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What Have We Learned?

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Virus
Virus photo by Andrii Vodolazhskyi/shutterstock.com and Portraits by Aaron Mayes

Doctors, specialists, and medical students share the sometimes difficult lessons they’ve learned in the age of COVID-19

Whether they’re toiling on the front lines or helping from the sidelines, healthcare workers are navigating a strange new world in the pandemic age. We’ve all read stories about doctors and nurses working to exhaustion as COVID-19 strains our healthcare system. But there are other
stories that, while less daunting and dramatic, tease out some nuanced lessons about public health and community welfare. We asked five people, from doctors to technical specialists to medical students, to express in their own words what they’ve learned during their work amid the pandemic. Answers have been edited for length and clarity.

Gigi Guizado De Nathan

Standardized Patient Coordinator in the Clinical Simulation Center of Las Vegas

What Gigi Guizado de Nathan has learned from the pandemic comes from her unique background. For some 20 years (10 in Las Vegas), she’s educated standardized patients. What’s that? Imagine a scenario in which a medical or nursing school student is being trained or tested through a simulated interaction with a patient — kind of like role-playing. Who plays the sick person? An actor, called a standardized patient. Guizado de Nathan got her formal education in acting and has continued to act alongside her day job overseeing the local SP program. In addition, she’s bilingual, having been raised speaking Spanish.

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LAS VEGAS NEEDS MULTILINGUAL MEDICAL EDUCATION

The process started with all our events getting canceled one by one, because the learners could not congregate, for their own health. The university shut everything down. The Simulation Center was among the first invited to reopen, because healthcare education was considered essential. We need to be graduating as many healthcare workers as we can. That process must not be slowed down.

We went back to the drawing board and started to reimagine how we deliver a modality so based on human interaction, physical touch, being in the room with someone, and giving them feedback on the nuances. We needed a simulation about COVID-19. People had thought of that and written it, but it was intended for use with an avatar, AI, or mannequin. The thing that struck me about it was, I can look at this and reimagine it with a live human being, but also, what occurred to me, because of my perspective as a bilingual, bicultural person was, it was all geared toward native English speakers. In Las Vegas, we have a large percent of our population for whom English is not the primary language. And also, we invite people from around the world — our economy is based on tourism — who don’t speak English as their first language. When the pandemic hits and you have a multilingual population and a virus that doesn’t discriminate, how will healthcare professionals help them? So, I wrote a simulation to address that.

NECESSITY IS THE MOTHER OF INVENTION

Visually, it’s not unlike what we’re looking at right now — Skype or Zoom. The scenario is, a patient who is ill, a Las Vegas resident whose first language is not English, calls the UNLV School of Medicine COVID-19 call center, because they’re sick. Assuming they have a medical interpreter, they have another person (a physician) come into the meeting and then the conversation continues with the interpreter. It becomes a three-way call. I train the bilingual standardized patient so the medical student can see how to engage that person effectively and have the skills they need to help that patient.

I’ve been pleasantly surprised and reminded of how much we can accomplish if we set our minds to it. And, I’ve been pleasantly surprised by how well we’re doing in this online environment. It’s out of hardship, but I do believe that, moving forward, when maybe all this online work isn’t required anymore, we might retain some of it because we found that it was useful.

THERE IS EAGERNESS TO HELP UNDERSERVED POPULATIONS

I have a collection of moments that stuck with me. In general, I was moved by how moved other people were by the recognition that we’re all human and we don’t all speak the same language and if we don’t do this work, there will be undue suffering.

I did not limit it to Spanish. That’s my go-to, because that’s my skill set, but being well aware Las Vegas has multiple communities that speak a variety of languages, I reached out to my colleagues in the simulation center and we were able to translate it to Tagalog (a Filipino dialect).

At a staff meeting I asked, “Is there anyone among us that could help?” and people immediately volunteered their family members. I couldn’t even offer them a guarantee they’d get paid. (I asked the director of finance if they could, and she said yes, eventually.) But even under those circumstances — outside their comfort zone and they may not get paid — they jumped on board without a second thought and were proud to do so. It touched their heart, and they couldn’t have been happier to be there. Heidi Kyser

Dr. Derek Meeks

Medical Director, Emergency Department, Boulder City Hospital

Dr. Derek MeeksDr. Derek Meeks is a 23-year resident of Southern Nevada. He serves as a trustee on the Clark County Medical Society board and is vice dean of Touro University Nevada College of Osteopathic Medicine. He is a medical provider for Envision Emergency Medicine Physicians group, which oversees roughly half of the ERs in the valley.

BE PREPARED EARLY AND OFTEN

We learned that we need to be more self-reliant and much better prepared for similar pandemics. We were not ready for this pandemic. There were so many shortages, which put us and the patients at risk at times. We were so short on PPEs (personal protective equipment).

People did inventories in their hospitals, and they started making decisions right then about how we are going to utilize the limited number of PPEs, realizing that the whole country is going to be demanding whatever’s left from the companies that make these. So many of the PPEs and other things were built in other countries that were also facing similar problems, so they didn’t really want to sell them to us. That led to a huge shortage. If you didn’t have a great stockpile, you were at risk.

People didn’t know how to use them: Do you change it after every patient? Do you change it once a shift? What do you do? What do you need? Do you need masks, eye protection, caps, foot protection? This stuff was all unclear, and there definitely was too few of these as well as ventilators.

EDUCATE NON-COVID-19 PATIENTS ON THE BIG PICTURE

Patients actually stopped coming to the ER out of fear of catching the disease. At times they even stopped coming when they had an actual really serious condition, like a stroke or a heart attack, which was probably worse than if they would have caught COVID.

I had a patient who came in a couple days late for a stroke. I had patients who came in a couple days late for a heart attack. They normally would have come in, but they were so scared of COVID. The longer you wait, the more irreversible damage is going to occur. It broke our hearts to see people wait for something that they didn’t even really need to be concerned about. Because your likelihood of catching the coronavirus in the ER is so remote since we’re all using masks — the patients and the doctors — and we’re social distancing. It was just heartbreaking to see stuff like that.

The result of these patients not coming to ER resulted in shifts being cut for staff, nurses, and physicians. The hospital’s losing a lot of revenue, and it happened also with doctors’ offices. The last stats I saw is that they’re seeing about 50 percent less than their normal patient loads. So they’re having to cut staff and questioning if their practices will survive. So my fear is that if this continues and practices close, our medical shortage could reach really disastrous levels.

What I’ve been hearing is that doctors who were closer to retiring are saying, “This is now my time to retire,” whereas they may not have retired for another three to five years. I have one in our practice who hasn’t gone to work. He’s a bit older, but still a great doctor and able to practice. And he hasn’t come to work at our place or in other places Downtown because of the coronavirus.

FORTIFY YOURSELF FOR ISOLATION

It’s been really lonely. When you’re exposed to a patient as a physician or a health provider, and you know that patient has the coronavirus, you then have to decide how will you interact or distance to keep your family safe. What do you do when you go home? What I would do is I’d shower and bring an extra pair of clothes and change my shoes before I left work. And then I’d come home and I’d isolate myself. I secluded myself on one side of the house, my spouse on the other.

When my kids came with their families, I couldn’t see them. My daughter had been out of the country with her family for a few months. When they returned, her kids (ages 3 and 5) started to run up to me to hug me because that’s what they’re used to doing. Their parents had to grab them and stop them. That was extremely heartbreaking because they didn’t understand. For two weeks I couldn’t see them.

You’re in there seeing patients. It’s stressful because you worry about everything you touch, everything you breathe in. You’re worried about how you’re taking care of these patients, where we don’t have a clear-cut pathway. So you’re stressed, and then you come home and you’re alone. It’s hard. Paul Szydelko

 

Cassandra McDiarmid

Medical student at Touro University

Cassandra McDiarmidAs is the case with all of us, the pandemic happened while Cassandra McDiarmid was making other plans. She was in her second year of medical school at Touro University, pursuing a focus on OB/GYN, when the outbreak hit and shutdown began, disrupting her medical education. But the pandemic didn’t disrupt her will to help. With fellow Touro students Parisun Shoga and Ashlie Bloom, McDiarmid launched #MedReady (tun.touro.edu/medready), a website that organizes volunteers to offer free K-12 tutoring; medical undergrad and Medical College Admission Test tutoring; and community help such as senior grocery pickup and COVID-19 screening assistance. The site also includes a news and research section, “Getting It Right,” which features weekly capsule summaries of the latest research on the novel coronavirus and COVID-19.

HELP HOWEVER YOU CAN

It’s interesting, because if (the pandemic) happened two years from now, I would be out there right now, I’d be in my first year of residency, I’d be in the hospitals working and taking care of people. But we were just finishing up our second year of medical school, and so, unfortunately, we had not yet had any clinical experiences. So we weren’t really able to go into the hospitals and help out in that sense. So we had to come up with other ways to help, like provide volunteer opportunities. Actually, a lot of my classmates — and a lot of the class below mine who were just finishing their first year — reached out to ask what they could do. Could we put them in touch to help volunteer and help out the community? Obviously, we are future physicians going into healthcare, and part of that is you want to take care of people, you want to give back, you want to help out in any way that you can.

RESPOND TO NEEDS THAT HIT HOME

Part of the reason we offer K-12 tutoring is because my boyfriend’s parents and sister are teachers, and a lot of our classmates are married to teachers. We saw what was happening in education at the time when all the schools were shutting down, and they were trying to figure out how to do distance learning. Just knowing that there are parents out there who aren’t able to help their kids out with schoolwork at home — maybe it’s a subject that they don’t understand — and then hearing from the teachers about how they want to be able to help every student, but it’s hard because you can’t give that individualized time to 30-40 students all at once during the week. It’s just too difficult. We wanted to provide help with that.

THERE’S NO SUCH THING AS TOO MUCH INFORMATION

Another part of our website that we have is an information corner. We have a Twitter account, and our students are going through articles and they’re doing research, they’re checking their facts, they’re making sure that everything is accurate before they share it. But just finding another place to put accurate information like that — you can never have too much. Not everyone knows how to look through the research, how to do fact-checking. Scientific papers can be dense. That’s why we wanted to have our students go through and put that information into a common vernacular so that everyone can understand.

Part of the problem is a lack of trust among people. And it’s true, the information that came out in the beginning is not the same as the information that is factually accurate that’s coming out today. People think, “Oh, well, they said this six weeks ago, and today, that’s not the case anymore.” But that’s what science is. A lot more research is being done on the virus, and that’s why the information is changing. For some people, it’s kind of hard to understand that, yes, what they told us six weeks ago was accurate six weeks ago, but as we’re continuing to learn, things are changing. For instance, the coronavirus infectivity rate has increased because the spike protein on the virus has actually mutated, which enables it to more easily infect us. So the virus itself has changed. Things are changing, and the information being given is accurate at the time it’s being given. Yes, it will contradict some of the older information, but it’s because we’ve learned more. Andrew Kiraly

Dr. Rakesh Kalra

Practice manager, Intermountain Healthcare

Dr. Rakesh KalraWith 10 Intermountain Healthcare (formerly HealthCare Partners) practices around Southern Nevada under his purview, Kalra, like most physicians, had been watching the coronavirus closely since the beginning of the year. When it came to the U.S., he says, his company immediately turned their clinics inside-out, changing indoor operations to protect both caregivers and patients from contracting the virus, while setting up outdoor stations for people who feared they had it. Kalra himself was on the front lines, doing nasal swabs and personally calling all the patients who tested positive.

PREPARE FOR THE WORST

We weren’t prepared to go to this extent. It helped to turn our operations around, but (nobody was) anticipating this type of pandemic. The major lesson is, this is a serious virus. When it first came on board, we were thinking it was similar to the flu, but it’s really serious. It’s taken over 10.5 million people, 500,000 lives (to date). Personally for me, even one life is devastating. So, imagine, a half a million, it’s just unthinkable.

We’re already focusing on the next crisis, because we’re anticipating this flu season to be devastating with the coronavirus. So, we’re turning our clinics inside-out to take care of those patients. We’re actually building permanent structures to continue drive-up testing and have rooms available outside to treat patients with respiratory symptoms. We’re focusing on PPE. We were lucky that we did not have a shortage within in our company, but we want to be well-stocked, because we feel the next season, coming in a few months, will be just as bad as it was back in March.

HEALTHCARE WORKERS NEED MENTAL HEALTH SUPPORT

What’s hard is the unknown. We’re on the front lines, so we’re scared for ourselves, our families, contracting the virus, and you have to stay positive to take care of patients. They’re already concerned, so if we’re negative, it’s not going to be a good experience for them.

My personal frightening experience was, a family member who was asymptomatic got coronavirus. We often preach about wearing a mask and staying away from patients unless you’re taking care of them, but when it hits home, it’s harder to deal with. It’s more easily said than done, and it’s frightening. My family member was sick. I have young children in the home, and we had to have them wear masks, we were wearing masks, isolating (the sick person) in a room, and that really has an impact on everyone emotionally and mentally. It was hard. So, seeing that firsthand, I was able to relate better to patients’ fear.

… AND PATIENTS NEED IT, TOO

We’ve dealt with many patients, unfortunately, whose spouses passed away and who also tested positive, so we kept in close touch with them. Both would come in at the same time, test positive, and one would pass away, and the other would get well. It was really tough with one patient — she needed clearance to get back to New York and bury her husband. It was very tough working with them and supporting them. HK

Corie Nieto

Director of Telehealth Services, Nevada Health Centers

Corie Nieto has been involved in the telehealth industry in the state since 2010 and has been instrumental in starting two telehealth programs from the ground up. After implementing virtual methods for patients to see providers from one of 18 NVHC locations, three mobile programs and 25 schools, she was just getting ready to introduce the healthcare organization’s direct-to-consumer service through smartphones, tablets, and desktop computers when the pandemic hit.

PUT MORE RESOURCES INTO TECH

(Before COVID), next on our (telehealth) strategy was to launch our direct-to-consumer campaign, which is our providers seeing patients (via the internet) in their homes. Up until March, we had developed all the clinic algorithms: What’s appropriate to see at home? What can you effectively treat? We were just getting ready to launch that program when COVID hit. Holy cow! For the months of March and April, I didn’t sleep! Within a week, we launched our program. March 16 was our go-live date. We went from 200 telehealth visits a month to almost a thousand visits a month overnight. We have gone from a handful (about 12) of virtual providers to every single provider (close to 100) in our organization.

Prior to COVID, there were a lot of obstacles. There were providers who just aren’t interested in doing this. There are patients who aren’t interested in doing this. You can train hands-on, you can train through video, you can train through documents. If people aren’t motivated, it can be difficult to do that. Once COVID hit, I couldn’t manage the requests: “Can I be next for training? I want to go live tomorrow.” There was absolutely no resistance from the providers and no resistance from administration. And what’s really crazy? No resistance from the patients. The patients were saying, “God bless you. Thank you for doing this. This is an amazing program. What would we do without this?”

STOCK UP ON TECH GEAR

So not only are you looking for PPE and sanitizer wipes, but you’re looking for webcams. And they were sold out! You could not get a webcam if you tried. You have two or three providers in an office, all doing virtual care. Well, now they need headsets, because otherwise you’re hearing three conversations and there’s not privacy for those patients in their virtual appointments. Well, you couldn’t get a headset! So we’re moving doctors so that we can get them a private place because we can’t offer a headset and it’s just coming out the speaker. We fortunately had quite a few laptops in the organization, so we’re dedicating a laptop or two per front-office person or provider so that we could manage it from a technology standpoint.

Our (telehealth) vendor is able to assess the bandwidth connectivity rates of all of our participants. Prior to the pandemic in February, 83 percent of all the sessions on our video-conferencing platform had connection speeds of 350 kilobytes per second. That’s (a baseline). If you get below 350 kilobytes per second with our platform, you start getting poor audio and poor video. So 83 percent of the sessions were above that in February. For the month of April, 45 percent were below that. Because everybody was at home and everybody was drawing bandwidth, we lost capacity for all these patients to connect.

CAPITALIZE ON THE MOMENT

Anybody in the telehealth field is very passionate about what we can do — increasing access to care, reducing cost, all those things — but has constantly struggled with acceptance and changing the culture across the board — patients, providers, and administrators.

COVID, having forced patients, providers, and administrators to use telehealth, has given us, the telehealth industry, the kick-start to make them try it. We knew if we could get patients to try it, if we could get providers to try it, they would recognize the amazing benefits that telehealth has for our patients. Patients would recognize this is so much easier, so much better. Patients like that the provider is completely dedicated to them during that encounter and sometimes feel like (it is) more dedicated than an in-person appointment.

All the positive things of telehealth are being (showcased). It’s not just Corie spouting it out anymore. It’s “I have experienced it and I like it and I’m going to do it going forward.” That is a positive consequence about what has happened because of COVID.

We need a NVHC tech squad. We can have open house or have videos on how to make the technology work because that will be our biggest restriction going forward, which is amazing. It’s not culture anymore. We’ve moved the needle on acceptance for this type of care and excitement for this type of care, so now we just need to fix the technology, fix the bandwidth to make sure we can have good solid connectivity with our patients. PS

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