PART 14. CORONAVIRUS. March 17, 2020. “ “Most physicians have never seen this level of angst and anxiety in their careers”…. One said “I am sort of a pariah in my family.”

to read posts 1-14 in chronologial order click on http://doctordidyouwashyourhands.com/2020/03/coronavirus-tracking-jonathan-m-metsch-dr-p-h-parts-1-14-and-prequels-march-17-2020/

(From PART 2. CORONAVIRUS. January 29, 2020)

With SARS preparedness underway in NJ, LibertyHealth/ Jersey City Medical Center, where I was President, proposed that our 100 bed community hospital with all single-bedded rooms, be immediately transformed into an EMERGENCY SARS ISOLATION Hospital.

The Hospital was in a small town at the intersection of many major highways. It could be easily secured since it had no immediately contiguous neighbors. It had a helicopter pad. Its patients could be easily transferred. And it could be managed by the Public Health Service or military medicine if necessary.

It didn’t happen!

In July of 2009 I encouraged the Mayor of Hoboken initiate a H1N1 “Swine Flu” Task Force. I was appointed co-chairman with the Health Officer.

We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor

Interestingly Swine Flu never flourished in the Hoboken area probably due to herd immunity acquired from the Swine Flu in 2008 in New York City, where many Hobokenites work and visit.

“One Seattle-area hospital has already seen patient care delayed by the stringent infection-control practices that the government recommended for suspected coronavirus cases. Another in Chicago switched Thursday morning into “surge” mode, setting up triage tents in its ambulance bay and dedicating an entire floor to coronavirus patients. At least one is already receiving emergency supplies from the federal government’s stockpile.

With the bow wave of coronavirus infections still to come, hospitals across the country are trying to prepare for a flood of critically ill patients who will strain their capacities like nothing they have seen in at least a generation. Even with some time to prepare, administrators fear they will not be ready.

Staffing shortages could hinder care if doctors and nurses become infected. There may not be enough ventilators or bed space for a crush of seriously ill patients.

“Our hospitals are already stretched to capacity,” said C. Ryan Keay, the medical director of the emergency department at Providence Regional Medical Center in Everett, Wash., near Seattle, which is dealing with the largest outbreak in the country. “We’re a hospital that is always full, so it doesn’t take much to tip us over the edge.”…

The strain is already playing out in unexpected ways. Since admitting the first known case in the United States, Dr. Keay’s hospital has followed Centers for Disease Control and Prevention protocols for sanitizing facilities used by multiple patients with suspected coronavirus infection, which resulted in slower treatment.

“If somebody had to go in for a chest X-ray, as most of these patients do, the X-ray room would need to be down for 30 minutes afterward to reverse the airflow and sanitize,” Dr. Keay said. “If you have lots of patients, that becomes a huge issue and delay.”

Another unanticipated development: More moderate forms of breathing support, such as nebulizers and Bipap machines, should spare ventilators for the worse cases, but those technologies cannot be used on coronavirus patients because they risk releasing particles into the air.

Hospitals can take steps to increase their capacity, for instance by canceling some elective procedures or repurposing facilities meant to care for psychiatric patients. The most critical action, however, is outside hospitals’ control: slowing the spread of the virus through hygiene and social distancing, so cases spread out and the health system can treat patients who need care.

Most hospitals maintain disaster preparedness plans for multiple situations, such as mass casualties and novel infectious diseases. Those contingency plans are typically for a surge in capacity of up to 20 percent, hospital executives said. Some experts believe that hospitals could increase their capacity by resorting to more extreme measures, such as sending patients home earlier than planned or renting space at nearby facilities to set up makeshift hospital rooms…

Rush University Medical Center, the largest hospital in Chicago, put its surge protocols into effect Thursday morning for the first time in its 183-year history. The hospital has treated four confirmed cases of coronavirus and expects an onslaught in the coming weeks.

“We made the decision to surge because of the concern we’re seeing nationally and internationally,” said Omar B. Lateef, the hospital’s chief executive. “The W.H.O. is making statements about the risks of inaction, so we felt a responsibility to do something.”

Rush officials estimate that new triage tents outside — with chairs spaced 6 feet apart, the distance the World Health Organization recommends for separating infected individuals — and additional beds inside will increase the hospital’s emergency department capacity by 40 percent.

“We have to accept that this is a tremendous challenge for the health care system,” Dr. Lateef said. “If we allow uncontrolled spread, we will be overwhelmed. But if we practice mitigation, then hospitals can handle it.”  (A)

“As the coronavirus has swept across New York, officials have become increasingly alarmed about a bleak reality: The state may not have enough ventilators for everybody who could need one.

It is still possible that the state could slow down the spread of the virus enough to curb the demand for ventilators, the machines that help the sickest patients to breathe. But a panel convened a few years ago by the state found that in the worst-case scenario of a flulike pandemic, New York could be short by as many as 15,783 ventilators a week at the peak of the crisis.

The panel, the New York State Task Force on Life and the Law, studied ventilators for years before issuing a 2015 report offering guidance for hospitals on how to decide who to ventilate and who to effectively let die during an emergency. The advice is now frighteningly relevant…

Most of the New York’s major health systems have declined to provide details about their ventilators or what they will do if they run out. Some hospital administrators have said they believe new measures, such as closures of schools and restaurants, can slow the spread of the virus and keep the number of critically ill people below levels that could overwhelm hospitals.

But officials have repeatedly said that a ventilator shortage is one of their top concerns…

In interviews, ventilator manufacturers warned that, amid the pandemic, they do not have the ability to provide New York more ventilators — which can cost at least $25,000 apiece and require significant training to use…

New York’s hospitals are considered to be among the best in the world. But the state has slightly fewer ventilators per capita than the national average, according to a New York Times comparison of the 2015 state task force report and a study by the Johns Hopkins Center for Health Security.

The task force found that in 2015, there were about 7,250 ventilators in New York hospitals and about 1,900 in nursing homes. But the vast majority of them were already being used. Even with the state’s own emergency stockpile, the group found there were only 2,800 available.

The New York State Department of Health has declined to provide updated numbers…

Part of the problem is that the shortage goes far beyond the nuts and bolts of a machine. Ventilators must be operated around the clock by trained employees…

Only a few hospital systems have so far been willing to say publicly what they would do if they have more patients in need of ventilation than machines.

Northwell Health, which has 23 hospitals, and Montefiore Medical Center, with 11 hospitals, both said that if supplies ran out, they would adopt the task force guidelines.

Generally, when patients are mechanically ventilated, a flexible tube is placed into their windpipe, and a finely calibrated pump sends oxygen-rich air into the lungs.  Managing everything — from air flow to medicines — is labor intensive. Intensive care nurses are typically assigned just a few such patients at a time.” (B)

‘Two prominent emergency medicine physicians are calling for hospitals and other health care organizations to be vigilant and proactive in protecting health care workers during the coronavirus crisis…

“The first is the potentially overwhelming burden of illnesses that stresses health system capacity,” they write, “and the second is the adverse effects on health care workers, including the risk of infection.”..

Personal protective equipment (PPE) is one of the best defenses of health care workers, Adams and Hall note. However, they say the primary concern is surfaces that become contaminated via droplet and contact, rather than by airborne transmission.

“Therefore, ensuring routine droplet barrier precautions, environmental hygiene, and overall sound infection prevention practice is indicated,” the co-authors say, noting that US Centers for Disease Control and Prevention guidelines suggest health care workers working with such patients wear gowns, gloves, and either N95 respirators with face shields or goggles, or powered air-purifying respirators…

 “In a study of outpatient health care personnel in diverse ambulatory practices, medical masks applied to both patient and caregiver provided effectively similar protection as N95 masks in the incidence of laboratory-confirmed influenza among caregivers who were routinely exposed to patients with respiratory viruses,” they note…

Unfortunately, health care facilities can be chaotic places at times, particularly in the emergency department, where healthcare workers face the potential of a large number of unannounced and undiagnosed patients arriving at once. Hall and Adams say health care workers must be quick and vigilant about isolating anyone who seems to be experiencing a respiratory illness. Such measures include putting face masks on patients upon arrival, promoting coughing etiquette, and providing for hand hygiene…

Ultimately, Adams and Hall say, health care workers ought to consider themselves at elevated risk of exposure, and act accordingly. One way to address that reality is to ameliorate concerns health care workers might have about the safety of their own families. Addressing such concerns could include things like providing priority access to testing, treatment, and vaccination if and when it becomes available. It can also mean providing employees with adequate time off to care for loved ones who become ill. (C)

“The American Red Cross is urging healthy residents to make an appointment and donate blood as the country faces a “severe blood shortage” due to the coronavirus outbreak.

Nearly 2,700 Red Cross blood drives have been canceled, resulting in about 86,000 fewer donations and more cancellations are expected.

“I am looking at the refrigerator that contains only one day’s supply of blood for the hospital,” said Dr. Robertson Davenport, director of Transfusion Medicine at Michigan Medicine in Ann Arbor. “The hospital is full. There are patients who need blood and cannot wait.”…

Eduardo Nunes, Vice President of Quality, Standards, and Accreditation at AABB, said most hospitals are down to a blood supply of two to three days…,

Nunes said the best cure for the national blood shortage is for young, healthy people to make an appointment with their local blood bank and donate.” (D)

“Hospitals in Michigan are preparing disaster plans to free up beds that could be used to handle a possible surge of hundreds or thousands of patients with COVID-19, the disease caused by coronavirus, after the federal government declared a national emergency Friday.

While the number of people with the disease would have to drastically increase for these plans to go into effect, hospitals are planning for worsening scenarios that would include canceling elective surgeries, creating additional inpatient space set up for infectious patients, and sending patients home earlier or to doctor’s offices instead of the hospital for less urgent cases…

Ruthanne Sudderth, the hospital association’s senior vice president for public affairs, said each hospital has a worst-case scenario based on its capacity and level of care it provides. But the association has advised hospitals to shore up their patient care, facilities and staff during the national emergency caused by the coronavirus outbreak, which has killed more than 5,400 people worldwide, including 41 in the U.S.

“We have told them try to prepare for surge capacity. Look at elective procedures and whether to continue to do so. Use virtual visits (telemedicine) wherever possible, to free up physical capacity for COVID-19 or any other issue,” Sudderth said.

Hospitals generally have 25 percent to 35 percent of their beds filled by elective patients. There are approximately 23,000 staffed hospital beds in Michigan, according to the American Hospital Association. That would be enough for about 1 in 500 Michiganians who need hospital-level care.

“When patients are ready to be discharged, open those beds. Provide additional medication to take home, if possible, or offer mail order, so they don’t have to return to free up capacity,” she said. “If someone doesn’t need to be in the hospital, they don’t need to be there.”

Sudderth said hospitals also are considering transferring patients who don’t need inpatient settings to ambulatory care centers to free up additional beds.

Under emergency conditions, tents or temporary structures can be set up in parking lots to screen patients before they enter the hospital to avoid having them come into contact with vulnerable patients inside, Sudderth said.

“Emergency planning for infection disease outbreaks allows them to set up facilities outside,” she said. “This can increase inpatient capacity and also protect patients and staff.”

Bob Riney, president of health care operations and COO of Henry Ford Health System, said the six-hospital system with more than 40 medical centers has discussed and planned for a worst-case scenario. Every day, more than 200 managers discuss plans in conference calls.

“We have very high occupancy” at Henry Ford already because of flu patients and the health system’s advanced specialty care programs, Riney said. “We have scenarios and plans to invoke … deferral of elective procedures” and other actions to expand the number of available beds for sicker patients…

Henry Ford also has more than 150 negative pressure rooms for coronavirus patients or those with other contagious diseases such as tuberculosis. It also has 19,000 N95 respirator masks — a high-quality disposable device that covers the nose and mouth — that medical staff wear in caring for patients.”  (E)

“Holy Name Medical Center in Teaneck is grappling with the coronavirus outbreak, CEO Mike Maron said.

Eleven cases. Six of which are in the ICU. And 40 more patients under observation…

It’s why Holy Name CEO Mike Maron thinks all the attention the coronavirus has been getting in New Jersey — from the school closings, banning of public gatherings, suspensions of pro sports leagues and even the fights over toilet paper and bottled water — is not enough. Not even close…

Maron and his staff are working around the clock under the most trying of conditions. The vitally important single-use N95 masks that are needed to care for patients who have been identified — you know, the ones the state is running out of? Holy Name went through 795 of them. Just on Friday. By 7 p.m.

“They say we are getting more,” he said. “And we’ve asked (Gov. Phil Murphy) to get into the stockpile. We need them.”

The same goes for test results.

Maron said he has given up on the Centers for Disease Control and Prevention.

“They haven’t even confirmed our first case,” he said.

He knows the state lab is overloaded. And, while Maron praised the efforts of LabCorp — “they’ve really been great to work with” — he has seen firsthand, every day for a week, how quickly the disease can spread.

“The labs are very, very slow,” he said. “I’m still waiting to hear back on two of my cases that are in ICU. We’ve seen enough patients that our team feels it can make a diagnosis. We’re not taking any chances. We’re isolating people…

“Holy Name is at the epicenter of the outbreak in New Jersey,” he said.

Maron said the past week has been unlike any other in his more than four-decade career.

“I can fall back on my cholera experiences in Haiti, which was devastating, considering the lack of basic medical supplies after the earthquake — and then the other things that came here, everything from MERS and SARS, and even when we ramped up for Ebola — this is unprecedented,” he said…

Holy Name sits in an area with a large Asian population. Considering the virus began in China, one would assume …

Don’t, Maron said.

“Not one of my patients is Asian,” he said. “Not one. And, even though the outbreak in New Rochelle (New York) started in a Jewish community, only two of the 51 are Jewish.”

Maron said this point needs to be emphasized.

“We were on a call with all the rabbis here in Teaneck, and I said, ‘Let me be very clear: This is not a Jewish disease, this not an Asian disease.’”…

“If you call, we do a video conference with a physician — and, depending on your condition, we may tell you (to) self-quarantine at home,” he said. “We’ll have someone come and drop off a home monitoring system, which can take your temperature and take your oxygen saturation rate, your sb02. It gets automatically reported to us and we’ll monitor you.”

If it gets bad, Maron said, hospital personnel will come get you and bring you in — and isolate you. The hope is that treatment will help you recover enough to go home. He knows that’s not always the case. And he’s not taking any chances…

“One of my employees, who is a beloved guy here, got it in the community and came in,” he said. “We had him in our ER in isolation. We were monitoring him, and the decision was: ‘He seems to be doing a little bit better. We think we’re going to discharge him home under self-isolation and monitor him from there.’ But we wanted to wait another hour or two because we were just seeing a little indication that something’s not right.

“In that two hours, he decompensated so fast. He is one of the ones in the ICU on a ventilator. He’s fighting for his life. It goes that quick.”” (F)

“The announcement came one week after President Trump signed an $8.3 billion funding bill to combat the coronavirus crisis.

President Donald Trump declared a national emergency over the ongoing coronavirus disease 2019 (COVID-19) outbreak Friday afternoon.

The declaration makes $50 billion available to fight the spread of COVID-19.

“In furtherance of the order, I’m asking every state to set up emergency operations centers effective immediately,” Trump said. “I’m also asking every hospital in this country to activate its emergency preparedness plan so that they can meet the needs of Americans everywhere.”

Trump said the declaration will allow Department of Human Services (HHS) Secretary Alex Azar to “waive provisions of applicable laws and regulations to give doctors, hospitals—all hospitals—and healthcare providers maximum flexibility to respond to the virus.”

Among the regulations waived under the declaration are restrictions on telehealth usage, the requirement that critical access hospitals have a 25-available-bed limit for patients, and a maximum length of stay of 96 hours for inpatients.

Additionally, nursing homes will be able to waive the requirement that patients have a three-day hospital stay prior to admittance; and hospitals will have restrictions lifted for hiring new physicians, obtaining available office space, and caring for patients within the facility itself in order to “ensure that the emergency care can be quickly established.”

Trump also said the administration has been in discussions with pharmacies and retailers to make drive-through tests available at critical locations identified by public health professionals. “The goal is for individuals to be able to drive up and be swabbed without having to leave your car,” he said.

Trump announced several initiatives designed to stimulate innovation around solutions to the pandemic. Ten days ago, he brought together the CEOs of commercial labs and directed them to “immediately begin working on a solution to dramatically increase the availability of tests.” (G)

“ “Most physicians have never seen this level of angst and anxiety in their careers,” said Dr. Stephen Anderson, a 35-year veteran of emergency rooms in a suburb south of Seattle. “I am sort of a pariah in my family. I am dipping myself into the swamp every day.”

As the coronavirus expands around the country, doctors and nurses working in emergency rooms are suddenly wary of everyone walking in the door with a cough, forced to make quick, harrowing decisions to help save not only their patients’ lives, but their own.

The stress only grew on Sunday, when the American College of Emergency Physicians revealed that two emergency medicine doctors, in New Jersey and Washington State, were hospitalized in critical condition as a result of the coronavirus. Though the virus is spreading in the community and there was no way of ascertaining whether they were exposed at work or somewhere else, the two cases prompted urgent new questions among doctors about how many precautions are enough…

In emergency departments, the danger comes from the unknown.

Patients arrive with symptoms but no diagnosis, and staff members must sometimes tend to urgent needs, such as gaping wounds, before they have time to screen a patient for Covid-19, the disease caused by the virus. At times, the protocols they must follow are changing every few hours.” (H)

“Nearly 50 employees of Life Care Center of Kirkland, the Seattle-area nursing home that has been an epicenter of the coronavirus outbreak in the U.S., have tested positive for the virus, according to a report.

The results from Public Health – Seattle & King County, the health agency that serves the nation’s 15th largest metropolitan area, were reported in a Twitter post by a reporter from Seattle’s KIRO-TV.

The figures showed 47 employees tested positive, 24 tested negative, one test was inconclusive and five test results were still pending. In addition, 18 more employees were to be tested Saturday.

The 47 positive tests of employees, coupled with 63 positive tests for the home’s patients, means the nursing home accounts for about one-third of the state’s 328 confirmed cases of coronavirus, KIRO reported.” (I)

COVID-19 (Coronavirus) Outbreak Preparedness Center – Infection control and outbreak preparedness resources for hospitals and healthcare providers (J)

Coronavirus Disease 2019 (COVID-19) – Hospital Preparedness Assessment Tool (K)

“Proactive planning, in which leaders anticipate and take steps to address worst-case scenarios, is the first link in the chain to reducing morbidity, mortality, and other undesirable effects of an emerging disaster. It is vital that the principles and practices of crisis care planning guide public health and health care system preparations. This discussion paper summarizes some key areas in which CSC principles should be applied to COVID- 19 planning, with an emphasis on health care for a large number of patients. Hospitals routinely utilize selected principles of CSC to deal with seasonal outbreaks, lack of bed availability, and drug shortages, but a potential pandemic requires a deeper understanding and application of CSC.

Reduced to its fundamental elements, CSC describe a planning framework based on strong ethical principles, the rule of law, the importance of provider and community engagement, and steps that permit the equitable and fair delivery of medical services to those who need them under resource-constrained conditions. CSC are based on the following key principles [1]: (L)

Fairness

Duty to Care

Duty to Steward Resources

Transparency

Consistency

Proportionality

Accountability

  1. A. U.S. Hospitals Prepare for Coronavirus, With the Worst Still to Come, by Sarah Kliff, https://www.nytimes.com/2020/03/12/us/hospitals-coronavirus.html
  2. B. N.Y. May Need 18,000 Ventilators Very Soon. It Is Far Short of That,By Brian M. Rosenthal and Joseph Goldstein, https://www.nytimes.com/2020/03/17/nyregion/ny-coronavirus-ventilators.html?referringSource=articleShare
  3. C. Coronavirus: For Health Care Workers, Risk of Infection, But Also Burnout, by JARED KALTWASSER, https://www.contagionlive.com/news/for-health-care-workers-risk-of-infection-but-also-burnout
  4. D.The US faces ‘severe blood shortage’ as coronavirus outbreak cancels blood drives and regular donations, by Adrianna Rodriguez, https://www.usatoday.com/story/news/nation/2020/03/17/coronavirus-outbreak-us-faces-severe-blood-shortage-donations-plummet/5067055002/
  5. E. Hospitals prepare for potential surge of patients from coronavirus, by JAY GREENE,   https://www.crainsdetroit.com/health-care/hospitals-prepare-potential-surge-patients-coronavirus
  6. F.Life at the epicenter of N.J.’s coronavirus outbreak, by Tom Bergeron, https://www.roi-nj.com/2020/03/14/opinion/life-at-the-epicenter-of-n-j-s-coronavirus-outbreak/
  7. G.PRESIDENT TRUMP DECLARES NATIONAL EMERGENCY DUE TO COVID-19 OUTBREAK, INCLUDES HOSPITAL WAIVERS, by  JACK O’BRIEN AND MANDY ROTH, https://www.healthleadersmedia.com/strategy/president-trump-declares-national-emergency-due-covid-19-outbreak-includes-hospital-waivers
  8. H. Doctors Fear Bringing Coronavirus Home: ‘I Am Sort of a Pariah in My Family’, by Karen Weise, https://www.nytimes.com/2020/03/16/us/coronavirus-doctors-nurses.html?referringSource=articleShare
  9. I. Washington state nursing home sees nearly 50 employees test positive for coronavirus, by Dom Calicchio, https://www.foxnews.com/health/washington-state-nursing-home-sees-nearly-50-employees-test-positive-for-coronavirus
  10. J. https://www.ecri.org/coronavirus-covid-19-outbreak-preparedness-center
  11. K.https://www.cdc.gov/coronavirus/2019-ncov/downloads/hospital-preparedness-checklist.pdf
  12. L. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2, by John L. Hick, Dan Hanfling, Matthew K. Wynia, and Andrew T. Pavia, https://nam.edu/duty-to-plan-health-care-crisis-standards-of-care-and-novel-coronavirus-sars-cov-2/
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