First of all, we question how safe it is to protect ourselves only around patients with symptoms. We know asymptomatic people are spreading the virus — as early as three days before showing symptoms. For now, in Virginia, my patients with head injuries and heart attacks are much less likely to have asymptomatic Covid-19 than patients in New York or California, but that might not be true for long. Soon the virus will be widespread enough for us to have a high index of suspicion for Covid in anyone, whether they have respiratory symptoms or not. We already might be at that point; we just don’t know it because of the paucity of testing.
A colleague recently saw a patient triaged as “headache.” Only after he got close enough to put a stethoscope on her chest did she divulge that it was sinus pressure accompanied by fevers, cough and exposure to a family member who recently returned from Europe. We need enough PPE to wear a mask with every patient regardless of complaint.
Secondly, real life in the ER is nowhere near as neat and clear as the algorithms our public health officials are creating. While I’m trying to risk-stratify patients to know what level of protection I’m supposed to use according to the latest algorithm, I’m simultaneously navigating inefficient computer systems, fielding questions from three different people, trying to get to the multitude of patients waiting for me, and watching EMS crews bring even more patients through the door. As my colleague learned with his headache patient, patients don’t always give the full story when they’re triaged. Also, the virus won’t always wait for the highest risk interactions like intubating and suctioning to take the opportunity to spread. We shouldn’t wait until we intubate or suction to wear N95s. Furthermore, the Covid-19 test is not always completely reliable. Just like the flu test, there are going to be false negatives.
Thirdly, board certified emergency physicians are too precious a resource—just 39,000 of us for the entire country—to be gambling with their health. In small hospitals like mine, physician groups are small and staffing is slim with limited backup. Trust me, with our expertise in making fast decisions and rapidly directing flow, you want veteran ER doctors on the front lines protecting you, not quarantined, ill or dead. Without enough PPE, it’s a matter of when, not if we go down. Physicians from other specialties will take our place, but they will not have the same skills. The ophthalmologists, orthopedists, or nephrologists who will replace us in the ER will do their best, but with no disrespect to our friendly eye, bone and kidney specialists, are they really the doctors you want to see when you arrive in the ER with a suspected coronavirus infection?
The demoralizing reality I face is that more PPE might not be coming. So last week I went to my local hardware store and bought myself a face shield. I’m posting on social media, along with other doctors and nurses on the front lines, using the hashtag #GetMePPE. It’s crazy to be a physician shopping in a hardware store for medical equipment.
Meanwhile, I’m losing sleep over the predicament of having no good course of action. Do I use masks with every patient to protect myself from asymptomatic spread and risk running out of masks entirely? When the PPE runs out, do I keep going in, like a firefighter charging into a burning building in a Speedo and flip-flops? The deaths of Italian doctors Robert Stella and Marcello Natali, who valiantly kept working without PPE, are a terrifying warning.
Will I come to a point where I have to make a decision about saving my family or saving my patients? I worry about my two teenage sons and my parents in their 70s. My family didn’t sign up to take this risk. In an attempt to protect them, I’ve set up a decontamination zone in my laundry room—when I come home after my shift, I go straight to the laundry room, strip and leave all work paraphernalia there before setting foot in the rest of the house and hugging my kids. Last night I cried as I made the decision that, if it comes to a shelter-in-place situation, my sons will stay with other family members, not with me. There is nothing harder for a mother.