The Van Trump Report

How Healthcare is Changing… Worth the Quick Read

This was sent my direction yesterday and certainly makes  you stop and think about how many dominoes in the healthcare space are tied to the virus…  It was penned by Joshua Budhu one of the chief neurology residents at both Massachusetts General Hospital and Brigham and Women’s Hospital at Harvard Medical School.

MRI images pop up on my computer screen. They are scans from my first patient of the day, a 21-year-old college student named Jessica. She came into the emergency department for persistent numbness and tingling of her left arm. Her brain and spine are speckled with white spots, most old but a couple new — a textbook case of multiple sclerosis.

As I begin to call the emergency room physician to give Jessica high-dose steroids and admit her to the neurology service, I pause. COVID-19 has dramatically changed medical practice and patient care in the past couple of weeks. Doctors must now adapt to a new normal of delaying needed care to mitigate the risk of exposure to COVID-19.

As the senior neurology resident responsible for consults throughout the hospital, I have seen firsthand the effect that COVID-19 has on our patients. I initially thought it was solely a respiratory illness. I was wrong. It is a disease that has upended our entire model of care. Elective surgeries have been canceled, entire clinics are closed, and any nonessential services are now shuttered.

We are seeing an influx of new COVID-19 patients daily. Jessica, besides her newly diagnosed multiple sclerosis, is healthy. Should I prescribe her steroids that dampen her immune system when she could potentially be exposed to COVID-19 in the hospital? Decisions that were obvious only a few weeks ago are no longer so simple.

Before I can talk to Jessica, I get paged to see my next patient. A 63-year-old man named Allen is brought into the emergency room after falling off a ladder. As part of his trauma survey, we find a 3-centimeter mass that we suspect is a brain tumor. As I prepare to admit him for surgery to remove the mass, I again pause. COVID-19 has restricted us to performing only emergency surgeries.

I contact the neurosurgeon to review Allen’s case. She confirms that his mass is not large enough to be considered an emergency. I send Allen home with instructions to call us back for an outpatient surgery appointment. I also send him home with the fear that this mass will continue to grow until we can intervene.

My beeper goes off again and I meet Matthew, a young man with epilepsy. He comes in after experiencing a breakthrough seizure, a term used to describe a seizure that occurs after an extended seizure-free period. It’s unclear what triggered the seizure and I am ready to admit him to the hospital. However, Matthew’s mother arrives and is adamant that he not be admitted to the hospital.

Under normal circumstances, I would explain why it is important to conduct a thorough workup and hopefully convince Matthew and his mother that admission is the prudent decision. But in these unprecedented times, I honestly can’t tell them it is safer here in the hospital and respect their decision to leave. 

I circle back to Jessica and tell her the diagnosis of multiple sclerosis. She is overwhelmed and scared. Three weeks ago, I would have sent her upstairs to our neurology ward and have my colleagues counsel and treat her. But this isn’t three weeks ago. I give her a choice and she opts to go home. This is not the ideal treatment for my patient but it is the right decision at this time.

I make my way to the workroom and return a call about Bryan, a patient I recently diagnosed with ALS. His family had reached out because they think he has a urinary tract infection. After years of training, it is second nature to ask him to come in for basic lab tests to confirm. Instead, I prescribe him antibiotics because I do not want him anywhere close to our emergency room. ALS has weakened Brian’s breathing muscles. If he were to become sick with COVID-19, there is a good chance he would not recover. 

It’s remarkable that I am now a different physician than I was just several weeks ago. I am now practicing medical distancing ― delaying treatment where possible to mitigate the risk of exposure to a more deadly and imminent threat. Instead of doing the most good, I am trying to avoid doing the most harm.

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