Quiet. It’s a word that emergency room clinicians at University Hospital don’t like to say out loud.
But it’s the best word to describe the emergency department on Friday morning at the Newark hospital, which addresses the urgent medical needs of more than 90,000 urgent patients each year and is among the busiest in the state. University, the region’s only Level 1 trauma center, has also been among those on the front line in New Jersey’s battle against the coronavirus.
Doctors and nurses working there don’t want to revisit the COVID-19 crush they experienced in early April, when the numbers of sick and dying patients were nearly overwhelming. But they also don’t see a quiet ER as a good thing — especially during a global pandemic that has hit the Garden State particularly hard.
“It’s very frightening for us because I think there are a lot of people out there who are not taking it seriously,” said Sonia Gonzales, a senior nurse in University Hospital’s emergency department. She fears that people will interpret lower hospital volumes and initial steps to reopen society — like the state’s decision to allow people to again visit parks — as a sign that the virus has receded or moved on.
“It didn’t disappear. We’re still seeing COVID patients. We’re still testing (positive) patients,” Gonzales said. Her son, a police officer in Paterson, tested positive and recovered; her “feisty” 74-year-old stepmother also contracted the disease, but died in late April. “To see how quickly it just took her away? It’s horrible. This virus is vicious,” she said.
Emergency clinicians are also concerned that the quiet they are currently experiencing may reflect the public’s fear of going to a hospital during a pandemic — and the related fact that urgent health issues are going untreated. While ERs generally see many cases that are less urgent — or that could be better handled by a primary care physician — they also serve as a gateway of critical health care for those suffering from heart attacks, strokes, seizures, drug overdoses and other medical crises.
‘We don’t know where they’re going’
Dr. Lewis Nelson, chair of emergency medicine at Rutgers University’s New Jersey Medical School and chief of service at University’s ER, agreed it is “terrible” to have the ER this quiet. “So what’s the downside of not getting care for a heart attack or stroke? It’s that you’ll get worse,” he said.
“Even our mental health population, their numbers are way down. We don’t know where they’re going. And my concern is they’re not getting care.”
That said, Nelson concedes there was a benefit in the way these other patients avoided the ER at its busiest times last month. “It’s sort of a double-edged sword. Had they come in at the normal numbers, plus the COVID patients, we couldn’t have functioned,” he said.
“We went from zero to sixty in no time,” Nelson said, describing how the impact of the disease — and our understanding of it — has evolved rapidly in recent months. “And now we’ve gone from 60 to zero too quickly. It’s like we’ve slammed on the brakes.”
For more than six weeks, the coronavirus has been the primary focus for hospitals statewide — and many in certain northern counties were overwhelmed at times, something officials are now witnessing in central parts of the state. Despite limited testing among the public for the virus, as of Sunday nearly 127,000 New Jerseyans have been diagnosed with COVID-19 and more than 7,800 have died.
Gov. Phil Murphy ordered all but certain essential businesses closed in late March and insisted residents stay home unless they had necessary errands. COVID-19 can take two weeks to develop once someone has been infected and state officials have interpreted the peak and gradual decline of new case numbers and hospital admissions that followed as a signal these social-distancing measures have worked.
Reopening the state will require additional public health metrics to be met, Murphy has said, including widespread testing and a system to quarantine and care for those who need assistance. Securing sufficient testing alone could take until the end of May, Murphy noted.
ER staff support a slow reopening
But last week Murphy agreed to allow the public to return to parks and golf courses starting May 2, albeit with restrictions on gatherings and pleas for visitors to wear masks. At University Hospital, emergency room staff applauded the governor’s effort to take the reopening slowly, but they do worry about the likely spread of infection that could result as we start to loosen social-distancing measures.
“There’s no doubt that as soon as we open up there’s going to be an increase at some level of people getting sick. It’s just going to happen,” Nelson said. “But we want to make sure that increase is below the capacity level of the health care system. Well below.”
“If we go through what we went through the last time it’s not sustainable,” he continued. “We can’t function at that level where the entire hospital is full and the emergency department is brimming with patients.”
In late March, the emergency department — which can accommodate up to 75 people at a time — began to flood with patients, both COVID-19 and other cases, explained Jonathan Green, who has a doctorate in nursing and is executive director of University’s emergency department. That prompted the hospital to set up a tent in the parking lot nearby to help accommodate some of those with respiratory symptoms.
“This has been phenomenal. At the peak we were seeing more than 80 patients a day out here,” Green said, referring to the tent. “And that’s 80 patients a day that then did not occupy a waiting space in our ED that was already backed up with critical patients. This gave us the bandwidth to see patients in a timely fashion and get them the care they needed without sitting for hours.”
Even with the tent, there was a point at which hospital staff could barely keep up, Green recalled.
“It was a scary time. It was very overwhelming for the staff,” he said. “Our staff are very used to dealing with high acuity emergencies; we are not used to dealing with that many in such a short period of time — so the extent of death and dying was overwhelming for the staff.”
Gonzales, stationed inside the hospital’s emergency department, agreed. “To walk into an ER that has every other, if not every bed with an intubated patient, is not normal for our ER. That became pretty stressful,” she recalled. “To hear Code Blue (indicating the need for CPR, a common concern with critical COVID-19 patients) constantly over the PA,” she said. “To hear bed availability is really up to whether a patient is discharged or a patient dies. That’s not something we normally hear.”
Inside the tent
During the busiest times, a hospital staffer was stationed outside the tent, inviting patients with respiratory symptoms to enter and directing patients with unrelated issues to the brick-and-mortar ER nearby. That individual is no longer there, but the process remains the same: When patients enter the multi-unit tent, they are asked to wash their hands and given a mask; a triage nurse then takes their vital signs and asks about their condition. Video monitors allow for translators to participate virtually, if needed.
From there, patients proceed to a socially-distanced waiting room — where folding chairs are carefully spaced — at the center of the tent structure. At the back are a handful of beds where patients can be monitored by an advanced practice nurse and tested for COVID-19; results are now available within a day.
Respiratory patients who needed more care — including those who must be intubated and attached to a ventilator — are quickly transferred inside the hospital, Green said. But those with mild or even moderate symptoms are generally provided information about the disease and how to isolate themselves and protect others, and then sent home. Doctors from the outpatient department follow up by telephone with testing results and additional instructions, he added.
Green said it is unusual to send so many people home in that manner, but that was the best option available at that time. “I think the hard reality is, systemically across the entire health care system, across the region, there’s not enough hospital beds to keep people who are (infected but) stable,” he said. “And where do you draw that line?” he continued, as sirens wailed in the background. “I still don’t think we’re there yet.”
State officials took significant steps to expand hospital capacity, opening up acute care facilities that had been recently closed and working with the U.S. Army Corps of Engineers to stand up three field medical stations. But those facilities have remained largely unused, in part because of the nature of the disease — which we are just beginning to understand, experts note.
“The issue is, people are either not sick or they are very sick. And those field hospitals were made for people in the middle. And there weren’t a lot of people in the middle,” Nelson explained.
‘People can come in, we want to help them’
Looking back on the last six weeks, emergency room staff at University said they are thankful for the support of their colleagues, professionals from other states — including a team from the Army Reserve — hospital leadership and the community. Nelson said they have worked to ensure the team has hot meals for all shifts, plenty of hand sanitizer and access to mental health treatment, if needed.
Gonzales said some nurses have also been sewing their own caps when the disposable versions became hard to get; family members have also configured devices to help keep masks in place in less painful ways during long shifts. She is also deeply appreciative for the Army nurses and clinicians hired on contract, as well as the hospital’s own team, including the housekeeping service and individuals who take everyone’s temperature when they arrive for work. (Staff members get a colored sticker indicating they have been screened for the day.)
“The hospital has really been on point. If you’re feeling sick, no one has ever said to come into work,” she said. Her message for the public: “Let them know we’re battling the fight and we are going to win. And we’re here for them. People can come in, we want to help them.”