Cheryl K. Lee, MD, an Assistant Professor of Medicine at Northwestern Feinberg School of Medicine, practices internal medicine and pediatrics at Northwestern Memorial and the Ann & Robert H. Lurie Children's Hospital, both in Chicago, IL. She also serves on the Northwestern Medicine Covid Quality Committee and as core clinical faculty in the Internal Medicine Residency.
Is it fair to say that for hospitalists, the pandemic has been a sobering experience, why so?
Dr. Lee: There are several reasons; one stems from the increasing impact of Covid on children. Early in the pandemic, young children, teens, and young adults were not infected or hospitalized at the rate of older adults.1 For those of us who care for hospitalized patients, that early finding was somewhat of a relief, knowing at least one portion of the population wasn’t as heavily affected. In fact, I normally split my time as a pediatric and adult hospitalist, and I was reassigned to work full-time in the adult hospital because so few children had been admitted. But all that changed with the arrival of the highly transmissible Delta variant and the loosening of social distancing and masking guidelines and other regulations. The American Academy of Pediatrics2 reported that, as of October, 8,364 of every 100,000 children have been infected by Covid, largely driven by the summer surge. Furthermore, pediatric Covid hospitalizations increased five-fold in August 2021 as compared to the prior 6 weeks. And these numbers likely underestimate the true impact, as several states did not release complete reports and did not account for long-term sequelae from milder infections.
What other issues were far-reaching for hospitalists?
Dr. Lee: Early in 2020, we were scrambling to learn about a novel, deadly, highly transmissible disease. Some groups in our population were experiencing a high fatality rate, and the medical community had no proven treatments. We felt helpless in caring for these patients who pleaded for our help and ultimately died. When data proved that medications like steroids were effective and the vaccines arrived, I had hoped that the pandemic would be ending. But now with the quick dissemination of false information and the evolution of new variants, we are left caring for seriously ill, unvaccinated patients along with younger patients. The heartbreaking thing is that these are largely preventable tragedies now that we have effective vaccines.
What medications have changed the course of Covid in the hospital?
Dr. Lee: Steroids are interesting; they are a good reminder that Covid has different stages and that we should be mindful of how we treat patients within those particular stages. Simply, Covid infection begins with a phase of viral replication characterized by fevers, cough, loss of taste and smell, and gastrointestinal symptoms. In time, this is followed by a second phase of high inflammation and immune response, sometimes causing hypoxemia and respiratory failure. What we know is that steroids such as dexamethasone reduce mortality, but they are only effective during this second phase, and only in those whose oxygen levels are low enough to require oxygen. This was not an intuitive finding, since steroids do not help, and may harm, those with other viral pneumonias, such as influenza. Steroid use in severe, hypoxemic Covid, however, is life-saving and the mainstay of inpatient care which might include antivirals and interleukin-6 inhibitors3 in select patients. As with steroid use in other patients, physicians should watch their Covid patients for hyperglycemia4 and delirium. That said, steroids provide a mortality benefit that strongly supports their continued use -- in tandem with management of those expected side effects. Last, it is important to note that steroid use has been associated with possible harm when given to those with mild Covid,5 so its use should be avoided, in light of its expected side effects, unless a patient requires supplemental oxygen.
That said, although steroids can be helpful for our sickest patients, vaccines are the best medicine of all because they can allow patients to avoid hospitalization and death -- outcomes that far outweigh what steroids or any other medication can do for the gravely ill.
Given the complexity of the evidence surrounding the treatments for Covid in the hospital, no wonder some people are confused about which medicines work.
Dr. Lee: First, let me say that I have yet to encounter a patient or family member whose motivation to ask questions or question a loved one’s treatment wasn’t grounded in concern and fear for their loved one.
What do they ask about?
Dr. Lee: They ask about alternative treatments, anti-parasitics, even vitamins. I agree with them that there is so much out there about Covid that it is difficult for anyone to know what is true or false. I then explain what therapies are proven – medications such as steroids and supportive care such as oxygen and prone positioning. I also review the lack of good evidence for the alternative treatments that they ask about. It is sometimes surprising to folks that all research isn’t conducted with equal rigor, and that false conclusions can be made based on faulty evidence. A good example is how providers used hydroxychloroquine early in the pandemic, but ultimately it didn’t prove to be helpful. Although we are always hopeful and looking for new therapies, I say, those specific alternatives haven’t worked out. And I end with a promise that I will continue to keep up with the literature and let them know when something new does look promising.
Your responses to the above questions prompts this one: How do physicians who are treating Covid-19 stay on top of what is being learned about Covid-19? At last count, there were 191,968 results in PubMed, found using that sole keyword.
Dr. Lee: One of the amazing things about the Covid era is that members of the scientific community dropped everything to research Covid. But on the flip side, there is now a lot of research out there, and it frankly has become difficult to keep up with it. Our hospital system identified a core group of collaborators with backgrounds such as pharmacy, nursing, infectious disease, pulmonary, and hospital medicine to regularly review the evidence and identify anything that has strong enough evidence to change our system’s clinical practice. Furthermore, I regularly tap consultants in various specialties to help me contextualize new research. And I’ve found it helpful to review the living practice guidelines from the Infectious Disease Society of America and the NIH.3,6
What else has been remarkable about the last 19 months?
Dr. Lee: I have never spent this much time talking with patients and their caregivers. I’ve always been one to talk a lot with families, but it feels like the pandemic has created another level. My guess is that many colleagues are experiencing the same thing. Caring for hospitalized Covid patients is not only intense from a medical standpoint, but also from a psychosocial vantage point. Patients are ill and usually scared, and they are supported by friends and family who are equally afraid for them, who furthermore can’t visit because of isolation needs. And I often forget that, besides Covid, families have gone through immense social and financial changes. Sometimes communication can be fraught because of that stress. I am trying to be mindful that patients and families come into the hospital with a lot of these burdens, so that, if the conversation takes a tense turn, I will try not to take it personally. Some days are harder than others.
What you are describing isn’t necessarily an innate skill.
Dr. Lee: Absolutely. As have many others, our medical school and residency program has been incorporating communication skills into the standard curriculum, analogous to teaching anatomy or heart failure treatments. We are more aware that handling a difficult conversation isn’t an instinctive thing; that it must be modeled and learned. But I was surprised at how communication in a pandemic, when caretakers can’t see their loved ones, is truly a unique challenge. It is challenging for me despite being in practice for several years.
What will happen when the pandemic subsides? How much of the impact of Covid will stay with you, when dealing with a broken leg, or a patient with osteoporosis?
Dr. Lee: There will be lasting effects of this era on the health-care workforce, but I honestly can’t predict how severe that impact will be or how long-lasting. Already we are seeing health-care workers drop out of the workforce, driven by effects of the pandemic itself, increased workload, or being underpaid.7 This is occurring alongside a national conversation that cannot agree on life-saving interventions such as vaccines. I worry that the current environment will lead to many more dropping out.
What can hospital administrators do now to put stop gaps in place? What advice would you give to them?
Dr. Lee: Workers in each hospital will have unique needs and stressors, so it makes sense that the first step is to provide an opportunity to make their opinions heard. It may be tempting for hospitals to jump on quick fixes such as offering classes in “resilience training,” but that may not be a data-driven solution, particularly if burnout is being driven by an ever increasing workload.