The burden of non-COVID illness
I am a health worker, but those in my specialty are needed at the front lines only rarely. We continue with hospital duties, phone consults, and emergency procedures in uncomfortable protective equipment. But we don’t sweat for eight to 24 hours, as some of our colleagues do, under bunny suits while limiting bathroom breaks; we don’t spend extended shifts in specialized masks rebreathing our own carbon dioxide, struggling with lightheadedness and discomfort. We don’t deal directly with COVID deaths or the trauma to their families. Many medical professionals like myself—those outside of emergency medicine, anesthesia, internal medicine, and its specialties, among others — have not had to deal with the very worst that the disease can bring to the front lines. We might still count as essential workers, but we spend most of our time on the sidelines, humbled while the real heroes go into battle. This also means that we are a little more able to advocate for illnesses outside of COVID, which continue to take their toll on our patients as the lockdown extends and as health-seeking options are limited.
Elective procedures are postponed for now, and only rightly, but we worry about patients with conditions that are not emergent, but which are painful or at risk of progression. There are those with suspicious tumors who cannot get a work-up or a biopsy; those with already diagnosed cancer who must postpone treatment until the worst comes to pass, like organ failure or deadly metastases. The list of these worrisome, but not emergent, conditions is endless.
Specialty societies scramble to come up with interim guidelines for practice during the pandemic, devising ways to maximize resources—like blood, critical unit beds, or PPEs—by limiting admissions and consults to only the most necessary, while trying not to cause undue harm to those with nonemergent illnesses. Protocols for standard of care are being advised around the world: dialysis schedules and chemotherapy are being revised to minimize frequency; cancer patients who could be candidates for curative surgery are being offered other modalities.
However, because these are unprecedented times, even doctors are learning as they go along. We worry about the suffering of patients at home. We also worry about advising against discharge in case we get blamed when patients deteriorate. As Lisa Rosenbaum, MD, wrote recently for the New England Journal of Medicine, sometimes the line between urgent and nonurgent cases can be drawn only in retrospect. No one wins in this situation—not the doctors who must make decisions with limited resources and limited data; not the non-COVID patients who are collateral damage to this pandemic.
How do we maximize the care that we can offer? Local hospitals are looking into maximizing telemedicine, helping patients to decide on the next best step, helping patients to monitor their condition. It is a work in progress, but a necessary work as we adjust to this new frontier of health care, limiting physical contact where it was once the cornerstone of the art of medicine.
We should also work to remove other barriers to seeking care: A friend recently pointed out that even in Pasig, that most progressive of neighborhoods, dialysis patients are prohibited from passing some checkpoints with a companion, despite the fact that most dialysis patients require assistance and suffer, too, from fatigue and comorbidities. This is unacceptable, and the local government and police force must be able to make the necessary exceptions guided by the best available medical information.
Physicians in different sub-specialties must have the flexibility to revise guidelines and protocols as more information comes in, learning from local and foreign experience. Finally, health care workers in various sub-specialties should not be afraid to speak up when blanket decisions are being made by government and hospital administrations that can negatively impact the care of non-COVID patients. We need to help each other to learn the best way to navigate through the crisis.
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