Not once in my medical career have I seen a storm anywhere near the magnitude of the coronavirus deluge that is being predicted. It remains mostly on the horizon as I write this in early March, the day after the first two COVID-19 cases were identified in my home state of Virginia.
It feels like the calm before the storm. We hoard hand sanitizer, we watch the media frenzy, we try to ignore the ridiculousness on social media, and we wait, hoping we can find a place to buy toilet paper. We wait for the impending attack by a virulent enemy about which we know frighteningly little. My hope is that what we're dealing with is more akin to influenza than MERS or SARS, but until we have sufficient data, the winds of fear will continue to blow.
By the time my fellow EP frontline warriors read this, test-confirmed COVID-19 cases will be pouring down on us. As we're showered with more confirmed cases, we'll have more data to offset the scariness of the unknown. We'll get the answers we need to epidemiological questions about virulence, disease course, at-risk populations, and the fatality rate. As the virus declares itself, however, we may be rudely awakened to a multitude of vulnerabilities in our health care system. There is no truth or weakness the virus is afraid to expose or exploit. It simply doesn't care.
Already Overburdened System
The virus doesn't care if policies benefit Democrats or Republicans, drug companies or hospital administrators, as long as those policies don't put a damper on its foray into more hosts. The virus doesn't care about the stock market, and it pays no mind to what Trump does or doesn't say. While the pundits debate, it will go right on multiplying, blissfully ignorant of any political or economic agenda. Hopefully, we'll follow its lead, stop politicizing and monetizing it, and focus on good medicine.
The virus doesn't care if we run tests to identify who has it; it will happily run its course regardless. The more infected vectors who rush to EDs for testing despite not needing medical intervention, the better the virus is able to spread to health care professionals and vulnerable people who are in the ED for other emergencies. Yes, there are epidemiological benefits to testing everyone, but is it worth the strain on our already overburdened system?
Let's not forget one of the mantras of our specialty: Don't send a test if it won't change management. For patients well enough to quarantine at home, running tests will not only fail to change management but also overwhelm EDs and clinics. The virus will make plain the rude, ugly truth that health care consumers are too focused on knowing precise diagnoses. Folks are going to have to accept a little diagnostic uncertainty and go with presumptive COVID-19.
“But I have to work.” The virus doesn't care about our income. The brutal truth is that it's killing septa- and octogenarians, so two weeks of one's pay is small by comparison. That doesn't make it easy, and it will be a struggle for many to refrain from showing up sick for work or sniffling and sneezing their way into the ED for a work note. We live in a me-centered society where the needs of an individual are often allowed to eclipse the needs of the group, and that mentality will put lives at risk in an outbreak. We undoubtedly cannot rely on the healthy population to responsibly self-sequester, so we must take extra measures to protect people who are at increased risk.
The virus doesn't care how many are ultimately forced to quarantine because it can still linger tenaciously on every elevator button, gas pump, and shopping cart that a carrier touched on his way home to quarantine. The virus doesn't care if you cancel your European vacation, cruise, reunion, or wedding because it's already here and poised to spread; it's just a matter of time. The frustrating reality is that we'll sacrifice our spring breaks, and still ultimately find ourselves surrounded by the virus in our hometowns.
The virus doesn't differentiate between patient and clinician; it's an equal-opportunity infector, so we must protect health care workers. It certainly doesn't care if our colleagues will be pulled into a night or weekend shift if an EP doesn't come to work. Just a small percentage of doctors and nurses being out of commission will lay bare the overly lean staffing practices of corporate medicine.
When COVID-19 further diminishes doctor numbers while ruthlessly increasing patient arrival numbers, then what? We will no longer be able to overcome ED inefficiencies and throughput obstacles by sheer might and will power (i.e., hustling our butts off). If the virus is as devastating here as it was in the initial firsthand reports from northern Italy, we are going to need more than our usual hard-working A game; we are going to need more resources. How will it play out when the 100,000 ventilators in this country, for example, are not enough?
As we start dealing with this apathetic jerk of a virus, we're going to stumble and do things imperfectly. When the music stops, there will be complainers, the Monday morning quarterbacks who say we could have and should have done more and done better. That's the nature of emergency medicine. We frequently make life-or-death decisions with little to no information and limited resources. It will be easy, as you're reading this, to look back critically at our mistakes over the past few months. Don't judge us for difficult mass casualty decisions we might have to make. The virus won't be looking back. It doesn't care about pointing fingers and assigning blame. The virus will be spreading onward, so we must focus our energy not on what we screwed up yesterday but on how we will handle it tomorrow.
Are we ready? Is anyone ever ready for a pandemic? I know EPs in the trenches are going to give it everything they have to lead the way through the chaos and help their communities. Whatever happens, we will always have one advantage the virus doesn't: We care.
Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter @ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.