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ER Goddess

ER Goddess

COVID-19 is What EPs Were Trained For

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000669336.92787.ca
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    coronavirus, COVID-19
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    EPs train for much, much more than clicking boxes. We train to be triage ninjas, well-practiced in juggling multiple simultaneous emergencies with limited time, resources, and information. Our perpetual state of hypervigilance is honed over many years of studying and witnessing the acute phase of every disease process—what could kill you.

    After spending shift after shift on the lookout for the sickest patients, we innately know which questions to ask, vital signs to watch, and symptoms and exam findings to home in on to save lives. With just a glance, we know which patient with leg swelling has an ankle sprain and which has a DVT or PE. Our superpower is triaging attention and resources toward those who might die if we don't intervene.

    Unfortunately, over the past decade, a canyon has grown between what EPs are trained to do and what we actually do. We spend years of our life mastering life-threatening diagnoses and life-saving treatments, but we end up devoting our energy to order entry, charting, and patient satisfaction. We have stood by in frustration and watched helplessly as a job that was supposed to be about finding and caring for the sickest patients became a game of checking boxes and meeting metrics, no matter the complaint or acuity.

    The day I knew society had lost sight of triaging priorities in the ED was when I was running a code years ago and my patient with dental pain poked her head in the door, obviously saw CPR in progress, and asked, “How much longer am I going to be here?” Anyone who has devoted his life to the specialty knows that EM is not supposed to be like this.

    The EM Mindset

    Now with the seismic shift of the coronavirus pandemic, the pendulum is swinging back. People have been asked to stay home and not come to the ED unless they need emergent medical care, and as I write this in early April, ED volumes are down by 30 percent or more in my hometown of Richmond, VA. This makes it crystal clear that on a normal day in the ED, before COVID-19, much of what we dealt with was not truly emergent. People often came because they had no primary care physician, because the ED hours were more convenient for their schedule, or because they were scared and wanted reassurance. Now, in the calm before the possible deluge of COVID-19 cases, it is striking to see the reduction in ED volume when non-emergencies stay home.

    As society watches New York City EDs being overrun by very sick COVID-19 patients, the canyon between what EPs are trained to do and what we actually do is beginning to collapse. People are finally willing to embrace the EM mindset of focusing on priorities when resources are scarce. William P. Jaquis, MD, the president of the American College of Emergency Physicians, wrote to Alex Azar, the secretary of the Department of Health and Human Services, in March clarifying what these priorities should be during the COVID-19 pandemic: “A pandemic or other disaster will strain medical resources and thereby may require a shift in care that was previously focused on the individual patient to that which is focused on doing the most good for the greatest number.” (ACEP. March 13, 2020; https://bit.ly/2RKfVEq.)

    ACEP asserted that temporary liability immunity to EPs will give us the leeway we need to expeditiously treat more patients. They also expressed the need for EMTALA waivers to give front-line workers the flexibility to treat and keep up with unprecedented surges of patients. He noted that the Centers for Medicare and Medicaid should allow a reprieve from our obligation to report to quality performance programs, specifically the Merit-based Incentive Payment System (MIPS). This would save us from wasting energy on metrics or Press Ganey scores, and would allow us to put all our effort into dealing with the COVID-19 crisis. The time is right for these changes.

    This Is Ours

    We have already seen a handful of responses to the coronavirus pandemic that let us hierarchize attention and resources during mass casualty situations. New York enacted a change in liability standards that protects health care workers from lawsuits during this critical time. The standard is now gross negligence, so doctors can focus on treating emergent illnesses, not admitting people or doing extensive workups “just in case” illness develops. The Fire Department of New York ordered EMS not to transport cardiac arrest patients who can't be resuscitated in the field because right now all decisions must be about preserving hospital and ambulance resources.

    Health care corporations are starting to differentiate between vital roles and less vital ones, concentrating resources and pay on those on the front line fighting the coronavirus. My company's CEO and executive staff volunteered to reduce their pay by 25 percent, and administrative staff costs have been reduced by 20 percent. We need more changes like these across the health care system.

    Now is the time to let EPs do what we were trained to do. Other specialties have expertise, but this exact scenario—handling whatever comes through the door and making difficult decisions with limited information and resources—is ours. During a surge of COVID-19 patients, we will not be ordering imaging to cover our butts medico-legally, and we will not be admitting patients “just in case.”

    We will be quickly rolling through who needs to stay and who needs to go. The reality is that people are getting discharged from EDs with normal oxygenation and coming back two days later severely hypoxic. We know the virus depletes reserve so patients may rapidly decline, but during a time of concentrating resources on the critically ill, we can't admit for what might happen. People bouncing back is going to have to be OK. I have already made a dot phrase in my electronic medical record that says, “Patient seen amidst the COVID-19 pandemic and medical decision-making necessarily shifted.” The only question that will matter in an ED overrun with COVID-19 cases will be the same question that has always mattered most to EPs: Critically ill or not?

    The COVID-19 crisis is what we've trained for our whole careers. The world needs our knowledge base and skillset now more than ever—not the data entry and patient-pleasing skills we've all had to acquire, but the real emergency medicine skills that define our specialty. As we fight COVID-19 by practicing EM the way we were trained, we will reacquaint society with the merits of triage and show the world what EPs can do.

    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.

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