The Finest Hour

The COVID-19 crisis is a true world crucible. As only a pandemic can demonstrate, we are one people that number 7.7 billion. The global case count of more than 1.5 million as of April 9,1 mounting from a single patient zero in China five months ago, is the wave of chaos theory––a tidal surge that follows from the mere beat of butterfly wings half a world away. For better or worse, we are inescapably linked in the furnace of COVID-19. In the words of Sir Winston Churchill, emergency medicine is called to witness its “finest hour.”

America continues to escalate its response to the COVID-19 crisis. The federal government and states struggle to optimize and continually update varied interventions. SARS-CoV-2, the novel coronavirus at the root of COVID-19, has affected a wide swath of the population, severely impacting the elderly and those with comorbidities. No one knows this more viscerally than emergency medical soldiers fighting without armor to save lives in our neighborhoods and hospitals––the emergency medical technicians, paramedics, nurses, physicians, and support personnel at the frontline in the opening salvos of a sudden war.

Per CDC guidelines and of necessity, prehospital and hospital providers are using respirators, facemasks, and eye protection “beyond a single patient contact” while devising “alternative approaches” when commercial PPE is unavailable.2 Many are trying to secure source control with tissues instead of masks, are reusing PPE normally discarded after single use, are inventing decontamination protocols, and are wearing PPE far beyond manufacturer-designated shelf-lives. Many, unable to receive testing after suspected exposure, have withdrawn from the workforce out of fear of exacerbating the contagion. Inadequate testing has accelerated PPE shortages, with heavier and sometimes unnecessary PPE use stemming from the COVID-19 “fear factor.”3 They are heroes, yes, but they are human. They embody courage but are anxious for their patients and families, if not for themselves, as they stand in harm’s way.

The strain grows with the surge of patients, global recession, and consequent pressure on healthcare systems––furlough of medical staff and directives limiting information-sharing, for example, register the emergence of unsettling fault lines. As emergency medical personnel respond concurrently to unceasing public health burdens such as STEMI, out-of-hospital cardiac arrest, stroke, and trauma, our frontline providers and emergency medical systems are being tested as in no other time.

Amid such challenge, however, there is cause for optimism. Whether swiftly adapting clinical treatment paradigms or methods of intubation, our ingenuity as emergency medicine providers has never been demonstrated as in this crisis. In addition, the selflessness of colleagues across the country, the rapid diffusion of COVID-19 scientific literature, and the evolving measures to track and control resources at emergency medical service agencies and hospitals represent a massive counter-assault on the contagion. The rally of orthopedists and dermatologists to emergency rooms in New York City4, furthermore, represent a clarion call to the entire medical community: nothing short of the all-hands-on-deck ethos of “Rosie-the-Riveter” will do. We all must ask what we can do and give all we can at this critical point in history.

In estimates with varying levels of mitigation, White House medical experts, Drs. Birx and Fauci, expect a range from 60,000 to 240,000 U.S. deaths, a fraction of mortality in other projections that assume limited interventions.5 Their upper bound exceeds the estimated 235,000 U.S. causalities during World War II.6 The whole enlistment of society is required to blunt the present outbreak and prepare for additional COVID-19 waves that public health experts anticipate. Dr. Fineberg, former president of the Institute of Medicine, has called on the President to appoint a COVID-19 commander with “the full power and authority of the American President to mobilize every civilian and military asset needed to win the war.”7 We echo this imperative and propose a call-to-action that prepares for subsequent waves of COVID-19 and future pandemics by establishing:

  1. A national industrial plan to manufacture, stockpile, and disseminate PPE and COVID-19 testing that will (a) supply the present population of emergency medical responders beginning with the most resource-strained locations and (b) catalyze broad-based participation of medical personnel to serve as adjunct frontline providers.
  2. A national registry of available nurses, advanced practice providers, allied health professionals, and physicians able to function as frontline providers, perform telephone triage, conduct telemedicine consults for COVID-19 and specialty patients, and to serve in temporary field hospitals through patient care, strategic planning, and clinical decision-making.
  3. A national forum where civic and business leaders come together to transcend the interests of competing healthcare and insurance entities in order to provide the best care possible for the greatest number of patients.
  4. A national dashboard that identifies and links extant databases to create a single integrated Learning Health System that spans the entire country, allowing communities to optimize resources and deliver COVID-19 patients to facilities best suited to care for them. This system would also facilitate communication between regions at various stages of their COVID-19 surge, enabling communities with surplus resources to support those with less secure inventories.
  5. A national report commissioned to assess the status of emergency medicine training curricula for medical schools and advanced healthcare professions and to provide recommendations on how to integrate this training as a critical component of a complete medical education.

We cannot care for patients if we are not well ourselves. In service to our country and all humankind, we must find our voice, marshal our power, and manifest, if only by force of collective will, an emergency preparedness response that embraces the national manufacturing and distribution plan called for above. PPE and testing are the sine qua non of any effort to mobilize as needed. Assured of proper protective gear and testing, thousands of colleagues from non-emergency disciplines would rally to the front. The stream of goodwill, a triumph in itself, would galvanize the enterprise and commitment of public and private leaders needed to secure the nationally integrated response that would serve the country best. As the American community of emergency medical providers, it is our duty, whatever the course of the current trial, to lead, prevail, and render this time our finest hour.

References

  1. Johns Hopkins University Center for Systems Science and Engineering. Coronavirus COVID-19 Global Cases. https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Accessed April 9, 2020.
  2. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control and Prevention. https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/index.html. Published February 11, 2020. Accessed April 9, 2020.
  3. Christi A. Grimm. Hospital Experiences Responding to the COVID-19 Pandemic: Results of a National Pulse Survey March 23-27, 2020. U.S. Department of Health and Human Services Office of Inspector General; 2020. https://oig.hhs.gov/oei/reports/oei-06-20-00300.pdf. Accessed April 9, 2020.
  4. Sengupta S. With Virus Surge, Dermatologists and Orthopedists Are Drafted for the E.R. The New York Times. https://www.nytimes.com/2020/04/03/nyregion/new-york-coronavirus-doctors.html. Published April 3, 2020. Accessed April 9, 2020.
  5. Fauci Slashes U.S. Death Projection, Raising Hope for Reopening. Bloomberg.com. https://www.bloomberg.com/news/articles/2020-04-09/fauci-says-u-s-virus-deaths-may-be-60-000-halving-projections. Published April 9, 2020. Accessed April 9, 2020.
  6. U.S. Army Center of Military History. World War II, Korea, and Vietnam Casualties. https://history.army.mil/documents/misc/stcas.htm. Published May 4, 2004. Accessed April 9, 2020.
  7. Fineberg HV. Ten Weeks to Crush the Curve. N Engl J Med. April 2020. doi:10.1056/NEJMe2007263

Authors:

Bentley J. Bobrow, MD
McGovern Medical School @ UTHealth
Department of Emergency Medicine
Houston, Texas
Bentley.J.Bobrow@uth.tmc.edu

Micah J. Panczyk, MS
Texas-Cardiac Arrest Registry to Enhance Survival (CARES) State Coordinator
McGovern Medical School @ UTHealth
Department of Emergency Medicine
Houston, Texas
Micah.J.Panczyk@uth.tmc.edu

Normandy Villa, MPH
Translational Science and Quality Improvement Specialist
McGovern Medical School @ UTHealth
Department of Emergency Medicine
Houston, Texas
Normandy.W.Villa@uth.tmc.edu