The intensity of the surge of COVID-19 patients hasn’t let up at CHA Everett over the last two weeks, but new challenges have emerged as the face of critical patients gets older and legal questions arise more often about their wishes.
Last week, Dr. Melissa Lai-Becker, chief of the Emergency Department at CHA Everett, had a team of doctors and support staff ready to put an older woman on a ventilator – a task that is not easy or trivial. They had received information from the EMTs and nursing home to treat her. Literally a moment before they were ready to medicate the patient, the nurse manager came running in with paperwork they had just found on file – she was not to be resuscitated or intubated, known as a ‘DNR.’
“The nurse had the paperwork in hand and I was literally one moment away from pushing the drugs to intubate her,” said Lai-Becker. “It was a very intense moment because we have to have laser focus when we’re about to intubate. It was emotionally draining.”
Lai-Becker and most hospitals in the area over the last two weeks have absorbed the surge of critical patients who are older, especially those coming from nursing homes. As testing and information sharing has gotten better at those nursing home institutions, nearly all of them in the area have realized they have a severe outbreak even though some are asymptomatic. But it hasn’t stopped the spread in homes to more vulnerable patients who soon end up in the ER at CHA Everett.
Lai-Becker said one good thing about caring for older adults is they’ve often thought about end-of-life care decisions, and have clear instructions for doctors about what to do. However, in COVID-19, often times family members want that changed, or the circumstances aren’t clear – leaving doctors to try to sort out the madness in the midst of the hectic ER or ICU while on the phone with the hospital’s legal team.
“Many have had end-of-life discussions already and that part is good but there are less confident instructions at times, but thankfully the whole hospital system has stepped up,” she said. “No one could have predicted we’d be speaking to the general counsel of the hospital 24/7 for the legality of so many situations.”
In response, the hospital has created a small squadron of case managers to assist in the Emergency Room and that are part of the ER team now. Some patients come in with a “code,” meaning they are critical, but instructions from the first responders doesn’t match up with what the health care proxy/family tells them. Then sometimes the family health care proxy changes their mind at the last minute, not wanting their loved one to die of COVID-19. Other times, Lai-Becker said they learned, a legal guardian is not the same as a health care proxy, and in some families those two roles are fulfilled by different people with different ideas about care. It makes the daunting task of fighting COVID-19 even more difficult, and in a critical time-sensitive moment.
The case managers have stepped in to try to help solve those issues, she said.
“They are now an integral part of a critical care team,” she said. “When a patient comes in that is coding and we’re doing CPR, they are on the phone calling the next-of-kin, the health care proxy and pulling together information and making sure we’re respecting patient wishes. It’s a different challenge and a different aspect of this challenge…It’s another part of what we’re doing. It’s like having another appendage that is also doing something.”
She said she has heard from other sister institutions that the same thing is happening, and it has become an unfortunate trend in busy ERs.
“We have maintained the same intensity over the last two weeks with a slight drop off last weekend,” she said. “We’re still seeing a pretty broad age mix. The patients coming from nursing homes are older. Certainly being up the hill from Chelsea – there have been so many patients coming from Chelsea in their 40s, 50s who have an interesting mix of symptoms – asymptomatic patients and patients who have the atypical but prevalent symptoms.”
¥Icu’s Are Full, But One Glimmer of Hope Last Week
Nearly four weeks ago, CHA Everett converted an anesthesiology recovery room into an overflow ICU department, and since that time it has not emptied. The same has happened at the CHA Cambridge hospital, and both hospitals are completely full.
“The ICU overflow for Everett and Cambridge are full and the ICU departments in Everett and Cambridge are full all the time,” she said. “We are thankful we have a great critical care network.”
Many patients when there aren’t enough beds in the ICU are being transferred into Boston to their partner networks, including Beth Israel which has seen a major surge in patients starting last weekend. Nevertheless, they are hoping that patients in the ICU can get better through treatments – such as the innovative Tylenol poisoning antidote being used at CHA Everett – so they can come off a ventilator and make space for more critical patients.
“Every day patients are hopefully getting better and can be moved to the regular medical floor or to make room we’ll transfer patients to an in-town bed,” she said. “It’s a lot of moving parts…Now we are all looking for more and more ways to prevent someone from having to go onto the ventilator. That’s actually our greatest hope short of a cure or vaccine is that all the therapies and treatments can prevent people from going on a ventilator.”
Despite that sobering news, there was a silver lining moment at CHA Everett last week when a patient who had been on a ventilator was able to come off the ventilator and is recovering and likely able to go home. Typically up to now, when someone comes off a ventilator, it is because they aren’t going to make it and life-care is being discontinued.
“We have had our first successful extubation seeing the patient came off the ventilator,” she said. “We are very pleased we’ve had someone come off the ventilator and onto the floor and on their way out of the hospital.”
While some hospitals play the theme from ‘Rocky’ on such occasions, that didn’t happen at CHA Everett, but it was grounds for some celebration, she said.
¥Tylenol Antidote Treatment Gaining Steam
The new treatment being studied at CHA Everett under Dr. Lai-Becker is also gaining momentum – that treatment being to give the antidote for Tylenol poisoning to patients who seem to be having a huge immune system response to COVID-19, so much so that it is tearing them down instead of helping them. The idea in using the antidote is to slow down that immune system response and prevent patients from spiraling into a worse condition not caused by COVID-19.
They are almost done with an Institutional Review Board application to move the treatment to a clinical trial.
“We have been giving it now for about three weeks and we have just enough information to see whether or not it is working,” she said. “The hope is to register this as one of the 500 or so clinical trials going on right now – continuing it and spreading the word. Honestly, we want to convince some bigger institutions in Boston to add this in.”
She said there appears to be some credibility to the treatment, and the fact that is it already approved, it’s safe, plentiful and available in generic form make it a great option, if proven.
“We’re hopeful,” she said.
¥Comfort Care Unit Established for End of Life
At the Everett and Cambridge campuses, CHA has established Comfort Care Units to help COVID-19 patients be comfortable when they are expected to survive no more than two or three days. This is for patients whose families have decided not to pursue treatment and life-saving care. Palliative care physicians are on site to help them remain comfortable in their last days.
That unit has brought comfort to the staff and families affected by the pandemic, she said. In fact, many on the staff have had their spirits brightened by reading the patient stories written by those tending to folks in their last days.
“Frankly that’s been a comfort for patients and families and also the staff,” she said. “I’ll be honest; I have found comfort in following up on a patient there and reading the report from a palliative care physician that goes into all the considerations about the decision and a lovely, touching synopsis about the person’s life. It has meant a lot.”
¥Seeking Masks, New Testing Great
As the pandemic response at CHA Everett continued, Dr. Lai-Becker said they are still seeking new N95 masks made by 3M or Honeywell – as they are approved for full medical uses. They are running low, she said, and anyone with those kinds of masks are encouraged to bring them to the hospital for donation.
“We have run out of the small size of those and are on the hunt for them right now,” she said.
Last week, CHA announced it was moving to the Cepheid quick-test for its in-house lab – pushing wait times for a result down to four hours. That has been a fantastic addition, Lai-Becker said.
“It was successful enough we already ran out of those tests and were without them for 48 hours,” she said. “On Monday morning, we got a new shipment and I’m sure we’ll plow through them quickly too. It is amazing what Dr. Osgood was able to do for a small community hospital.”
¥COVID-19 Was Probably Here in January
As the pandemic has advanced, there are now great suspicions that COVID-19 was present and spreading quickly in Boston as early as January.
The new blood test for anti-bodies – which is being tested now across the country – is revealing quite a few people who apparently had the virus earlier this year and didn’t know it. Many reported having a cold or some type of flu in late January or February, but had no idea it was COVID-19.
Dr. Lai-Becker said they haven’t done any patient research, but anecdotally she is beginning to think that community spread was more prevalent in Everett and Boston as early as January.
She said last year many patients came in with the flu and 90 percent tested positive for the flu with the standard flu test. This year, starting in January, many were coming in with what appeared to be the flu, but were testing negative.
“Anecdotally, in February, I remember feeling that so many patients were having negative flu tests,” she said. “It will be very interesting to have a full roll out in a month. We’ll have a much better sense of real anti-body testing that will show perhaps all of us that it was around earlier…If you pressed me on it about whether it was community spread in January, I would say that yes it probably was. It’s the only way I can explain the BioGen super spreader event in Boston.”
She added that there hasn’t been research or case studies to lend credibility to those hunches, but she said more and more people are leaning towards the idea COVID-19 was around months before things got serious.
“It has been with uniformity that people agree it has to have been around much earlier than people thought,” she said. “I think that’s the best explanation for why the BioGen conference really turned out to be a super-spreader event.” That will remain to be seen as time goes on, but for now, call it a hunch.