COVID-19

From a Cerner doctor on the front lines of COVID-19: “My world changed overnight.”

by Anup D. Salgia, DO, FACEP

Published on 4/22/2020

Estimated read time: 7 minutes

In this blog, Anup D. Salgia, DO, FACEP, Cerner Medical Director, documents his experience caring for COVID-19 patients in Ohio and the professional and personal impact it brings.

Saturday, April 11

I arrive at work and stop by the triage area to have my temperature taken and answer a few screening questions to ensure I don’t exhibit symptoms of COVID-19. I’ve worked at this hospital for several years and most of the staff are like family, but I’ve stopped my usual greetings of high-fives and fist bumps to practice social distancing. There’s a highly-skilled, seasoned nurse I’ve known for decades – since my residency – who, when she’s on shift with me, makes me feel comforted knowing that her experience and judgment will carry us through. Today is different, though. We exchange nods of uncertainty, silently acknowledging that we might not be able to handle a crashing COVID-19 patient.

As I take off my jacket, the staff starts chuckling. My usual attire, a casual golf shirt and slacks paired with a white lab coat, is replaced by itchy, brand new starchy scrubs because we’re no longer allowed to wear street clothes due to the risk of bringing the virus inside the hospital walls. I had to order a few sets of scrubs because I didn’t own any, and we haven’t yet received them from the hospital.

A quick check on our personal protection equipment (PPE) shows we have an adequate amount of protective gear. How long that will last is anyone’s guess, though, as the emergency department (ED) has been careful to ration the supplies for COVID-19-suspected patients. The fear of running out is always a concern, as we anticipate the surge to hit. The unit manager stores the N-95 masks and hand sanitizer in her office. We‘ve been instructed to only use one N-95 per day and to use a regular surgical mask on top of that. I’m wearing my own goggles, which are rather heavy and a bit uncomfortable, but they do the job.

I’ve worked in a new routine of checking all our resuscitation equipment. We have video-assisted intubation gear, which will hopefully minimize the chance of me getting too close to a patient if I need to put in a lifesaving breathing tube.

The first few patients I see are routine – abdominal pain, chest pain, ankle sprains, lacerations and the like. Things feel normal until I see my first COVID-19 patient. He’s in a negative-pressure isolation room, an exam room that, admittedly, I took for granted until today. The staff and I put on our head-to-toe gear: caps, goggles, plastic shields, N-95 masks, surgical masks on top of that, gowns and gloves.

The patient is a man in his 60s who is accompanied by his wife. He has no history of asthma or other lung problems, but he’s experiencing shortness of breath. His brother died a few days earlier from COVID-19. His oxygen saturation is low and he looks uncomfortable. I tell him that it’s likely he has COVID-19 and his wife balks in disbelief.

The sensitive discussion around do-not-resuscitate orders is rushed and impersonal. I apologize several times for that, but the reality is, we need to know immediately. He consents to intubation if it comes to that. Luckily, we’re able to stabilize him without intubating, and he’s admitted without incident.

Later, as I write my note in the electronic health record, I’m interrupted by a call from the radiologist who asks me to pull up the patient’s chest X-ray. A few clicks later, I’m viewing the radiograph with her remotely. “This looks like COVID-19,” she says. I clear my throat and reply, “Yep, I think he’s got it, but we’ll see – testing comes back in 12-24 hours.” I hold out hope that this could be some other disease.

My shift is over. As I leave the ER, I use the surgical sink to wash my face and arms. I call my wife on the drive home. She’s readying an area in our garage, near our utility sink, with a lined trash can, floor mat and a bath towel. Upon arriving home, I go to the garage, strip down to my skivvies and slam-dunk them in the trash can before heading to the hot shower. After I get dressed, I run down to greet my wife and kids. My wife is eager to know how my day was – that is, had I seen any COVID-19 patients? I try to reassure her that I took every precaution, but she’s not convinced. She hugs me briefly, and we carry on with the evening.

Sunday, April 12

I receive a call from the infection control nurse who tells me that the patient I saw yesterday is indeed positive for COVID-19. She interrogates me to verify that I’d worn my PPE. I admire her for being at the hospital on a Sunday to look out for me and the staff. I ask if she called the patient’s spouse, and thankfully, she did. She will be in quarantine for at least 14 days. After the call, I just sit there and replay the entire patient encounter in my head as vividly as possible. Had I done everything in my power to protect my staff, myself and our families? Did my military training serve me well or did I botch it? I think I did ok, but what if I didn’t? Should I continue to hug my kids and wife?

My world changed overnight. Having a COVID-19-positive patient really hit home. This virus has finally invaded my community. I learn that the patient improved overnight and was discharged, but he lives in a nearby 55-and-over condominium community. So, there will be others.

I arrive at the hospital and start my day with the same routine of having my vitals checked, then doing an inventory of all the PPE. The prior shift saw a few COVID-19 patients. All were stable enough to be discharged. Hopefully we’ll have the same luck. I ask if anyone knows if/when we might get the new 15-minute point-of-care test. No one does, and I even contact the manufacturer on behalf of the hospital and receive an auto email reply. If we could get our hands on that, it would change the game. We don't have enough test kits to do the conventional 12- to 24-hour tests, as we’re forced to ration them. Like most hospitals, we’re sending our stable patients, who aren’t considered an at-risk population, home without testing, diagnosing them with an influenza-like illness or COVID-19 and giving discharge instructions on how to self-quarantine.

My thoughts shift to yesterday, realizing I brought my cell phone home without sanitizing it – something that is absolutely necessary in this new normal. As patients trickle in, I’m hyper-focused on making sure we don’t inadvertently get exposed to a possible COVID-19 patient without wearing PPE. I meet with the triage tech who assures me that he will let me know immediately if a suspected COVID-19 patient comes in. I review with him the signs, symptoms and questions to ask in triage. We couldn’t wear PPE all shift since we didn’t have enough. It makes sense, but also could leave us vulnerable.

We’re filling up with the usual ED patients, though overall volume has been down significantly. We have three patients who need CT scans. Two are “normal patients” and the other is a suspected COVID-19 patient with abdominal pain. We do the studies out of chronological order because once we scan the suspected COVID-19 patient, the machine will be out of service for an hour for decontamination. This is the new reality.

Nurses and doctors are being called off at the main hospital because there aren’t enough non-COVID-19 patients to justify their need. I wonder what a post-COVID-19 health care economy will look like. I think this pandemic will change the delivery of care forever. Telehealth, for example, is very likely to grow into a large segment of care delivery. The rapid adoption of virtual visits by patients and providers during this pandemic makes for great convenience, efficiency and safety for both patients and providers. Technology is the answer for how we provide better disease surveillance, better patient-consumer engagement and better care delivery. I think technology, and our experiences during this public health crisis, will lead our industry to do more, intelligently.

As the world responds to the COVID-19 pandemic, Cerner’s work continues to support health care providers and communities across the globe. Learn more here.

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