Physicians Face Challenging COVID-19 Work Conditions

Published May 18, 2020

The novel coronavirus has caused massive upheaval in everyone’s lives. Aside from patients and their families, those whose lives have been most altered are those on the front lines ─ the health care workers whose jobs require them to face the virus firsthand each day.

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‘Deep Gratitude’ to Health Care Workers

More than 500 faculty physicians and more than 700 medical residents from the Jacobs School of Medicine and Biomedical Sciences provide care to patients in the University at Buffalo’s affiliated teaching hospitals throughout Western New York, according to Michael E. Cain, MD, vice president for health sciences and dean of the Jacobs School.

Many of these doctors and residents, particularly those in the emergency departments and intensive care units, are treating COVID-19 patients. They work anywhere from 20 to 80 hours a week, enduring working conditions none have ever before experienced. Most UB faculty physicians are also balancing the role of professor, providing instruction and oversight to medical students and residents.

Their expertise and around-the-clock patient care, in such large numbers, is one of the benefits of having a medical school in a community, Cain says.

“I know I speak for our entire community in expressing deep gratitude to our dedicated health care workers and our UB faculty physicians and medical residents who are providing care to our community’s most vulnerable members during this pandemic,” he says.

Faculty, Medical Residents Pressing Forward

The global pandemic has posed a wide variety of challenges ─ both expected and unexpected ─ for health care workers on the front lines. Following the experiences of colleagues downstate and in Europe via social media prepared the doctors for some, but not all, eventualities.

“To begin with, there was a concern that we were not going to have enough personal protective equipment,” says David Janicke, MD, clinical associate professor of emergency medicine in the Jacobs School and medical director of the Emergency Department at Buffalo General/Gates Vascular Institute. “But the hospital had really geared up, so we didn’t experience that.”

“We knew that workers were going to get ill and wouldn’t be able to work, so we were worried about losing staff who would have to be quarantined and therefore not being able to optimally take care of our patients,” adds Janicke, who is affiliated with UBMD Emergency Medicine.

But UB’s faculty physicians and medical residents have pressed on.

“The attitude was, ‘this is what I do,’” Janicke says, adding that Robert F. McCormack, MD, professor and chair of emergency medicine, “really had our backs, too, both at the site and at the seven other UBMD Emergency Medicine emergency departments in Western New York.”

Triage Changed Drastically Due to COVID-19

Some doctors were concerned about what an outbreak here would mean for family and friends.

“This virus is hurting people in ways I had never seen before, and it is hurting people I did not expect to see it in,” says Brian A. Monaco, MD, assistant professor of emergency medicine.

Monaco — who works in the emergency departments at Buffalo General Medical Center, Gates Vascular Institute and Erie County Medical Center — notes he has sent patients from their 20s to their 90s to the ICU.

Several doctors point out that triage has changed drastically due to COVID-19, and the guidelines are continually changing.

“There is so much that we do not know about the SARS-CoV-2 virus … which makes caring for these patients very challenging,” says Karin Provost, DO, PhD, associate professor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine. She is also co-director of the Intensive Care Unit in the VA Western New York Healthcare System and a physician with UBMD Internal Medicine.

Time of Rapid, Daily Growth in Knowledge

“This has been a time of rapid, daily growth in our knowledge, as our colleagues who have had earlier contact continue to report their experiences,” she says. “There is a firehose of information that is coming forward.”

One example of the rapidity of change involved dealing with severely low oxygen levels in COVID-19 patients, Provost says. When the pandemic first hit in Italy and the United States, doctors quickly intubated many patients at the first sign of worsening blood oxygen levels. But within weeks, it became clear that intubating so rapidly was not having the same positive impact in patients with COVID-19 as it did in more traditional presentations of respiratory failures.

Therefore, doctors are now using other methods to “maintain a patient’s oxygen levels before resorting to intubation,” she says. “This is in response to information coming out of both New York City and Italy in real time.”

Every Patient Has Own Clinical Trajectory

Patients’ conditions change quickly. “With this disease, you see someone come in and they’re sick, but not that sick,” says Janicke. “And then suddenly they were dying. It was really surprising. These were not just people who were in their 90s or who had comorbidities. Some were patients with few health issues; otherwise healthy people in their 40s and 50s.”

Provost says she initially was apprehensive about being able to anticipate a patient’s sudden decline in a way that would allow her and her staff to safely put on all the needed personal protective equipment and intervene in time.

“Every patient has their own clinical trajectory,” she says. “They still rapidly and abruptly decompensate after variable periods of stability, and it remains an every-patient, everyday fear that one inadvertent movement will lead to accidental contamination that results in potential infection of myself, my staff or my family.”

One of the Hardest Parts: No-Visitor Policy

Another Jacobs School professor who has been on the front lines is David M. Holmes, MD, clinical associate professor of family medicine and director of global health education — who is a physician with UBMD Family Medicine. Holmes normally spends spring break on mission trips.

This year, he volunteered to care for COVID-19 patients at Woodhull Hospital in downtown Brooklyn, the epicenter of the crisis. At the peak of the crisis in New York City, the number of deaths at the hospital jumped from 15 patients each month to 40 patients each day.

The doctors say that one of the hardest parts about treating COVID-19 is the no-visitor policy.

“Patients are so isolated not having visitors. It is hard to know they were dying without family. We don’t feel good about that,” Janicke says.

The stress caused by the coronavirus has been unlike anything doctors have seen before. “In the ER we are used to that sort of dramatic up and down,” he says. ”This was different. The staff knew that any one of the patients coming through the door could have the virus.”

Challenge: Maintaining Staff Health, Morale

“Maintaining the morale and health of the staff is a considerable challenge,” adds Manoj J. Mammen, MD, associate professor of medicine in the Division of Pulmonary, Critical Care and Sleep Medicine and a physician with UBMD Internal Medicine.

“Understanding the best way to treat a patient with COVID-19 is another significant challenge, given the rapidly changing evidence.”

“ICU team members are highly qualified and dedicated to taking care of the most extremes of illness and compartmentalizing the stress,” Provost says. “This is a very different experience. All health care providers on the team are being put under stress levels we have not before experienced, in a situation where we are caring for a disease that we have never seen before, with never before observed clinical manifestations every day, it seems.”

She says the nature of treating COVID-19 patients is a 24/7 proposition, and it affects health care workers’ ability to connect and engage with their families and to decompress.

Families, Friends Show Support

“Many outlets for stress relief are no longer available, including gathering with friends, physical workouts, having a massage, and so on,” says Provost.

So Provost and her colleagues try to maximize their time with their families, going on Zoom for virtual get-togethers and happy hours with friends.

“My family, friends, colleagues and even my outpatients are sending me text messages, Facebook messages or words of support, which have been extremely meaningful as we combat both the disease itself and the misinformation and denial spreading through non-medical, non-peer-reviewed sources across the country,” she says.

Adds Holmes: “The needs are so great, and I feel that anything I do is just a drop in the bucket. But we all have a part to play. If everyone is putting their drop in the bucket, then soon it will be full.”