation, lodging and safety advice. They also worked with the crisis communications team to send employees daily case counts and the IT department to create online platforms for mental health services and support groups.
“We have seen a slow uptick in the utilization of those mental health resources,” Ripp said. “We anticipate that we will see a great deal more as this unfolds — even after the conclusion. In the midst of a crisis, people are in survival mode — they hunker down and get the work done. Then afterwards, it hits them, what they’ve been through.”
Recognizing that the pandemic will likely continue to have an emotional toll on employees, Mount Sinai is also creating a post-traumatic stress disorder and resilience center.
Ripp encouraged other health care systems to communicate with employees to better understand their concerns and tailor initiatives based on those issues.
“Even if you are not dealing with a large patient volume, almost certainly society has been disrupted,” he said. “I can’t emphasize enough the importance of hearing from your own what the issues are.”
Despite the uncertainties and the distress caused by the COVID-19 pandemic, Ripp said health care workers may be able to “look back on this as one of the more meaningful times of their career because of their role in it.”
Jain said it has been gratifying to see how colleagues have pulled together.
“It’s obviously a hard time, but when you work together — doctors, nurses, respiratory therapists, social workers and pharmacists — that’s a way to keep going because you’re working as part of a team. You don’t want to let anybody down and you obviously want to help these patients who are so sick to get through it. I think that’s the part that keeps us going.”
Kefalas said he is honored to have a role in “something vitally important to the human race.”
“It can be challenging, scary, heart-wrenching at times, but I am reminded why I got into medicine in the first place: to help, to heal, to connect,” he said. “And that perspective helps me cope in these uncertain times.”
Primary Care Collaborative. Quick COVID-19 Primary Care Survey — Series 8. https://www.pcpcc.org/sites/default/files/news_files/C19%20Series%208%20National%20Executive%20Summary%20with%20comments.pdf. Accessed May 9, 2020.