Gregory Weiss, MD, a cardiovascular anesthesiologist and critical care physician, reflects on his experiences during 2020 and coping with the additional stress and responsibilities that accompany the COVID-19 pandemic.
There is no doubt that we are living in unprecedented times. Yes, there have been pandemics in the past, even worse than the present. What is different this time?
The answer is that the world is much smaller now. Not smaller in size for sure, smaller in that information is disseminated instantaneously via the internet and twenty-four-hour news outlets often to the detriment of society. The world is tiny now. One person may get information from someone on the other side of the world instantly on social media.
A New York physician with a dying patient may read a case report published by a researcher in China and use it to inform her treatment. Contrary to when some great event like a moon landing or a Superbowl win occurs, a tiny planet is first sewn with fear in the face of a global pandemic of the magnitude of COVID-19.
Let me tell you a story about my experience over the last eight months and the impact of the COVID-19 pandemic on clinical life and cardiovascular care at my institution. First off, I am a cardiovascular anesthesiologist and critical care physician. I work closely with cardiologists, cardiac surgeons, and patients with cardiovascular disease.
At the beginning of February 2020, I hopped on a plane with my wife and children to Aspen for a medical conference I go to every year. It was “normal” to my life. The first case of COVID-19 in the USA was diagnosed on January 20th, 2020. I have to admit, I was one of many physicians who didn’t think much of it initially. As a critical care physician, I work with infectious disease physicians often and, again, many of those I know didn’t expect the scale the COVID-19 virus would take. We were wrong.
The temperature of the country and my institution remained cool throughout February 2020 both figuratively and literally. The local response mirrored the national response to COVID-19. My hospital sent out a few emails in late February encouraging appropriate use of personal protective equipment (PPE) but it wasn’t until March that the temperature began to rise.
As cases and deaths began to skyrocket into March everything changed. By mid-March, emails spoke of canceling elective surgeries and interventional cardiology procedures. By April, all elective surgical cases were canceled by order of the Governor of Virginia, a physician and locums and per diem staff were “let go”.
Without the revenue from outpatient surgical procedures and well-reimbursed cardiology procedures the hospital was put in a very difficult financial position, keep staff and lose money, or lay off staff and risk a full hospital and overflowing intensive care unit during a pandemic.
During the month of March through June we saw a dramatic decrease in outpatient visits. No routine outpatient echocardiography, stress testing, or purely diagnostic catheterizations were performed. Cardiac catheterizations and in turn, cardiac surgeries were performed on acute coronary syndrome patients who could not wait.
Underlying reductions in patient volumes were a wide variety of personal responses to the pandemic spurred on by often conflicting information circulating the tiny planet. I found the complete lack of a unified approach to be disheartening at least and downright frightening at most.
During the year I worked in the presence of hundreds of physicians, nurses, technicians, surgical assistants, and support staff. Even into April and May, I would commonly see invariably young healthy staff gathered together as usual laughing, hugging, eating in breakrooms, and seeing patients without masks. Being born-again worried I struggled with whether I should tell them they were being irresponsible which would alienate them or to keep my opinions to myself while adhering to best clinical practice for myself and my patients. Largely I kept my opinions to myself, after all, many of the people not wearing masks were in positions of leadership.
With regards to outpatient cardiology visits, reports indicate anywhere from 50% to 90% of office visits and cardiovascular procedures were canceled with many of us believing that we will never get back to “normal”. Reports of patients not coming to the hospital with chest pain, even dying in their homes for fear of coming to the hospital circulated. Some relief was had through shifting a portion of the canceled office visits to virtual consultations. Unfortunately, many of our urban and rural clients do not have the access to broadband or the training to use it effectively. In a practice where connecting with and engaging patients is crucial to their health, we were literally disconnected.
In April I dove into the deep end of the pandemic. Approximately, two weeks before the first peak of COVID-19 cases in Virginia I had the occasion to attend the medical intensive care unit (MICU) in my hospital. At this point, we were wearing positive air-purifying respirators (PAPR), N-95 masks covered by regular masks, and even full-face snorkel respirators when dealing with suspected or known COVID-19 patients.
My experience was exactly as one would expect from most media reports. I can’t say that I was afraid for myself. I imagine like most clinical providers I was so used to jumping in for the patients and my staff that those worries simmered underneath somewhere. That simmering quite possibly took its own toll on my subconscious. During that week I took care of many critically ill COVID-19 patients. I performed intubations, counseled families, and provided end of life care. It was both inspirational and heartbreaking. The only other thing I would say about that experience is that I have never worked with a kinder, more talented, and compassionate group of nurses, respiratory technicians, physicians’ assistants, and fellow physicians in my life.
Moving into late May and June 2020 there seemed to be a clearing in the forest or possibly the eye of the storm. In late May we reopened to elective surgical patients. The echo studies were being done again, the catheterization laboratory was seeing more traffic, and Virginia downgraded our COVID-19 alert level to spite the numbers continuing to ebb and flow with no clear pattern or trajectory. The national dialogue was so inconsistent that, left to their own motivations and needs, most health systems kept a cautious business as usual approach. Most services were permitted with more widespread sanitation and mandatory mask-wearing.
Of note, year to date, I do not personally know a single victim of COVID-19 a fact difficult to reconcile in light of nearly a quarter of a million deaths in the USA. Maybe we did something right, maybe we were lucky.
Below the surface, I am tired. I sleep less and worry more. I worry about this winter, I worry about my kids going back to school, I worry about my patients and their families. It seems like everyone has a prediction and that none of the predictions thus far have been perfect, and that is to be expected.
I encourage my fellow clinicians to protect themselves and follow the science rather than the rhetoric. We need to support each other and our patients by reassuring them that it is safe for them to come see us, that we will use the recommended precautions to protect them. Cardiovascular disease didn’t take a vacation during this pandemic, in fact, there is evidence that COVID-19 has serious novel effects on the heart and cerebrovascular system yet to be clearly defined.
With flu season upon us educating our patients about the difference in symptoms with COVID-19 and the importance of flu vaccination is vital and can hopefully prevent a tsunami of critically ill patients from overwhelming our intensive care units this winter. Finally, protect yourself, allow yourself to feel the pain and the hope in your altruism, your sacrifice, and your love for humanity.