August 25, 2020

'Like serving on the front lines of a war': 2 ED doctors on what it’s really like to treat Covid-19

Daily Briefing

    Houston and New York each have been hot spots of coronavirus transmission and have seen significant spikes in their numbers of hospitalizations from Covid-19, the disease caused by the virus. The Guardian recently sat down with Tsion Firew, an ED doctor in New York, and Cedric Dark, an ED doctor in Houston, to see what treating Covid-19 has been like on the frontlines of America's coronavirus hot spots. Here's what the doctors had to say.

    Covid-19 guidance from clinicians at the forefront

    'Is this when I drop dead like my patient?'

    Firew said she first became aware of the novel coronavirus after traveling to Sweden and Ethiopia for work in February.

    "There was some sort of screening for Covid-19 in both places," Firew said. "On Feb. 22, I came to New York City, and nothing—no screening. At that point, I thought, 'I don't think this country's going to handle this well.'"

    Firew said that in mid-March, just 15 days after New York City reported its first case of the new coronavirus, she was informed that she had been exposed to patients who had tested positive for the virus—and she was instructed to stay home from work.

    However, Firew said in late March, health care workers who had been exposed to the virus and were quarantining at home were told to return to work if they weren't experiencing symptoms of Covid-19. And when Firew went back, "[i]t felt like a tsunami hit," she said. "I've practiced in very low-resource settings and even in a war zone, and I couldn't believe what I was witnessing in New York."

    Firew said the ED "was silent" from having very sick patients and not allowing any visitors. Many of the patients were placed on ventilators or supplemental oxygen, she said.

    "The usual human interactions were gone. Everybody was wearing a mask and gowns and there were so many people who came to help from different places that you didn't know who was who," Firew explained. "I spent a lot more time on the phone talking to family members about end-of-life care decisions, conversations you'd normally have face-to-face."

    But the severity of New York City's coronavirus outbreak varied by hospital, Firew said.

    For instance, at a hospital near the Bronx—which saw high numbers of coronavirus cases—"people were dying in ambulances while waiting for care," Firew said. "The [ED] was overwhelmed with patients who needed oxygen. Its hallways were crowded with patients on portable oxygen tanks. We ran out of monitors and oxygen for the portable tanks. Staff members succumbed to Covid-19, exacerbating shortages of nurses and doctors."

    Meanwhile, Firew said friends who worked "in Lower Manhattan couldn't believe some of the things" she was seeing.

    At the beginning of April, both Firew and her husband became ill with Covid-19, and Firew said she feared for her and her husband's lives.

    "Walking from my bed to the kitchen would make my heart race; I often wondered: Is this when I drop dead like my patient the other day?" she said, adding, "I never imagined that in 2020 I would be writing out a living will detailing my life insurance policy to my family."

    Firew was especially concerned because of disparities in the way the novel coronavirus affects people of different races and ethnicities.

    "It was … around that time that a brown-skinned physician who was about my age died from Covid-19. So I knew being in my mid-30s wouldn't protect me. I was even more worried when my husband became ill because, as a Black man, his chances of dying from this disease were much higher than mine. We both recovered, but I still have some fatigue and shortness of breath," she said.

    As the novel coronavirus began to spread across America and infections surged in other states, Firew became "chronically angry" about the "negligen[t]" way some government leaders have responded to the epidemic, she said. "Our leaders do not lead with evidence—we knew what was going to happen when states reopened so quickly," Firew said, referring to recent spikes in new coronavirus cases that occurred after states began reopening nonessential businesses and relaxing measures intended to curb the virus' spread.

    But in New York, at least, the situation has improved. "There have been several days where I've seen zero [Covid-19] cases. If I do see a case, it's usually someone who has traveled from abroad or other states," Firew said.

    Instead, doctors in New York are once again beginning to see some patients seeking care for conditions that aren't related to the coronavirus but, in some instances, those patients' conditions still were affected by the epidemic.

    One such patient, Firew recalled, was a woman in her early 40s who had a "massive lesion on her breast." The patient said she had started experiencing pain back during the peak of the epidemic but had been too scared to seek hospital care.

    "By the time she made it to our hospital, the mass had metastasized to her spine and lungs. Even with aggressive treatment, she likely only has a few months to live," Firew said. "This is one of the many cases we're seeing now that we are back to 'normal'—complications of chronic illnesses and delayed diagnoses of cancer. The burden of the [epidemic] layered with a broken health care system."

    'Covid is everywhere'

    In Houston, Dark initially dismissed concerns about the coronavirus causing a widespread crisis in the United States. He explained, "On Feb. 26, at a department meeting, one of my colleagues put coronavirus on the agenda. I thought to myself, 'Why do we even need to bother with this here in Houston? This is in China; maybe it's in Europe?'"

    However, Dark said that, as he saw reports of coronavirus cases surging throughout Italy, he became worried. "I remember seeing images of people dying in their homes and mass graves," he said. "I started to wonder, 'Is this what we'll see over here? Are my colleagues going to be dying? Is this something that's going to get me or my wife, who's also an [ED] doctor? Are we going to bring it home to our son?'"

    Dark said his hospital initially converted its eight-bed urgent care space into a coronavirus unit and, at least "for a while, that was enough." Then, Dark and his colleagues began seeing some patients with Covid-19 meaning suspected community transmission was occurring in Houston even though officials hadn't yet acknowledged it.

    As the number of coronavirus cases increased in Houston throughout April, Dark said "it stayed relatively calm because the city was shut down." Still, Dark was concerned. He explained, "I went to medical school at [New York University] and have a lot of friends in New York I was checking in with at the time. I thought that in Houston, a city that's almost as big, we had the conditions for a similar crisis: It's a large city with an international airport, it attracts a lot of business travelers, and thousands of people come here each March for the rodeo."

    Sure enough, once Texas began allowing nonessential businesses to reopen and scaled back other preventive measures in May, new coronavirus cases began to surge in the state.

    Dark recalled the first Covid-19 patient he lost.

    "He started to crash right in front of me," Dark said. "We started CPR and I ran the algorithms through my mind trying to think how we could bring him back, but kept ending up at the same conclusion: This is Covid and there's nothing I can do."

    Dark said his experience on the front lines of the epidemic has been "like serving on the front lines of a war." He explained that he and his colleagues initially had trouble getting their own personal protective equipment while their hospital "worked to secure [its] supply chain." And "[a]lthough that situation has stabilized, a lot of patients who come in for non-Covid reasons wind up testing positive," he said. "Covid is everywhere."

    Dark said he thinks Houston's situation "was completely avoidable" and is a result of officials reopening "the economy too fast."

    Further, Dark expressed concern that the situation may not improve quickly. "Our hospital had some of the highest numbers of Covid cases among the nearly two dozen hospitals in the Texas Medical Center network," he said. "As area hospitals fill up, they reallocate additional floors to Covid patients. Who knows, if we don't get this under control, maybe one day the whole hospital will be Covid" (Renwick, The Guardian/Kaiser Health News, 8/14).

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