Physicians For Fair Coverage

Dr. Bill Chester: I'm a physician. This is what we do. I still love my job.

Thursday, 04/23/20

 "I'm a physician. Most days start off the same. I get up about 6:00 am, shower, have coffee with my wife and maybe a quick breakfast.  I sneak into my 3rd grader's room and stroke his hair just because. Then I’m off to what others would call work but in truth is so much more. I'm a very lucky doctor. I'm an anesthesiologist and just returned from a medical mission in Suriname.

It’s March 1, 2020. I’m on the 30-minute drive through the Maryland countryside and get a call from a pre-op nurse about a lab abnormality, blood pressure, or cough that will shape my day a little but could shape my patient's day a lot more. I get to work, change into scrubs, and greet my first patient and her family. I shake her hand or maybe rest a hand on her shoulder. No English, no worry:  "Allergies", "diabetes", "sleep" and "no pain" aren't difficult to learn in Spanish, Swahili or Russian.  In these precious few minutes, I extract the medical, social, and psych history, and reassure her and her family before they hand over her life to this stranger in blue pajamas. 

I speak to the surgeon about last-minute issues, review the electronic medical record, then head to the OR. Inside the sterile OR "cockpit," I check my equipment, monitors and drugs for sleep, pain, and control of heart and blood pressure to make sure they are ready to see my patient safely through the painless assault on their body. The nurse wheels in my patient.  I give some amnestic sedation and begin idle chitchat while putting on the monitors. I ask, "Where were you born? What’s your favorite song?  Do you like to travel? Any kids or pets? What are their names?"

Then my real work begins: Induce unconsciousness, paralyze muscles, control breathing, blood pressure and heart stress, anticipate the surgeon's next moves, adjust the depth of anesthetic, replace lost fluids, monitor the medications to control pain, nausea, bleeding and infection. When surgery ends, I reverse everything that's been keeping the patient asleep and motionless, verify return of breathing, and remove the tube. I reorient my patient to where she is and what's happening, ease her back into consciousness.  Wheeling to the recovery room, I continue to ask my patient questions. After leaving recovery, I am off to pre-op to meet my next patient. I do this routine five to10 times over the next 10 to12 hours.  I love my job.

Now it’s March 31, the eve of the COVID-19 surge in Maryland, I feel things are different.  I still get up, have coffee with my wife and watch my son sleep before going to the hospital. Now I take the expressway (20 minutes, no traffic). I change into scrubs as usual but add a couple of extra gloves, an N95 mask and carry a face shield in my pocket. The pre-op area has moved. Post Op is now an overflow ICU. Half the ORs are cut off and isolated and being segregated as "dirty" ORs. There are no family or loved ones with my patient (unless it’s a child, in which case there is one parent). I stay a respectable six feet from my patient. Both of us are masked so it's a little harder to gauge my patient’s anxiety (and thankfully for them to gauge mine). I have to use my voice and body language more than ever to reassure and convey confidence.  The trip to the OR is new.  There are no "normal" elective surgeries happening right now. Instead of 50 or 60 patients there are only five or six emergencies. Now, these emergencies threaten me personally, and by extension, my family. 

There's no idle chitchat anymore. The OR staff doesn't hover next to me ready to assist when I induce unconsciousness. They stay six feet away lest they enter a viral plume from an unrecognized COVID infection released from my patient's airway. Surgery goes about as smoothly as usual. I ease my patients into unconsciousness or insensitivity to painlessly have their broken bone repaired, cancer removed, or intractable newborn eased from their body, oblivious to or unaware of what transpired.  I delay their wakeup, making sure there's no life-threatening cough to contaminate the staff or me. Everything in the OR is considered potentially contaminated, including me. I keep my patient sedated while I put a mask back on them. In recovery, I turn over to the nurse who jumps when I accidentally violated her personal six-foot space.  I leave the recovery room tense and a bit exhausted. My patient goes back to the now locked down hospital room or returns home to family to heal in isolation. Today I'm on call, and things are different now. 

The local lead of our anesthesia group, U.S. Anesthesia Partners (USAP), was busy last week. There was no traditional anesthesia work, but he was at the hospital all week, working with the chiefs of surgery, ER, ICU, nursing and engineering. This work doesn't generate income. It's not "doing anesthesia."  But it's what we do. Early in the COVID crisis, we requested a hold on all elective surgeries to prevent the spread of the virus. At the same time, USAP sent a letter to all of our surgery center clients stating we will no longer provide anesthesia for elective surgery and that we were taking urgent and emergent cases only.  We are a large private group and we know this decision shuts down all of our income.  But it is the right thing to do.  

My colleagues and I gather and share all the information we can about how to change our practice to protect the OR staff and ourselves from being another burden on this system. Deep extubation under a clear barrier, regional anesthesia whenever possible, double gloves and face shields for every case and even redesigning snorkeling masks to become PPE. There is no end to it. 

I’ve been busy doing other things too. I did my anesthesia training in the Navy, I am a pilot and diver, and have been organizing medical missions in remote areas of Africa, Asia and South America for 35 years. Planning and preparing is something I'm familiar with.  This has proved useful during this crisis.

No hospital can function without fully integrated anesthesiologists. And no hospital system has ever experienced the combined economic and clinical catastrophe that is overrunning our country and the world. They need our help to keep it together and that is part of what we are doing now.  We are helping our hospitals re-purpose Maryland’s payment models to allow them to staff their ICUs and deploy critical professionals in roles where we are needed. We are also planning how to undo all that we're doing now when this crisis passes.  New roles indeed. 

It’s somehow already April and I was lucky that my hospital call wasn't that bad last night, at least for me. My partner saw a dozen or more new babies come into the world and didn't sleep for 24 hours. Just as he started a C-section at 5:00 am, a COVID patient took a turn for the worse and could no longer survive without intubation. Our recent protocol for anesthesiologists to do all intubations hit a snag. Five minutes after the phone call, I was on the expressway wondering how there could still be so many cars still on the road just 48 hours after a mandatory stay home order was put in place by Governor Hogan?  Just as I pulled into the hospital, my colleague called to say the patient was successfully intubated.  I guess I will have plenty of opportunities to use that newly designed PAPR mask I created between cases. When I get home, there’s a plastic bag hanging on the garage door for my work clothes and a change of clothes is in the basement bathroom. New routine.

Today my wife, son and our neighbors unpacked 200 pounds of gloves and gowns squirreled away in our storage for medical missions and sent them off to Colorado where they're in short supply. FedEx will have them there tomorrow morning. Now I’m waiting to get on a conference call about how to fund newly formed anesthesiologist-led intubation teams.  I will be on hospital call again in just a few days. Until then, I’m hanging out at home, hoping that I did not bring COVID-19 back to my family.

 So, this is what we do. I still love my job."

Dr. Bill Chester is an anesthesiologist in Maryland