<\/a><\/p>\nIn admissions, Goodell\u2019s days were usually dedicated to reading MED applications and interviewing applicants. This time of year, in addition to speaking engagements and panel discussions, she also saw patients on Tuesday mornings and Thursday evenings, mainly at the family medicine clinic. The first hint that that might change, she says, arrived in early March.<\/p>\n
\u201cWe were starting to keep our eye on the pandemic,\u201d Goodell recalls. \u201cThere had been one case in Boston\u2014a UMass student who had come from China. We knew about the situation in China and elsewhere. At the medical school, we started asking what this could mean for Boston and what we needed to be thinking about.\u201d<\/p>\n
Goodell had wondered how a family medicine doctor like herself could help, particularly at the time of year when her office workload was a little lighter than usual. Like most BMC doctors, she had considered the possibility that a surge of COVID-19 patients might call many to the front lines. But the gravity of the impending crisis didn\u2019t hit home until she received a survey from the family medicine clinic, asking those not routinely involved with inpatient care to rate their ability to provide such care. \u201cThat was one of my greatest moments of coronavirus terror,\u201d she says. \u201cMy first thought was, things must be really bad if they need doctors like me to take care of patients in the hospital. I haven\u2019t done that since 2009.\u201d<\/p>\n
At the ILI clinic, Goodell was outfitted in complete personal protective equipment (PPE), which includes a cap, a yellow gown, and an N95 mask and face shield. Clinic doctors wear two sets of gloves, changing the outer pair from patient to patient. She told administrators that she was available to work any hours. \u201cI was thinking morning or afternoon, maybe eight to five,\u201d she says. \u201cThey said, \u2018OK, it\u2019s going to be eight to eight.\u2019 I didn\u2019t expect that. After the first day, I said, \u2018You know, 12 hours is a really long time when you are wearing personal protective equipment that\u2019s hard to put on and take off.\u2019 You can\u2019t just go to the bathroom or even take a drink of water. You have to take everything off and put everything back on.\u201d<\/p>\n
The clinic now offers doctors two shifts: from 8 am to 1 pm and from noon to 5 pm, with two doctors on each shift. Goodell\u2014along with other doctors from family medicine, internal medicine, and pediatrics\u2014works varying shifts each week. The clinic sees about 50 patients a day, and tests about 18, taking a nasopharyngeal swab that is sent to the lab.<\/p>\n
Although doctors at the clinic query patients using a clear template with yes-no answers, Goodell says she can\u2019t stop being a primary care doctor. \u201cI start by asking them, \u2018So, what\u2019s going on with you?\u2019\u201d she says. \u201cI find that about 50 percent of the people have symptoms and are actively worried that they have the coronavirus. The other half aren\u2019t worried, but they \u2018screened in\u2019 when they came to the hospital or called their doctor for another reason. I try to figure out their risk for coronavirus, ask them to go over their symptoms, and then if testing is warranted, we do the test.\u201d<\/p>\n
The decision to test or not is complicated. \u201cWe don\u2019t have enough tests for everyone who I think should be tested,\u201d says Goodell. \u201cSome days we are able to test more people because we have enough supplies. Some days we are told that we are only testing people who are at a high risk of spreading the virus to others\u2014for instance if they live in a homeless shelter or are sleeping on the street or are healthcare workers.\u201d<\/p>\n
Goodell comforts patients who aren\u2019t being tested, assuring them it doesn\u2019t mean they aren\u2019t being appropriately treated. \u201cThe difficult fact is, even if it is coronavirus, if you don\u2019t need to be in the hospital, the correct treatment is to rest, take Tylenol, and monitor your breathing,\u201d she says. \u201cIf it\u2019s a virus, it has to run its course. People should stay home and take good care of themselves.\u201d<\/p>\n
Despite the frustrations stemming from equipment shortages, Goodell says the patient contact at the clinic can be immensely rewarding. \u201cIt\u2019s why I became a doctor,\u201d she says. \u201cI thought the thing that\u2019s most important to people is being healthy and if I could be a doctor I could help people get healthy and stay healthy. It\u2019s gratifying. Even though I can\u2019t test all the people I want to test, I can use every communication skill I ever learned. I can dig deep into my well of patience and concern and have moments of connection with people who are really scared. I can make them feel a little bit more comfortable, a little less scared, and a little bit better prepared with some actions they can take.\u201d<\/p>\n
She says she is not scared. She is careful to protect herself at the clinic and her family at home. When she comes home at night, she enters through the lower level, where a one-bedroom, one-bathroom guest suite will be her primary living space for at least the next three months. From the upstairs, she can hear her family preparing dinner\u2014another family routine that she no longer shares. She still does eat dinner with her family, but sits alone at the far end of the table.<\/p>\n
In the morning, Goodell makes her own coffee and toast and gets out of the house by 7 am. The minute the door closes behind her, she says, her husband wipes down the kitchen with disinfectant.<\/p>\n
None of the new routine comes naturally, and some of the seemingly trivial changes have been surprisingly difficult. \u201cWe have a decent-sized playroom,\u201d Goodell says. \u201cThat\u2019s where our television is, and we can still watch movies together if we sit far apart. Normally, when we watch movies, we like to cuddle. These days, I can tell that my kids keep wanting to give me a hug. We can\u2019t do that.\u201d<\/div>\n<\/div>\n<\/p>\n
<\/p>\n
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\nAnxiety, determination, and hope
\nJames Hudspeth<\/h3>\n
On Friday, April 3, James Hudspeth admitted three patients to Boston Medical Center. \u201cI would not have told you at the end of that shift I was worried about any of those patients going to the ICU,\u201d says Hudspeth, who oversees the hospital\u2019s COVID-19 response inpatient floor. \u201cBut at the end of 24 hours, two of those patients were in the ICU. As an experienced doctor, that is very disconcerting. I\u2019ve been doing this for 14 years, and I have a very good sense of a patient with pneumonia, who looks good and who looks bad, and what kind of patient I need to worry about. COVID-19 upends all that.\u201d Read more<\/h5><\/strong><\/p>\n
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On Friday, April 3, James Hudspeth admitted three patients to Boston Medical Center. \u201cI would not have told you at the end of that shift I was worried about any of those patients going to the ICU,\u201d says Hudspeth, who oversees the hospital\u2019s COVID-19 response inpatient floor. \u201cBut at the end of 24 hours, two of those patients were in the ICU. As an experienced doctor, that is very disconcerting. I\u2019ve been doing this for 14 years, and I have a very good sense of a patient with pneumonia, who looks good and who looks bad, and what kind of patient I need to worry about. COVID-19 upends all that.\u201d<\/p>\n<\/div>\n<\/div>\n
Hudspeth\u2019s general medical admissions floor houses COVID-19 patients who are too sick to stay home, but not sick enough to require intensive care, and patients undergoing testing for COVID-19. On April 5 <\/sup>\u00a0there were 176 such patients at BMC. Most will get better. Some will get worse.<\/p>\n\u201cOne patient came in with a positive COVID-19 test and about six days of symptoms,\u201d he says. \u201cHe was a slightly heavier gentleman with hypertension\u2014all of which we increasingly appreciate are risk factors for worse outcomes. He came in just on the edge of where we would put someone on oxygen, and I would typically expect someone like that to get better or worse over the course of several days. He was in the ICU the next morning, and on a ventilator the next evening. That speaks to how this is a new disease that acts in different ways.\u201d<\/p>\n
One difference is the speed at which the disease can move, both through patients and through the population. Hudspeth is reluctant to estimate the number infected, largely because things have been changing very fast. \u201cIn the beginning of March, when we had 20 patients who were being ruled out for COVID-19, one or two actually had the disease,\u201d he says. \u201cNow we are seeing an epidemiological shift. At this point, when a patient comes in, our thinking is that this is COVID-19 and that\u2019s what we\u2019re going to work up first.\u201d<\/p>\n
Nurses and doctors on the floor do what they can to support the patients. They check the lungs, kidneys, and blood pressure, and carefully monitor breathing. And they try new things.<\/p>\n
Every day, Hudspeth says, the hospital\u2019s infectious disease doctors revamp treatment algorithms used to help make medical decisions and devise new treatment approaches based on literature being produced day by day, week by week, across the world. Over the course of a month, they considered using HIV medications, such as lopinavir and ritonavir. But a small study indicated those may not be helpful. Other small studies have supported the use of azithromycin and hydroxychloroquine.<\/p>\n
\u201cOur infectious disease doctors have a very nuanced perspective,\u201d Hudspeth says. \u201cThey don\u2019t think that these are miracle drugs, and they still don\u2019t know if they work, but if there is enough of a suggestion that they may have a benefit, and don\u2019t cause a problem, then it\u2019s worth using them for the moment, but being very thoughtful about what the data show us as new information comes out.\u201d<\/p>\n
At BMC, many patients arrive with health problems like diabetes, hypertension, or heart disease\u2014medical conditions that could be exacerbated by either COVID-19 or by its treatments. Almost every COVID-19 patient in the hospital is extremely stressed, and many live each day with high levels of psychosocial stress.<\/p>\n
\u201cWe are used to dealing with an underserved population at BMC and dealing with patients who have a great deal of psychosocial stress across the board,\u201d says Hudspeth. \u201cWe try to reassure patients who are afraid because of the disease, and we try to address psychosocial issues concerning things like homelessness and substance abuse. COVID-19 adds another level of complexity because patients can\u2019t go back to a shelter, can\u2019t go back to some treatment programs, and some can\u2019t go back to crowded housing they share with vulnerable family members.\u201d<\/p>\n
At the same time, BMC\u2019s healthcare providers are dealing with their own unprecedented levels of stress\u2014much of which, Hudspeth says, depends on people\u2019s home situations. \u201cFor me it\u2019s not so bad,\u201d he says. \u201cI don\u2019t have children and I don\u2019t live with my parents. My wife is a primary care physician who is working in an ILI clinic at BMC. We had a forthright discussion at the beginning of this. We decided that we were both comfortable working with these patients. We accepted that there was some level of risk, and we accepted that if we become infected the probability of either of us having a bad outcome was low. I think for colleagues that have children or older parents at home or have personal medical issues placing them at higher risk, this is a very challenging decision. I\u2019m thankful that at BMC we have enough providers that we can keep people who are at higher risk away from the front lines and use them in other roles to support our efforts.\u201d<\/p>\n
For Hudspeth, however, COVID-19 has curtailed a reliable routine exercise in stress relief. \u201cOrdinarily, when I have a tough day, I just go sit with one of my patients and talk to them for a while,\u201d he says. \u201cThat is a very restorative thing, to be reminded that this is a human who I am helping to try to feel better with my work. With this situation, I have to be gowned up, I have to be wearing a mask, and that really detracts from the human connection. It adds a lot more stress to the situation.\u201d<\/p>\n
Hudspeth says he has seen \u201ctremendous progress\u201d in the four weeks since the inevitability of COVID-19 settled on doctors at BMC. \u201cI feel like the people in infectious disease grasped the enormity of what was going to happen,\u201d he says. \u201cThen everyone agreed that this is real and this is happening, and we started to see patients, and since then there has been a very well-organized structure to address this. Operationally, we have reorganized the hospital in very fundamental and important ways.\u201d<\/p>\n
Collaboration has been critically important in that regard, Hudspeth says. \u201cWe know the strategy people, and the head of physical therapy, and head of the lab, and this situation is requiring all of us to come up with new operations and new workflows on a daily basis, and to communicate that to our front lines and reinforce them in real time,\u201d he says. \u201cIt\u2019s a real testament to the people we have here and the connections that people have built up over the years that we\u2019ve been able to do this with the degree of success and precision that we have seen. Two months ago, to think that we would be doing this would have been risible.\u201d<\/p>\n
\u201cWe\u2019ve built structures,\u201d he adds. \u201cNow the question is whether what we built is going to be resilient enough and strong enough to make it through the next several weeks.\u201d<\/div>\n<\/div>\n<\/p>\n
![\"\"](\"\/camed\/files\/2020\/04\/BU-Today-thumb-kimball.jpg\")
\nStemming collateral damage
\nSarah Kimball<\/h3>\n
For Sarah Kimball, a primary care doctor and codirector of Boston Medical Center\u2019s Immigrant & Refugee Health Center (IRHC), life has changed with two sudden shifts. First, three weeks ago, the IRHC halted in-person visits and moved all communications to telephones. The risk of infection from COVID-19 had made person-to-person contact far too risky. One week later, Kimball accepted an invitation to codirect BMC\u2019s newly launched influenza-like illness (ILI) clinic, which operates in the Shapiro Building. Read more<\/h5><\/strong><\/p>\n
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For Sarah Kimball, a primary care doctor and codirector of Boston Medical Center\u2019s Immigrant & Refugee Health Center (IRHC), life has changed with two sudden shifts. First, three weeks ago, the IRHC halted in-person visits and moved all communications to telephones. The risk of infection from COVID-19 had made person-to-person contact far too risky. One week later, Kimball accepted an invitation to codirect BMC\u2019s newly launched influenza-like illness (ILI) clinic, which operates in the Shapiro Building.<\/p>\n<\/div>\n<\/div>\n
There, Kimball wears full personal protective equipment (PPE), which includes a face shield, an N95 mask, a gown, and double-layered gloves. She moves from patient to patient, each seated at least six feet apart, asking about symptoms and their occupations. \u201cWe want to know how sick they are, what symptoms they have experienced, where they work, and if they are homeless,\u201d Kimball says. \u201cWe do a symptom screener and then we do a risk screener.\u201d<\/p>\n
Patients are sent in one of two directions, based on Massachusetts Department of Public Health guidelines. They either go home or to the emergency room. That protocol is necessary, says Kimball, but it can result in some painful partings. For instance, a married couple visiting from out of town came in with potential COVID-19 infections, but while the sicker husband was triaged to the emergency room, the wife was only symptomatic.<\/p>\n
\u201cOur current rules state that you can\u2019t send people to the emergency room if they are only symptomatic,\u201d Kimball says. \u201cSo, we had to tell the wife that she couldn\u2019t go with her husband. This woman doesn\u2019t even live here. We had to figure out where she could go. I can\u2019t imagine being sick enough to go to the emergency room right now, when people are very afraid, and having to do it removed from a family member. It\u2019s so hard on people. It adds to the fear factor.\u201d<\/p>\n
In her first week on the job, March 30 to April 3, the busiest day saw 100 patients. Kimball expects the number to climb quickly in the next few days. In addition to directing patients to the proper level of care, she tries to ease the stress on a patient population that is very scared, often about their income as well as their health. One patient, for instance, came in with a sore throat and mild fever, but was most anxious about her ability to return to work.<\/p>\n
\u201cIf she couldn\u2019t work, she couldn\u2019t pay the rent, and she was really worried about food. So, even more than her health risk, she was worried about her family making it through the week economically,\u201d Kimball says. \u201cThat speaks to the level of difficulty that many patients are living with. If you are living on the margin, COVID-19 can push you over. Working at BMC, a safety net hospital, reminds us what a privilege it is to be able to quarantine, to have the space in your home, and the financial security to not go to work.\u201d<\/p>\n
Kimball does her best to reassure patients. She provides them with \u201cwork letters,\u201d stating when it is safe for them to return to work, based on US Centers for Disease Control and Prevention guidelines. Those guidelines require that at least seven days have elapsed since the start of symptoms, and that there have been no symptoms for three days, including the resolution of fever without medication.<\/p>\n
Kimball\u2019s concerns about the collateral damage of COVID-19 include the many people who depend on BMC\u2019s Preventive Food Pantry. \u201cIf those people are sick and can\u2019t come in, how do we get food to them?\u201d she asks. \u201cI know that people at BMC have been working hard to develop a COVID-19 fund that would help send food and groceries. Our development team has put a lot of energy into this.\u201d<\/p>\n
She also worries about the immigrant and refugee community that has been the focus of her work at the IRHC for six years, and is now served only by telephone. \u201cA lot of these people have limited proficiency in English,\u201d she says. \u201cMany of them have gig jobs like driving for Uber, or are frontline health workers like health aides. We have to think about how to adapt the model of care to a population that has so much more vulnerability.\u201d<\/p>\n
For people who live with immigration-related fear, Kimball says, COVID-19 has really ratcheted things up. \u201cPatients tell me they\u2019re worried about deportation, and we are seeing many immigrants avoid healthcare services because of the Public Charge Rule, which can complicate immigration for people who accept some public benefits, even though COVID-19 testing and treatment is not considered under the rule,\u201d she says. \u201cSo right now we are doing a lot of damage mitigation so they know it\u2019s safe to come in for testing and treatment. That\u2019s really important: if people don\u2019t know it\u2019s safe to go to the hospital, they put themselves and people around them at risk.\u201d<\/div>\n<\/div>\n<\/p>\n
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\nGreater distance, stronger bonds
\nMichael Ieong<\/h3>\n
Michael Ieong, medical director for the Boston Medical Center\u2019s intensive care units and assistant professor of pulmonary, allergy, sleep, and critical care medicine at Boston University\u2019s School of Medicine, is accustomed to 12-hour days. But before the ICU filled with COVID-19 patients, his 12-hour days were spent coordinating disciplines and workflows, and as he puts it, \u201cmaking sure everything works well.\u201d He did rounds, did some teaching, and like other ICU doctors, responded to situations with the confidence that he was applying evidence-based best practices. Read more<\/h5><\/strong><\/p>\n
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Michael Ieong, medical director for the Boston Medical Center\u2019s intensive care units and assistant professor of pulmonary, allergy, sleep, and critical care medicine at Boston University\u2019s School of Medicine, is accustomed to 12-hour days. But before the ICU filled with COVID-19 patients, his 12-hour days were spent coordinating disciplines and workflows, and as he puts it, \u201cmaking sure everything works well.\u201d He did rounds, did some teaching, and like other ICU doctors, responded to situations with the confidence that he was applying evidence-based best practices.<\/p>\n<\/div>\n<\/div>\n
\u201cWhat has changed,\u201d he says, \u201cis we are now dealing with something where it\u2019s not entirely clear what the best practice is. We are in uncharted waters, and it\u2019s very hard to apply our regular clinical acumen to something we\u2019ve never seen before.\u201d<\/p>\n
Ieong says COVID-19 presents doctors with two disturbing medical problems. One is the rapidity of the severe and often-fatal lung injury that afflicts some patients. The second is the length of time during which patients may recover. In most lung-injury cases, doctors can often tell within days if the patient is likely to recover. With COVID-19, the trajectory is much less clear, and it can take weeks to recover, tying up ventilators that are in very short supply.<\/p>\n
\u201cAnother aspect of this that\u2019s very different is the sense of personal threat to us and our colleagues and families,\u201d says Ieong. \u201cIt\u2019s something that every single nurse, provider, and student trainee is carrying around all the time. How you manage that is a challenge. It colors everything you do. We are being very conscious of everything we touch. We develop protocols and recommendations on what people should do\u2014how they should get dressed in the morning, how they should disrobe in the evening when they come home, things they should think about at home.\u201d<\/p>\n
In his home, says Ieong, he no longer kisses his six-year-old daughter and no longer sleeps in the same room as his partner. And on those now painfully infrequent occasions when he visits his 93-year-old mother, who lives just across the street, he insists that both of them wear masks and stay six feet apart.<\/p>\n
At BMC, much of the customary camaraderie has been put on hold. \u201cThe normal practice is that we will do rounds together,\u201d Ieong says. \u201cIt\u2019s always been very much a team effort. Now we try to stay away from each other. It\u2019s very difficult to function as a team when you practice social distancing, and it\u2019s impractical. Even things like using a computer that someone else has used has changed. The whole infrastructure of the hospital is designed to pull people together so they can collaborate. Now you are literally fighting to hold on to the collegiality, because that\u2019s what keeps you going.\u201d<\/p>\n
However, he adds, \u201cthe overwhelming universal sense of one common opponent\u201d in COVID-19 has helped maintain\u2014and even intensify\u2014the team\u2019s single-minded goal of slowing and stopping the novel virus.<\/p>\n
And all of this is happening far too fast. The ICU saw its first COVID-19 patient in mid-March. Within one week, there were four. Now an entire floor of the unit is filled, completely displacing its regular patients, who have been moved to the surgical space. All elective surgeries have been canceled. Surgical, cardiology, and neurointensivists are helping out with COVID-19 patients. All treatments are supportive, says Ieong. None are curative. \u201cIt\u2019s mainly an effort to mitigate the patient\u2019s severely impaired capacity to extract oxygen,\u201d he says.<\/p>\n
Ieong says BMC is ensuring that all patients are treated equally and that no group of people are shouldering the burden over others. The patient surge has not yet required doctors to make decisions about allocating potentially scarce resources like ventilators, but Ieong, who cochairs the hospital\u2019s ethics committee, expects they might get there soon.<\/p>\n
\u201cThe established ICU capacity in all hospitals in Boston is almost entirely tapped, and we are having to surge beyond it by creating new ICU beds,\u201d says Ieong. \u201cAll of the ICU ventilators are being tapped, and we are starting to use operating room anesthesia ventilators. There are more patients getting placed on ventilators than are being liberated. In the end, the number of intubated patients just keeps increasing, accumulating in a way that you can\u2019t get your head around. I suspect that sometime next week, we are going to be in dire circumstances.\u201d<\/p>\n
Under these circumstances, Ieong emphasizes that BMC will still \u201cstrive for transparency\u2014being clear about what we are doing, so that we have the trust of our patients and our leaders, and everyone knows what we are doing, even if it\u2019s less than optimal. The important thing is that everyone is certain that they are doing the best they can with what they have.\u201d<\/div>\n<\/div>\n<\/p>\n
This BU Today<\/em> story was written by Art Jahnke.<\/p>\n <\/p>\n
<\/p>\n","protected":false},"excerpt":{"rendered":"
For faculty that serve as doctors at BMC, treating the city\u2019s most vulnerable patients, every day is a sprint and a marathon as they race to save lives and work around the clock to contain the coronavirus pandemic.<\/p>\n","protected":false},"author":903,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[254,146,91],"tags":[],"_links":{"self":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts\/82796"}],"collection":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/users\/903"}],"replies":[{"embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/comments?post=82796"}],"version-history":[{"count":14,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts\/82796\/revisions"}],"predecessor-version":[{"id":129665,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/posts\/82796\/revisions\/129665"}],"wp:attachment":[{"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/media?parent=82796"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/categories?post=82796"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.bumc.bu.edu\/camed\/wp-json\/wp\/v2\/tags?post=82796"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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