UB’s front line physicians face exhausting, rapidly changing work conditions posed by COVID-19

BUFFALO, N.Y. – Brian Monaco, MD, recalls vividly the day he saw his first known COVID-19 patient. “It was March 15,” he recalled. “I’m sure because that was the last time I came in contact with my parents,” he said.

When the patient’s test came back positive, Monaco, an assistant professor of emergency medicine in the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, who works in the emergency departments at Buffalo General Medical Center, Gates Vascular Institute and Erie County Medical Center, knew that his life was going to be vastly different for the foreseeable future.

The novel coronavirus has caused massive upheaval in everyone’s lives. Aside from patients and their families, those whose lives have been most altered are those on the front lines – the health care workers whose jobs require them to face the virus head on.

More than 500 faculty physicians and more than 700 medical residents from the Jacobs School provide care to patients in UB’s affiliated teaching hospitals throughout Western New York, according to Michael E. Cain, MD, vice president for health sciences at UB and dean of the Jacobs School.

Many of these doctors and residents, particularly those in the emergency departments and intensive care units, are treating COVID-19 patients. They work anywhere from 20 to 80 hours a week, enduring working conditions none have ever before experienced. Most UB faculty physicians are also balancing the role of professor, providing instruction and oversight to medical students and residents.

Their expertise and around-the-clock patient care, in such large numbers, is one of the benefits of having a medical school in a community, according to Cain.

“I know I speak for our entire community in expressing deep gratitude to our dedicated health care workers, and our UB faculty physicians and medical residents who are providing care to our community’s most vulnerable members during this pandemic,” Cain said.

The global pandemic has posed a wide variety of challenges – both expected and unexpected – for health care workers on the front lines. Following the experiences of colleagues downstate and in Europe via social media prepared the doctors for some, but not all, eventualities.

“To begin with, there was a concern that we were not going to have enough personal protective equipment,” said David Janicke, MD, PhD, clinical associate professor of emergency medicine in the Jacobs School and medical director of the Emergency Department at Buffalo General/Gates Vascular Institute. “But the hospital had really geared up, so we didn’t experience that,” he said.

“We knew that workers were going to get ill and wouldn’t be able to work, so we were worried about losing staff who would have to be quarantined and therefore not being able to optimally take care of our patients,” added Janicke, who is affiliated with UBMD Emergency Medicine.

But UB’s faculty physicians and medical residents have pressed on.

“The attitude was, ‘this is what I do.’ Our chairman, Dr. Robert McCormack, really had our backs, too, both at the site and at the seven other UBMD Emergency Medicine emergency departments in Western New York,” Janicke said. McCormack is a clinical professor at the Jacobs School and Chief of Service of Emergency Medicine for the Kaleida Health system.

Some doctors were concerned about what an outbreak here would mean for family and friends.

“This virus is hurting people in ways I had never seen before, and it is hurting people I did not expect to see it in,” Monaco said, noting he has sent patients from their 20s to their 90s to the ICU.

Several doctors noted that triage has changed drastically due to COVID-19, and the guidelines are continually changing.

“There is so much that we do not know about the SARS-CoV-2 virus … which makes caring for these patients very challenging,” said Karin Provost, DO, PhD, associate professor in the Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, at the Jacobs School. She is also co-director of the Intensive Care Unit at the VA Western New York Healthcare System and a physician with UBMD Internal Medicine.

“This has been a time of rapid, daily growth in our knowledge, as our colleagues who have had earlier contact continue to report their experiences,” she said. “There is a firehose of information that is coming forward.”

One example of the rapidity of change involved dealing with severely low oxygen levels in COVID-19 patients, Provost said.

When the pandemic first hit in Italy and the United States, doctors quickly intubated many patients at the first sign of worsening blood oxygen levels. But within weeks, it became clear that intubating so rapidly was not having the same positive impact in patients with COVID-19as it did in more traditional presentations of respiratory failures.

Therefore, doctors are now using other methods to “maintain a patient’s oxygen levels before resorting to intubation,” she said. “This is in response to information coming out of both New York City and Italy in real time.”

Patients’ conditions also change quickly.

“With this disease, you see someone come in and they’re sick, but not that sick,” said Janicke. “And then suddenly they were dying. It was really surprising. These were not just people who were in their 90s or who had comorbidities. Some were patients with few health issues; otherwise healthy people in their 40s and 50s.”

Provost said she initially was apprehensive about being able to anticipate a patient’s sudden decline in a way that would allow her and her staff to safely put on all the needed PPE and intervene in time.

“Every patient has their own clinical trajectory,” she said. “They still rapidly and abruptly decompensate after variable periods of stability, and it remains an every- patient, everyday fear that one inadvertent movement will lead to accidental contamination that results in potential infection of myself, my staff or my family.”

Another Jacobs School professor who has been on the front lines is David Holmes, MD, clinical associate professor of Family Medicine, director of Global Health Education and a physician with UBMD Family Medicine.

Holmes normally spends spring break on mission trips. This year, he volunteered to care for COVID-19 patients at Woodhull Hospital in downtown Brooklyn, the epicenter of the crisis. At the peak of the crisis in New York City, the number of deaths at the hospital jumped from 15 patients each month to 40 patients each day.

The doctors said that one of the hardest parts about treating COVID-19 is the no-visitor policy.

“Patients are so isolated not having visitors. It is hard to know they were dying without family. We don’t feel good about that,” Janicke said.

The stress caused by the coronavirus has been unlike anything doctors have seen before. “In the ER we are used to that sort of dramatic up and down,” said Janicke. “This was different. The staff knew that any one of the patients coming through the door could have the virus.”

“Maintaining the morale and health of the staff is a considerable challenge,” said Manoj J. Mammen, MD, an associate professor in the Division of Pulmonary, Critical Care and Sleep Medicine of the Department of Medicine at the Jacobs School and a physician with UBMD Internal Medicine.

“Understanding what the best way to treat a patient with COVID-19 is another significant challenge, given the rapidly changing evidence.”

“ICU team members are highly qualified and dedicated to taking care of the most extremes of illness, and compartmentalizing the stress,” Provost said.

“This is a very different experience. All health care providers on the team are being put under stress levels we have not before experienced, in a situation where we are caring for a disease that we have never seen before, with never before observed clinical manifestations every day, it seems.”

She said that the nature of treating COVID-19 patients is a 24/7 proposition, and it affects health care workers’ ability to connect and engage with their families and to decompress.

“Many outlets for stress relief are no longer available, including gathering with friends, physical workouts, having a massage, and so on,” she said.

So, like the rest of us, Provost and her colleagues try to maximize their time with their families and going on Zoom for virtual get-togethers and happy hours with friends.

“My family, friends, colleagues and even my outpatients are sending me text messages, Facebook messages or words of support, which have been extremely meaningful, as we combat both the disease itself, and the misinformation and denial spreading through non-medical, non-peer-reviewed sources across the country,” she said.

Added Holmes: “The needs are so great, and I feel that anything I do is just a drop in the bucket. But we all have a part to play. If everyone is putting their drop in the bucket, then soon it will be full.”