By Duane G. Koehler, DO, FACOFP dist.; ACOFP Immediate Past President

Learn from the Past

In the early ’80s, there were reports that relatively young gay men, prostitutes, IV drug users, and (initially) Haitian males were dying of a cluster of diseases previously only seen in elderly men and in immune-compromised individuals.

There was no known cause. There was no known treatment. But folks were dying. This was when universal precautions were instituted to protect health care workers. Uncertainty abounded and health care professionals at all levels were scared!

When hemophiliacs and others who had received blood transfusions started developing the disease, there was another wave of concern. The disease was now impacting folks who were in monogamous long-term relationships. It was not until then that it became a national emergency. And that was several years after the first cases were described.

This created a push to find a vaccine to prevent HIV disease—a search that is ongoing 30+ years later! What we have done is develop the anti-retro viral drugs to combat the disease, which has significantly extended the lives of those infected with HIV.

Fast Forward to 2020

There is a great deal of consternation about the ability (or not) to test for COVID-19 disease.

I was harassed on a regular basis by the medical director of the hospital right after I went into practice about ordering seemingly esoteric tests in critically ill patients. His query was in terms of: Will this test change the treatment of the current illness? If the answer was no, then why order the test?

The point is that we have a disease for which the only available treatment is oxygen, IV hydration, and if necessary—for now—we have ventilators.

There are no drugs that have been verified or approved to alter the course of disease. There are some studies; but for now, not much else.

A World-Wide Disaster

Hospitals are required to have disaster drills on a regular basis as part of the accreditation process. We have all tolerated and participated at some level. Decisions were made during those drills regarding who would receive the green, yellow, red or black tags—and it could be a gut-wrenching experience.

What we are experiencing now is a world-wide disaster drill. Decisions are being made all over the world. Which patient will benefit the most from being placed on a vent? Will those who are not vented survive? How is a physician to choose who lives or dies?

When Joplin, Missouri, was smashed by a tornado, or the Gulf Coast is smashed with a hurricane, the first responders in the area begin the search and rescue work. Then there are waves of teams from all over the country who are deployed to relieve the first responders who live in the disaster area. Strategic reserves are deployed as needed and seemingly everything needed materializes.

Unfortunately, because the entire country is likewise overwhelmed, there are no fresh teams to come into an affected community to provide any relief. In each of our own communities, we are our own backup! It is up to each of us to continue to try the best that we can to deal with the hand we are dealt! Back to the training analogy: We may, in a short period of time, begin to feel like the unending shift of residency where everyone was getting sicker and there was nothing you could do but watch.

As noted, this is a world-wide disaster. We will not be able to provide all services to everybody because hospitals all over the world will be and are being overwhelmed! The nursing and medical staffs are overwhelmed. In response, immune systems are overwhelmed, and medical personnel are getting sick—physically and mentally.

For those who are in rural areas and accustomed to sending critically ill patients out, hospital beds will be filled, and there will be no place to send those patients.

Suggestions Going Forward

Just as with localized disasters, critical incident debriefing should occur on a daily basis. If this is not happening at your medical facility, it needs to be implemented now. If we do not take care of the mental health of frontline workers, we will run out of folks to do that job, either because they have left the profession, or because of the PTSD likely to develop. Individuals are overwhelmed, as are the health care systems.

I would also suggest that we get past the mindset of doing everything for everybody. It is simply is not possible. Decisions will have to be made about who is put on a vent and who is not. Medicine has done a great job of keeping folks alive with chronic diseases that fifty years ago would have been lethal. When we reach the mindset that not all will survive, we will be able to look at reality and live with ourselves. We will know that we did the best job possible with the resources that were available at the time. We have become complacent because we do have some great resources available to extend life, but those are being taxed to the maximum during this pandemic.

The most important resources are those likely to be discussing the thoughts and suggestions that you are collecting. They will be the ones taking care of me as I age and become more infirm. I would like them to be relatively healthy mentally in the meantime.

I continue to hope and pray for the best, knowing—based upon planning at the Public Health Services Corps and CDC levels—that we have just spotted the iceberg. We are not even seeing the whole tip. We just spotted it!

My advice remains: Don your protective gear. While it may not be perfect, it is the best we have.

My next bit of advice: Take care of yourself first, physically and mentally. Because when you incapacitate yourself, you are of no use to anyone. Not to yourself or your patients. In fact, this can be very disruptive to the team and its ability to work.

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