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COVID-19 Perspectives & Plea from an LRH Emergency Physician

March 18, 2020 – A Plea & Perspective from LRH ER Physician Joe Dinsmore

Joseph DinsmoreI'm just a simple ER physician, not a virologist or epidemiologist, but I figured I'd offer a few thoughts regarding COVID-19 (Coronavirus) since I will be working at the front lines of this pandemic if/when it hits our area at anywhere near the levels that experts fear. I've been avoiding contributing to the cacophony of noise regarding Coronavirus, but I still see many people on social media minimizing this pandemic, and many pictures of large gatherings of people ignoring recommendations regarding social distancing.

This article is a brutal wake up call for anyone still in doubt. There is a human element to this pandemic that supersedes the often mind-numbing statistics. It Italy, whose healthcare system is literally on a war-footing, rationing of care due to the overwhelming of medical resources has become a reality.

As an ER doctor, one of the things that I fear more than virtually anything else is finding myself in a position where I am unable to help a patient not because I lack the skills or knowledge, or because further care is simply beyond the reach of modern medicine, but because resources are depleted. I literally have lost sleep worrying about the possibility that I could find myself taking care of your parent or grandparent, and the only treatment I have left to give is to hold their hand as they gasp for air. Read this article. Imagine page after page of local newspapers filled with obituaries. Imagine your loved one dying alone, in isolation, with possibly nobody at their side besides a masked nurse or doctor offering little more than the artificial touch of a gloved hand. Due to the imperative of preventing the spread of infection, that is the lonely death that often claims the victims of pandemics like this one. As the article states, funerals in Italy are often attended by no more than a priest and a funeral home worker since social distancing is necessary even as we usher our loved ones out of this world. As an ER doctor, I have held the hand of many dying patients. No one deserves to die alone. No one deserves to die like this. Please, please, please: practice social distancing and "flatten the curve" to spare your loved ones this fate. I don't have much wisdom to offer during such unprecedented times, but here are a few points to consider:

  • This isn't "just" the flu. Current numbers may seem underwhelming in juxtaposition to the mortality statistics of other diseases, but it's the potential trajectory of this pandemic that truly matters. The mortality rate of this virus is, at best, 10 times higher than seasonal influenza. Conflicting data regarding the true mortality rate often obscures another important point: because of the high rate of severe illness (perhaps as high as 15-20% requiring hospitalization), mortality rates varying considerably, in part, depending on whether or not healthcare systems become overwhelmed. Italy is a case study in this reality.
  • To be perfectly blunt, this will likely be the second war I will fight in during my relatively brief 34 years on this planet. The first, as an army medic, was a war of violence. The second, as an emergency physician on the front lines of a global pandemic, will be a war on the fragility of our species against the onslaught of infectious disease. I volunteered for the first war. Nobody volunteered for this war, but its reach will be global and its victims largely indiscriminate but for age and comorbidities. We as healthcare workers will be immersed in this fight, exposing ourselves and, by extension, our families to a potentially deadly disease. We're proud to carry out this duty, but the costs are real: 2 ER physicians in the U.S., among many other healthcare workers worldwide, are currently hospitalized in critical condition with COVID-19 - a harsh reminder of the hazards of this job. There are costs for non-healthcare workers as well: the cost of loneliness inherent in social isolation, the cost of domestic abuse victims secluded with their abuser, the cost of children of low-income families without school lunch, the cost of a retiree with an evaporated 401K. But for most, your mission in this war is quite literally "Netflix and chill," and you should binge-watch Breaking Bad (or some other show) at home like someone else's life depends on it.
  • Please use your local ER and other emergency services responsibly. Most ERs in this country operate at or near capacity during "normal" times. An ER is a communal environment. That means that you are sharing limited resources with every other patient in the ER, and the resources of caring for every individual ER patient are extensive. My job as an ER doctor is to assume that you have a life-threatening illness or injury and work backwards from there. This takes A LOT OF RESOURCES. I can only auscultate one set of lungs at a time, intubate one airway at a time, suture one wound at a time. Numerous professionals are required for providing you care in the ER: nurses, numerous physician consultants, techs, CNAs, radiology techs, sonographers, radiologists, respiratory therapists, anesthetists, phlebotomists, nurse supervisors, registration, administrators, security, paramedics, chaplains, social workers, law enforcement, etc. Your presence in the ER literally affects every other patient because of this massive deployment of resources. During "normal" times, your impact on other patients in the ER is typically as benign as making stable patients wait longer - no big deal. During times of disaster and strained resources, an unnecessary ER visit can actively harm others by delaying time-sensitive evaluation and treatment. I don't say this to guilt you out of coming to the ER. If you feel that you may be having an emergency, I beg you to come to the ER. I spent 11 years training to care for you and I take pride that I work in a healthcare system where you are legally entitled to my care in the ER during your time of need. But please don't unnecessarily use the ER - especially during times of national emergency - if you don't think you are having an emergency.
  • Regarding COVID-19, if you are having mild symptoms that are not severe enough to otherwise go to an ER, please call your hospital triage line or health department hotline to determine if testing is indicated and PLEASE STAY HOME TO AVOID INFECTING OTHERS unless instructed to come in for testing. My hospital, and many others across the country, have implemented drive-through testing if you call in advance and meet screening criteria for testing. This helps prevent exposing others. Under more ideal circumstances, if our government had prepared for this further in advance, we'd have more readily available testing and broader testing criteria. That isn't the current reality, but is likely to change in the days and weeks ahead. From an epidemiological standpoint, wider testing would be massively important for better defining the scope of this and determining how to manage the pandemic. From the standpoint of patients with mild symptoms, testing does not change treatment (there is no current approved treatment beyond supportive care), and even a negative test does not absolve you from the need for social distancing to prevent further spread.
  • Avoiding unnecessary ER visits decreases both the likelihood of exposing you (and your family) to illness and protecting healthcare workers.
  • Please treat other emergency responders with respect and acknowledge the huge risks they take. Law enforcement are among the most exposed during a pandemic because they must continue to patrol our streets to keep the peace, but often don't have the luxury of using adequate PPE due to the nature of their jobs. Please give them space to work, make their jobs easier, and keep them safe. The same goes for paramedics who are by far the most vulnerable profession to infectious diseases. Use ambulance services responsibly.

If our efforts at social distancing are ultimately successful and the worst case scenarios are avoided; if the crematoriums are not running day and night to unceremoniously dispose of the dead; if patients are not dying alone, isolated from loved ones; there will be a temptation to believe this was all an unnecessary panic. It is so important to understand it is not. If our efforts to "flatten the curve" work and healthcare systems do not become overwhelmed, it will still be a very long road ahead before return to normalcy. If Americans are lulled into complacency by low body counts and they become impatient, our efforts to flatten the curve can quickly be undone if social distancing halts too abruptly. This is going to be hard for all of us in a way that no living person has comparative experience. This is our shared humanity. Stay safe and take care of each other.

"These dark days will be worth all they cost us if they teach us that our true destiny is not to be ministered unto, but to minister to ourselves and to our fellow [humans]" —FDR 1933