How physicians can prepare for the winter COVID wave

By Alistair Gardiner
Published November 11, 2020

Key Takeaways

We’re roughly 10 months into the COVID-19 pandemic and the number of Americans infected with coronavirus has surpassed 10 million. The most recent million of those cases were reported over the course of just 10 days, according to Johns Hopkins University. After a small decline during late summer, the virus is now spreading exponentially across most of the country, with 43 states reporting a 10% increase in COVID cases since last week.

With a surge in winter cases anticipated, MDLinx spoke to Lakshman Swamy, MD, MBA, a pulmonary critical care specialist who works as an ICU doctor with Cambridge Health Alliance in Boston. In this exclusive interview, he offered insights as to how physicians can prepare for the coming weeks and months.

On the frontline from the beginning

In the early days of the pandemic, Dr. Swamy was finishing his fellowship in pulmonary and critical care medicine at Boston Medical Center, one of the large safety-net hospitals in Boston, which, he said, “came as close to being overwhelmed as it could.”

“The whole hospital was essentially a COVID hospital. We were creating new ICUs to manage the volume of ICU patients. We were bringing in a lot of volunteer staff,” Dr. Swamy said. “Suddenly we had a lot of people coming in who were basically the sickest patients we’d ever seen, all at once, all requiring that level of attention and detail. The other challenge was there was a lot of fear in that environment. There was so much that was unknown. We were terrified of getting sick. We knew our colleagues were getting sick. We were worried about protective equipment running out. We were worried about people not taking it seriously in the community and more and more people were getting sick and coming in.”

Dr Lakshman Swamy and nurses

Lakshman Swamy, MD, MBA, salutes members of the nursing staff amid the COVID-19 crisis.

Over the summer, Dr. Swamy said, things began to improve. Lockdown measures appeared to be working and healthcare workers were learning how to treat COVID patients. Drugs like dexamethasone and remdesivir emerged as effective treatment options in some cases and, after getting a better understanding of the progression of the illness, doctors found that they didn’t need to put as many patients on ventilators.

“Over time we realized there are different therapies, like high-flow nasal cannula—there are different ways we can give people a lot of oxygen, a lot of support,” Dr. Swamy said. “At first, we were really concerned that it was going to spread the virus, but we’ve learned a lot about how safe that stuff actually is.”

While the summer saw mortality rates drop and fewer patients admitted to the ICU, Dr. Swamy says that’s all changing as winter approaches.

“I was in the ICU all of last week and basically there were a lot more people coming in, critically-ill with COVID. It was like ‘Oh, this feels like the spring again,’” he said.

Despite a much higher rate of COVID infections, the healthcare community has learned a lot since the pandemic’s first wave. That means physicians can use their experience to protect against suffering, fatigue, and burnout as we head into what could be a brutal winter.

As COVID heats up, physicians burn out

As part of his fellowship at Boston Medical Center, Dr. Swamy researched physician burnout. Now, he’s in the middle of an intense, real-world case study of the phenomenon.

“Before COVID happened, burnout was rampant in healthcare workers of all kinds. Doctors, nurses, everyone,” he said. “Just a general sense of not doing the work you’re supposed to be doing, doing a lot of documentation, that kind of thing—and having a great deal of responsibility and not necessarily enough support to meet those demands. The system was not well. Then this happened.”

The pandemic has only exacerbated burnout, he said, calling it a “surgical attack on the psyche of the healthcare worker.”

“In the workplace, the things we had to support us were all taken away, the biggest one being the camaraderie and the closeness of the clinical team. Gone,” he said. “On top of that, the families were gone. In the ICU, that’s a huge part of what we do and what humanizes the patient. Instead, people were watching their loved ones die on Facetime. And we were sort of bearing witness to that. What’s it like for the person holding the iPad in that situation? Obviously, it’s not even comparable to what the families are going through, but it really leaves a lot of marks. A lot of people including me had nightmares for a long time.”

Dr. Swamy said that the other issue is a deeply ingrained culture of healthcare workers refusing or avoiding seeking help. With the additional burdens of dealing with a surge of patients during the next wave of the pandemic, it’s even more crucial to recognize the signs of burnout and take proactive measures to address them.

How to prepare for the hard road ahead

According to Dr. Swamy, there are three primary elements to burnout.

“The first is a sense of deep emotional exhaustion. The second is a sense that you’re not accomplishing things professionally—a lack of a sense of personal accomplishment, like I’m not productive, my work is meaningless,” he said. “The third is a sense of just being disconnected from what’s happening, like you’re just a robot going through these things and just watching it all happen.”

Dr. Swamy said he’s experienced all of these components personally or seen them in colleagues. He explained that physicians who may be approaching emotional exhaustion typically find replenishment and nourishment in relationships with colleagues and patient families. These interactions typically provide meaningful emotional connections. “But a lot of that is gone,” he said. “If you can’t find that at work, find it outside of work. For me, that’s spending time with my kids. That’s my emotional replenishment.”

He also conceded that, in the early stages of the pandemic, he experienced some level of meaninglessness in his work. “I felt like this was what I’d been working toward my whole life, right? I’m a pulmonary critical care specialist, and this is a pulmonary critical care problem,” he said. “At first there’s a lot of motivation you can get there, but you quickly felt useless. There was a long time where it felt like we were just watching people die. It felt like all the work we were doing was meaningless.”

If physicians are feeling this way, he said, the best plan is to find this sense of productivity and accomplishment outside of work. “For me, that’s running and baking,” he said. “I feel like I did something: I finish running and no one can take away from me the fact I did that. I finish baking and there it is in front of me, a tangible thing. Feeling like you created something can be really helpful.”

Intentional reflection is key to coping with the final component of burnout: detachment, he said. For some, this can be journaling, for others, painting. According to Dr. Swamy, it simply needs to involve digesting and reflecting on what’s happening. “For me, sometimes, it’s Tweeting,” he said. “I just have these discussions in a public forum and that’s my own personal way of digesting some of these difficult issues.”

Humor is another good way that many doctors cope with the difficult realities of life, including trauma. 

The golden rule

The most crucial part of being able to manage the burden of the forthcoming wave: Healthcare workers must look after each other and pay attention to any changes in behavior or mood, Dr. Swamy said. Two examples of symptoms are irritability or abdominal pains.

“Those are the warning signs I would look for in myself and my colleagues. Are you talking a lot more about drinking? Are you being a little more cynical where it’s kind of pushing the edge?” he explained. “It’s hard to recognize that stuff in yourself. I think a better solution as a culture and a system is to say: Look out for each other.

“Through the pandemic, we saw physicians taking their own lives, as what looks like a direct result of this. We’re all vulnerable. You don’t need this long history of depression to have that happen to you or someone you love,” Dr. Swamy added. “The right thing to do is talk to that person: ‘Are you OK?’ It’s a rough time for all of us, it’s OK for it to not be OK.”

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