Emergency docs: ‘For us it’s a war’
Yale doctor: Every patient could carry coronavirus
NEW HAVEN — Yale New Haven Hospital’s Emergency Medicine Department has become a war zone.
A mother returned from maternity leave and is isolating herself from her newborn. The staff goes through an entire shift without eating or drinking, so as not to contaminate their N95 respirator masks.
Every patient who enters is presumed to be infected with the coronavirus, and everything doctors, nurses, technicians and aides do is based first on keeping themselves and their patients safe.
Dr. Sharon Chekijian has worked in Yale New Haven’s Emergency
Department since she started her four years of residency in 2003, after graduating from the Yale School of Medicine. She said she has never experienced anything close to life with the coronavirus, which is “complicating all our ways of doing things.”
“All of our attention is focused on this. For us it’s a war,” Chekijian said. “We try and prepare and eat enough so we don’t have to interrupt work. … All of our attention is focused on not getting sick ourselves, taking care of our families and patients.”
When they’re at work and not caring for patients, the emergency staff read up on the coronavirus, “the latest findings, the latest drug trials,” Chekijian said. They talk about the latest medical news in a WhatsApp chat. When they’re not at work, people ask them about the pandemic.
“It’s like a 24-hour radio station in our heads,” she said.
Work has become a continual battle to stay protected while caring for patients, any one of whom could be carrying the virus.
“You have to do all of this evaluation now cloaked with all this … protective equipment. It’s also hard to connect with the patient because we look intimidating,” she said.
“Everything takes more energy to do. Just from the minute you’re going into a room, everything has to be completely disinfected,” Chekijian said.
“It’s actually harder to think” with all of the extra precautions, she said. “It’s very extensive. … You can’t adjust the mask once you put it on. It’s tedious but it’s really the way to do it if you want to be safe.”
Showers, living apart
Keeping the virus at bay doesn’t stop when a shift ends. “All of us are showering right away and throwing our clothes in the washing machine,” Chekijian said. “A lot of people are actually taking their clothes off at the front door. I’m not doing that.”
Chekijian did not want to describe her living situation but said others’ are complicated by having children, or parents caring for the children. Some have had to stop having parents care for their children, leaving them without childcare.
“This woman has actually completely separated herself in the house from a newborn baby, and she came back from maternity leave the first day this started,” Chekijian said.
Another has a 93-yearold father who he plans to visit by talking through an open window. “This isn’t for a week or two weeks. This is going to be for the next several months,” she said.
Some have moved into separate apartments or the hospital has put them up in hotel rooms. “We’re very concerned because health care workers in all countries where this has happened have been very affected,” she said.
In order to ensure a tight-fitting mask, “many people have shaved their beards,” Chekijian said. “Some of our residents I had never seen without beards and they’re all clean-shaven right now.” One had worn a beard since he was 14, she said.
Chekijian asked others in the Emergency Department to share what they’ve been doing to stay safe. All wanted to remain anonymous, but they revealed the extent many are going to in order to avoid spreading the coronavirus to their families.
One wrote: “After my shift, I leave ‘shift shoes’ in the attending office; go to the men’s room in the YNHH atrium, change clothes, and bag my scrubs; text teenage daughter that I’m coming home, so she knows to stay in her bedroom when I arrive; go home, strip naked in garage, bag new change of clothes, wrap self in towel, throw out trash bags on driver’s seat, go upstairs to guest bedroom and shower, bring garage bath towel and shower towel down to laundry and launder with previous 2 changes of clothing; eat food from the minifridge I moved into my study; sleep in the guest BR; confine myself to the guest BR, the study, and the basement, where I can work out.”
Another wrote: “All groceries sit in the basement for 72 hours or get washed immediately with strong soap and water or 95% alcohol. My kids know to stand outside and hand wash each apple and orange (“happy birthday, dear orange!”) before the fruit comes into the house. Then THEY get washed with strong soap and water. Anything that can't wait 72 hours and/or can't be washed with soap gets sprayed with 95% alcohol until soaked and then allowed to dry.”
Phone calls to patients
In the Emergency Department, in order to preserve masks and gloves and to keep at a safe distance, doctors are avoiding going into patients’ rooms. “We’re calling people from right outside the room,” talking to patients through the window, whenever possible, Chekijian said. “The patients seem to actually like it. It gives you a little bit of time where you can actually explain things” without being completely masked.
Communicating by phone is “kind of fun,” Chekijian said. “It’s good because it was hard to make any connection … to the level that I would like to.”
Ultrasounds and CT scans have been cut way back, because every piece of equipment must be disinfected before and after each use. The X-ray technicians are “definite heroes,” Chekijian said. “It’s one test after the other, lugging heavy equipment around.”
The number of people coming to the Emergency Department has declined since the start of the pandemic, when “everybody was told they could be tested before they could be,” she said.
While coronavirus patients are on the increase, other cases the emergency doctors normally would see have dropped in numbers, people with heart attacks and strokes. “We’re really, truly not seeing our patients. Everybody’s saying, ‘Where are these people?’ Chekijian said.
“I think they’re giving it a lot of thought before they come in … As a result, we’re seeing much sicker people when they do arrive.”
Also, the number of trauma patients — car crash and bike accident victims, assault victims — is “way down” because fewer people are on the streets. “People are trying to be very careful,” Chekijian said, reasoning that if they have an accident, “I’m taking the ambulance away from people who really need it.”
Everyone who does arrive is treated as if they are positive for coronavirus. “We really don’t know as we’re seeing them,” Chekijian said. “We’re seeing a lot of suspected COVID cases.” Most are considered “persons under investigation. We by and large actually don’t know who’s confirmed” because, once they’re tested, they leave the Emergency Department.
Unless they show severe symptoms, such as lacking oxygen, patients are not admitted to the hospital. “They’re placed in selfisolation. We don’t admit people just because we think they have COVID,”
Chekijian said.
The exception is homeless people and those who live in long-term care facilities, because they have a higher likelihood of infecting others. City officials are working on a plan to house homeless people who test positive for the coronavirus in Hill Regional Career High School, but it has met with opposition. Chekijian said a COVID-positive nursing home is being considered.
Personal protective equipment
Putting on and taking off the personal protective equipment or, as medical professionals say, donning and doffing PPE, are tedious and slow. “You have to take your face shield off without touching it,” Chekijian said. “It’s a long process and all the time you’re being asked questions” by other doctors who may be starting their shifts.
Of all the equipment worn in the Emergency Department, the face shield is most important when a patient has to be intubated. “It’s the highest-risk procedure that we do because the patient’s secretions can be aerosolized into the room,” Chekijian said. After each intubation, all protective gear must be changed and the face shield must be disinfected.
The number of intubations has “been increasing every day. Right now, on a given shift, three to four times,” she said. “Every one of those is very high risk.”
Soon, CAPR helmets, which include air-purifying respirators and face coverings, will be used for intubations, Chekijian said.
While the Emergency Department staff are considered “radioactive” — a nurse wearing scrubs was asked to leave a car dealership — “the one really nice thing that we’ve had happen … is that different restaurants have sent us food,” Chekijian said. They have included P&M Deli, Eli’s, Modern Pizza, Frank Pepe Pizza Napoletana and Miso Japanese restaurant.
As for morale, “I think it’s OK right now,” she said. “We have a young, energetic group. Our big concern right now is making sure everybody stays healthy.”
Many on the staff have personal interests in emergency medicine, such as wilderness medicine or research. Chekijian has an interest in traffic safety and in global health, and has worked on projects in her family’s native Armenia. She’s consulted for the World Bank and the U.S. State Department and is working on a film about human rights relating to the 1915 Armenian genocide.
Chekijian at first planned to become a surgeon, “then I decided that emergency medicine was all of the fun and none of the really boring stuff.”
She said she’s never regretted it. Even now.