In the midst of the outbreak, people will still have heart attacks and strokes. Babies will still be born. Appendixes will still burst. And so hospitals are figuring out how to juggle the patients who require ordinary urgent care with those who are sick from the new coronavirus.
At first, Long Island Jewish Medical Center’s emergency department tried to keep people with suspected COVID-19 separate from patients with other complaints. But since the volume of patients exploded, every patient is now treated as a possible COVID-19 patient and given a mask, says Adam Berman, associate chair of emergency medicine at the Queens hospital.
The same thing is happening at Zuckerberg San Francisco General Hospital and Trauma Center; even if a patient comes in with a different complaint, they are treated as though they may be infected. Keeping likely COVID-19 patients separate from those who don’t have the illness becomes difficult as the virus spreads, and virtually everyone is “COVID-possible.” “A woman came in with vaginal bleeding, but she was COVID-positive,” says Chris Colwell, the chief of emergency surgery at SF General. Her complaint wasn’t the disease; it was the bleeding. “It’s very hard to cohort in a situation like this.”
Hospitals around the country are closing some services to make sure that people who have medical emergencies can still get help — even with an influx of people sick with COVID-19. In many hospitals, any surgery that could reasonably wait is canceled. That frees up surgeons, internal medicine doctors, and others to help in the emergency department. Some hospitals have stopped offering outpatient care to conserve resources. Visitors are being limited or banned.
“The issue here is one of crowding out,” says Stephen Shortell, a professor of health policy and management at the University of California Berkeley, where he is also a dean emeritus. “The concern here is that COVID-19 will crowd out other people who need hospital care, which puts a premium on hospitals’ ability to set priorities.”
Hospitals have to figure out how to distribute available rooms or beds, staff, and equipment to ensure all patients get care. 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’s a duty to care for patients, while also trying to preserve the maximum number of lives. Hospitals must make sure that all patients are treated fairly, and that the public understands how these decisions are being made, she says. And it’s important for patients to show solidarity for each other — for instance, by understanding why your own surgery has been rescheduled in light of the crisis.
At most hospitals, figuring out how to provide the best care starts with emergency planning documents. At the University of North Carolina Medical Center, for instance, those documents include hurricane plans, floods, electrical outages, and two kinds of plans for highly communicable disease, says David Weber, the medical director of infection prevention there. That hospital has limited visitors and developed guidelines for what counts as a truly urgent surgery, he says.
Both LIJMC and SF General have pandemic planning documents — as well as documents for other kinds of emergencies, such as mass shootings — but even with a plan, it can be difficult to predict in advance what course a pandemic will take. Both hospitals began monitoring the outbreak in China in January.
LIJMC had kept a particularly close eye on the new coronavirus, since the hospital is near John F. Kennedy airport in New York, and there was a direct flight from Wuhan, the city hardest hit by the virus, to JFK three times a week. COVID-19 patients require special rooms and special precautions, so LIJMC began tweaking its emergency plans immediately, Berman says. No one has stopped tweaking them. “It’s literally every day being revised and changed and updated based on new information and the capacity of our hospital,” he says.
Ordinarily, the hospital’s emergency department is staffed based on the amount of demand the hospital sees historically. But the volume of patients has gone up, so LIJMC has brought in extra providers, mostly emergency physicians. Elective surgeries were canceled and visitors aren’t allowed. The hospital’s lobby is now used for screening.
At first, COVID-19 patients were sent exclusively to the intensive care unit, but it was filling 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 now is a COVID wing,” Berman says. But if a patient comes in with another emergency — a heart attack, a stroke, or trauma — they will still get the same standard of care they would have before the pandemic, he says.
One benefit of the shelter-in-place order effective March 17th in San Francisco has been a drop in moderate trauma cases, says SF General’s Colwell. When people don’t leave home much, they’re less likely to be exposed to COVID-19 — but also less likely to have an accident, resulting in an emergency room visit. Those people who do have other kinds of emergencies are still receiving normal care.
The biggest constraint on his emergency department now is the number of people with marginal, inadequate, or no housing, Colwell says. No shelter or skilled nursing facility will take them without a negative COVID-19 test, and they can’t be sent back to the streets where they might pass the virus on to others. Right now, he has 15 patients in beds who might have COVID-19, but who don’t have acute medical issues and have nowhere else to go. “As we sit here today, the problem is not ventilators,” Colwell says. It’s that he has nowhere to send these patients. That’s been an issue for a long time — but it’s particularly acute right now.
Both Colwell and Berman say that they are particularly grateful for community support. Colwell was particularly delighted by donations of N95 masks, but other gifts have also flooded in. “We have gotten such an outpouring of donations of food and equipment and things that help the mental state of the people working in the emergency department — because this is taking a toll on everyone,” Berman says.
Despite the stress, both of their departments were doing all they could to keep the pandemic from taking a toll on their ability to treat patients. The doctors said they want to continue giving usual care, even in these unusual times.