‘We Knew We’d Be Unprepared’: An ER Doctor’s Reflection on COVID-19 & America’s Healthcare System

April 10, 2020

By Leigh Vinocur, MD, FACEP
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As an ER doctor practicing for the last 25 years, I know all about emergency preparedness and being ready for the worst-case scenarios. A pandemic, like COVID-19, hitting the U.S. has been one of doctors’ greatest fears for years: we knew one would eventually come and we knew we'd be unprepared. For at least 10 to 15 years, the American College of Emergency Physicians has been going to the federal government asking for help and support to secure our public health and emergency medical system to handle surge. We are the nation’s healthcare safety net and, as seen with COVID-19, not having enough resources can put many lives at risk.

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Unfortunately, this country has taken our emergency departments for granted, believing that emergency services will always be there for us when we need them. And I am afraid in a sense, we are victims of our professions’ success. My emergency medical colleagues, physicians, nurses, techs, and respiratory therapists have been holding down the fort for years. We have managed to stay afloat through natural disasters, mass casualties from gun violence, and every year during our regular busy flu seasons. We tirelessly work 24/7 in overcrowded ERs with patients sometimes lining hallways, waiting for beds in the hospitals or transfers to psychiatric facilities. We have done such a good job mending the holes in this safety net and continuing to carry on, that the public assumes our system is secure. But it is not.

We started this pandemic behind the eight ball. Over a decade ago, before the Affordable Care Act, the RAND Corporation estimated that about one-quarter of hospitals and their ERs were closed due to uncompensated care. And we already know that our rural communities have been, and continue to be, at risk lacking ICU beds and skilled medical professionals to provide care.

For as long as I can remember in practice, we have had an issue with healthcare provider shortages for both nurses and doctors. Prior studies predicted a shortfall of 200,000 nursing professionals this year. Additionally, the Association of American Medical Colleges published data in April 2019 predicting a physician shortage of 122,000 doctors by 2030. That is why states have been asking their retired nurses and doctors to help during the pandemic, as well as graduating new nurses and doctors early. This deficit is critical now more than ever; these shortages could potentially be exacerbated by COVID-19 as our frontline healthcare workers are now starting to fall ill.

Added to all of this is the shortage of personal protective equipment (PPE) needed to protect our healthcare workers. These shortages started before we saw any COVID-19 cases in the U.S. and they were due to supply chain disruptions when China shut down in the beginning of the year due to COVID-19. In general, all of this equipment, including the raw materials used to make this equipment, are outsourced to countries like China. The importance of having and accessing large secure national stockpiles of personal protective equipment (PPE) and ventilators is critical to saving lives and crucial for protecting our public health system — both our patients and our healthcare providers. We need to outsource less and be able to control our own supply chains.

Because testing is so limited now in the U.S., we are probably using more PPE than we might really need. Since we have no idea about the prevalence in the general public, we must assume all patients coming in are at high risk and we must protect ourselves using these precious resources of PPE which might not be necessary if we really knew the status of each patient. Many people have speculated why a powerful country like the U.S. is falling flat on testing availability in comparison to places like South Korea. The reason is South Korea learned lessons from their prior SARS epidemic and knew they would need to be prepared for next time with more effective testing strategies. For COVID-19, South Korea quickly ramped up testing for hundreds of thousands of people, which allowed them to expediently identify and isolate infected people and then do immediate contact tracing to help stem the spread of the infection and save their resources. And just this week Korea has now reported a higher number of recovering patients than newly diagnosed patients.

My emergency medical colleagues are doing what we always do in times of crisis: putting our heads down and getting to work to take care of our communities. We are used to death and dying, but the scale we are seeing now is not something any of us have ever seen in our local hospitals. Every day, I see acts of heroism, as my emergency medicine colleagues put their own lives on the line by going to work without question and without always having all the equipment that is needed. We are desperately trying to hold our emergency medical system together, but I know we are all worried and frightened.

The global pandemic of COVID-19 is the perfect storm we have worried about for so long and now our healthcare safety net is at risk. We can’t afford to be complacent anymore. We have to make our emergency medical and public health system a priority. We need to make sure our ERs can handle surge with extra hospital beds and staff to make sure we do not board patients in the emergency department overnight. We need to have a strong central government national stockpile of medications, vaccines, PPE, and ventilators as back up, because states and local communities can’t do this alone. We need to control our own supply chain in the U.S. for all these items. We need to discuss how to ramp up testing in the event of another incident. This is the biggest wake-up call I have seen in my 25 years of practice.

After we get through this — and we will get through this — the next step is to make sure our emergency medical system is built up again and protected with the resources, supplies, and protocol we need. These actions will help us get ready for the next pandemic, because there will always be another — the key difference is that next time we should ensure we are prepared.

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Article written by Leigh Vinocur, MD, FACEP
Board-certified Emergency Physician, spokesperson for the American College of Emergency Physicians (ACEP)