Harry J. Lieman, M.D.
It was a usual day in our fertility practice offices a few weeks ago when I learned that a member of my community had been admitted to a local hospital. He was suddenly transferred to a major medical center in the New York area. All I heard was that he was intubated and, in the ICU, had tested positive for COVID-19.
That is when my life and all our lives changed. It is no longer business as usual, but a major concern for all of us: how will our future look? Life with this novel virus has become completely unpredictable. It has caused some added panic as evidenced in the world around us.
Shortly after the hospitalization, the Governor of New York and the New York State Department of Health, in collaboration with the local health department and local government, decided. All the members of our community who had come in contact with this man on a particular day would have to self-quarantine for 2 weeks.
I am not sure what I expected with the quarantine, but on day one I made a lengthy to-do list. The list included many outstanding work-related items that are often hard to complete during a day in the office. There were also numerous personal to-do lists that frequently are neglected. Soon after getting used to life in quarantine and finding new ways to communicate with large “WhatsApp” chats with friends and family in quarantine as well as a transition to meetings on Zoom, I honestly believed I would be able to tackle my list.
Within a couple of days, however, I had a new call to action. Several doctors in the neighborhood were concerned. We were hearing rumors of many other community members who had started having symptoms of the infection. And when testing became available, some had a positive result. Our community leaders quickly began meeting regularly with state and county officials on “next steps” to curtail this quickly spreading virus.
At the same time, I and a few other doctors discovered that some of our friends and family were in real trouble. Two more people in our community needed ICU beds with ventilators. Local friends and neighbors who had tested positive and were now in isolation also were not aware of all the potential sequelae of this infection. Our doctor group realized that there were significant gaps in the information the health department had provided for these patients, such as:
- How does one care for an isolated patient?
- How does a family member looking after such a patient stay safe and avoid infection?
- When does a caregiver call a primary care doctor?
- When should a caregiver call 911 and request admission to the hospital?
These are all vital questions, and yet isolated patients and their caregivers wouldn’t necessarily know the answers. I learned that many people were in denial and really did not want to make that 911 call. Many of them did not want to be a statistic of hospital admission.
COVID-19 has 2 stages. The first stage seems like the standard flu. However, I learned in my 3 weeks of experience with this virus that the 2nd stage of this infection, around day 7-12 of symptoms, is when things rapidly go from bad to worse.
To help manage and control the outbreak, our physician group quickly wrote literature for the community to use as guidance, all culled from several respected online sources. We also made simple recommendations to help our neighbors cope better. An emergency hotline, set up to connect community members to teacher volunteers whose schools had closed, functioned as a makeshift answering service for our doctor group. We counseled our affected neighbors over the phone and conducted video chats to the best of our ability.
All of this gave us a chance to provide a service and to help families who needed to make tough choices. Some were interested in staying at home and taking care of themselves with oversight from a distant family member. Others wanted to know if they should make a trip to the ER for possible admission. Many of the calls we received were made in panic. Two weeks in isolation is difficult, and that alone can cause tremendous anxiety. But the symptoms were often real and required immediate medical attention. Yet when people called a primary care MD or a pediatrician for a child with fever, they often got the same response: “Do not come to my office. I do not have the means to properly isolate you in the office. Call 911.”
The manpower needed to deal with a health crisis of this nature is staggering. Emergency medical service personnel will always need PPE. And if a patient is known to be positive, they too must be gowned in PPE before entering an isolation room in the ER in order to prevent spreading the virus to other patients in the ER. It was all our small volunteer doctor group could do to stay on top of the situation, despite the quick adherence to the quarantine by the community. And there were still an alarming number of patient hospital admissions and patient trips to the ER for dehydration and fluid resuscitation.
COVID-19 is no longer just in Asia or Europe. It is here and it is deadly. Yes, 80% will have mild symptoms, and most will recover without hospital care, but the number who need help is enormous. Most of the people we helped were less than 60 years of age and many were in their 30-40’s. Fifteen to twenty percent will need hospitalizations. The governor of NY is reporting that he has 55,000 hospital beds in his state. He wants the hospitals to double this capacity. Forget space. How will the system have enough doctors to oversee the care of these patients with a 100% increase in beds?
I applaud the decision by the ASRM to publish clear guidelines. I know this was not an easy choice for the task force to make and I am sure it was a difficult option. The task force consists of providers from all over the country. They certainly appreciate the seriousness of the conclusions made and placed in these guidelines. Not easy choices, but necessary now.
Do I appreciate the impact on patients who had cycles cancelled or the patients who were told they could not start their anticipated cycle? I had to make many of those calls to patients, too. They were not easy, especially when I could not give my patients a time when we can start up again. We are all advocates for women and their rights. Fertility treatment cycles are not the only treatments being held back. Last week, the governor of NY mandated all elective surgeries to be placed on hold. Today, he announced that all noncritical services/surgeries are to be withheld. In the middle of the only public health crisis any of us have seen, day to day changes are fluid. Adjustments are constant and it is hard to gauge what will be the next thing the public has to change or what will be the expectation of the medical community.
ASRM’s decision to take a strong stand was the high road choice. It respects the fact that COVID 19 is an enemy that is real and can be deadly. My community’s experience is a week ahead of everyone else’s in the NY Metropolitan area. If the rest of the country does not take these warnings seriously, I am concerned that patients infected with the virus will overwhelm the medical systems, and many more will not have access to health care and eventually succumb to this virus. How can our professional community resist ASRM’s guidance while everyone else in the public sphere and in other disciplines of medicine is changing their daily routine? Do we proceed with business as usual? If we do not as a professional group adhere to the guidelines, it won’t be long before government regulation of our practices is imposed on us.
The ASRM guidance on COVID-19 is in effect until March 30th. It may be updated to accommodate modified patient care with recommendations for telemedicine, screening, physical distancing, and counseling, once the coronavirus peaks and starts to flatten out, perhaps by modeling what has worked well in other countries. However, drafting a single guidance document for the entire US, a large country where regional outbreaks happen at different times, is a big undertaking. Patients may be unwilling to wait further for their delayed or cancelled fertility care, while at the same time fertile women of reproductive age are not being advised to avoid conception. Delayed patients with diminished ovarian reserve, patients who may be deployed in the military or have partners who will be deployed are particularly adversely affected. Further, the economic impact of suspending patient cycles and effectively closing clinics has already started to be felt with layoffs, furloughs, reduced pay and reduced hours of clinical and laboratory staff, particularly in non-university and non-hospital-based clinics. The issues of patient autonomy and economic hardship are weighed against the issues of public health safety and our responsibility to our patients and to each other. This is not easy to balance and the scale must be re-calibrated as this pandemic unfolds to avoid both unnecessary infections and economic collapse.
It is far too early to say what life will look like in one month. If we learn from our experience how to live with COVID-19—which may be our new normal--and the public crisis is held in check, then perhaps we will all be practicing reproductive medicine like we were 3 weeks ago before COVID-19 came into our lives.