Hospitalists Are Natural Leaders in the COVID Battle

Larry Beresford

October 28, 2020

Christopher Pribula, MD, a hospitalist at Sanford Broadway Medical Center in Fargo, North Dakota, didn't anticipate becoming his hospital's resident expert on COVID. Having just returned from vacation in March, he agreed to cover for a colleague on what would become the special care unit. "When our hospital medicine group decided that it would be the COVID unit, I just ran with it," he said. Pribula spent the next 18 days doing 8- to 14-hour shifts and learning as much as he could as the hospital — and the nation — wrestled with the pandemic.

Christopher Pribula, MD

"Because I was the first hospitalist, along with our infectious disease specialist, Dr Avish Nagpal, to really engage with the virus, people came to me with their questions," Pribula said. Working to establish protocols for the care of COVID patients involved a lot of planning, from nursing protocols to discharge planning.

Pribula was part of the hospital's incident command structure, thought about how the system could scale up for a potential surge, and worked with the North Dakota Medical Association to reach out to outlying medical centers on safety and infection control. He even drew on his prior work experience as a medical technologist doing negative-pressure containment in a cell-processing facility to help create the hospital's negative-pressure unit in an old ICU.

"We did a lot of communication from the start. To a certain extent we were making it up as we went along, but we sat down and huddled as a team every day at 9 and 4," he explained. "We started out with observation and retrospective research, and learned piece by piece. But that's how science works."

Hospitalists across the country have played leading roles in their hospitals' and health systems' response to the pandemic, and not just because they are on the front lines providing patient care. Their job as doctors who work full-time in the hospital makes them natural leaders in improving clinical quality and hospital administrative protocols as well as studying the latest information and educating their colleagues. Responding to the pandemic has required lots of planning, careful attention to schedules and assignments and staff stress, and working with other departments in the hospital and groups in the community, including public health authorities.

Where Is Hospital Treatment for COVID at Today?

As knowledge has grown, Pribula said, COVID treatment in the hospital has come to incorporate remdesivir, a broad-spectrum antiviral; dexamethasone, a common steroid medication; and convalescent plasma, blood products from people who have recovered from the illness. "We went from no steroids to giving steroids. We went from putting patients on ventilators to avoid acute respiratory distress syndrome (ARDS) initially to now working to avoid intubation at all costs," he said.

"What we found is that we need to pressure-support these patients. We do proning and CPAP while we let the lungs heal. By the time they arrive at the hospital, more often than not they're on the backside of the viral load. But now we're dealing with the body's inflammatory response."

Navneet Attri, MD

Navneet Attri, MD, a hospitalist at Sutter Santa Rosa Regional Hospital in Santa Rosa, California, 50 miles north of San Francisco, experienced fears and uncertainties working at a hospital that treated early COVID patients from the Grand Princess cruise ship. Early on, she wrote a post describing her experience for The Hospitalist Leader, the Society of Hospital Medicine's blog page.

Attri said she has gone through the gamut of emotions while caring for COVID patients, addressing their fears and trying to support family members who aren't allowed to enter the hospital to be at their loved one's side. Sometimes, patient after patient with COVID becomes almost too much. But seeing a lot of them in the intervening 6 months has increased her confidence level.

Understanding of how the disease is spread has continued to evolve, with a recent return to focusing on airborne transmission, she said. Frontline workers need N95 masks and eye shields, even if all of that PPE feels like a burden. Attri said she hardly notices the PPE anymore. "Putting it on is just a habit."

Navneet Attri, MD, hardly notices the PPE anymore.

She sits on Sonoma County's COVID surge planning group, which has representatives from the three local hospitals, the public health department, and other community agencies. "I report back to my hospitalist group about the situation in the community. Because our facilities were well prepared, our hospitals have not been overwhelmed," she said.

The Importance of Teamwork

Sunil Shah, MD, a hospitalist with Northwell Health's Southside Hospital in Bay Shore, New York, is part of the massive hospital medicine team, including reassigned specialists and volunteers from across the country, deployed at Northwell hospitals in Greater New York City and Long Island during the COVID surge. Northwell probably has cared for more COVID patients than any other health system in the country, and at the height of the surge the intensity of hospital care was like nothing he's ever seen. But he also expressed gratitude that doctors from other parts of the country were willing to come and help out.

Sunil Shah, MD

Southside Hospital went almost overnight from a 200-bed acute facility to a full, 350-bed, regional COVID-only hospital. "On busy days, our entire hospital was like a floating ICU," he said. "You'd hear 'rapid response' or 'code blue' over the intercom every few seconds. Normally we'd have a designated rapid response person for the day, but with COVID, everybody stepped in to help — whoever was closest," he said.

Majid Sheikh, MD, a hospitalist at Emory University Hospital in Atlanta, Georgia, also became a go-to COVID expert for his group. "I didn't specifically volunteer, but my partner and I had the first cases, and the leadership group was happy to have us there," he explained.

Majid Sheikh, MD

"One interesting thing I learned was the concept of the 'happy' hypoxemic patient, who is having a significant drop in oxygen saturation without developing any obvious signs of respiratory distress," he said. "We'd be checking the accuracy of the reading and trying to figure out if it was real." Emory was also one of the leaders in studying anticoagulant treatments for COVID patients.

"Six months later I would say we're definitely getting better outcomes on the floor, and our COVID patients aren't landing in the ICU as easily," Sheikh said. "It was scary at first, and doubly scary when doctors sometimes don't feel they can say, 'Hey, I'm scared too,' or 'By the way, I really don't know what I'm doing.' So, we'd be trying to reassure the patients when the information was coming to us in fragments."

But he also believes that the pandemic has afforded hospitalists the opportunity to be the clinical detectives they were trained to be, sifting through clues. "I had to think more and really pay attention clinically in a much different way. You could say it was exciting and scary at the same time," he said.

A Human Fix in the Hospital

Pribula agreed that the pandemic has been both a difficult experience and a rewarding one. "I think of the people I first admitted. If they had shown up even a month later, would they still be with us?" He believes that his group and his field are going to get to a place where they have solid treatment plans for how to provide optimal care and how to protect providers from exposure.

Christopher Pribula, MD, garbed in PPE

One of the first COVID patients in Fargo had dementia and was very distressed. "She had no idea why nobody was visiting or why we wouldn't let her out of her room," Pribula said. "Instead of reaching for sedatives, one of our nurses went into the room and talked with her, prayed a rosary, and played two hands of cards with her and didn't have to sedate her. That's what people need when they're alone and scared. It wasn't a medical fix but a human fix."

Larry Beresford is a freelance medical journalist in Oakland, California, with a particular interest in hospice, palliative care, and end-of-life care. He also contributes to the MDedge publication The Hospitalist.

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