Residency Diaries Series #8: the physical space of the ED (COVID Part II)
The following is my second entry during the height of COVID pandemic. I remember everything was changing so fast. Everyday we got update emails on the number of cases, PPE preservation, city regulations, etc. This particular entry was written during a period of “calm before the storm.” The overall volume was down in the ED, most patients were what we called “worried-wells”. For the most part we were able to reassure our patients and send them home. This was about to change in a week.
I had the interesting experience of working in two different hospitals during the pandemic. Both are located in Manhattan but still very different. Due to the differences in their structure of the emergency department, there was a huge discrepancy in how the patients were “housed” during their stay in the ED. One hospital (called Hospital A here) had way more isolation rooms and the other (Hospital B) had much fewer. Normally this is not a huge issue— pre-pandemic, very few patients needed negative pressure rooms (air is pulled into the room so any airborne disease, such as tuberculosis, remain inside the room whenever the doors are open).
During the pandemic, we struggled to place potential intubation patients in these few negative pressure rooms to prevent “aerosolizing” the virus and spreading it to everyone in the ED. Other potential “aerosolizing procedures” such as placing patients on BiPAP was discouraged. We weren’t allowed to give albuterol nebulizer treatments to patients and instead gave out inhalers.
It made me think about how the physical set up of the ED can affect clinical care. At Hospital A, all potential “respiratory” or infectious patients were routed to Area C, which had the most number of negative pressure rooms. But all serious traumas still went to Area A where the main resuscitation room is. This meant patients would come in for a car accident, and later be found to have COVID (incidental finding as patients who were being admitted got tested for cohorting purposes). We soon found that there were a ton of asymptomatic carriers and we had to wear our full PPE for ALL patient encounters, not just the symptomatic ones.
At hospital B, we struggled to keep our COVID-possible patients in their "rooms,” really just a large open area divided by curtains. They wandered around despite the staff begging them to stay put. Who knows how many patients got COVID from just being in the ED alone?
I think this pandemic probably gave future hospital planners a lot to think about. Physical space makes a huge impact on how medical care is delivered. Do we want bathrooms inside the rooms so patients do not have wander the halls? Do we want physical doors and actual wall barriers? Does that limit how many patients can actually be “roomed” and increase the number of patients stationed in the hallways? How do you respect patient privacy if there’s only 1-2 ft of distance between each patient? Where do we want the nurses and doctors stationed? There is no “right” way to set up the department but I think it’s such a fascinating problem to think about. I would love to part of that discussion one day.
3/17/2020 Tuesday 4:46pm
It feels like a lot has changed since my last post but it’s only been a week. Everyone is seeing potential COVID-19 patients, not just attendings because there are simply too many. Majority are still what we consider “worried-well’s”-- people who are sick (or not sick) but not sick enough to be admitted to the hospital. Most patients come to the hospital with the expectation that they will be tested for COVID-19. As of now testing is still very limited and we are only testing people who are going to be admitted. We’re not quite overwhelmed yet-- if anything it feels more like the calm before the storm.
I worked a Hospital B shift for the first time since the COVID-19 outbreak. Here is what I saw:
Only curtain barriers between most rooms with a sign in sheet hanging outside to document who went into the “room”
A COVID rule-out patient sleeping in the hallway, snoring. No mask.
Masks locked up in the nurse’s medication room (residents and attendings do not have access to this room)
Significant delays to imaging due to machines having to be wiped clean after every rule-out patient use (many are getting CT studies because travel history + hypoxia + often tachycardia = suspicious for pulmonary embolism… or COVID)
We have all been given goggles (like ones we used to wear in high school chemistry class) to use along with our masks. Unlike Hospital A, there are much less isolation rooms (actual physical rooms), so patients often wander around the halls freely. At Hospital A, it did feel as though we were locking patients in the room, nurses vigilant about keeping the patients in there at all times. Bed pans, commodes were provided to prevent patients from walking to the bathrooms. No such arrangement is possible at Hospital B.
I figured if I don’t have COVID already I’m likely to get it at Hospital B from an asymptomatic patient who has the freedom to walk all around the emergency department.
Reading about the COVID-19 situation in Italy scares me. I hope that we don’t ever get to the point of having to choose who we intubate and who we don’t out of scarcity of equipment and rooms. The other day I discharged an elderly French man because he wasn’t very symptomatic (no fever, cough-- just sore throat with negative chest x-ray). He became emotional as I was discharging him and explaining that he wasn’t going to be tested. He said “I understand you guys have to save the young people but I don’t want to get sick.” It made me so sad. I explained to him that I wasn’t sending home because I’m prioritizing someone else over him but because he should avoid being in the hospital if he doesn’t want to get sick or get the virus.
Anyway- it’s a constantly evolving situation. Hopefully it doesn’t get too crazy. I feel emotionally and physically drained. Tonight is my night 5 out of 5.
On shift with goggles and an N-95. We also wore a surgical mask or a shield mask over the N-95 mask.