I am a surgeon-in-training at one of the ten regional respiratory isolation and special pathogen centers in the United States. As surgeons, we are not on the front lines of treating the coronavirus epidemic, but we do play an important role in caring for some of the most critically ill COVID-19 patients.
My hospital is currently undertaking dramatic changes to maximize our ability to address the oncoming flood of COVID-19 cases, while simultaneously preserving our ability to deliver essential care for all life-threatening illness and injury. But our efforts are only meaningful if the rate of new infections can be drastically curtailed.
This crisis is most survivable only if it is slow and long. That idea is at the core of the “flattening the curve” strategy. The best way to address this is through social distancing—avoiding large congregations of people and maintaining a distance of at least six feet between others.
At this moment, we have a responsibility to bring immense social pressure to those who are not complying with the spirit of the Centers for Disease Control’s recommended social distancing behaviors. This includes the elements of the private sector which are trying to “tough out” the pandemic and continue business-as-usual. That sort of shortsighted and selfish behavior fundamentally undermines America’s only available strategy to contain this public health disaster. Additionally, the uptake in this behavioral change must be more thorough than any government intervention can accomplish.
Just yesterday, an AT&T employee recommended that I come into the store to get a new e-SIM for my phone (this is a card with a QR code on it—something that can easily be delivered digitally or by mail). The fact that this happened is a failure on several levels. First, it revealed a failure of store management to protect their staff and instruct them to advise customers to perform all possible business over the phone or online. Second, it demonstrated a failure of central management to give individual stores the flexibility to deliver additional services remotely and to plan for an extended hiatus in store traffic.
This type of inaction is ubiquitous and the severity of this crisis is beyond the power of the U.S. federal government to solely address. As a society united by a common purpose, we are obliged to use our anger and outrage to force everyone—businesses and individuals alike—to immediately implement extended plans to limit all non-essential interactions.
Why take such extreme measures? Because this virus is particularly problematic since it lies in the “Goldilocks zone” between not-too-fatal but fatal enough. Because COVID-19 is not extraordinarily fatal, it can rapidly spread unnoticed and an unknown number of infected people are asymptomatic and don’t realize they are carriers. At the same time, COVID-19 is fatal enough that it can quickly overwhelm medical professionals’ ability to deliver care. This virus is especially problematic due to the fact that it affects the young and otherwise healthy. Patients aged 20-50 make up about 40 percent of COVID-19 patients who are so ill that they require hospitalization. As a result, Ambassador Deborah Birx, response coordinator for the White House Coronavirus Task Force, has made a special plea to millennials to take this pandemic seriously.
As this is a respiratory illness, ventilators—machines that help the lungs breath—are in short supply. America does need more ventilators, but we have some ability to creatively expand our capacity. Anesthesia units used for surgical procedures can be modified for long-term ventilatory support. Moreover, additional ventilators are already being made available from the federal strategic reserves. But what happens to patients whose lungs are too sick for even a ventilator to support?
The answer is Extracorporeal Membrane Oxygenation (ECMO), which can sustain life when the heart and lungs fail. However, fewer than 300 hospitals in the United States have ECMO capabilities, and the expertise and costs to run an ECMO program are immense. At baseline, the U.S. national ECMO capacity is relatively saturated, with little ability to rapidly scale to need. In some cities, this capacity is already stretched to the breaking point. This means that when the surge comes, patients too sick for a ventilator will have no life-saving options available, no matter how many ventilators we manage to produce. Our only choice is to slow the spread of the disease.
Right now, we must keep as many health care professionals healthy as possible, both to manage the ventilators for the critically ill as well as to provide triage and care for those less severely—but still seriously—affected. The unfortunate nature of hospitals is that it is nearly impossible to maintain “social distancing” among the staff. Physicians, nurses, therapists, and others frequently cluster together in workrooms or shared offices.
Hospitals where the pandemic has not yet hit need to operate with the bare essentials to keep personnel in reserve for the coming surge of patients—most notably because the normal medical needs of our population will continue. Medical professionals will continue to care for heart attacks, appendicitis, cancer, and trauma. My hospital has implemented extreme staff conservation measures to limit the number of simultaneous in-hospital staff and to prevent entire departments from being sidelined by the virus.
However, this response is not universal. Across the nation, there are many hospitals which continue to perform elective surgical cases. There are other hospitals where residents (physician trainees like myself who have graduated from medical school and are bound to a specialty training program)–are being forced to work with substandard safety equipment. Furthermore, some residents are even being told that any illness or quarantine time may be unpaid and could extend their professional training. There are also nursing homes which are offering no additional sick leave for their workers. At this moment, communities must have zero tolerance for hospitals or healthcare facilities that provide any disincentive for sick employees to properly sequester themselves away from the remainder of their staff. To fail to do so critically endangers the communities that these hospitals serve as well as their fellow healthcare providers.
I’ve been asked many times how people can support the fight against COVID-19. The answer is simple: while you are sidelined at home and working remotely, take a moment to investigate whether the companies you do business with are limiting all possible in-person contact and advising customers to perform transactions digitally. Call your local hospital, nursing home, or dialysis center and find out if they are taking the proper steps to protect their patients and staff. Ensure they have no financial barriers to protecting their co-workers and patients from infection. While the federal response to this outbreak has been clearly lacking, it is reinforced daily by innumerable smaller failings in our communities. Our voices and outrage are key to successfully managing the spread of this disease.
Dr. Sagar S. Deshpande is currently in his surgical residency. He was awarded a 2019 Excellence in Public Health Award by the United States Public Health Service, and received his Doctorate of Medicine from the University of Michigan and his Master’s of Public Policy from the Harvard Kennedy School of Government.