Spotlight: On the Front Lines

ER doctor Kelley Wittbold ’03 details her experiences with COVID-19.

Kelley Wittbold ’03 is an attending physician in the Massachusetts General Hospital (MGH) Emergency Department and is involved in managing the hospital’s evolving emergency telehealth program. She shared her experiences with the COVID-19 pandemic with Alumni Horae editor Jana Brown.

What was a typical day like before the pandemic?
MGH has always been a bustling academic referral and level-1 trauma center. During residency training and in my first year as an attending, our Emergency Department (ED) felt like it was bursting at the seams in terms of bed supply and patient demand, which became one of the main impetuses for my involvement in operations and capacity management, alternative care delivery, and the deployment of digital health and telemedicine programs. On a busy shift, I’d be responsible for overseeing as many as 50 patients, and for evaluating up to 30 new patients over a 9- to 10-hour shift, while managing a team of up to eight residents and physician assistants.

How has that changed since COVID-19 arrived?
In anticipation of the surges seen in Italy and New York, with the goal of ‘flattening the curve,’ we in Boston had the privilege of an interval time period (and lower population density) during which preparations could be made in staffing redistribution, amplification of virtual care programs, and acquisition of ventilators, medication supplies, and PPE supplies – as well as robust teams to support the logistical operations of carrying out such coordinated efforts. Throughout the entirety of this process, MGH has remained at least one step ahead of the curve, turning almost half the 1,000-bed hospital into additional ICU capacity. We were fortunate in that we reached our peak in mid-to-late April, with nearly 175 ICU patients on ventilators at MGH alone, greater than any other partner hospital and much greater than the typical average of 45 patients vented on any given day prior to COVID. We also engaged in a partnership with Battelle, whose equipment makes it possible for PPE decontamination and re-use to ensure continual supply of reliable PPE for staff when supply chains for new N95 masks fell short.

Notably, our ED volume overall has fallen by about 30%. Much of this can be attributed to social distancing policies that prevent emergencies such as alcohol-related car accidents and other types of trauma, as well as the increased adoption of virtual care programs. However, we are also noticing that many patients who do need to come to ED do not because they are afraid of contracting COVID and end up with more severe complications than they would have otherwise experienced because of delays in time to critical care. For example, I saw a young patient who came in two days after he became weak and lost the ability to walk. He was found on MRI to have a clot in the blood supply to his spinal cord, ultimately leaving him paraplegic. Had he presented to the ED sooner, this would have had the potential for successful treatment, and he may have had a greater opportunity to walk again. We are also seeing delayed presentations in strokes and heart attacks, with poorer prognoses the longer the delay in care.

Of the patients who do come in – the vast number of them do have COVID, and the patients we are seeing are coming in sicker, requiring intubation and, at times, cardiopulmonary bypass. On one day in late March, over 12 patients in the acute unit of the ED were intubated within a 12-hour time period – one per hour. On a typical busy day prior to COVID, intubations would average anywhere from two to four per day.

There is also an increase in palpable anxiety among physician and nursing staff (as well as our support systems) about contracting COVID or spreading it to loved ones when they return home. We have been fortunate in our ED at MGH with strict PPE protocol adherence; to date, no attending or resident physicians or nurses have contracted COVID.

In what ways are the realities of what you are seeing in the ER reflected in the media and in what ways have they been captured inaccurately?
COVID can present in many ways and is not limited to respiratory symptoms or fever. One other reality that differs from what has been advertised in the news is the policy promoting the use of temperature checks as a means for screening for COVID patients. Carriers of the virus can be asymptomatic, or patients with certain autoimmune diseases or on certain medications may be unable to mount an immune response that involves a fever (including the very old or very young, transplant patients, patients on steroids for inflammatory diseases, etc). In addition, fevers can be hidden or masked by a single dose of Tylenol or Ibuprofen, which anyone can get.

What is the worst thing you have seen during this pandemic?
Clinically, the worst thing I’ve seen has been young patients presenting with strokes attributable to the highly variable inflammatory response to the virus. We’ve also seen some patients on ventilators and high-dose blood pressure support medications, whose ICU course is complicated by blood clots compromising blood flow to their intestines, leading to decreased oxygenation of their guts and surgical removal of much of their small and/or large bowels. From an ethical and psychological wellbeing standpoint, one of the hardest things is trying to communicate with foreign-language-speaking patients through interpreters and iPhones, with policies limiting family members and visitors at the bedside when the patient is critically ill.

How has the pandemic made you rethink your role as a healthcare worker and the role of science and medicine in general?
In many ways, the pandemic has reiterated the importance of big data and technology in healthcare for policy decision-making and widespread coordinated care across large enterprises. Before the pandemic, I thought I was going to have to spend the next 10 to 20 years of my life convincing physician colleagues, policymakers, and insurance payors that digital health and telemedicine is worthwhile. However, the virus has done this for me in a matter of weeks, and the relevance and necessity of digital health and virtual care has never been so uniformly appreciated as it has during this time of emerging infectious diseases and limited personal protective equipment supply chains. I am grateful I chose emergency medicine and even more grateful that the world is now embracing digital health to get the right patient to the right place at the right time – which sometimes might be right in their own home.

What signs of hope have you seen since the pandemic began and in more recent days?
We are on the decline in terms of cases and reached our peak in early April – we now (as of May 7) have approximately 115 intubated patients in our ICUs. Unwavering support from the community – endless waves of food to support our workers day in and day out and messages of support, as well as those offering their homes or other assets to assist with healthcare workers’ needs to isolate from at-risk family members when they return from work. Governor Baker’s steadfast and rational leadership as a former healthcare executive has made the policies in Massachusetts something we as healthcare providers all tend to respect and hold up as they are intended to protect the wellbeing of our vulnerable fellow humans.