TMC PULSE

20 t m c n e w s . o r g RICARDO NUILA, M.D., is a hospitalist and teaching attending physician affiliated with Ben Taub Hospital and Baylor College of Medicine. He spoke to TMC Pulse on April 13, 2020. As a clinician, you feel the tremors of COVID. It's not a linear course, like what you expect when giv- ing antibiotics to a patient for an infection. With COVID, the oxygen level goes down a bit and then you don't know where it's going to go from there. The patient gets a little bit better one day and you have hope. Then the next day things regress and you think, 'Wait a minute. No.' The first COVID patient I saw must have been three or four weeks ago on a night shift. " As a clinician, you feel the tremors of COVID. … You have to train yourself to do less and observe more. " One of the particularities of hospital medicine and hospitalists is that we admit patients from the emergency room and we're the people responsible for those patients up until they require a ventilator. I think the stats show that for every person who goes to the ICU [intensive care unit] there are two or three patients who are managed by hospitalists on the floors. So it's really one of those situations where you want to be the only doctor a patient sees, because if that patient sees other doctors it's usually ICU doctors and that means that things have taken a turn for the worse. And here's the thing: The doctor is in a priv- ileged position. The doctor sees the patient and then writes orders and those orders are imple- mented by other people. So the doctor manages how much exposure there is to COVID in the Spotlight on COVID-19 hospital. All orders engender more exposure, so you have to weigh all of your choices really carefully. COVID causes you to be as efficient a diagnostician as possible. There was one patient at Ben Taub, she had a week of sudden onset cough and she was clearly short of breath—oxygen levels low. The COVID test came back negative, but we know there are false negatives and you just have to reckon with that. Are you going to push for a different diagnosis? There came a point where I had to say, 'Let's look for something else.' We did find something else and it was an even worse diagnosis than COVID. Those are the difficulties we face. This pandemic has put a premium on patience. We don't have any known therapy against COVID, and I think there's an inclination in all doctors to feel unsettled by not giving certain treatments or by not actively trying to solve an illness. Patients can be on oxygen in the hospital for a while and you can't bring them off of the oxygen. This illness can just linger. I think physicians need to ask them- selves: Can I be patient? Is the breathing getting better or is the breathing getting worse? Can we wait another day before sending the patient to the ICU, where they may need to be put on a ventila- tor? If we're not worsening, can we just continue to keep doing the same thing? Ordinarily, the health care environment is about getting things done and getting things done quickly. With COVID, you have to train yourself to do less and observe more. It's an era of uncertainty and that has made being a doctor very difficult. After Hurricane Harvey, I went to care for some of the displaced at the George R. Brown Convention Center pretty early on, when we just didn't know how many people would be coming in. You saw people who were shivering. You saw people who were still wet from being rescued from the water. At that point, before we had a plan to get people medications and tell them where to go, the best you could do was reassure them, to say, 'You're OK without your blood thinners for one day.' In that way, COVID is similar. One of my COVID patients told me he always felt good when we spoke. That made my day because, other than the oxygen, the most that I could give that person was my attention and my words. But that's also the case with everybody in the hospital right now because there are no visitors. Even with

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