Editors’ Note: This article was accepted on April 14, 2020, and was accurate at that time. Because information about SARS-CoV-2 and COVID-19 is evolving rapidly, please verify these recommendations and information.
While we are at our computer desks, as we quickly put in orders and type up charts, we can hear the sounds of a busy emergency department in Brooklyn, New York, but it sounds different this time. An elderly woman with a parched mouth asks for water and a meal. A man asks for a phone charger to call his wife after his phone had died. Another patient asks if their family had called. Patients’ requests are punctuated by beeps and alarms of ventilators, bilevel positive airway pressure (BiPAP) machines, medication pumps, and monitors, in a sea of people struggling to breath. Our nursing staff is already stretched thin, overwhelmed with admitted patients in the emergency department waiting for a bed upstairs for days at a time. Some never make it upstairs. We became increasingly aware that we needed to do more.
In accordance with our state health department’s guidelines and like many other emergency departments across the nation, visitors are not allowed at this time to mitigate the spread of SARS-CoV-2. Unfortunately, this presents a situation where a patient can only contact their loved ones through a phone call. Some patients arrive in our emergency department picked up by EMS in haste, unprepared, without a phone charger, or sometimes without a phone at all. Those who fall critically ill and die, die alone. There have been many times where a request for a phone call or a cup of water became their last request. Many health care workers feel defeated as we are grappling with this unknown disease. Despite our best efforts and best medicine, patients will continue to succumb to this virus, but what we can provide is compassion.
At this time, New York City alone has more than 200,000 cases of COVID-19. We have seen unprecedented issues that may arise in your ED and would like to offer guidance to our fellow EM community.
At New York Health + Hospitals/Coney Island Hospital, we formed the Compassion Committee, made up of residents, nurses, physician assistants, and attendings, dedicated to providing compassion to these patients with COVID-19. We developed “Compassion Rounds” asking each patient three very important questions:
Are You Comfortable?
We know COVID-19 causes dehydration and unfortunately placing patients on BiPAP further dehydrates their oral mucosa. We began handing out bottled water and sitting with patients on BiPAP while monitoring their oxygen saturation. When patient meals arrived in the department, we spent extra time handing out meals, opening packages for the elderly, and feeding patients that could not feed themselves.
Now that visitors are no longer allowed, we noticed that this not only took away embracing comfort for the patients but also removed their greatest advocates, their loved ones. We know family members play a critical role in patient care. They are a voice for the patient when they are too altered or too ill to speak. They advocate for quality care, explanations, and humane treatment. Our committee noticed early on that this component was missing. We feel a sense of responsibility to advocate for each of these patients as though they are our loved ones, suffering in a stretcher gasping for air from the terrible effects of COVID-19.
Nursing and ancillary staff shortages coupled with an overwhelming number admit holds in the emergency department lead to cracks in basic patient care. We noticed that many patients were sitting in soiled sheets or lying in bed at an uncomfortable and unproductive position for proper oxygenation. We helped maintain human dignity and comfort by changing patients to clean sheets and diapers, positioning them upright while eating, and moving them into a prone position for better oxygenation.
Have You Talked to Your Family?
We know that treating the human spirit can have beneficial effects on the healing process. A simple question of “Have you talked to your family?” or “Can we help you communicate with your loved ones?” brought large dividends.
If a photo is worth a thousand words, then a video is worth a million to patients’ families.
One day while we were rounding on admitted patients in the emergency department, there was a 65-year-old man on BiPAP who had forgotten his phone. It was shocking to hear that he had not spoken to his wife for three days, and when asked if he would like our team to send a message to his wife, he jokingly said, “I hope she hasn’t forgotten about me.” The patient’s wife, in turn, asked us to relay back, “I love you.” Even better, she dropped off a phone for him.
We reached out to our friends, family, and community for donations for phone chargers, headphones, iPads, and cell phones. We received an overwhelming response, as well as donations from companies that supply portable power banks. Logistical barriers included managing inventory of donations, accessing hospital Wi-Fi, and making numerous video chat accounts for each iPad. In retrospect, we wish we had started this initiative sooner.
On numerous occasions, a family member’s voice had offered hope, helped calm patients, and encouraged them to adhere to recommended medical treatment. Our video messaging initiative has allowed families to see and hear how their loved ones are doing. It has also allowed families to gather, pray, and say goodbye for the last time. If a photo is worth a thousand words, then a video is worth a million to patients’ families.
What Are Your Goals of Care?
Often, patients are too ill to aid in their own care plans. When contacting family is unsuccessful, we believe it is necessary that physicians act as direct patient advocates. We emphasize our concern for causing unnecessary suffering and we advocate for do-not-resuscitate/do-not-intubate (DNR/DNI) orders when the prognosis is poor. Unfortunately, extubation success rates have been low. If a patient lacks medical capacity and has no contact available for medical decision-making, it is at the ethical discretion of the physicians to utilize a two-physician DNR/DNI order to reduce patient harm and appropriate resources. Patients that are on comfort care are taken off cardiac monitors and moved from the critical zone to free the bed for a patient requiring monitoring.
During a pandemic of this proportion, hospice care is limited due to space and isolation restrictions. In rare cases, family members are able to procure oxygen tanks and patients are able to go home. The majority stay boarded in the emergency deepartment under our care. We found it necessary to create a peaceful space for their end-of-life care. There was a silver lining in the no-visitor policy: the ability to repurpose the family waiting room to an advanced comfort care room. Here, one or two patients are cared for and are able to video chat with families in peace away from the chaotic emergency department.
No other health crisis has tested the emergency medicine specialty like COVID-19 has. The field of emergency medicine was developed long after the 1918 Spanish Flu pandemic. We face challenges we have never seen before and we must pave the way. As emergency physicians, we are the specialty created to protect human dignity and provide compassionate care to every patient in times of catastrophe. There may be no current cure for COVID-19, but the human spirit deserves not to be another casualty. In a time where the surge of patients made our resources limited, the most rewarding and abundant thing we could offer was our own compassion.
Dr. Viguri is director of emergency medicine pain management at NYC Health + Hospitals/Coney Island Hospital in New York City. Dr. Cocchiara is a PGY-4 emergency medicine resident, Dr. Ngo is a PGY-3 emergency medicine resident, and Dr. Sokup is a PGY-1 emergency medicine resident at NYC Health + Hospitals/Coney Island Hospital