The Washington Post - 21.03.2020

SATURDAy, MARCH 21 , 2020. THE WASHINGTON POST ez re A

The Coronavirus Outbreak

BY FRANCES STEAD SELLERS

In a Georgia emergency de-
partment, where patient num-
bers have swollen even as flu
season is fading, staffers are be-
ing asked to wash off and re-wear
single-use face shields because
they are in such short supply.
One sleepless ER physician
who has worked in trauma cen-
ters and jails and during bomb
threats said the chaos caused by
the coronavirus pandemic makes
her frightened to go to work.
Other health-care professionals
are setting up separate bedrooms
at h ome to isolate themselves and
protect their families.
“ ‘Where are you sleeping to-
night?’ That’s the question going
around,” said anesthesiologist
Michelle Au. Emory Saint Jo-
seph’s Hospital in Atlanta, where
she works, has streamlined pro-
cedures to accommodate the in-
flux of sick patients, Au said. But
the demands on front-line facili-
ties are “beyond the scope of any
one medical system to deal with.”
As anxious and infectious pa-
tients flock to hospitals across the
country, the new virus is exacer-
bating long-standing pressure
points in the nation’s emergency
rooms, forcing hospitals to ex-
plore ways to reduce exposure
even as they provide care.
Te mporary triage tents on am-
bulance ramps, drive- or walk-
through screening facilities and
greater emphasis on telemedi-
cine are all aimed at relieving the
burden on facilities that have a
legal — and, many doctors say,
ethical — o bligation to screen and
stabilize everyone who shows up,
whether with a broken finger,
major trauma, a chronic illness or
now, potentially, covid-19.
“We’re trying to keep people
out of the ER,” s aid Frances Lloyd,
a nurse practitioner who volun-
teered to help staff a bright yellow
testing tent erected last week in
the employee parking lot at the
Newton-Wellesley Hospital in
Newton, Mass.
The number of people ap-
proved to receive testing is grow-
ing rapidly, from 46 on Monday to
around 100 by midweek, Lloyd
said. And the pop-up facility is
key, allowing the ER to focus on
routine community needs while
adapting to new demands im-
posed by the pandemic.
“Things are changing so fast,”

said Jodi Larson, the hospital’s

chief quality officer. “We had to

figure out how to scale.”

Scaling is not easy in a system

that typically operates at maxi-

mum capacity, driven in large

part by insurance companies’

push to keep costs down.

“Efficiency makes it really hard

for ‘just in case,’ ” said Brendan

Carr, chair of emergency medi-

cine for the Mount Sinai Health

System in New York.

Even major hospitals such as

Johns Hopkins in Baltimore have

only two or three isolation rooms

in their emergency departments.

Many big-city hospitals have just

one, posing dilemmas: where to

house patients who may have

covid-19 until they can be moved

for treatment — and what hap-

pens when the next presumed

positive comes in?

“The ED is the gateway to the

hospital,” said Lauren Sauer, di-

rector of operations at the Johns

Hopkins Office of Critical Event

Preparedness and Response, and

a sign of how well the entire

institution is functioning.

Johns Hopkins has set up a

large white tent on its ambulance

ramp and plans to open a screen-

ing center in conjunction with the

University of Maryland, much

like the new facilities that sprang

up in Seattle and Denver. Other

cities, including New York, are

looking into walk-through facili-

ties that would similarly limit

contact among patients and with

hospital staff.

“This is 21st-century forward

triage,” said Carr, whose hospital

is prioritizing telehealth. Many

ER patients with respiratory in-

fections are return visitors, Carr

said. Once practitioners get a bet-

ter understanding of where pa-

tients are on the risk spectrum,

they can offer reassurance or, if

necessary, send an ambulance or

a paramedic, or encourage them

to go to a testing center.

“It’s not just added volume,”

said William Jaquis, president of

the American College of Emer-

gency Physicians. “It’s seeing ad-

ditional people who could be

highly contagious.”

Add to that what Christopher

Greene, a professor of global

health and international emer-

gency medicine at the University

of Alabama at Birmingham, calls

the “pandemic of fear.” It’s natu-

ral, Greene said, for people cut off

from their usual social support

network to say: “I feel ill. I need to

go to the ER right away.”

“But that’s a very dangerous

thing to do,” he said.

Using experience from the

H1N1 swine flu epidemic in 2009,

clinicians can assess patients’

symptoms and their risk of devel-

oping severe illness before they

enter the ER. And keeping low-

risk or mildly sick patients out is

not only in their best interest but

also in the best interests of other

patients.

“There’s a high likelihood they

could get infected or infect people

who are not infected,” said Paul

Kivela, former president of the

American College of Emergency

Physicians.

The coronavirus crisis comes

as many emergency departments

throughout the country already

struggle to keep up with the vol-

ume and variety o f problems their

patients present. The challenges

are compounded by gaps in pri-

mary care coverage, particularly

for the uninsured.

For many low-income people,

emergency rooms are the first

stop in the search for health care.

Increasing numbers of older pa-

tients tend to visit the ER in need

of highly complex treatment. And

in rural areas, some 60 million

Americans rely on hospitals ex-

clusively for their care, although,

over the past decade, 119 rural

hospitals have closed, according

to the Cecil G. Sheps Center for

Health Services Research.

“Essentially, we are increasing-

ly the provider of acute, unsched-

uled care in a lot of communities,”

Jaquis said.

Even in cities such as Boston,

which has five of the most sophis-

ticated — or Level 1 — adult

trauma centers (in addition to

two Level 1 pediatric trauma cen-

ters), the volume and complexity

of ER care had been increasing

before this outbreak, according to

Eric Goralnick, medical director

of emergency preparedness at t he

city’s Brigham and Women’s Hos-

pital.

“We’re always challenged by

capacity, operating at high vol-

umes,” Goralnick said.

At Jefferson Health in Philadel-

phia, a command center is coordi-

nating across 14 hospitals and

seven urgent-care centers to pre-

pare for what doctors anticipate

will be a surge in coronavirus

cases.

Patricia Henwood, director of

global health, said new drive-

through and walk-up testing fa-

cilities have been set up in some

hospital parking lots to accom-

modate patients within the sys-

tem who have been identified by

their doctors, often through the

telehealth program. The flagship

hospital’s ER has been divided to

segregate people who may be pos-

itive, and all triage is being moved

outside — steps that are being

taken, said Henwood, before the

system is actually stressed.

These measures, as well as so-

cial distancing, are to protect not

just the most vulnerable but also

anyone who needs treatment in

the ER.

“People are not going to stop

having strokes and heart attacks

and car accidents,” Henwood

said.

[email protected]

Emergency rooms look to keep people at a safe distance

Health crisis exacerbates

long-standing problems

in how m any get care

PHotos By AdAm glAnzmAn For tHe WAsHIngton Post

Nurse practitioner Frances Lloyd talks to other nurses by a tent in the parking lot of the Newton-Wellesley Hospital in Newton, Mass.,

where she v olunteered to test possible coronavirus patients. The number of people approved to receive testing is growing rapidly, she said.

Nurses put on protective gear in a tent in the parking lot of the

Newton-Wellesley Hospital before conducting coronavirus testing.

BY KATIE ZEZIMA,

DESMOND BUTLER

AND LENNY BERNSTEIN

As t he U.S. government calls for
hospitals to suspend elective sur-
geries amid the spread of corona-
virus, health-care workers say pa-
tients and staff members a re being
put at risk at both hospitals and
outpatient c linics across the c oun-
try where surgery schedules are
filled with breast augmentations,
nose jobs a nd bone spur removals.
Health-care workers, particu-
larly anesthesiologists who must
insert a breathing tube during se-
dation for surgeries, known as in-
tubation, have been asking insti-
tutions to end elective surgery for
much of the month, according to
interviews with more than a dozen
health-care workers nationwide,
some of whom spoke on the condi-
tion of anonymity. The anesthesi-
ologists raised concerns a bout sci-
entific reports that found covid-
can be aerosolized during intuba-
tion and spread from patients who
have n ot b een tested.
They describe facilities with
barely enough surgical gowns to
go around, masks in short supply
and doctors discussing how to re-
use single-use N95 masks. One
doctor put maxi pads inside to
make it last longer. They also said
there are shortages of drugs, in-
cluding propofol, used for seda-
tion, and saline. One nurse said it
is “immoral” that the drugs are
still being used for elective sur-
gery.
Workers fear that using these
supplies will prevent health-care
workers from being adequately
protected when a wave of c ovid-
patients overwhelms their hospi-
tals.
As the federal government is
asking Americans to stay home
and limit gatherings t o fewer than
10 people, many wonder why sur-
gery centers — where patients in-
teract with numerous people —
are still open for elective proce-
dures and why the federal and

state governments are not being

more aggressive about shutting

them down.

“If we’re trying to do this social

distancing thing, what are we do-

ing having people come to the

elective surgery center and have

totally elective surgeries? That’s

totally bananas to me,” said a doc-

tor in Connecticut whose hospital

is still performing elective surger-

ies. She, like most other doctors

interviewed, spoke on the condi-

tion of anonymity for fear o f losing

her j ob.

Jonathan Zenilman, an epide-

miologist who is a professor of

medicine at J ohns Hopkins School

of Medicine, said continuing elec-

tive surgeries without proper pro-

tections of medical workers and

patients is “ethically repugnant.”

“If you need your boobs done,

why can’t that w ait?” h e said.

He added that dropping these

procedures is a real conundrum

for hospitals facing dire financial

straits from t he coronavirus crisis.

“The hospitals rely on elective

surgery to actually keep them-

selves solvent,” h e said.

One anesthesiologist in S an An-

tonio said the ambulatory care

center where she works is going

“full steam ahead” with surgeries

this week despite the f ederal guid-

ance. S he worries t hat people who

are contagious but not showing

symptoms can spread the virus,

potentially infecting both people

in the waiting room and the sur-

gery t eam.

“They closed down casinos in

Vegas,” she said. “They’re doing

the r ight thing, and we’re not?”

The doctor said she can barely

sleep at night because of her anxi-

ety. She also cannot find N

masks; her father has some in his

home metalworking shop and

plans to drive them t o her h ome.

Eric Shepard, an anesthesiolo-

gist at an outpatient surgery cen-

ter in Maryland, says he has been

receiving dozens of anguished

messages from colleagues at mul-

tiple surgery centers across the

country.

The surgery centers should in-

stead be doing urgent operations

that would free up t he h ospitals to

treat people with the virus, he

said. Instead, many are trying to

stay afloat by performing purely

elective surgeries that hospitals

have stopped doing.

“This needs to stop, and it has

unfortunately become obvious

that many centers will not stop

voluntarily,” h e said.

Another anesthesiologist in

Te xas said doctors are being is-

sued one mask a day and that her

surgery center is running low on

supplies, including gowns. She

worked a steady stream of surger-

ies including hernia repairs and

colostomies this week.

A month ago, she said, doctors

were being chastised for not

throwing away their masks after

each use.

“I feel like a s physicians we have

taken a n oath t o do no harm t o our

patients, and I do not feel that

doing s ome of these cases, I ’m a ble

to do that,” she said. “I don’t feel

like bringing in 80-year-old pa-

tients to have a hernia repair that

does not have to be done today

may be the safest thing to do for

them.”

But for some operations, shut-

ting down elective surgeries is

shutting down their whole busi-

ness and potentially the liveli-

hoods o f their staff.

Roger Friedman, a surgeon who

runs the Plastic Surgery Institute

of Washington in Bethesda, said

Wednesday that in a difficult situ-

ation, his clinic is taking what

precautions they can: screening

patients based on foreign travel

and symptoms. The clinic a voids

having people in t he waiting room

and is for the most part treating

only one p atient a day.

He said his anesthesiologist

had not raised concerns about in-

tubation. “We’re like a family,”

Friedman replied w hen a sked i f he

had given staff the option of not

working, “If anybody would re-

quest t hat, I would honor t hat. But

nobody has.”

A nurse in Maryland quit her

job Monday after being told a sur-

gery c enter that is still performing

elective procedures was running

out of masks and would not re-

ceive a ny m ore.

“I feel like I can’t be part of a

surgeon t aking advantage of a bad

situation. A global pandemic isn’t

time for us to make money,” she

said.

On Wednesday, the federal gov-

ernment issued voluntary guide-

lines, calling on surgeons, physi-

cians and dentists to limit nones-

sential s urgery and medical proce-

dures.

The guidelines are not manda-

tory. They leave final decision-

making authority to state and lo-

cal health officials, as well as phy-

sicians and p atients.

“The reality is the stakes are

high, and we need to preserve

personal protective e quipment for

those on the front lines of this

fight,” said Seema Verma, admin-

istrator of the Centers for Medi-

care and Medicaid S ervices, which

issued t he new guidelines.

The tiered system proposed by

the government recommends

postponing “low-acuity” s urgeries

and medical procedures such as

carpal tunnel releases and

colonoscopies in healthy patients,

and s creening endoscopies for un-

healthy ones. It asks doctors to

consider postponing care such as

knee and hip replacements, low-

risk cancer surgery and elective

angioplasty.

And i t says m ost cancer surgery,

as well a s transplants, trauma sur-

gery and cardiac surgery for peo-

ple with symptoms should not be

postponed.

Te ns of millions of these sched-

uled surgeries and procedures are

performed each year in hospital

outpatient departments and am-

bulatory care centers.

Chip Kahn, president and chief

executive of the Federation of

American Hospitals, which repre-

sents the 20 percent of hospitals

that are for-profit, said, “CMS has

been extremely careful in design-

ing these guidelines to make it

clear that local communities, hos-

pitals and physicians need to

make the ultimate decision with

their patients on what care is es-

sential. That policy will help us

work our way through this crisis.”

Even the American College of

Surgeons has called on hospitals,

health systems and surgeons “to

minimize, postpone, or cancel

electively scheduled operations,

endoscopies, or other invasive

procedures” until there is confi-

dence that the health-care system

can support a massive increase in

critically i ll patients.

Given the guidance, the situa-

tion is changing rapidly around

the country, with many places

ending elective surgeries this

week. In Massachusetts, officials

ordered hospitals and surgery

centers to stop performing nones-

sential s urgery, effective March 18.

Ohio, Colorado, Florida and Min-

nesota have also moved to restrict

surgeries.

But in other places, they are

continuing at a regular clip. One

anesthesiologist, who works at a

hospital in C onnecticut t hat is still

doing elective surgeries, said doc-

tors and nurses are having to

choose between their jobs and

their safety all f or the s ake of l ucra-

tive but non-urgent procedures.

“It’s pretty clear that this is

about the hospitals’ bottom lines,”

she s aid.

Among the procedures she has

prepared patients for this week: a

breast lift, a tummy tuck and a

hernia o peration.

She says the hospital has pro-

vided sporadic information about

once a week on plans to treat

coronavirus patients and to pro-

tect doctors. But it is running low

on protective gear and has begun

rationing even as doctors are

asked to reuse disposable equip-

ment and draw down stocks for

the unnecessary procedures.

Some staff members have begun

improvising reusable face masks

intended for construction work

that they b leach in between opera-

tions.

The University of Utah Hospital

in Salt Lake City stopped doing

elective surgeries Monday, said

Candice Morrissey, vice chair of

safety and quality in the depart-

ment of anesthesiology. Two anes-

thesiologists n ow perform intuba-

tions while wearing head-to-toe

protective gear, including pow-

ered air purifying respirator

masks.

Morrissey said the lack of test-

ing is having an impact on the

hospital workforce. Every time a

worker is sick, even with what

appears to be a run-of-the-mill

cold, he or she must stay out of

work for 14 days because there are

not e nough coronavirus tests.

“We just know we have to fight

for it every time we want to get a

physician tested,” s he s aid.

kat [email protected]

[email protected]

[email protected]

F rances stead sellers and Jennifer

oldham contributed to this report.

Health-care workers raise concerns about elective surgeries during crisis

“This needs to stop, and it has unfortunately

become obvious that many centers will not stop

voluntarily.”

Eric Shepard,

an anesthesiologist at an outpatient surgery center in maryland