The Future of Emergency Medicine Post-Pandemic: A Changed Landscape?

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For MedPage Today‘s “After the Pandemic” series, we asked our editorial board members to discuss what significant and lasting effects the COVID-19 pandemic will have on medicine and the delivery of healthcare.

Here, we interview Amy Faith Ho, MD, an emergency physician, published writer, national speaker on healthcare issues, and host of MedPage Today‘s Anamnesis podcast.

Check out some of our other articles in the series here.

Can you share an anecdote about a patient you saw in the emergency department and how the pandemic influenced their situation? What was the outcome?

Ho: Death is a reality in medicine. A quiet, looming possibility in every encounter. The pandemic, with all of its news coverage, cast death and its inevitability in quite a public, concrete, and harsh way. From ticking death tolls to pictures of plastic tubes invading comatose patients’ every orifice in the ICU, the media forced us to confront death in quite a crude way.

In medicine, part of our personal transformation is certainly in defining our relationship with death.

Its inevitability. Its reliability. Its certainty.

The concept of death I was very familiar with, but the pandemic brought a new light to what it meant to die.

When the world shut down, so too did hospitals. There were no visitors, no “nonessential” staff. Chaplains, social workers, case managers were often not allowed into patient care areas for safety and contagion reasons.

Within a couple weeks of these changes, I’d already witnessed too many patients dying in COVID-19 times: alone, scared, surrounded by masked faceless staff and no family or friends. One of my physician colleagues circulated standard prayers we could read to patients as they passed. I tried this once, but the sentiment was lost as I screamed at the top of my voice to be heard through my PAPR, reading off a printed sheet titled “Prayer for the Dying.”

I remember soon after this experience, I met a 90-plus-year-old woman who came from a nursing home for nausea. I got an EKG and saw a clear-cut STEMI [ST-elevation myocardial infarction] — but she was DNR and very verbal about not wanting any invasive therapies like a cardiac catheterization to save her dying heart.

She knew her time had come and wanted nothing more than to pass peacefully surrounded by her three daughters, who lived a couple hours away. I knew as her heart weakened, it would eventually stop — likely within hours — but not before it sent her down a trail of nausea, pain, and then a slow suffocation as her lungs filled with the fluid that her heart failed to pump out.

She had the option to come into the hospital for comfort care — IV pain meds, diuretics, anxiolytics, and oxygen — that could make her final hours a bit more comfortable. While more humane, it also meant she would do so alone, in the stark white hospital beds, accompanied only by the low hum of staff PAPR motors as they shuffled around rooms administering unnamed drugs.

Her priority was to see her daughters one last time, but her nursing home was also on a no-visitor policy because of COVID-19. With a few phone calls to her daughters and her nursing home, we devised a plan to rush her back to the nursing home so that her daughters could drive to the front and wave at her through the window before she passed, hopefully peacefully, in her own bed, surrounded by staff she’d known for decades.

In the moment, I recall being struck with her bravery — she had no fear of death, no concern for the discomfort and pain that would come with dying. This was a woman who understood, with her nearly century-old wisdom, that the only thing that mattered in this life was your loved ones. And she wanted nothing more than to see her family one more time, even if it was through glass panes.

I coached her on what to expect — that her symptoms would only worsen, that her breathing would be the hardest to get by. We called the ambulance to transport her home. I remember telling the young EMTs to drive fast, sirens on, because I didn’t know how much longer she had. Her breath had already become haggard, and we started to hear a horrible grating sound emanating from her throat — what we call colloquially in the medical world, “the death rattle.”

The paramedics nodded understanding. Armed with tanks of oxygen and some basic pain and anxiety medicines, these young men were her only stewards of life as she rushed towards death, and they rushed her home.

In medicine, we are trained to sustain life — “save” lives, if you will. But it’s rare that we are taught to welcome death. I felt uneasy about the situation, despite knowing it was the best option for both her and her family.

I continued on my shift, working faster and harder than I perhaps had to. Seeing other patients and flexing the muscle memory of sustaining life and treating ailments was therapeutic to me. The more diseases and symptomology I could treat and medicate away, the most I felt like my world was being restored back to order.

A couple hours later, I got a call — it was the eldest daughter of the 90-plus-year-old woman. “She made it. And now she’s finally home,” she said on the phone.

Her intonation told me that she meant “home” in the spiritual way.

“We said goodbye,” she choked. “Thank you.”

All the unease I’d had before melted away, and after a pause to collect myself, I choked back, “you’re welcome.”

There have been reports of patient hesitancy to visit doctors and hospitals during this time. Do you see this trend continuing post-pandemic, and if so, what are the health implications? Has this or is this likely to spur a surge in need for emergency care?

Ho: Necessity is the mother of invention, and as patients stayed home, we, as an industry, came up with ways to reach them. This came in the form of telemedicine, video consults, and home care. The trend of patients staying home has certainly persisted — most emergency departments around the country have yet to see their pre-COVID-19 volume fully return. While initially there were some tragic outcomes of patients waiting too long to seek care, over time we’ve evolved methods to provide care outside the walls of the hospital and better educate about what issues create a need to come in and when.

These methods are continuously being perfected, and there are still questions of how to best determine which patients need which level and method of care.

But the fact that these new methods exist now is quite incredible and should help us address not only a post-COVID-19 world, but also underserved populations and healthcare deserts.

What are the most urgent changes needed in emergency medicine that have been surfaced or exacerbated by the pandemic?

Ho: Social disparities were exacerbated and brought to light in ways that weren’t necessarily as obvious before COVID-19. Race was an independent risk factor for poor outcomes in COVID-19 patients, particularly for African-American and Hispanic populations. It meant not only a higher likelihood of COVID-19 severity, but also less healthcare resources, less vaccine accessibility, and more distrust of the medical system.

Similarly, the impact of wealth disparities in healthcare was highlighted. At a time when hospital beds were scarce and we were sending home patients who were newly on oxygen tanks (a virtually unheard of practice before COVID-19) because of lack of capacity, rich politicians were being electively hospitalized “out of an abundance of caution.” There was no greater example of this than when President Trump contracted COVID-19 and received a cocktail of specialty drugs completely inaccessible to the general population.

These disparities have long existed, but the pandemic shed light on how severe some of these imbalances are. For our society to function, these need to be addressed immediately.

There has been a significant amount of discussion about physician burnout and mental health during the pandemic. What do you think needs to change in emergency medicine going forward to address this issue?

Ho: More than anything, we need engagement.

The solution to burnout in healthcare isn’t holding Zoom yoga classes or, God forbid, mandatory webinars on wellness. We need systems-based change. This can be everything from promoting physician leaders in medicine who “get it,” to undergoing the uncomfortable introspection about abusive practices inherent in our training culture, to designing elegant technological solutions to alleviate, not worsen, bureaucratic burden inherent in metrics and finance.

Is there anything I haven’t asked about that is important to mention about the future of emergency medicine or healthcare more generally post-pandemic?

Ho: The entire infrastructure of healthcare underwent seismic shifts and challenges with COVID-19. The pandemic revealed more than anything how friable the whole system is, and how incentives of different interest groups within healthcare are not only misaligned, but sometimes completely oppositional to one another. Administrators versus physicians versus insurance versus pharmacies versus pharmaceuticals versus regulators versus public health versus mid-levels versus hospitals versus primary care versus specialists — the different stakeholders of our country’s health exist in an extremely complicated, cumbersome, and often counterproductive web, one that’s not as geared towards “patient-centered care” as we would like to see. The concept that there were “winners” and “losers” at different stages of COVID-19 should say more than enough as to the fact that the system needs to be completely revamped and thoughtfully redesigned with the patient truly at the center, not patched between competing interests of an industrial machine. This is a critical topic I’ve written about before.

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