What is “war medicine” during the coronavirus? Louisiana Health Care Workers Prepare For It | Coronavirus


As coronavirus patients flood New Orleans and Baton Rouge hospitals, health workers who treat them on the front lines say the decisions they face are painful and emotionally draining – and would have been unimaginable there. is just a few weeks old.

At East Jefferson General Hospital, two employees said they had received instructions from their supervisors to distance patients with dire coronavirus prognoses from extreme rescue by urging them to sign orders ” do not resuscitate ”, which could help release ventilators.

On the main campus of the Ochsner healthcare system, a doctor said that the number of critically ill patients has changed the way they react when a patient’s heart stops. Typically, 10 or more people would flood a patient’s room flat to alternate chest compressions and offer rescue measures. Now, this is just the most essential staff, said the doctor.

At Tulane Medical Center in New Orleans, a supervisor said efforts to revive a patient who “coded” should be limited to save resources for patients who need it most, according to an employee. A month ago, staff may have spent up to 60 minutes trying to revive someone whose heart had stopped. Now, a COVID-19 patient with a poor prognosis could get as little as 15 minutes of rescue effort.

Workers say the measures are well-intentioned and aim to focus resources on the patients who need care the most and have the best chance of survival.

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Hospital administrators, on the other hand, deny having been forced to ration care in any way. They say such scenarios will only happen if harsh forecasts of hospital overtaking become a reality, which Governor John Bel Edwards has warned could happen in less than a week.

These unforgiving prospects are not unique to Louisiana. Hospitals across the country are facing similar concerns, although the spread of the coronavirus here has been among the fastest in the country. In Italy, the global epicenter of the epidemic, healthcare workers had to make difficult decisions about how to prioritize who gets a ventilator and how to distribute other supplies. Healthcare workers in New York are also facing predictions that they will soon run out of ventilators.

Most healthcare workers caring for coronavirus patients in Louisiana say that a few weeks after the coronavirus pandemic started, they now know what to expect: patients presenting to the emergency room with respiratory symptoms and often deteriorate quickly, requiring oxygen first and then ventilators. Workers are content with shortages of masks, gowns and other protective gear, with some resorting to purchasing reusable face-worn respirators used in construction.

But a new and growing concern for many health workers is the way in which the crisis forces them to allocate their time, care and supplies carefully. They are adapting to a new reality, a world in which it is normal to use FaceTime to connect families when a patient begins to deteriorate and when he has to decide how long he can afford to spend at the bedside. a patient before continuing.

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“If this continues, we will start practicing war medicine,” said the Tulane employee.

A spokesperson for HCA Healthcare, who runs the Tulane Medical Center, said that the hospital system has been examining each cardiac arrest in the past few weeks and “in no case was the care interrupted because the staff had to go move to another patient. ” The HCA spokesperson said the Tulane hospital “had no way of rationing the care we provide.”

“No one disputes that care will likely be different if the community demands higher hospital capacity,” said spokesperson Sarah Balyeat. “But that is not yet the case in our community, and to paint it as such is irresponsible. “

Ochsner’s nursing manager Tracey Moffatt said the hospital system always sends rapid response teams to respond when a patient is coding, and denied that those teams were cut to save staff and supplies .

A spokesman for East Jefferson declined to comment on the story.

But hospital staff from all New Orleans and Baton Rouge systems who spoke to The Times-Picayune and The Advocate say they are already rationing their time and care and expect much more difficult ethical decisions to come as conditions deteriorate. Employees who spoke to reporters did so provided their names were not published because most hospitals have policies prohibiting employees from speaking to the media about their experiences, even during this pandemic. The newspaper has taken steps to verify their identity.

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Hospitals also made certain employees available to the newspaper upon request, and these employees were able to use their names.

Front-line workers who spoke to the newspaper said that the differences for patients begin before a patient lands in the emergency room with respiratory symptoms. Many saw their temperature taken at the entrance to the hospital. And if they are potential coronavirus patients, like most of these days, hospitals generally separate them in a practice known as a “cohort”, to prevent the virus from spreading too widely.

Before the coronavirus, doctors made multiple visits to emergency patients, said Dr. Greg Fernandez, director of emergency at Saint Bernard Hospital. But not more.

“The goal of patient satisfaction and care was multiple visits,” said Fernandez. “We would tell them about the laboratories, the x-ray results, the CT results. Whereas with these people, this is not the current norm. We have to be more careful about time and contacts. “

The coronavirus wreaks havoc in the lungs of many patients, which can lead to organ failure.

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Patients going through emergency rooms are admitted to a coronavirus unit, where they are often given oxygen and medication in the hope that they will be able to return their oxygen levels to normal. Many patients with coronavirus end up in intensive care.

Tulane employee says patients have cardiac arrest so often they are afraid of running out of ‘code carts’, which house drugs and equipment to help save someone’s life in a crash . But that hasn’t happened yet.

In the age of the coronavirus, nurses often face FaceTime so that patients can communicate with loved ones who far prefer to be at their bedside. And one nurse said that all the personal protective equipment they wear makes them less familiar to patients.

“If someone is there, they have trouble breathing,” said a Tulane Medical Center nurse who works with coronavirus patients. “They are afraid, they have nothing to do. They are worried, they are afraid and they see these aliens coming in blue. ”

Ethical choices weigh heavily on health workers

Nurses are saying more than ever that they are multitasking. A nurse from East Jefferson says nurses working with coronavirus patients have lost the auxiliary support of other staff who would normally help provide care: physiotherapists, occupational therapists, environmental services.

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When she enters a patient room, she says, she usually tries to balance the transportation of a tray, ice, medicine, linens, washcloths and everything in it.

This nurse lamented her inability to develop personal relationships with her patients because there is too much work to do. And she said she was uncomfortable with the instructions given to her about how to talk to patients about their options, saying that staff were asked to keep sicker patients away from the respirators.

“What they said was, ‘If you don’t think they’re going to succeed, we would appreciate it if you encouraged them to go in the right direction,'” said the nurse about how supervisors advised them to discuss life. conservation measures.

Hospital health workers received a message from a supervisor this week – shared with the newspaper – referring to the need to clarify “do not resuscitate” orders, saying, “We have some patients who should not resuscitate and others in advance clearly instructed not to intubate. The post went on to explain how an older patient’s request for intubation should have been clarified before the patient needed more oxygen.

A hospital worker interpreted the message to mean that the supervisors – rather than the patients themselves – wanted to have more control over the patients who had to sign MNR prescriptions.

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“I feel pressured to push patients with a worse prognosis to become a” do not resuscitate “code,” said a doctor at East Jefferson, who pointed out that at this point the hospital always did everything he could. to revive the patients who coded.

Other hospital workers have expressed concern that concerns over MNR prescriptions will drive hospitals away from desperately ill people. A UMC nurse noted that the hospital still allows families to decide whether or not to sign a DNR, and said that caregivers are not pressuring patients to do so.

Nurses and doctors have realized that when COVID-19 patients deteriorate, they usually do so quickly. Several staff have said that they are trying to sneak into a last video chat with relatives when they know a patient is using a ventilator.

“We say, you’re on four liters of oxygen, we’re going to have to intubate you soon, do you want to talk to your family?” Said a nurse from Notre-Dame du Lac, who works with coronavirus patients. “We want these people to be able to see their family members for the last time.”

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An Ochsner nurse said that when a patient deteriorates rapidly from a coronavirus – but not from cardiac arrest – a nurse will enter the room alone, while other caregivers will cry out back and forth, separated by a door. Normally, the whole team entered the room, but due to shortages of masks and dresses, they had to limit the number of people dressed to enter, said the nurse.

“I scream vital signs out the door for them,” said the nurse. “They yell things at me through the door. “

Moffatt of Ochsner pointed out that there is a difference between how nurses react when a patient’s condition changes, and how they react when a patient has a cardiac arrest. Moffatt said that when a patient at Ochsner codes, a full team rushes to help him, although an Ochsner doctor contradicted him and said the team had been reduced to basics. Moffatt said that when a patient’s condition just changes, sometimes only one staff member takes care of it.

By the time patients arrive at the intensive care unit, they need more care and nursing attention, than hospitals strive to provide.

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Olivia Breeland, a Tulane intensive care nurse, said that Tulane uses travel nurses to help maintain a ratio of two patients per intensive care nurse. But she said they may have to use “team nursing” if the hospital experiences a large number of patients, in which case the intensive care nurses, nurse anesthetists and medical and surgical nurses would team up to manage a greater load of patients.

Notre-Dame du Lac said she maintains a similar ratio, but one nurse said that limiting patient visits means that staff are not able to do everything they did for patients, such as wipe dry mouth.

“This is very basic nursing care, which may not be” medically necessary “, so to speak,” said the nurse. “But this is what is necessary for you to feel like a human. “

Nicole Telhiard, chief nurse of Notre-Dame-du-Lac, said the hospital continues to focus on oral care.

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Nurses from several hospitals said they were doing everything they could to help their patients. The nurse from Notre-Dame du Lac makes sure they have fresh sheets and often prays for them because they are too sick to do it themselves. An intensive care nurse from Ochsner said that she and her colleagues also try to style and hold patients’ hair.

On track to run out of resources

As staff numbers, ventilators and protective equipment decrease, assessing the risk of exposing staff to coronavirus during chest compressions in a coronavirus patient may be one of the first difficult but necessary ethical decisions that must be made. providers could be confronted. Edwards has repeatedly warned that the New Orleans area is on the verge of running out of ventilators on Tuesday and hospital beds by April 12.

Hospital administrators in New Orleans and Baton Rouge have said they will count on the governor to adopt “crisis of care” standards, which outline how hospitals should sort in the event of a disaster, in case they are missed. fans and beds. But they stressed that they had not yet reached this point.

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“We did not end up in this situation where we had to ration the fans,” said Moffat d’Ochsner.

Health care workers across the country face similar ethical dilemmas. As the New York Times reported this week, city doctors are pushing for more advice on triage plans and legal immunity for all decisions they need to make about rationing ventilators.

Dr. David Doukas, bioethicist at Tulane University, has spent his career studying such difficult questions. He said hospitals generally have frameworks in place to make almost impossible choices.

Hospitals will consider everyone a candidate for valuable resources like ventilators, but can rely on a calculation that takes into account their relative health to serve the patients who need it most and are most likely to recover.

“Each place will do it differently based on its own perception of what is right,” said Doukas. “If identical patients are before you, how can you be fair?” This is where they use criteria such as first come, first served or lotteries. ”

ST. JOSEPH – After all the churches were closed, almost everyone in this declining agricultural town in the Delta took the pandemic to heart.

Hospital staff say they were shocked by the large number of younger patients struggling to fight coronavirus – patients in their thirties in the ICU, patients in their forties and fifties dying while not have never been hospitalized before. They can go from “reasonably well” to unable to breathe within 15 minutes, said nurse from East Jefferson.

Seeing it happen day after day is unlike anything many veteran nurses say they have seen or experienced before.

“The second we take one out, either to the morgue or the descent unit, we get one,” said Ochsner’s intensive care nurse. “You are just a little standing, feeling defeated. “He was my patient from last week. He was better. What happened?’ “

They don’t have time to dwell on it. More patients continue to come.

Editors Blake Paterson and Matt Sledge contributed to this report.

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