On the Other Side of the Curve: Ramping Down and Preparing for the Fall

Make no mistake, the Emergency Department and Intensive Care Unit (ICU) are still steadily full of COVID-19 patients, but more patients are now coming in with traditional ailments as well, and the overwhelming surge situation is now starting to ramp down as medical professionals march into a ‘new normal’ and prepare for what could be a difficult fall and winter.

All over the hospital, plans are being put in place to ramp down from the “all hands on deck” situation where every available corner and resource was used to potentially treat sick patients over the last 10 weeks. For instance, right off the bat the post-surgical recovery rooms were transformed into overflow ICU units and all surgery was cancelled or shipped to Cambridge Hospital.

That is now changing, said Dr. Melisa Lai-Becker, chief of the Emergency Department at CHA Everett.

“The ICU and our overflow ICU are still at capacity, but we’re now entering the phase of looking to be able to disassemble the overflow ICU and return it to be the post-anesthesia care unit in anticipation of a very thoughtful, well planned out return to what things might be like when we return to elective surgery,” she said. “In mid-May CHA is planning a staged return to elective surgeries, and more in-person visits to primary care and the ambulatory side beginning in June. Unless we have a dramatic swing in patterns we’ve seen here for two weeks, it will be our plan to very carefully move forward with the staged re-opening across the board.”

That decision, she said is based in part on the better supply chain of PPE and the hospital’s ability to secure what they need – which has been a challenge at times over the last 10 weeks.

“A lot of this is related to how the supply chain for PPE has started to better even out at our hospital,” she said. “We are not out of the woods though.”

The PPE issue was one of the reasons emergency surgery was routed to Cambridge during the surge of patients starting in March. To do such surgeries would have taken up equipment that needed to be used for patients fighting COVID-19- and also would have taken up the time of doctors who needed to be on the floor attending to the endless emergency situations involved with COVID-19 care. Now, they are moving back to doing those emergency surgeries again.

“One week ago we opened one operating room that is prepped and open to be able to do emergency surgery,” said Lai-Becker.

That was accompanied with the breaking down of the Comfort Care Unit, where patients who were dying of COVID-19 were taken when they had decided not to be resuscitated. That transition began two weeks ago, and the area has now been returned to its original use. That is a good sign, she said, as it signals the initial surge of patients is on the downslope and other medical care can now take place.

The changes also include a slow shift to a more manageable patient load, which has led to more space available in the hospital and fewer transfers of patients to other CHA campuses or into Boston’s major hospitals. That had become common as patient loads overwhelmed the hospital over the past 10 weeks, but it has slowed, and that is a relief.

“We are still continuing our rhythm, the new normal here,” said Dr. Lai-Becker. “We are now seeing a steady slow change…We really are now on the other side of the flattened curve.

“We no longer have to play that game of Tetris in scrambling to move patients  because we have bed space in our own facility,” she continued. “That’s a big relief from the operational movements as well as the cognitive load.”

Still, every patient that comes in is suspected of COVID-19, as symptoms seem to morph, change and new discoveries are reported about the virus every day. It has led to a great deal of skepticism as to whether every patient might be infected and, perhaps, a new symptom is emerging. That said, Dr. Lai-Becker said they have to remember that there are sometimes just simple reasons for patient ailments, which requires 10 weeks of unlearning the COVID medical mindset.

“Sometimes back pain from lifting a heavy box is simply back pain from lifting a heavy box, and has nothing to do with COVID-19 whatsoever,” she said.

The biggest piece of planning in the ramping down puzzle is the fact that the hospital is actually preparing for the fall – when there is great speculation that COVID-19 cases could spike along with the traditional influenza and cold season.

“It’s good to feel we can much better see the trajectory of how we need to continue with preparedness and go forward into the summer as the second phase is probably going to be in the summer,” she said. “We can continue to prepare and gird our loins for the fall…We are grateful to the City of Everett and the surrounding communities and the state. We need to take this opportunity because the community as a whole bought us the time needed to be ready and to not be scrambling for resources needed in what is anticipated to be something really different when we have the flu running around with COVID-19 as well.”

Right Where They Want to Be

Dr. Lai-Becker said they often get well-wishers who feel bad that medical professionals – including doctors, nurses and techs – have to work around the clock through such an unprecedented outbreak of a dangerous and unknown disease.

Many have said such professionals didn’t sign up for this kind of care, but Lai-Becker said across the board everyone in the hospital wants to be there fighting this virus and caring for people.

“This is exactly what we signed up for,” she said. “For the majority of physicians, nurses and techs, this is exactly what people want to be doing. They want to be here taking care of patients…This is what we trained for and what people want to be doing.”

Like many medical professionals, Dr. Lai-Becker said she spends her life either at the hospital, or at home. There is no longer any in-between or personal time. However, she said most at the hospital feel fortunate to be still working and doing what they trained to do. She said she sympathizes with those who are out of work, who are living lives of Zoom meetings and who are trying to take care of children now at home 24/7.

“When I am at the hospital I am with my colleagues doing our work and it’s actually very fulfilling to be with them and to have the opportunity to do what you trained to do,” she said.

Some Kids Have Reactions

Dr. Lai-Becker said the staff is watching and monitoring the reports of some children having adverse effects to COVID-19, particularly inflammation of the blood vessels that feed the heart.

The situation is rare, she said, but mimics what is called Kawasaki Disease – which is something very well-known in pediatric medicine and has to do with children suffering inflammation of the blood vessels around the heart.

In some kids, she said, doctors are seeing a similar reaction after they have had COVID-19.

“That’s what they’re seeing,” she said. “Kids who have had COVID-19 are mostly mildly symptomatic or asymptomatic, but there is a subset where this inflammation – like Kawasaki’s – is related to having COVID-19. It’s not often, but we’re starting to be aware of it.”

It is, she said, just another characteristic of a virus that shows up in so many different ways in so many different people.

Behavioral Health Starts to Emerge

One setback in what has been a good two weeks at CHA Everett is the uptick in behavioral health issues and the struggle to get beds for those suffering from such issues.

While it has always been an issue, there is an uptick in associated issues brought on by COVID-19 and also a lack of space for those patients because of the surge.

“The pandemic has a lot of secondary behavioral health impacts,” she said. “When our patients without COVID-19 are experiencing stress, anxiety and disruption of how people are living or working – or not working – we’re glad patients are coming in and seeking help.”

She said the behavioral health team has ramped up efforts, seeing patients with full PPE on and also resorting to a lot of tele-health appointments. She said it has been inspiring to see how that treatment, including for the ongoing opioid crisis, has continued through the pandemic.

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