A Moment of Panic, Then Teamwork

What your doctor is reading on Medscape.com:

APRIL 16, 2020 — Although I work in Rhode Island, I live across the border on the South Shore of Massachusetts where the news is concerning, to say the least: nearly 30,000 cases total, with 1755 new cases reported today, according to Governor Baker. We have entered the surge.

I have colleagues whose spouses have required intensive care, including intubation, and some whose fathers or mothers have died due to complications of COVID-19. The gravity of the situation—on a personal level, outside our practice of medicine—is not lost on me.

At our cancer center, which continues to operate, we are preparing for the surge. This was the second day without interns or residents on the oncology service; we are now fully staffed with oncology-trained hospitalists, fellows, and attending physicians covering consults, including our patients infected with COVID-19. When we prepared our surge schedule, I was most concerned with issues of fairness; I wanted to ensure that no one was placed at excess risk for contagion, while also protecting those who would be at greater risk for severe infection.

Now that we’ve pulled the proverbial trigger, I realize that I assumed one very important thing: that we all could do what the role required. I mean, we are all trained in internal medicine. As attendings, we all understand the work required to take care of an inpatient service. We’ve also never stopped doing inpatient consults within our fields of expertise.

I now realize that I probably shouldn’t have assumed anything.

Inpatient medicine today is quite different compared with how it was when most of us were house staff. I got really great training in acute medical care for very sick patients while dressed in personal protective equipment. As the outbreak escalated in the US, I didn’t think that doing inpatient care during our local COVID-19 response would be an issue.

I now fear that I might have overestimated my abilities. After all, I trained in internal medicine 20 years ago—with paper charts. I could call a nurse on my patient, give a verbal order, and then sign it at a later date. Patients were allowed to have loved ones stay with them, and family meetings were attended by as many people as the patient wanted. Discharges were written out and documented via Dictaphone.

Things are much different now. Electronic medical record systems are in place; there is no paper record. Orders must be entered so they can be completed; verbal orders are not allowed. Would I even know how to enter an order or place a consult? How do I discharge a patient?

And beyond simple logistics, I realize now that the medical issues are also far more complex. While I maintain certification in internal medicine, I haven’t practiced outside of oncology for the entirety of my medical career. I believe it is the same for each of my colleagues. Would I be able to handle severe respiratory distress? What about multiorgan system compromise?

A colleague of mine recalled the experience of caring for a patient who tested positive for COVID-19 during his initial hospitalization. Although the patient’s advance care planning wishes were well documented, over the course of several hours he became progressively unstable, requiring multiple hours at his bedside trying to stabilize him. Ultimately, he died. As I listened to her, I began to panic a little. Would I even know what to do?

As a leader of our program, however, my job is not to panic—it’s to solve problems. And the solution to my own concerns, which I know were shared by many, was to point out something right in front of us: We were part of a larger division, one that prides itself on taking care of each other. Our inpatient team would not be left alone to fend for themselves; each of us would be backed by an attending hospitalist, an attending hematologist, and our fellow, who in all honesty would probably be the most capable of helping.

We need to lean on each other to care for our patients admitted to the hospital—with or without COVID-19—and we would be a team. As I told my colleagues how important it is for us to act together, even I started to feel more capable of the task at hand. At the end of the day, our patients with cancer require an oncologist’s guidance to get them through their hospitalization. This is the principle that will guide us during the surge. So, can we do this? Yes, I answer. Yes we can.

Don S. Dizon, MD, is an oncologist who specializes in women’s cancers. He is the director of women’s cancers at Lifespan Cancer Institute and director of medical oncology at Rhode Island Hospital.