The quiet before the surge: US physicians speak on the COVID-19 pandemic

The WSWS spoke to three physicians as the coronavirus pandemic continues to escalate in the United States. They shared their current experiences and provide insight into their work and life as medical professionals. Their names have been changed to protect their identities.

Karen is an obstetrician in Las Vegas, Nevada. Her state has seen the number of cases jump from 109 on Thursday to 190 on Saturday. She said that the city has essentially shut down all normal business. Governor Steve Sisolak issued a new directive on Friday closing all nonessential businesses, allowing local government to issue criminal penalties for any business that defies the order.

“Nevada’s health system won’t be able to handle excessive number of patients all at once without quickly straining all their resources,” she said. “If we don’t slow this virus, we aren’t going to have enough hospital beds.” She has one young patient with COVID-19 who is 28 weeks pregnant. “She’s only on a nasal canula for now [supplemental oxygen].” Her surgical colleagues have been canceling elective cases in anticipation of a rush of patients to the hospital. “It’s the quiet before the storm.”

“The transformation in the city has been eerie. There’s hardly anyone on the streets. The casinos are closed. We are all waiting to see what’s going to happen.”

Karen still sees her obstetric patients and is on call at the labor suite. She said, “It’s so strange ... so many of my friends are out of work. We are reusing masks, only allowing one surgeon per case unless the case becomes difficult. We are also starting to use handmade masks—it’s just so sad.”

She paused a moment, then added, “I feel that if Trump would have been serious from the beginning, we would not be facing a huge medical disaster and economic disaster. He is terrible. But everyone is hanging together.” She had to leave the interview to start a cesarean delivery.

Mark is an emergency room physician working in Chicago. He explained that the hospital’s response to COVID-19 has been an evolving process, so cautioned that the response may change soon. “They now have a tent in the ambulance bay,” he said. “Everyone that is not urgent or serious, is directed to the tent where they undergo screening. If they are there for respiratory symptoms, they are assessed for risk. If they are low risk, they are sent home without testing but given precautions.

“For patients with moderate to high risk, we do a viral panel with three separate swabs—one for the Flu/RSV (respiratory syncytial virus), a viral panel and one for COVID-19. However, I think that the first two are unnecessary because what we really want to know is if they have COVID-19. We all get the flu shot and invariably the viral panels will be positive but offer no value.”

The Flu/RSV tests take approximately 45 minutes and the viral panel 24 hours. Patients are sent home to wait for results. However, the COVID-19 tests have been a source of frustration. “There are three different tests we use,” Mark said. “State labs can take several days to result, so, we have to constantly keep an eye open for them. ALVERNO labs can turn them around in less than a day. Couriers pick up the specimens and transport them down to Indiana.

“North Shore can turn the tests around in about six hours but have only a limited supply, running about 200 tests per day systemwide. This means that they will only accept very high-risk patients who are admitted to the hospital. The administration is saying that we should be able to run in-house testing but I’m not sure when that will happen.

“Their protocol is to directly admit patients with severe symptoms to the emergency department, bypassing the tent. The patient is given a facemask and the health workers are in personal protective equipment, which include gowns, gloves, eye protection and an N95 mask. They are also recommending hair nets because the virus droplets can fall on their heads. Corporate continues to assure the hospitals they will have everything they need, but on the ground, the hospital is asking everyone to conserve their PPEs. They are even using UV light to clean their facemasks and equipment.”

With regard to the question of the surge, Mark said, “If we follow the Italian curve, then we can expect that it will happen in the next week or two, if not sooner. Our patient volumes are down for now, but the number of respiratory cases is going up. People are scared to come to the emergency room out of fear they’ll get infected. I had a guy with a sprained ankle who wanted to get out as soon as possible.

“We have also seen an uptick due to psychiatric illnesses. There’s a lot of suicidal ideation and anxiety we are seeing. One person came feeling suicidal because he thought he had infected all the people around him. He tested negative.”

Nurses, physicians and health care workers are turning to social media platforms to share their concerns, send queries for homemade PPEs and figure out how to access equipment in construction industries to makeshift into personal equipment. Mark said, “My mother is a seamstress and she offered to make everyone masks. I’m trying to find a full-face respirator from the industry. My friend in Texas posted that her hospital has emailed everyone that they would be out of PPEs soon and should look to find their own. There is a movement beginning among ED [emergency department] docs, ‘No PPEs, no work.’”

When patients need to be intubated, they are using a minimum of three providers—himself, a respiratory therapist and a nurse—in a negative pressure room. He uses PPEs, but they are only of benefit for droplet precautions and not airborne precautions, which requires he have a positive air pressure respirator. He uses a video scope to intubate to avoid bringing his face close to the patient’s.

Asked about the ethical issues behind such a movement among ED doctors, he said, “I go back and forth on this every day. It is the system’s responsibility to supply us the equipment to do our job. It’s not safe for me and my patients to spread the infection to other people, least of all our patients if they aren’t infected. The health care system has dropped the ball here. If we don’t protect the health care workers, then it doesn’t help the mass of people.

“We are as prepared as we can be for now. We work well together in the ED and there is a good attitude among the team. They are shifting extra people who aren’t busy, such as surgery residents whose elective cases have been canceled, to help.

“But it will be important to understand why they dropped the ball. I mean, I heard that senators were selling their stocks before the markets crashed. What did they know? Why didn’t they make the public aware of what was going on? I hope they are put through the ringer. We will need scrutiny on various governmental departments that dropped the ball. If they knew this was serious, why didn’t they ramp up production of PPEs? Obviously, they were more interested in their finances than in people.”

Nellie trained as a physician in Iran and practiced there for 20 years before migrating to the United States. She is a mid-level provider in a gastroenterology clinic in Turlock, California. She said, “Our facility has started the drive-through testing out in our parking lot for all suspected patients who come here. They are screened before they enter the facility. Anyone having symptoms of cough, fever, headache and muscle aches is sent in their vehicle to the parking lot. One of the physicians from the urgent care will take a brief history and review of systems and determine if they should be tested. There is a scarcity of available tests, so they reserve the tests for those at high risk and with severe symptoms. These tests take about five days … for now.”

Asked about patients who call their hot line, she described the procedure. “They are referred to a triage nurse and if they are exhibiting symptoms deemed serious, they are asked to call their provider. If the physician thinks they should be tested, they will order the test and send the patient to our drive-through. I think, on average, we have done maybe 1-2 tests a day because of shortages. So far, there are four patients that I know of that have tested positive in Stanislaus County, but none in Turlock.”

She admitted she is concerned that the epidemic would sweep through this region where there are many elderlies. When asked about care of health care providers, she anecdotally offered her own experience at work: “My medical assistant was coughing in the office. She had some wheezing, some shortness of breath. She has mild asthma and had to use her inhaler. Our nurse encouraged her to call her doctor, but they told her to stay home for five days and if she developed a fever or had worsening symptoms, to call back so they could order the COVID-19 test.”

Our discussion moved to developments in Iran. She speaks to her brother daily and he told her that people are out on the streets. There is no real quarantine, even though the authorities have recommended they stay home. “They aren’t using their military force to prevent people from gathering and going out and about. The government is following the idea of letting the population develop herd immunity.”

She also remains in contact with her medical colleagues. She said, “Iran has the same problems as Italy, and much worse than that. There aren’t enough hospital beds, ventilators or testing capability. My colleagues there are very worried. Every day another doctor or nurse is dying from respiratory failure because they are infected. They don’t have enough PPEs. I heard that at least 53 medical professionals have lost their lives due to COVID-19 in Iran.

“The present protocol they are using to treat COVID-19 is when patients exhibit severe symptoms, they will start the anti-malarial drug, chloroquine, Remdesivir and the antiviral HIV medication, Kaletra. The head of infectious diseases, Dr. Mino Mohrez, told us she is infected but hasn’t developed any symptoms, yet.”

Nellie also shared an open letter from artists in Iran that was sent by a friend. The letter reads; “We need our message to be passed on as hastily as possible. We are all equally vulnerable to this microscopic adversary. The salvation of one depends on the salvation of all. The coronavirus is not just a virus, it is a simple and historic question that is waiting for complex answers from the people and governments of the world … the crisis will pass, with small or catastrophic losses, but the collection of tales will also remain. The stories of exhausted nurses dancing in contaminated hospital hallways to raise the moral of patients, as they hide their worries about the lack of medicines and basic hospital necessities. Stories of physicians who haven’t been home in weeks and are forced to work without masks or gloves or gowns as they search for victims in the hallways of hospitals.”