Wow—it’s been several busy weeks!
In Minnesota, where I practice, the hospitals have been besieged by patients suffering from COVID-19.
While most people who catch SARS-CoV-2, the virus that causes COVID-19 disease, will have no or minimal symptoms, some people will have severe symptoms that require hospitalization. For the hospitals that care for these patients, the late 2020 surge faces two challenges—space and staff.
Space, staff and stuff is the basis of preparedness for any mass event. In early 2020, when we were caught flatfooted with a novel respiratory pathogen, Stuff was at a premium—globally. This included personal protective equipment (PPE), ventilators for patients with respiratory failure, and testing supplies, especially in the United States. In New York City, which was hit hardest in the first wave, Space (hospital beds) and Staff (especially nurses) was also at a premium. Many fearless professionals volunteered (and were paid) to rush to the aid of Gothamites. Field hospitals and a hospital ship arrived to provide extra space. After several weeks, the new cases stopped, and New York, and other metro centers that were hit in the first wave were able to stand down.
A second wave hit the Sunbelt of the USA during the summer, but the severe shortages of needed support did not match the first wave. While stressful for hospitals, resources were marshaled.
Now the much-feared (at least by those of us educated in the ways of epidemiology) Fall of 2020 wave is here, and it has again stressed hospitals. We are running out of Stuff (gloves, disinfectant wipes), Space (field hospitals are starting to appear in some places) and, most importantly, Staff. Isolated outbreaks, whether geographically or within populations, could be managed by moving Staff. But at this point, where COVID-19 seems to be everywhere and afflicting everyone, Staff is getting sick and isolated (or exposed and quarantined).
Hospitals are starting to make hard, and costly, decisions about managing this wave of increased patients, while having decrease resources, especially staff. Many important surgeries, that are not time sensitive, are being delayed. (This has been called “elective” surgery—but in truth, only the timing is elective, not the necessity.) The drop in surgeries will affect the income to the hospital—and surgeries are often more lucrative for hospitals than non-surgical admissions.
Even more difficult for hospitals, and all of us who provide care, is the opening of discussion about Crisis Standards of Care (CSC). CSC is the ethical and legal framework that is invoked when demand irrevocably exceeds the supply of care. Occasionally seen in war or severe natural disasters, most of us are not familiar with the uncomfortable choices poised by CSC.
For all of my professional career, shared decision making with patients—prioritizing patient desires for level of care, also known as patient centered care—has been the mantra. I started medical school in 1983, just as paternalism in medicine was starting to wane. CSC flips all that over. Now we may have to prioritize the good of the many over the wishes of the few. While comfort will always be a priority, the desire of patients (and their families) to preserve and extend life may have to be let go, if those resources can be used to save even more lives.
Of course, for those of us who are providing care, it means very difficult decisions and very difficult conversations. And little time to train on how to make those decisions and have those conversations. All of this introduces moral hazard into our lives, accelerating the burnout that we are already feeling.
We will be living in uncertain times, likely until the middle of January 2021, when travel/holiday related transmission will start to ebb, and (hopefully) vaccines against SARS-CoV-2 start to generate some protection for the most vulnerable.
Stay safe!