‘We’re waiting for the other shoe to drop’: Dr. Ali Raja, emergency medicine physician at Mass. General, braces for surge

Dr. Ali Raja, an emergency medicine doctor at Massachusetts General Hospital, says what he's seeing at MGH is "unlike anything I’ll probably ever experience in my entire career."Erin Clark/Globe Staff

Dr. Ali Raja, 42, is the executive vice chair at Massachusetts General Hospital’s department of emergency medicine and an associate professor at Harvard Medical School. This is his account of his April 2 shift in the emergency department, as told to Globe reporter Deanna Pan.

The very first patient I saw had an oxygen saturation level of 60 percent, which is exceptionally low. Normal oxygen saturation is 95 percent or above. Anything in the 80 percent range is concerning. Sixty percent means you’re about to die.

Mass. General physician bracing for a COVID-19 surge

Dr. Ali Raja and his team have plans for coping with a tsunami of COVID-19 patients at New England's largest hospital, but nothing is certain. (Video produced by Caitlin Healy/Globe staff)

He looked OK. But as soon as we put the pulse oximeter probe on him — that’s the device we use to measure oxygen levels in the blood — we knew we had to intubate him immediately. This was before 8 a.m. And it didn’t stop from there. By five hours, we had intubated five patients. By six hours, we had intubated six. By the end of my eight-hour shift, we had intubated 10 patients in the acute area of the emergency department, and I’m leaving now at 4:45 p.m. as they continue to see sick patients.

Before the outbreak, we would intubate two, maybe three patients on any given day, so this is insane.

What we’re seeing now are patients who came to our walk-in clinic or another hospital, who tested positive for COVID-19, and then were discharged and sent home because they looked great. Then they’ll come in and say, “Hey, I actually tested positive for COVID two days ago and now I can’t breathe.” They won’t actually say it, they’ll gasp it. We’re also seeing more patients who we presume have COVID-19 because they were exposed to the disease or they decompensated to the point where they can no longer get enough oxygen on their own. They were feeling fine yesterday and now they can barely breathe at all.

Some patients are tachypneic, meaning they’re breathing very fast. I saw a patient today who was breathing 40, almost 50 times a minute. Usually, we take a breath every four to five seconds, so that’s 12 to 15 breaths a minute. But this person had to breathe that quickly because if they didn’t, they wouldn’t stay alive. I also saw patients who just looked exhausted. There were some patients who we were shouting at, trying to wake up, but we couldn’t arouse them at all.

Now here’s our saving grace: We still have beds in the intensive care unit. What I’m worried about is what hospitals in New York are seeing. One of my friends at Elmhurst Hospital Center in Queens just tweeted that they’ve got 30-some patients in their emergency department on ventilators, waiting for beds in the ICU. The emergency department is only meant to be a holding area, and if we hold patients any longer than five or six hours, patients still coming to the emergency department won’t have a place to go and they’ll end up waiting. That’s usually OK, but these days, a lot of our patients are really sick, so they can’t wait. We need to get these patients in the emergency department and upstairs to the ICU, so we can keep taking more patients into the front door.

I think over the next two to three weeks we’re going to see a surge. All of the models point to mid-April and that’s when we expect to see the most patients with COVID-19 around the state and in Boston. That’s also when we expect to see the most patient deaths, unfortunately. It’s like we’re waiting for the other shoe to drop. We don’t know how bad this is going to be. Is it going to be a massive surge that overwhelms us? Or is it going to be something we can manage? We just don’t know and that’s what makes this so different.

This is the most unique situation I’ve ever experienced in medicine and unlike anything I’ll probably ever experience in my entire career. I worked the Boston Marathon bombing. I’ve treated abused children, gunshot wounds, and heart attacks. But those are temporary events. I don’t take them home with me.

My family’s worried. My wife is sick. She probably has the coronavirus. She’s a nursing professor at Regis College, so the only way she could have gotten it is from me. I don’t have it; I feel fine. I probably exposed her two or three weeks ago before I did everything I do now after a shift: I throw all of my clothes in the garage washing machine. I go straight to our guest shower. I get totally clean before anyone gets near me.

I feel pretty guilty about it. She’s in bed all the day and she feels miserable. A lot of my colleagues have moved out of their homes. One of my colleagues has moved into a completely separate apartment and hasn’t seen his wife in a week. I’ve got coworkers who are uprooting their spouses and kids to their in-laws’. So this is really taking a personal toll on people. And there’s no chance for our staff to decompress. It’s going to happen again tomorrow and the next day and the next day and maybe the entire month of April. Normally after a shift as crazy as this, I would take our residents across the street to one of the bars by MGH and we would all have a beer together, but we can’t do that anymore.