Dr. Laurence Busse: “When patients get to me, they’re in dire straits.”

For our 21st Century Plague project, we spoke with 17 Georgians about the toll of COVID-19.

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21st Century Plague: Coronavirus in Atlanta
Dr. Laurence Busse: “When patients get to me, they’re in dire straits.”

Photograph by Audra Melton

For our 21st Century Plague project, we spoke with 17 Georgians about the toll of COVID-19. Below, Dr. Laurence Busse—medical director, critical care, at Emory Johns Creek Hospital—describes how his hospital is handling COVID-19 patients and his hopes for the future. (Busse was interviewed on March 21.)

On March 13, it was profound the amount of people coming into the ER. There was a real sense of uncertainty and unease among everyone. That was a scary day, and we all finished that day thinking, What are we in for?

I think the message is out there that if you’re mildly ill [with COVID-19 symptoms] and don’t need to be admitted to the hospital, don’t even come in for testing. And so the volume, believe it or not, has been somewhat manageable. But we’ve seen a steady increase in cases of COVID-19. As we start to ramp up in our ability to test, we are uncovering cases that are out there. So my guess is that there’s obviously a lot more cases that are [out there], and we’re just now beginning to learn of them because we’re testing.

Testing capacity is changing day by day. Even today it’s different than it was yesterday. But originally when none of us had the capability, we were relying on the state testing, which I think was [very few tests]. And then we were fairly rapidly able to get some in-house equipment and were able to increase that I think to around 80 to 100 tests per day.

I’m critical care. So, when patients get to me, they’re in dire straits. The typical thing that’s seen down in the emergency room is fever, some increased work of breathing, some hypoxia [low levels of oxygen in tissue], and some malaise or body aches. Those folks who have, let’s say, a little bit of increased work of breathing or need some oxygen would be admitted to have supportive care while they get through their illness. But if they have a higher degree of oxygen needs, or they’re in septic shock, or they’re in kidney failure, then they come to me. And those folks can be exquisitely ill, anywhere from just needing a few extra liters of oxygen to having multi-organ failure and needing a full bevy of life support.

In terms of folks that get admitted to the hospital, probably around 10 percent of them are sick enough to need my services. And that’s probably a fair ratio throughout the system.

The optimist in me hopes that we in Georgia have done enough social distancing and planning that we’re not going to see the calamity that’s going on in New York or Washington state. It’s also getting warmer here, and what we know from prior viral outbreaks is viruses seem to kind of fizzle out. So, the optimist in me hopes that we’ve done enough, that we’re going to see a linear increase in cases until things calm down. But I do worry that as we continue to test, we’ll uncover more and more folks. And we will outstrip our resources, and that’s a big concern for me. We are like every hospital in the country, we have a finite amount of acute care beds and critical care beds. And once we hit capacity, things become much more challenging.

We’re looking at how many ventilators we have, how many isolation rooms we have. We’re looking at our provider core, looking at cohorting patients or sharing supplies. We have the same challenges that everyone is having, which is, when you’re sick, you’re sick. And if you have to be admitted to the hospital and you need care, we’re here to do that. We’re here to help. But when we run out of ventilators for example, that’s not something that we can just pull out of the closet. So we’re relying on and hoping for support from the government to get more vents. We’re relying on and hoping for support from industry to get us more resources. We’re using what we have now and once that’s it, once we’re out, we’re going to have to get creative.

The preparation [by the federal government] has been poor, but I didn’t really expect it not to be. Do you plan for the worst-case scenario? Or do you put resources elsewhere? So the response in general has not been great. And I think that’s sort of what I expected. And frankly, if I was in that position, I’m not sure I would’ve done it differently. I mean, it’s really hard to plan for something like this. I’ve never had this in my lifetime. And I’ve been here for Ebola, for H1N1 influenza, and I was here for the first SARS illness back in 2003. We’ve seen these things erupt on a regional level but never really become a global pandemic. This is new in our generation.

I’m in meetings for resource planning and process planning. I do a lot of coaching of our team and answering questions. I do some patient care when I’m not on service. I go back on service in a week or so, and then I’ll be the physician managing the ICU and someone else probably will be taking my place to sort of go around and sit in on the meetings and learn what new processes we have and what resources we need to hold on to and things like that. So my days are longer and they’re never ending.

We’re using the right equipment, but we are reusing the equipment, like every other health system in the country. We don’t have enough N95 masks. We don’t have enough personal protective equipment. We’re using what we have and we are hoping that we don’t get the virus. Throughout the system we’ve got a number of providers that are already out sick, no one critically at this point. But there are folks that have fevers and are self-quarantining. I’m hoping that we don’t go down too many folks and get into a critical situation, but that is a worry of mine. I worry personally myself. I’m 49, so I’m not in the older higher-risk age group. But there’s a lot of evidence that younger folks are getting pretty serious illness as well.

I’ve got a couple of young kids at home. My wife’s a pediatrician, so she’s seeing patients too. We’re doing our part by practicing social distancing. My parents are staying away. This will sneak up on you too, this illness. There’s reports of profound illness and kidney failure and liver failure and respiratory failure. Unfortunately I see that in my line of work. So, there’s a healthy degree of worry.

It’s a new reality. And I certainly think about how this may change who we are as a society. I worry about the economy. I worry about small businesses that are just surviving or failing to survive. It’s scary that something that started on the other side of the globe can affect us so profoundly. But I’ve also seen some positive things that give me a little hope. It’s less crowded outside. It seems more peaceful. I’ve seen photos of neighbors sitting at the end of their driveway, each neighbor at the end of their driveway, just out there visiting and talking across the street. And it’s nice to see parents reconnect with their kids.

Right now we’re not seeing the normal volume of patients that show up needing care at the hospital. And is that because patients are being more careful and taking their medicine and having telehealth visits with their primary-care doctors? Are they no longer using the emergency room as a sort of a primary-care outlet? And it makes me think: Is this what healthcare could be if we were sort of using the system appropriately? Now, of course, the pessimist in me worries that when this is all said and done, we’re going to look at mortality and morbidity of people that were not infected with COVID-19 and we’re going to see that go up.

[In six months], I think this will all be said and done. Viruses, epidemics, pandemics, they have a lifespan. This is no different. We’ll be sort of getting back to business as usual, maybe with some new changes. Some folks will be suffering from the economic impact of this. Certainly we’re going to have some mortalities attributed to this, but this’ll go. And then I think what we will do though as a society is understand that this can happen. And I think that we’ll be more ready for it if and when it happens again.

China is reporting few new cases, so this virus has a lifespan and it’s finite. I’m waiting on the inflection point in Europe, which hasn’t happened yet, but I’m hoping it will. With every infectious illness, an airborne illness like this, there’s a peak and then it wanes. So, I’m hopeful based on what I’m seeing in China. And I’m certainly hopeful that our social distancing will allow us to flatten the curve.

I would say this: If you need help, come to the hospital. We’re here for you, and we’re not closing. Otherwise, stay home, and stay safe.

Interview edited for length and clarity.

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