In the midst of the outbreak, people will still have heart attacks and strokes. Babies are still being born. Attachments will still burst. And so hospitals are figuring out how to juggle the patients who need regular emergency care with those who are sick with the new coronavirus.
Initially, the emergency department of the Long Island Jewish Medical Center tried to keep people with suspected COVID-19 separate from patients with other complaints. But as the number of patients exploded, each patient is now treated as a potential COVID-19 patient and given a mask, said Adam Berman, assistant chair of emergency medicine at Queens Hospital.
The same happens at the Zuckerberg San Francisco General Hospital and Trauma Center; even if a patient comes up with another complaint, they are treated as if they could be infected. Keeping COVID-19 patients separated from those who don’t have the disease is likely to become difficult as the virus spreads, and pretty much everyone is ‘COVID possible.’ “A woman came in with vaginal bleeding, but she was COVID positive,” said Chris Colwell, chief of emergency surgery at the SF general. Her complaint was not the disease; it was the bleeding. “It is very difficult to live together in a situation like this.”
Hospitals across the country are closing some services to ensure that people with medical emergencies can still receive help, even with an influx of people sick with COVID-19. In many hospitals any operation that could reasonably wait is cancelled. That frees surgeons, doctors of internal medicine, and others to help in the emergency department. Some hospitals have stopped offering outpatient care to save resources. Visitors are restricted or banned.
“It’s about crowding out,” said Stephen Shortell, a professor of health policy and management at the University of California Berkeley, where he is also emeritus dean. “The concern here is that COVID-19 will crowd out other people who need hospital care, which is a priority for hospitals’ ability to prioritize.”
Hospitals should consider how to distribute available rooms or beds, staff and equipment to ensure that all patients are cared for. The way they allocate resources in a global pandemic must necessarily change, says Lisa Eckenwiler, a bioethicist and associate professor of philosophy at George Mason University. There is a duty to care for patients while trying to maintain the maximum number of lives. Hospitals need to ensure that all patients are treated fairly and that the public understands how these decisions are made, she says. And it is important that patients show solidarity with each other, for example by understanding why your own operation has been postponed in the face of the crisis.
Figuring out the best care starts with emergency planning documents at most hospitals. For example, at the University of North Carolina Medical Center, those documents include hurricane plans, floods, power outages, and two types of plans for highly communicable diseases, says David Weber, the medical director of infection prevention there. That hospital has limited visitors and has developed guidelines for what counts as a really urgent operation, he says.
Both LIJMC and SF General have pandemic planning documents – as well as documents for other types of emergencies, such as mass shootings – but even with a plan, it can be difficult to predict in advance the course of a pandemic. Both hospitals started monitoring the outbreak in China in January.
LIJMC had kept a close eye on the new coronavirus, as the hospital is located near the John F. Kennedy Airport in New York and there was a direct flight three times a week from Wuhan, the city most severely affected by the virus, to JFK. COVID-19 patients need special rooms and special precautions, so LIJMC immediately started adjusting its emergency plans, Berman says. No one has stopped adapting them. “It is literally being revised and changed and updated every day based on new information and the capacity of our hospital,” he says.
Normally, the hospital’s emergency department is staffed based on the amount of demand the hospital historically sees. However, the number of patients has increased, so LIJMC has brought in additional healthcare providers, especially emergency doctors. Choice operations have been canceled and visitors are not allowed. The hospital lobby is now used for screening.
Initially, COVID-19 patients were sent exclusively to the intensive care unit, but it filled up – so other floors of the hospital were equipped as makeshift ICUs. Just about every floor has a COVID-19 patient on it. “Most of our hospital is now a COVID wing,” says Berman. But if a patient comes in with another emergency – a heart attack, stroke, or trauma – they still get the same standard of care they did before the pandemic, he says.
One benefit of the shelter-in-place order in effect in San Francisco on March 17 was a decrease in moderate trauma, says SF General Colwell. When people don’t leave home much, they are less likely to be exposed to COVID-19, but are also less likely to have an accident, resulting in a visit to the emergency room. Those who do have other types of emergencies continue to receive normal care.
The biggest limitation in his emergency department now is the number of people with marginal, inadequate or no housing, Colwell says. No shelter or competent nursing home will take them in without a negative COVID-19 test, and they cannot be returned to the streets where they may be able to pass the virus on to others. Currently, he has 15 patients in beds who may have COVID-19, but who do not have acute medical problems and have nowhere else to go. “As we are sitting here today, the problem is not the fans,” said Colwell. It is that he cannot send these patients anywhere. That has long been a problem, but it is now particularly acute.
Both Colwell and Berman say they are deeply grateful for the support of the community. Colwell was particularly pleased with donations of N95 masks, but other gifts poured in as well. “We’ve had such a flow of donations of food and equipment and things that the mental state of the people who work in the emergency department – because this is what everyone is demanding,” says Berman.
Despite the stress, both departments were doing everything they could to prevent the pandemic from taking a toll on their ability to treat patients. The doctors said they want to continue to provide usual care even in these unusual times.