People with severe cases of Covid-19 often require hospitalization, and many of those patients are cared for by physicians who specialize in hospital medicine. Hospitalists work within hospitals, caring for patients from the time they are admitted to the time they are discharged.
Nearly two dozen physicians comprise the College of Community Health Sciences’s University Hospitalist Group. These hospitalists work primarily at DCH Regional Medical Center in Tuscaloosa caring for University Medical Center patients who are hospitalized there. The College operates UMC.
Dr. Charles Lehman leads University Hospitalist Group and has cared for Covid-19 patients during this pandemic. He said hospitalists have had to navigate caring for patients through layers of personal protective equipment, while also adapting to logistical elements required in hospitals during a pandemic. “You lose the personal interaction, and that’s been hard for us in taking care of patients,” he said.
What kind of symptoms do patients show when they’re being admitted to the hospital or are suspected of Covid-19?
Lehman said shortness of breath is key to determining whether people having or suspected of having Covid-19 need to be hospitalized. “If someone gets to the point where they require oxygen supplementation, that would be the big thing.” He said other symptoms of Covid-19 can include fever, sore throat and chills – “typical flu-like symptoms.”
How do you tell the difference?
To determine whether someone has Covid-19 or the flu, “you test, and that’s been a challenge,” Lehman said. “The tests aren’t as good as we would like them to be. They don’t always give us the answers we need.”
Can you explain a little more about that?
“If a test comes back positive that’s good, not necessarily for the patient, but it lets us know what’s going on,” Lehman said. He said a positive result means the patient is very likely positive for the virus. Where doctors struggle is if results come back negative because the tests have a false negative rate of about 30%, he said.
How do you and other health-care providers protect yourselves when taking care of patients in the hospital if you don’t know for sure who has Covid-19?
Lehman said wearing personal protective equipment (PPE) and limiting exposure to suspected Covid-19 patients as much as possible are among the strategies used by hospital health-care workers to keep themselves safe. “The first thing I do is put on a pair of gloves so that I protect the PPE from myself. Then I put on a gown, shoe coverings, another pair of gloves, a face mask and then a head covering,” he said. Lehman said the reason for the second layer of gloves is so that physicians have another pair when changing their PPE, which is done between every patient visit.
Is there enough personal protective equipment?
Lehman said there currently are enough gowns and gloves, but doctors have had to improvise a bit with masks, especially N-95 masks, which are respirator masks that protect the wearer from the virus. “There’s a shortage of these nationally, but DCH has done a great job with this,” he said. “We set up a program where we’re basically recycling the masks. We’ve developed a process where we can sterilize the masks between usage, and that’s enabled us to have enough masks for what we need to do.”
Are there any other challenges for taking care of Covid-19-positive patients?
The number of hospitalizations of Covid-19 positive patients at DCH has been unpredictable, and that has been a challenge, Lehman said. Numbers were initially low but have started to pick up.
Does take longer to see a Covid-19 patient?
Lehman said it takes longer to see and care for patients with Covid-19, primarily because they are more sick than other patients and because of the additional time required to change PPE between every patient. “You multiply that by 20 or 30 patients you’re trying to see in a day and it really does put a strain on things.”
When do you decide that a patient can go from a regular room to intensive care?
Respiratory status is the primary factor in determining whether a Covid-19 patient might need to be moved to the intensive care unit, Lehman said. “If someone is in a room and they’re on two liters of oxygen and they’re comfortable, they can stay there,” he said. “If their oxygen
requirements start going up, or you’re worried about them breathing, that’s the point where you make the decision to move them to intensive care.”
How do you decide if someone needs to be on a ventilator?
“What we really watch for is oxygen saturation,” Lehman said. “If we get to the point where we can’t give someone enough oxygen, that’s when we have to put the breathing tube in.”
Is there any risk to being on ventilator?
Lehman said the main risk is infection. He said if a patient has to stay on a ventilator for a significant period of time, the tube can become a source of infection.
Typically, how long would a Covid-19 patient stay on a ventilator, and is that different from a patient who might need a ventilator for, say, pneumonia?
Covid-19 patients who need to be placed on ventilators typically tend to stay on them for between 10 and 14 days, which Lehman said is much longer than patients who might need them for other reasons.
Are there other problems that Covid-19 patients might have that are not lung related?
While problems with the lungs are the main complication from Covid-19, “you can get damage to any organ in your body from it.” He said many of the early problems he and other hospitalists observed were cardiac and kidney issues. “I think the other big complication we’re recognizing more and more is blood clots.”
When can you let somebody go home from the hospital?
Once patients are able to breathe without supplemental oxygen, they can be discharged, Lehman said. He said many people who get Covid-19 won’t need to be hospitalized, and many of those admitted to the hospital will recover and be discharged.
How does this affect you as a health-care worker, as far as stress, on you and the providers who are taking care of these very ill patients?
Lehman said it’s hard because doctors are worried about their patients, themselves and their co-workers. “It reminds me of early in my training, of HIV,” he said. “We didn’t have any appropriate treatments for it, and everyone was afraid to walk into a room with an HIV patient. We’re kind of in the same stage with Covid-19 right now.” But Lehman said studies have shown that wearing masks, which is required at DCH, and PPE, can significantly reduce transmissions of the virus. “It doesn’t take long to get used to this, either,” Lehman said. “It’s getting over the fear.”
So, you’re saying masks are really important?
“Absolutely,” Lehman said. He said if everyone wore masks when they were away from home, “the rate of transmission would drop to a manageable level and it would be like having a flu season.”
Having Covid-19 patients, does that put a lot of stress and strain on the hospital itself?
“Yes, but I’ve been impressed with our hospital and its response to this,” Lehman said. “They’ve
really come up with some pretty good solutions to the problems that we’ve come across.” He said there are some things that remain challenges, like trying to obtain enough N-95 masks. “That’s a supply chain problem that you just can’t do anything about, but the hospital’s N-95 mask recycling program has helped,” Lehman said. He also area businesses have made needed equipment for the hospital, and DCH has created more intensive care rooms in case they’re needed. “It sounds simple, but the logistics of that with Covid-19 numbers moving up and down has been a challenge. But I think (the hospital) has done a good job.”
Are there other things about caring for Covid-19 patients that are difficult?
Lehman said personal interaction with patients is sometimes lost, and that’s been hard. “You walk into a patient’s room and you’re wearing a gown, head covering, a face shield and a mask that covers half your face. It’s hard to say, ‘Hey, I’m Dr. Lehman, how are you?’” He said visitor limitations are also hard – for patients and doctors. “Patients can’t have family and loved ones with them in the hospital. And picking up the phone or doing FaceTime just isn’t the same when you’re trying to have a conversation with a patient’s family members, especially if they’re not doing well.”
Do you find a higher risk of not doing well with Covid-19 compared to the flu?
Lehman said there is a higher risk of poorer outcomes with Covid-19 “if for no other reason than we can treat the flu. We’ve got medicines that we can use to treat the flu and we just don’t have that with Covid-19.”
Do you see any treatments on the horizon?
DCH has a limited supply of Remdesivir, which doctors are using on Covid-19 patients, Lehman said. He said Remdesivir can reduce the severity of illness in Covid-19 patients and reduce their length of stay in the intensive care unit. Lehman said doctors are are also using convalescent plasma. “The idea behind that is you take someone who has had Covid-19 and recovered, so they should have antibodies in their plasma that can be recovered and given to (Covid-19) patients. We have had some decent results there.”
That’s probably an old, old treatment, isn’t it?
“It was around during the Spanish Flu,” Lehman said.
Speaking of vaccines, do you think that getting a flu shot in the fall is going to be helpful?
Covid-19 is an influenza-like illness, and while the symptoms of Covid-19 and the flu are similar, “they are very different diseases,” Lehman said. He said everyone needs to get a flu shot this fall. “Anything we can do to ease the burden on the healthcare system this fall and winter is going to be important.”
Are there other things individuals in the community can do?
Lehman said wearing masks and social distancing are very important “but the biggest thing, I think, that people should do is act like they have it (Covid-19). When you’re out and about in the community, assume that you’re infected. And you really need to try and stay away from people who might have a bad outcome if they were to get infected. And if you are one of those people who could have a bad outcome if you get infected, then you need to stay home.”