Just finished my fifth shift in a row in our Emergency Department COVID-19 unit, and I have to say, I’m spooked. I’m pretty worried about what’s coming. Our health care system is about to become completely overwhelmed. And I know that in some parts of the country it already is.

‘WORRIED WELL’ TIE UP EMERGENCY ROOM

In the ED we think a lot about “volume,” or how many people are coming through who need to be seen. We’re getting a big surge in what is called the “worried well,” who take up a lot of time and a moderate amount of resources. We’re doing everything we can to keep these people from tying up the Emergency Department, but there is no place else for them to turn. They are terrified. They want to get tested. We don’t have any tests. It makes my job easy. In my mind, anyone who felt sick enough to come to the Emergency Department during a pandemic is sick enough to quarantine at home for 10 days. It will help with social distancing and keep people from coughing on each other while they fight over toilet paper at Costco. But they have no place else to get information. Every urgent care and primary care office is terrified and sends them directly to the Emergency Department to “get tested,” but we don’t have any tests. It overwhelms the system.

Another issue we have had is people in group living situations: patients sent in from homeless shelters and detox or sober living programs. They can’t quarantine where they live. But if we tell the program we can’t rule out COVID-19, they could lose their bed and be on the street during a time when all businesses and restaurants are closed. We don’t have a plan. We have been secretly testing some of these people – sending tests to California, telling them to wear a mask when they go back and calling them with their results. I hope. I can’t get the results because they’re run in a lab in California, so a nurse in Infection Control is supposed to get their results and call them. I can’t see the results myself.

Also seeing a fair number of people with mental health issues who are having trouble with quarantine. Their therapists offices are closed, or if they try to get treatment, their insurance company is closed. They are stressed and anxious about being quarantined and losing their social support.

INFLUX OF YOUNG COVID PATIENTS

Today was a turning point. Much higher volumes; the staffing plan we put in place five days ago has started to fail. We’re going to need to shift more doctors and nurses over from the main ED into the isolation unit as volume picks up. At the beginning of my shift it was a lot of the worried well, but as the night went on, we started to see some sick patients. What’s spooky is that a lot of them are young, and they go downhill really fast. My worry is that because we are seeing a skew toward younger patients in the beginning, there will be no beds or ventilators left when the surge of older patients comes.

Intubation is another issue. Normally, intubation (inserting a breathing tube) is a fast process. Maybe five minutes for setup, 30 seconds for procedure, 10 minutes for post-procedure care. Can be even faster if needed. But intubating a COVID-19 patient is very dangerous for staff because it creates aerosols and makes it much more likely that the virus will spread. It takes much longer to set up and perform. Everyone needs to be in real full protective gear.

One of the big changes in emergency medicine and critical care over the past few decades was the introduction of BiPap, a kind of breathing machine that helps patients breathe without them needing a breathing tube inserted or needing to be sedated. It helps patients who are too tired to breathe, it helps push fluid out of the lungs, it helps patients with asthma and chronic obstructive pulmonary disorder. We can’t use BiPap on COVID-19 patients because it creates aerosols that spread the virus. And since we don’t know who has COVID-19, we can’t use BiPap on anyone. We also can’t give nebulized breathing treatments, the mainstay of therapy for asthma and COPD exacerbations, because those create aerosols. I’ve had to learn how to use alternate medications that have been out of practice for decades to treat these conditions.

HOSPITAL WORKERS UNPROTECTED

On top of all this, none of us knows how to protect ourselves. There is a lot of confusion about what personal protective equipment we should be wearing, but that debate is kind of settled because we don’t have high-level PPE available anyway. We still have N95 masks and I get one of those per night (recommended wear time is five hours, I wear mine for 10). I save all my used masks for the day when we run out of clean ones. I wear safety glasses, which may or may not be the right level of protection. I wear one gown through my whole shift and take it off if I leave the unit and put it back on when I get back; that is not the way you are supposed to handle PPE, even of this level. We are out of sanitizing wipes in the hospital, largely because many of them were stolen. These are what we use to sterilize beds and equipment between patients. I have a Ziploc bag with a few wipes in it that I have been bringing with me to each shift to reuse on my stethoscope between each patient. I fully expect to get infected and just hope that my relatively young age is protective against severe disease.

I see videos online of people who have no daily contact with the virus getting packages from Amazon: going outside, wiping down the outside of the box with a wipe, opening the box, wiping down the contents with a wipe, then taking off their shoes and going inside. I work every day with patients I’m 100 percent sure have the virus, and I don’t have the time or resources to live like that. I’ve started stripping my scrubs off into the wash when I get home, but there’s really no way for me to avoid contamination. I don’t wash my hair every day (once a week is good at this point), but I wear a bouffant. I drive to and from work in my car and touch the inside. My phone is marginally cleaned by one of the few wipes I have. I carry my bag to and from work and leave it outside the unit, but there are things I put in and take out of there that I can’t wipe down. I definitely can’t spend my energy focusing on whether I touch my face. The message here is not that you shouldn’t be cleaning things, but it seems skewed that people with no exposure to the virus are able to clean everything and those of us actually caring for COVID-19 patients are not.

My daily schedule is like this: Wake up, attend a Zoom meeting about COVID-19 for several hours, read about COVID-19, drive to work, work in the COVID-19 unit for 10 hours, drive home in silence thinking about the day or decompressing with a friend on the phone, shower, sleep three to five hours, repeat. Having friends going through the same thing around the country is my only sanity saver. We’re all scared.

U.S. NOT TAKING THE RIGHT STEPS

When I do get some time to run errands, the grocery stores are empty. I can’t get basics I would like to have to continue taking care of myself while I work tons of extra hours. The grocery stores are sold out. Scarcity is a powerful human motivator and the hoarding and stealing are making my life difficult. I’ve decided that I’m going to try to switch to ordering takeout and delivery during the business shutdown to support local businesses, in the hopes that they will be able to open normally again when this is all over.

In the U.S. we’re making changes that are destroying our economy, but we haven’t taken the steps that will actually slow transmission. We’re not checking people’s temperatures. In the rest of the world, your temperature gets measured at every exit and entry point including pizza shops and your own apartment building. In the U.S., we’re not monitoring for symptoms and we’re doing any surveillance testing. We don’t have tests.

My boyfriend lives in another state. I don’t know when I’ll be able to see him again. I don’t know when I’ll be able to see my parents again, because of their age. All my life plans are on hold. I was planning on visiting my boyfriend next month. Now I’m not sure if I should go because every day we have more shifts to fill as doctors get stuck out of state due to flights being canceled, or are self-quarantining because they have symptoms, or are removed from the schedule because their risk of severe disease is high if they are infected due to their age or underlying medical conditions, or we simply need more doctors to work in the department. I feel like it would be irresponsible to leave and risk getting stuck out of state. Everything I do now feels irresponsible because I could be carrying the virus at any time.