On Thursday afternoon, Dr. David Brown stood in the emergency department at Massachusetts General Hospital and took in a troubling indicator. One after another, sedated patients in the glass-doored bays were hooked to ventilators to help them breathe, thick tubing disappearing into their throats.
Doctors here normally intubate one or two, maybe three, patients a day, before sending them to an intensive care unit.
“We’ve done 10 so far today and it’s only 4 o’clock,” said Brown, chief of emergency medicine. “These patients can’t wait until they get to the floor.”
A senior resident dressed in a light blue gown, Dr. DaMarcus Baymon, raced by, and Brown asked how he was doing.
“Busy, very busy,” Baymon said, the steady rhythm of beeping monitors nearly drowning him out. Asked about the intubations, Baymon said, “We’ve never done this many, back to back like this.”
Here at the state’s largest hospital, staff are coping with unprecedented realities in this coronavirus pandemic — and deeply worried about what is yet to come. There is an odd juxtaposition inside this normally bustling world-renowned hospital: Expanded intensive care units are packed with COVID-19 patients, while other floors and places such as family waiting rooms are deserted, quiet.
The staff here are suspended in a limbo of anxious waiting. As before, they rush about, updating patient records, checking monitors, and tracking available beds. But all at a higher level of intensity.
And even with much of their energy focused on the patients before them, it’s this uncertainty that nags at Brown and other medical staff: not knowing exactly how many more very sick patients will arrive at the door.
“The question remains, what will the actual need be?” Brown said.
Mass. General allowed a Boston Globe reporter into the hospital for one day, to witness firsthand how doctors, nurses, and other staff are coping with this crisis. Everyone yearns for signs the sacrifices that they — and everyone else, too — are making are paying off, that the transmission of the virus is finally ebbing; that there will be enough beds, ventilators, doctors and nurses, and medications for the COVID-19 patients.
Yet they know there is only one plan of action: Prepare as if this will be Italy, New York — a worse-case scenario in which critically ill patients threaten to outnumber available beds and ventilators. Some epidemiologists say peak hospitalizations in Massachusetts could be as soon as one week away.
By mid-afternoon Thursday, Mass. General had 154 patients with confirmed COVID-19 — plus others being tested for the virus and those still in the emergency department. Among confirmed cases, 40 percent in intensive care; 84 patients on ventilators.
In the emergency department, two views of this surreal pandemic are evident: One section that handles more routine non-virus cases was quieter than usual — perhaps the “stay-at-home” edicts mean fewer car accidents and virtually no sports injuries. Along one wall were dozens of empty blue wheelchairs.
But inside the emergency area for acute patients, the numbers have ominously climbed. Several dozen doctors and nurses in masks and face shields adjusted ventilator settings, ordered medications on computers, and called specialists for advice. All 17 rooms were full and at least one patient lay on a bed in a corridor.
It was one of the worst days so far, as patients arrived one after another by ambulance or by car, struggling to breathe and deteriorating fast. Those on ventilators were awaiting beds in one of 10 intensive care units, four of which were opened in the last several weeks.
Brown is proud that no emergency room nurses or doctors have been infected on the job with the coronavirus yet. But he is still frightened for them.
As he talked, a physician sped by, giving Brown a thumbs up about a young male patient, one of the few not on a ventilator. Doctors were using a new procedure to try to improve his breathing and raise the oxygen level in his blood — so he doesn’t end up needing a ventilator. “His saturation went up by 2,” the doctor said, clearly pleased by the improvement.
“For the moment, thank goodness we have the ICU capacity for these patients,” Brown said. “The doomsday scenarios you’re facing in New York and Italy is when you run out of ICU beds, despite every effort to expand your capacity. Then you have to make decisions about who you’re going to intubate and who you’re not. These are horrible decisions for care providers to make.”
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There is relative stillness — and regimented safety procedures — that dominate other parts of the hospital. Visitors are not allowed in the hospital now and most appointments have been canceled or moved online. Elective surgeries were canceled to create more space for COVID-19 patients.
Rows of chairs are gone from Mass. General’s main lobby in the White Building. Several security officers on Thursday stood sentry inside the automatic doors, feet apart, hands behind their backs.
Essential employees flashed identification, and held up their phones with an app that showed them "cleared for work,'' indicating they had signed a document promising they do not have symptoms of COVID-19 that day.
Hospital workers were greeted by one colleague dispensing hand sanitizer, another doling out surgical masks. They were then allowed into the building, where a tiny silver lining of these times awaits: no twisting line 25-people deep at Coffee Central, which serves caffeinated drinks, smoothies, and muffins 24 hours a day. Several blue-masked cafeteria workers were ready to take orders.
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Averting large-scale tragedies requires meticulous planning, and much of that happens inside the hospital’s trustees conference room. There, the incident command team that manages the pandemic meets twice a day. When they arrived before 7 a.m., cafeteria workers had already arranged coffee, granola bars, and bananas and oranges, individually wrapped in plastic. Five people hunched over laptops 6 feet apart at a long polished wooden table, as 100 of the hospital’s top managers logged into the Zoom meeting broadcast on a wall-size screen.
Mass. General President Dr. Peter Slavin joined remotely and began with rare good news: the Kraft family deployed a New England Patriots team plane to China to pick up about 1 million desperately needed N95 respirator masks. "Alleluia,'' said Ann Prestipino, a senior vice president and incident commander.
In normal times, Jonathan Kraft can be found at this table as chair of the Mass. General board. “Any worry we’ve had about the availability of N95 masks to protect our staff is behind us,” Slavin said.
That same day, news also broke that the hospital had played a role in bringing about the arrival of a mammoth new machine that can safely sterilize about 80,000 N95 masks a day and will benefit numerous hospitals in the state.
Still, Dr. Paul Biddinger, chief of emergency preparedness, issued a small caution: “I don’t want anyone to assume they are growing on trees. They are not growing on trees.”
Another reality check came in the form of updated numbers from the hospital’s intensive care units: Four patients were hooked up to ECMO machines, specialized devices for the most dire cases that pump blood outside a patient’s body, infusing it with oxygen, so the heart and lungs can rest. Even at Mass. General, four patients on ECMO machines at the same time is nearly unheard of.
“ECMO is one of our most aggressive last-ditch therapies,” Biddinger said. “This reflects how much serious illness there is. Seeing this amount of critical illness is really hard. Knowing it’s going to get worse is really sobering.”
The command team was planning to spend Friday scouting out several new locations to accommodate the mounting number of patients. Theresa Gallivan, an associate chief nurse, told the group the hospital will need 120 more ICU nurses — a herculean task in the limited time. She had a plan, though: pair regular floor RNs with ICU nurses to stretch their expertise.
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In a packed seventh-floor intensive care unit called Blake 7, 15 of the 18 patients were sick with COVID-19 and on ventilators. And in a scene rarely witnessed in pre-coronavirus times, most were on their stomachs, not their backs.
Medical staff have rolled patients with acute respiratory distress syndrome onto their stomachs for years; the difference now is there are so many. Coronavirus patients also remain on the breathing machines for far longer than normal, sometimes for several weeks. Doctors said a prone position removes pressure from the heart and allows the lungs to expand more fully.
But Dr. Charles Hardin and other Mass. General physicians are taking this idea further. Just 48 hours before, they rolled out a protocol to put patients on the regular floors on their stomachs before they require ventilators — just like the young man in the emergency room whose oxygen level improved.
Though based on anecdotal reports of success at a few other medical centers, the fervent hope is this intervention will mean fewer patients will ultimately need ventilators.
Doctors “in Italy told us they did it,” Hardin said. “But no one has written it up yet” in a scientific journal.
The intensive care staff hopes this strategy will be crucial in the days ahead as they frantically work — and wait — for what is yet to come.
Liz Kowalczyk can be reached at firstname.lastname@example.org.