“Between stimulus and response there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.”
—Viktor E. Frankl
The first news reports of a cluster of severe pneumonia cases in Wuhan, China, back in January sent a shiver down my spine. It sounded too much like the first warning signs of the SARS outbreak in 2003. At that time I was the ED director at Mount Sinai Hospital in Toronto, Canada, which became actively involved in the response to the local cluster of SARS cases. Before it was over Toronto had 247 cases and 44 deaths, including three health care workers. Sinai’s ED assessed and admitted more than 20 confirmed cases with no transmission in our department. It took over my life 24/7 for about four months¾so much so that I remember wondering how I had kept busy before SARS.
Now we are back in a similar situation, although this time it’s not a few cities around the world that are affected, it’s a global problem. This virus is different, and the world is not the same as it was in 2003; but my experiences with the SARS crisis and with COVID-19 have inspired some personal reflections I’d like to share.
This is not SARS
While these are both coronaviruses that appear to have jumped from an animal reservoir to humans in the specific incubator of Asian “wet markets,” and the acute respiratory distress syndromes appear similar, there are crucial differences that influence our responses as ED leaders.
First, this virus is far more contagious than SARS. We can no longer dream of containing it and eliminating it; we are engaged in mitigation.
Second, it is more contagious during mild illness and perhaps during the prodrome phase. Therefore, COVID-19 is much more a community-acquired disease, whereas SARS was effectively a hospital-based illness because people were maximally contagious during advanced illness. This time, health care workers are at risk not just at work but outside the hospital, as well.
Third, COVID-19 is not as deadly as SARS¾but it is much more deadly than seasonal influenza and poses a public health crisis when the mortality rate of 1 per cent to 4 per cent is multiplied by the huge number of people potentially affected.
Fourth, because we cannot eliminate it, we need strategies that are sustainable for a longer period, lasting many months if not a year or two, during which we may have several waves of outbreaks.
Fear = 1/Risk
We are all scared. It’s normal; not only are we scared of illness in ourselves and/or our loved ones, but there are also the spectres of economic uncertainty and political/cultural upheaval to consider. But do we let the fear paralyze us and interfere with our work performance? Or do we use it to motivate ourselves?
One of my lessons from SARS was that fear is inversely proportional to risk. That is, in my experience, the staff on the front line¾in EDs and ICUs¾ generally closed ranks and soldiered on while staff at much lower risk in the hospital, other facilities, and community often issued more work refusals, demands for excessive (non-evidence based) protections, etc., during the crisis. While these fears were likely driven by limited experience with infection control, they can be a distraction or worse if they are not addressed. To me, the experience of front-line workers suggests that for all of us, despite our fears, we can be mobilized to take constructive action through a combination of receiving good information and being given or finding a job to do that is important and creates a sense of mission.
Still, fears and risk need to be addressed in the ED. I’ve devised a two-pronged strategy: Ground your behaviour in facts and embrace your mission.
Assess the facts
We know this virus is of greater risk to older individuals and those with co-morbidities such as diabetes, chronic heart disease, and lung disease. How do we address that reality without appearing to sacrifice our younger and healthier staff to high-risk duties? I think the answer can be found in an evidence-based risk analysis.
We are all energetically encouraged to do our part to “flatten the curve.” This is based on evidence that has shown that the mortality rate is lower where hospital capacities are not overwhelmed, and standards of care are maintained. It also delays infections and deaths and buys us time to improve treatments, develop a vaccine, and perhaps benefit from a serendipitous viral mutation or some other life-saving factor. However, even developing a vaccine is not a certainty, and should one be successful, it will still take time to test, manufacture, and distribute it for broad vaccination efforts.
Realistically, we are most likely going to have to develop a decent amount of herd immunity to truly move beyond this pandemic. That implies for most of us, it’s not so much a question of whether we encounter this virus, but when. Ideally, those at highest risk encounter it later rather than sooner, with the hope that a vaccine or other intervention becomes available by then. If we don’t all do our best to delay our exposure, the curve will not be flattened, and it will result in many preventable deaths. But taking a longer view of the pandemic’s course may at least provide some context about our risks now and over time.
What is most effective in keeping us safe?
It’s tempting to try to gain a feeling of control to conquer our fears. Some people scour the Internet for case reports or rumours of new treatments, or they stockpile important goods they don’t really need. But in doing this we risk discounting the importance of consistent adherence to familiar, proven measures. So, I think it is worth saying yet again that these are the best ways to stay safe, both at work and in the community:
- If you don’t feel well, stay home! At home, isolate from your family.
- If you care for possibly contagious patients, use droplet-/contact-level precautions, but use them properly every time. Doff carefully, follow a checklist, and have a buddy watch you doff if you are out of practice, stressed, or tired.
- Follow hand hygiene protocols consistently.
- Avoid aerosol-generating medical procedures unless they are life-saving and well planned (intubation, primarily).
- Follow public health guidelines on physical distancing in the ED, at home, and when you must go out.
We face many potential unintended consequences if we succumb to tempting actions based on limited or false evidence. For example, if we use N95 respirators casually, they may not be available when we truly need them. If you are tempted to use a powered air-purifying respirator, realize they are complex to doff and if you are not using them regularly (as you would in a COVID-19 ICU) the risk of contaminating yourself is high.
Many of our colleagues are understandably worried about keeping their families safe, but the benefits of separation must be weighed against the ongoing risks to all of us from community contacts. We also need to consider the sustainability of such strategies if they must be followed for an extended period of up to a year or more. It is hard enough to maintain the crucial and evidence-based changes in our lives; I fear extra steps may eventually lead to frustration or exhaustion and a drop in compliance overall. (See resource 2b for a more detailed discussion of this issue.)
Take pride in your mission
During SARS I was proud of my colleagues and our hospital. We came together to take care of ourselves, our patients, and our community. There was a tremendous esprit de corps. We took pride in our mission and in the way we conducted ourselves. All of us who worked in an ED, or in fact anywhere in a hospital caring for SARS patients, were seen as leaders. Although some people avoided us in case we were carrying the virus, many turned to us for information or inspiration, and to check our pulses; if we were able to be calm and carry on, surely they could, too!
When I think of the above facts with respect to COVID-19, my own philosophy is firm. I want to stay up to date with curated expert guidance to ensure I keep myself as safe as I can and give the best advice. I want to use that information to protect as many people as possible. I can’t hide from this pandemic (truly no one can, as it is in the community), and since I have the knowledge, skills, and experience to help, I feel honoured to contribute.
I’m at a stage in life where I’ve had my share of challenges and scars. When faced with a crisis – what I call “a character-defining moment” – I’ve developed an approach. First, I ask myself how I will want to feel when I look back on this period in a few years. Will I look back with pride that I did my best? Or with regret that I could’ve done more? And when I feel overwhelmed, I try to simplify the problem by focusing on the immediate future and determining what I need to do now.
COVID-19 is a character-defining moment for us as individuals, EDs, and communities, and even as a country and a species. How will you look back on this period?
In mid-March I stepped back from clinical work for a few weeks to join the Ontario provincial response to COVID-19. But before that I was in the ED assessing patients under investigation, including symptomatic travelers returning from COVID-19 hot spots, and I hope to return to that work as soon as circumstances allow or require.
- For concise and excellent evidence-based reviews of key questions related to COVID-19, see https://www.thennt.com/review-covid-analysis-april-2020
- The Canadian Association of Emergency Physicians (CAEP) has developed some excellent resources and position statements, including:
- COVID-19 and the Older Emergency Physician:https://caep.ca/wp-content/uploads/2020/04/COVID-and-the-Older-Physician-FINAL-Formattedv2.pdf
- Reducing Disease Transmission to the Emergency Physician’s Family: https://caep.ca/wp-content/uploads/2020/03/Reducing-disease-transmission-to-the-emergency-physician-hjo-clean-v-march-29PP.pdf
- Two articles on leadership:
- Lang, E, Ovens H, Schull MJ, Snider C. Authentic Emergency Department Leadership During a Pandemic [published online ahead of print April 6, 2020]. CJEM. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/EEBEF10E86C4CDC7B13B689C7AFBAB33/S1481803520003607a.pdf/authentic_emergency_department_leadership_during_a_pandemic.pdf
- Koehn N. Real Leaders are Forged in Crisis. Harv Bus Rev. Published April 3, 2020. https://hbr.org/2020/04/real-leaders-are-forged-in-crisis?ab=hero-subleft-2