Last year when the SARS-CoV2 was just starting to circulate in the US (or, more accurately, the awareness of its presence was becoming more obvious), our proactive healthcare system was getting prepared for the onslaught of patients expected to need care in our hospitals, based upon initial epidemiological data. Our local COVID-19 infection growth curve was steep, so our hospital was expecting an exponential increase in cases similar to those in the Seattle, WA area.
When the director of our rehab hospital told the medical staff that the hospital was expecting three-to-four-times the number of patients our hospitals could absorb or provide with beds and staff, I did not want to believe him. It had to be exaggerated. Where did these numbers come from? And where would these patients go? The organization went immediately into overdrive to makes plans for this increased patient load. Our parking garage was rapidly made into an alternative care site not unlike a M.A.S.H. unit (one that our past president tweeted was just more “fake news”). Algorithms were quickly created as guides for taking care of the potential thousands of COVID-19 patients. Outpatient clinics were closed, elective surgeries canceled, and resources were quickly conserved for the oncoming patient surge. We were then asked how we could assist in this: where could we as physicians use our skill sets best? We even made plans to put acute care patients at the rehab hospital, with cots in the rehab gyms, if it came to that.
I was terrified that I would be asked to practice internal medicine, something I had not done in six years since I was an intern, as I become sub-specialized in stroke and brain injury rehabilitation. To prepare myself, I immediately bought the updated common intern guide “Pocketbook medicine.” My rehab colleagues online were taking crash courses and reviews in internal medicine so that we could assist when the surge arrived. We also learned about crisis standards of care, defined as “a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g., pandemic influenza) or catastrophic (e.g., earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations.”1
“Crisis standards of care” means that during a catastrophic public health event like the current COVID-19 pandemic, the surge of patients has the potential to overwhelm a healthcare facility’s ability to follow normal standards of medical care due to scarce resources (e.g., ventilators, oxygen, medications), too few hospital beds (e.g., ICU), and increased demand for services in the setting of too few providers of care (e.g., nurses, physicians, respiratory therapists). Crisis standards of care are designed to guide organizations and states to provide the most ethical care during a disaster, something that makes all people very uncomfortable even to think about. States in the US are in different stages of developing their own crisis standards of care models as it is a complex process, involving countless persons and systems served. These plans are designed to decide to whom and when to trigger the crisis standards of care, as well as how to effectively triage (i.e., which patient is most likely to survive without any significant medical intervention as well as which patient is not likely to survive, regardless of medical care provided). This reminds me of an ethical exercise in my college philosophy class: if there are two people in a boat that is sinking, a frail old man and a young child, which one to throw overboard if doing so will save the other? There is no “right” answer, either is morally unfathomable, and yet, initially with the COVID-19 surges around the country and world, these conversations are happening.
Part of the crisis standards of care, and the part that fills me with the most fear, is the request during a crisis of caregivers to work outside their scope of practice which would be legally protected. When a nurse isn’t available, then a nursing assistant may suffice; when a physician isn’t available, a nurse may fill in, etc. To prepare for this possibility our physical therapists were trained as nursing and respiratory extenders. To prepare for this myself, I read up on general medical care (i.e., not stroke or brain injury rehabilitation). We had to prepare for the eventuality that caregivers might also become sick with the virus and need at least some time off for sleep.
Going to work at this time was like waiting for the start of a war. My ex-military husband remarked to me that soldiers often have a harder time while waiting for the fight as compared to the fight itself. We got a daily briefing from our medical director regarding how full the hospital was, how many COVID tests were available (in the beginning not so many) and how much PPE (personal protective equipment – gowns, gloves, masks) we had available. There was so much tension in the air, non-stop, every day, not only because of the anticipation of the upcoming increase in patients, but also because, at that time, there was so little known about the disease, its manifestations, and its treatment.
It was akin to my most stressful days in medical school and residency, but without any break. My stress did decrease slightly when we learned we would not be asked to “man” a station in the hospital where we were not comfortable providing care. There was no way I could competently or efficiently take care of ICU patients, but I could likely provide care to patients with less severe medical illnesses like pneumonia or COPD exacerbations, something I could easily look up in my Intern guidebook. I could also easily talk to patients and family about death and dying, which is what I finally told my medical director I would do if needed. Clearly, if we ever had to implement crisis standards of care, many patients would die and would need compassionate palliative care.
Fast forward several months, to the surge that initially never occurred, mostly because people were scared to come to the hospital for anything else (for fear of getting COVID-19); in addition, elective surgeries were canceled, both of which translated to more open hospital beds. While the stress level has slowly continued to decrease, there is still the background effect and awareness that this pandemic is not going away anytime soon. To keep myself sane, I stopped listening to the news for many months, I stopped looking at the daily body counts on the John Hopkins site, and I stopped going onto social media platforms. I needed some mental and emotional space to take care of myself so that I could continue to provide good care to my patients. I was initially successful in decreasing my stress and anxiety level, but what I wouldn’t learn until much later was that I hadn’t finished with the stress cycle. That came many months later, when the COVID-19 surge finally did smack into our community.