As I write this, it’s summer in Canada and we are thankfully sliding down the curve of the first wave of the pandemic, even in parts of the country that have had our most stubborn outbreaks. Yet it’s clear from international experiences that the virus is still here, it is still as contagious and as virulent as it was a few months ago, and it will rapidly punish any excessive resumption of normalcy with a flare that can easily ignite a second wave without a rapid response. Still, as Canadians enjoy our brief and precious summer, it seems like a good time to take a deep breath and consider what we have learned so far and how to best prepare for an uncertain but risky future. In this post my mentee, friend, and colleague Dr. Lucas Chartier starts that process.
—Dr. Howard Ovens, June 2020
Opportunities exist to maintain positive changes and keep improving to prepare for coming challenges in the COVID-19 era
The 1918 Spanish influenza pandemic infected approximately one-third and may have killed as much as 5% of the world’s population over the course of three or four successive waves.1 While we haven’t fully closed the books on the first wave of the COVID-19 pandemic in Canada, let’s make sure we don’t wait any longer before reflecting on and learning from what we’ve been through so we can prevent a toll as big as the one a century ago.
Here are some thoughts to make sure our emergency medicine community and system/policy leaders start addressing the right issues right away, especially on the topics of communication and care, mental health and leadership, and infectiousness and humanity.
Communication and care in the COVID-19 era
Maintaining effective and reliable communication has been challenging during this pandemic because there is a paucity of evidence on most issues, there is a lack of transparency coming from various levels of authority on the rationale for their decisions, and leaders have been reluctant or unable to convey uncertainty to the public appropriately. Adding to this is the fact that the Twittersphere has been ahead of the news cycle (and often spreading misinformation), let alone official messaging from said authorities.2 This has led to significant anxiety, fear, and frustration among front-line workers, who have felt unprotected, disconnected from safety decisions, and unprepared to care for patients in their own environments.
Thankfully, our emergency medicine community has benefited from a strong network of communication and collaboration that predated the pandemic and that helped us stay organized, connected, and consistent. In Canada, for example, this has included the national specialty society (the Canadian Association of Emergency Physicians) releasing numerous public statements and organizing action-oriented webinars, as well as regional collaboratives of practice being forged over time or newer approaches being used, such as simulation.3,4,5 The next step is to ensure that more isolated locales and groups are part of the discussion, and to recognize that we all own a part of the responsibility to reach out to peers to support all members of our community equally and improve care for all patients.6
One of the few silver linings of the pandemic has been the astronomical gains made in virtual care, which helps patients and providers obtain expertise not previously available to them. As we push forward on this journey in the ED, let’s ensure that we do so in patient-centered ways rather than in medicine’s historically provider-convenient approach.
This means, for example, ensuring that we broaden the accessibility of care and prioritize it for those who may have challenges coming to the ED (e.g., due to caring for children or as a result of disability) rather than simply making it more convenient for those who already have many other options. It also means ensuring that we offer options beyond the traditional weekday hours (despite it creating even more work for ED teams during socially disadvantaged hours) so that patients don’t bear the burden of deciding for themselves whether their epigastric pain is from reflux or an acute coronary syndrome.
And it means, perhaps most importantly, that the gains made by or for some patients should not come at the expense of others who are not as psychosocially or financially fortunate or as technologically connected and savvy. Some leading organizations have already started to work on these solutions, such as the Children’s Hospital of Eastern Ontario, so let’s follow their lead and keep improving.7
Mental health and leadership in the COVID-19 era
The relatively high morale we have seen in colleagues through this unprecedented world crisis, the high level of collaboration between disciplines and professions given health care’s historical silos, and communities’ support (e.g., the banging of pots and pans at 7:00 p.m. and in-kind donations to “front-line heroes”) have all been refreshing to witness. They have helped members of the medical community reaffirm our sense of purpose and it has reassured us that the risks we take daily are not going unnoticed.
Unfortunately, we also know that many health care providers have suffered, are suffering, and will suffer mental health consequences as a result of this pandemic.8 Leaders have a role (no, a responsibility) to foster an environment in which they support their teams while making it acceptable for members to voice cries for help.9 A recent British Psychological Society (BPS) report beautifully delineated some of the ways in which leaders can do this for their teams.10 Our teams are our most precious resource; we must ensure we keep them healthy and well so they can keep going on this challenging journey. The BPS report included these helpful strategies:
- Ensure we have visible and authentic leadership with a transparent communication strategy11
- Ensure there is consistent access to physical safety needs (e.g., personal protective equipment [PPE], breaks) and human connection such as peer support (e.g., buddy system)
- Normalize psychological responses (i.e., we are all human; you are not alone)12
- Deliver formal psychological care in stepped ways (e.g., information, support, first aid, intervention)
Infectiousness and humanity in the COVID-19 era
It unfortunately seems as if it takes pandemics (e.g., SARS in 2003 and COVID-19) for our health care system to recognize the importance of infection prevention and control practices and the need for adequate PPE stockpiles.
Compounding this year’s version of infectious diseases mayhem will be the overlap of the COVID-19 pandemic with … drum roll… the flu season! Yes, it’s coming back again! I hope our recent experiences will significantly improve health care workers’ and population immunization rates.
Additionally, one can hope that health care workers’ historical habit of going to work while mildly ill to show how “tough” they are or because they feel bad for those who would need to work instead (thereby exposing patients and colleagues alike to their own illness) will finally stop for good. This may require more than education and role-modelling, however, such as a re-engineering of incentives (financial and otherwise). For example, a “five days on, nine days off” model13 may allow the 14-day incubation period (median 5.1 days) to take its natural course while increasing the likelihood that providers are already off (and not contributing to the virus spread) when they become symptomatic.
Finally, and perhaps most importantly, let’s find a way forward to maintain safe care while not allowing physical PPE barriers to affect the human connection we have with patients (and among colleagues). I have personally found it extremely challenging to develop therapeutic relationships with patients while hidden behind layers of cloth and plastic, and to interact with colleagues while trying to maintain physical distancing. COVID-19 is quite challenging for patients in the ED: They are vulnerable, scared, and in pain, surrounded only by strangers in garb and unable to be comforted by their loved ones at the bedside.
While I am not sure yet where we will land on the spectrum of protection versus humanity, let’s engineer solutions together. They may include the use of larger face shields but without masking to allow for the easier reading of facial cues while allowing protection and safe physical proximity, or the use of virtual care options that at times may paradoxically allow for more compassionate interactions (especially if a three-way video can be organized with a patient’s caregiver who is off-site).
The sprint must now become a marathon
The pace at which the health care system has evolved in 2020 has been staggering. What system improvements we sustainably hold on to may be the most important factor in determining our community’s future success. We may need to rest and recover from this period of intense change for our own sanity, but let’s make sure we also build on this momentum to fix other glaring issues in our system. The sprint must now become a marathon so we don’t run out of acceptance of change, of creativity to tackle new issues, and of money to operationalize solutions!
COVID-19 is the greatest challenge our healthcare system has faced in a century. Let’s make sure we learn fast, and learn the right things, to get ready for the next challenge.
—Dr. Lucas Chartier is a physician and Deputy Medical Director in the emergency department of the University Health Network (UHN) in Toronto, Ontario, as well as UHN’s Medical Director of Quality and Safety. He is the Lead for emergency medicine for the Toronto Central Local Health Integration Network (LHIN).
Thank you to my esteemed and insightful colleagues Drs. Howard Ovens (as always and especially!), Amit Shaw, Gary Mann, David Ng, and Gary Bota for having indirectly nudged me to write this piece through their thoughts and leadership during this pandemic, and to the many dozens of interprofessional leaders and front-line heroes with whom I have the pleasure of working.
- Centers for Disease Control and Prevention. 1918 Pandemic (H1N1 virus) web page. https://www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1.html. Accessed June 28, 2020.
- Rosenberg H, Syed S, Rezaie S. The Twitter pandemic: The critical role of Twitter in the dissemination of medical information and misinformation during the COVID-19 pandemic. CJEM. 2020:1-4. DOI:10.1017/cem.2020.361
- Canadian Association of Emergency Physicians. COVID-19 web page. https://caep.ca/covid-19/. Accessed June 28, 2020.
- Chaplin T, McColl T, Petrosoniak A, Hall AK. “Building the plane as you fly”: Simulation during the COVID-19 pandemic. CJEM. 2020:1-3. DOI:10.1017/cem.2020.398
- Hanel E, Bilic M, Hassall K, Hastings M, Jazuli F, Ha M, et al. Virtual application of in situ simulation during a pandemic. CJEM. 2020: 1-4. DOI:10.1017/cem.2020.375
- Johnston A, Booth K, Christenson J, Fu D, Lee S, Mawji Y, et al. Building and strengthening relationships between academic departments/divisions of emergency medicine and rural and regional emergency departments. CJEM. 2019;21(5):595-599. DOI:10.1017/cem.2019.359
- Children’s Hospital of Eastern Ontario. Emergency Department virtual care web page. https://www.cheo.on.ca/en/visiting-cheo/emergency-department-virtual-care.aspx
- Watkins A, Rothfeld M, Rashbaum WK, Rosenthal BM. Top E.R. doctor who treated virus patients dies by suicide. New York Times. April 27, 2020. Available from: https://www.nytimes.com/2020/04/27/nyregion/new-york-city-doctor-suicide-coronavirus.html. Accessed June 28, 2020.
- Wong AH, Pacella-LaBarbara ML, Ray JM, Ranney ML, Chang BP. Healing the healer: protecting emergency health care workers’ mental health during COVID-19 [published online ahead of print May 3, 2020]. Ann Emerg Med. https://www.annemergmed.com/article/S0196-0644(20)30336-X/fulltext.
- British Psychological Society Covid19 Staff Wellbeing Group. The psychological needs of healthcare staff as a result of the Coronavirus pandemic. Leicester, England: British Psychological Society; 2020. Available from: https://www.bps.org.uk/sites/www.bps.org.uk/files/News/News%20-%20Files/Psychological%20needs%20of%20healthcare%20staff.pdf. Accessed June 28, 2020.
- Lang E, Ovens H, Schull MJ, Rosenberg H, Snider C. Authentic emergency department leadership during a pandemic [commentary]. CMEJ. 2020;1-4. DOI:10.1017/cem.2020.360
- Bakewell F, Pauls MA, Migneault D. Ethical considerations of the duty to care and physician safety in the COVID-19 pandemic [commentary]. CJEM. 2020:1-4. DOI:10.1017/cem.2020.376
- Lauer SA, Grantz KH, Bi Q, et al. The Incubation Period of Coronavirus Disease 2019 (COVID-19) From Publicly Reported Confirmed Cases: Estimation and Application. Ann Intern Med. 2020;172(9):577-582.