In mid-April, as the number of hospitalized patients with COVID-19 at The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center continued to grow, we checked in with pulmonologist Brian Garibaldi, director of the newly established COVID-19 Precision Medicine Center of Excellence, to find out about the life-and-death challenges that he and his colleagues are facing each day.
Garibaldi, the Douglas Carroll, MD, CIM Scholar, is also medical director of the Johns Hopkins Biocontainment Unit and associate director of the Osler Medical Residency Training Program. The Q&A that follows is adapted from a podcast produced for “Public Health on Call” at the Johns Hopkins Bloomberg School of Public Health, conducted by interviewer Stephanie Desmon.
Has the onset of the pandemic raised the need for new treatment methods and protocols?
Yes, it’s not very often that you encounter patients who have a completely new disease. Those of us who have been seeing these patients feel an incredible sense of urgency to make sure that we’re not only providing care for these patients, but that we are using the best evidence in terms of different treatment options. We are in touch with our colleagues who are doing both clinical and basic science research to contribute to how we move forward and hopefully positively impact the care provided – across the country and around the world
– throughout the rest of this epidemic.
What’s different about caring for patients who come in with COVID-19?
The patients who are getting very sick are shorter of breath. The normal respiratory rate is somewhere between 12 to 15 times a minute. We’re seeing lots of patients who are breathing in the 20s and even 30s and working very hard to breathe. And that usually corresponds to people who have a need for more oxygen. That’s when we worry about whether they will require care in the ICU and potentially need help breathing with a breathing machine.
“We have to be very proactive in identifying who might need that extra support so that we can get them to the units that can handle them, and get the right providers into their gear to help patients with an urgent need.” – Brian Garibaldi
One of the things that’s different about caring for these patients is that it takes time to get into your personal protective gear and to get into a patient’s room if they’re not doing well. So, we have to be very proactive in identifying who might need that extra support so that we can get them to the units that can handle them, and get the right providers into their gear to help patients with an urgent need.
That has implications for our normal care policies in the hospital, since it takes time to make sure that you are protecting yourself and the rest of the team to be able to respond. We’re hoping that the protocols and monitoring we put into place can help us identify those patients early so that we can really minimize the number of times there is an unexpected emergency where people have to rush into the room – because in this particular climate you can’t do that safely.
Given the need for social distancing and isolation, how has the atmosphere within the hospital changed in recent weeks?
Usually the hospital is a bustling metropolis with thousands of people going about their daily lives, so it’s odd to be walking through the hallways and to just see people who work at the hospital. For us as providers, it’s odd to be in the hospital but to have to socially distance from each other. That whole idea of rounding together, and the community you develop who normally would meet together and huddle – that’s gone. We’ve had to move to virtual communications, either through email or online chat platforms.
Our patients don’t have the physical support networks they normally have, and it certainly has been a different experience for us as providers not being able to meet face-to-face with families. Many of our patients are relying on their smart phones and other ways to keep in touch with friends and family. And we’re doing the same things: relying on phones and sometimes face-timing or using some other ways of connecting with families to keep them on top of what is happening. That’s certainly different from usual, when we walk into a room and say “Hi” to patients’ families and update everyone all together.
One of my big jobs prior to this outbreak was working on teaching clinical skills to our house staff. We had an active initiative to increase the amount of time we spend with patients and their families at the bedside. Obviously, that is not something we can physically do right now. But I think leveraging that energy around the importance of spending time with patients to try to figure out what other things we can put into place to ensure we are spending the time we need – both to make medical decisions but also to make sure our patients are getting what they need from us – I think that’s a huge challenge and lots of great ideas are starting to surface about how we can do that better.
“Our patients don’t have the physical support networks they normally have, and it certainly has been a different experience for us as providers not being able to meet face-to-face with families.” – Brian Garibaldi
The news is abuzz with stories about potential treatments for COVID-19, particularly hydroxychloroquine, a drug used to treat malaria and lupus, which President Trump has repeatedly referred to with great optimism as a cure.
Yes, there’s been a lot of excitement about a number of different potential treatment opportunities.
For me personally, I’ve enrolled myself in a trial of hydroxychloroquine sulfate for post-exposure prophylaxis – this will look at health care providers like me who have treated COVID-19 patients and have been wearing personal protective equipment. The reason I signed up for the study is that I feel like this is my opportunity to really add to the data that we have about that drug and to see if it is safe, and to determine whether it has a role to play.
I hope that it will, but I think that we have to maintain a pretty healthy dose of skepticism right now and resist the urge to give this medicine to everyone. We all want to do something to help our patients, but sometimes doing something can be more harmful than doing nothing, and I think we need to keep that in mind.