COVID-19: Insights from a Tampa emergency room specialist

Second in a series of interviews.

Retired OB/GYN Dr. Bruce Shephard of Tampa interviews Dr. Jay Rao, an emergency room physician at St. Joseph's Hospital in Tampa and president of the Hillsborough County Medical Association, about the local COVID-19 situation.

Dr. Shephard: Dr. Rao, how did you first become interested in becoming a physician?
 
Dr. Rao: Medicine has been 'the family business.' My father is a physician, my mother is a nurse, my sister is a physician. But I’ve always been the rebellious type and at first resisted that idea. I've always loved the sciences though and earned my degree in physics. But after college, the positions that were offered did not really interest me. Then I came across a quote from Aristotle: ‘Where your talents and the needs of the world intersect, therein lies your vocation.’ That resonated with me and pointed me back toward medicine. Ultimately, I let go of my resistance and started my journey to becoming a physician.
  
Dr. Shephard: And why emergency medicine?
 
Dr. Rao: In med school, my sister gave me some really good advice. I was struggling to settle on a specialty and she suggested, ‘Your personality will dictate your field.’ During my ER rotations, I really connected with the people there. Emergency medicine is a team sport. You need nurses, techs, radiologists, consultants, etc. It's a highly collaborative field. And every day presents a new challenge. You never know what your day is going to look like and you always have to be on your toes. Some days can be fairly routine and other days are totally crazy. You have to know how to approach anything because you never know what's going to come in the door. Before I knew anything about medicine, I had this notion of being on a plane or in a restaurant and someone suddenly yelling out ‘Is there a doctor in the house?’. The doctor you would want in that situation is an Emergency Physician. That was the kind of doctor I wanted to be. Someone who had the skillset to approach ANY clinical scenario. For all these reasons, that was the specialty that most suited me.
 
Dr. Shephard: How is your emergency department team deployed?
 
Dr. Rao: I work at three different emergency departments within the BayCare system -- St. Joseph’s Main, North, and South. Each has a different layout, patient population, and staffing model. St. Joseph’s North in Lutz is very suburban, Main in central Tampa is a Level 2 Trauma Center and is more urban, and South in Riverview is kind of a mix of both. All are really different in terms of socioeconomics, demographics, volume, etc. I enjoy working in different environments and find it to be valuable as a clinician.
 
Dr. Shephard: Let’s talk about St. Joseph’s Main.
 
Dr. Rao: St. Joseph’s Main is one of the busiest ERs in the country and is split up into zones: The Green zone sees lower acuity/urgent care types of cases. The Red zone manages sicker patients (traumas, codes, etc.). And the Orange and Yellow zones see a bit of everything. We typically have a doctor and a mid-level (nurse practitioner or physician's assistant) in each zone. Currently, our Yellow zone is dedicated to COVID suspected patients in order to separate them and reduce exposure to our other patients. We’ve been able to convert most rooms in the Yellow zone to negative pressure rooms where the air is sucked out to lower transmission risk.
  
Dr. Shephard: How do you screen patients for COVID?
 
Dr. Rao: Anyone driving into the ER entrance is screened for suspicious symptoms like cough, fever, or chills. If they have concerning symptoms or risk factors, they are directed to a tent area where they are more formally assessed and triaged. If they are determined to require further evaluation, they are then sent to the Yellow zone. If their symptoms are mild, they are given self-quarantine instructions and advised to follow up with their primary doc.
 
Dr. Shephard: The CDC recently reported that up to 11% of healthcare workers have acquired COVID, most of them are females in their 40s. Have you had colleagues who have gotten the virus?
 
Dr. Rao: We’ve had a few providers who developed respiratory symptoms after caring for COVID patients. They had to self isolate for a period of time, but fortunately, they have all recovered and are back at work. However, in several instances, their COVID tests came back negative, which was quite hard to believe. The testing is getting better, but we definitely have more work to do in improving the reliability of the tests.
 
Dr. Shephard: The AMA has recently called upon the White House to use the Defense Protection Act to provide more PPE (personal protective equipment) to health care providers. Do you have enough PPE in the ER?
 
Dr. Rao: For the most part we’ve had adequate PPE thus far, but a lot of the docs were concerned about the stories of shortages out of New York and New Orleans and purchased some of their own PPE. And everyone remains concerned about the possibility of a surge which could potentially stretch our resources. We’ve been especially cautious with N-95 masks. I’ve had a few shifts where we were out of the N-95 that fits me best. This is very problematic because, without a good mask seal, you are not fully protected from exposure to the virus. Overall though, I have to commend BayCare and hospital leadership. They have been really on top of things and have been communicating regularly with all staff through daily email updates. They’re taking screening temperatures and providing masks for anyone walking into the building, staff included. They have definitely been doing everything they can to protect patients and staff and to prepare for a possible surge.
 
Dr. Shephard: Has the local community become involved in any way?
 
Dr. Rao: The outpouring of support from the community has been truly overwhelming. There’s been this campaign called #FeedtheER that has sprung up and has kind of gone viral. Small businesses and others in the community have been sending in food to show their support for the hospital staff. Many people have been stitching masks for us and some with access to 3D printing have been making face shields and other PPE. The flood of community support has been remarkable and definitely has helped our morale.
 
Dr. Shephard: In a pandemic like this, it is optimal for different health care organizations to work together in a collaborative way. In our area, we have four major hospital systems: Advent, BayCare, HCA, and TGH. Do these systems have an existing mechanism to coordinate care?
  
Dr. Rao: This area represents an opportunity for improvement in my humble opinion. It's a challenge because these organizations are direct competitors in the healthcare market and there is generally little incentive for them to improve coordination/collaboration between the different systems.
 
I can say without hesitation that BayCare has done a great job facing this crisis as a system. I can also mention that there has been some collaboration with TGH regarding testing materials, but I have not seen much else in the way of inter-system collaboration among the 'Big 4' from my vantage point. There was some talk of a countywide COVID task force, but I have not seen that materialize as far as I know. But, there may be meetings going on that I have not been privy to.
  
Dr. Shephard: At your facility, how has the onslaught of COVID patients affected the care of other patients?
 
Dr. Rao: I'm seeing sick patients every shift, but in fact, our overall volumes have been lower than normal at all of our facilities. We're seeing a lot of patients with respiratory complaints, but most other people are heeding the expert's advice and staying home. One side benefit has been a huge reduction in traffic and in car accidents. I'm used to seeing multiple car accident victims in a shift, but I've only seen 1 or 2 in the past three weeks. In general, we’re seeing fewer patients, but the ones that are coming in have been higher acuity.

Tragically, we've had a few patients that delayed coming in out of fear of exposure to COVID patients and were in much worse shape due to the delay in care. I would encourage anyone with serious symptoms not to delay coming in.
 
We're doing an excellent job of separating higher risk COVID patients from the non-COVID patient population.
 
Dr. Shephard: How is the morale in the ER among your colleagues since COVID?
 
Dr. Rao: In the ER we deal with crises all the time. For example, anytime there’s a hurricane potentially coming through, we have to prepare. And we've faced other outbreak scares in the recent past like Ebola, SARS, and the Zika virus, but this crisis has been very unique, especially considering how long it’s been dragging on. We were all hearing about what was happening in China, Italy, and then in New York with the reports of healthcare workers getting sick. So understandably, my coworkers and I were very concerned.
 
We were all still coming to work to do our jobs, but there was definitely a lot of fear and anxiety initially, and the tension was palpable. However, emergency departments are remarkably adaptable. We are doing everything we can to protect ourselves and to avoid becoming the next New York or New Orleans. As time has passed, we have become more comfortable with our new processes and I think that fear and anxiety has diminished to some degree. But still, there remains a background low-level anxiety which ramps up when a sick COVID patient comes in. And the concern about a possible surge or nursing home outbreak still exists. So we have to remain vigilant and not let our guard down.
 
Dr. Shephard: And, initially, you don’t even know which patients may have the virus.
 
Dr. Rao: Yeah, unfortunately, people don't come in with a sign that says, 'I have COVID-19.' Many patients present with fever or cough due to conditions that are unrelated to COVID. What's even more challenging is that COVID patients can present with a range of other symptoms such as diarrhea, loss of taste, altered mental status, and some are completely asymptomatic and coming in for a totally unrelated complaint. It’s not until we fully evaluate them that we get a clearer picture. That’s what makes our job in the ER different than most other specialties, being that they have much more diagnostic information available from the beginning.
 
Dr. Shephard: And, you have come into very close contact with COVID patients?
 
Dr. Rao: Yes. I had to intubate a patient recently because they weren't breathing well. We are now using a special transparent box that is placed over the patient’s head to reduce our exposure during high-risk procedures like intubation. I’ve done hundreds of intubations in my career, but when you know you're in a very high-risk situation for virus transmission, you're wearing all this extra gear, you have a very sick patient in front of you, and you're trying to manipulate the endotracheal tube inside this box, it's definitely stressful.
 
Dr. Shephard: Speaking of stressful, I know that you as President of the Hillsborough County Medical Association (HCMA) have been involved in starting a new program to help with physician burnout.
 
Dr. Rao: This is something we’ve been working on for several years and are very excited to be able to provide to our members. Physician burnout has gotten a lot of much-needed attention as of late and many hospitals have responded with lots of great programs. However, unfortunately, there's still a huge amount of stigma associated with mental health issues and many doctors fear some form of professional repercussion if they are discovered to be struggling with a mental health issue. Our program through the HCMA provides members with 24/7 access to completely confidential counseling and other services and has no affiliation with their workplace, providing an extra level of anonymity. So we have removed this barrier for physicians seeking help.
 
Dr. Shephard: And, COVID has added even more stress on doctors?
 
Dr. Rao: Yes, COVID has completely changed the conversation. In place of feeling overworked and overwhelmed, like the rest of the country, many physicians today are facing significant financial stressors. With no elective surgeries being done, fewer office visits, etc., many physicians are concerned about being able to cover their overhead costs and paying their employees among other things.
 
Dr. Shephard: Given that a vaccine appears to be a year or more away, how do you see society changing?
 
Dr. Rao: It’s really hard to say at this point. Some have discussed the possible 'death of the handshake.' Even riding in an elevator seems different. I live in a high-rise and have noticed that people are more afraid to interact with each other. I think there will continue to be a lot of fear especially among the elderly and in people with underlying conditions. I also have concerns about the possibility of a second wave, especially after the summer (which may temporarily slow the pandemic down) when the cooler weather returns. Without a vaccine or better treatment options, a huge part of the population will remain susceptible for quite some time.
 
Dr. Shephard: And how has the virus impacted your family and colleagues?
 
Dr. Rao: It’s been challenging for us all but in different ways. Some of my colleagues have rented places and are staying away from their families to avoid exposing them to the virus. Some are single parents and have been struggling with balancing work with home-schooling and childcare. Personally, I'm quite fortunate that my fiancee, Sheila, also works in the emergency department, so we have continued to live together and that's been a blessing and we don't have children to worry about. However, I'm a very social person by nature and am extremely close to my parents, my sister, my niece, and my nephew, and my friends and I haven't been able to be in the same room with any of them for over a month now. FaceTime calls have helped, but it's not the same thing. Social distancing has been especially hard on my mom. Her grandkids are her life and it was a real battle at first to get her to understand that she could not babysit anymore, especially given that she is over 60 and thus at increased risk.
 
Dr. Shephard: Given all the uncertainties surrounding healthcare today, including COVID, what advice do you have for students considering medicine as a career?
 
Dr. Rao: COVID is creating new opportunities in care coordination and?an explosion in telemedicine. The field of medicine is not going away and will continue to be a rewarding career path in my opinion. But, the day-to-day practice of medicine will continue to evolve as it always has. I foresee more and more utilization of telemedicine, remote monitoring, wearable biometric technology, and utilization of artificial intelligence to name a few. There will always be a need for great clinicians and physicians will always play a central role in making sense of an ever-increasing amount of information and data.
 
Dr. Shephard: It sounds less personal.
 
Dr. Rao: There are plusses and minuses for sure. We’re social animals, so I believe there will always be a role for direct human contact. But we've also become more and more accustomed to using apps and tech to manage our lives. I think many patients will enjoy being able to get expert medical advice on their phones instead of having to come in for an appointment. There's definitely a convenience to it for patients.
 
It's up to us as medical professionals to figure out how to incorporate this new tech into our practices and still somehow maintain that personal, human touch. The field of medicine has always been 'a calling' and attracts smart people who want to make a difference and serve others. I believe there will always be a place in medicine for people with big hearts.
 
Dr. Shephard: If you had to do it over, would you be an emergency room physician again?
 
Dr. Rao: I definitely would. When these crises come up, it reminds me of why I chose this field. It is one of the most essential specialties in medicine and vital to a strong health system. Tampa is fortunate to have a lot of excellent emergency physicians in this community.
 
Dr. Shephard: Do you have any final thoughts for how the public can be helpful to healthcare providers?
 
Dr. Rao: There's no question that social distancing has helped flatten the curve in our area. I appreciate the efforts of [Tampa] Mayor [Jane] Castor and many other leaders in advocating for the 'Safer at Home' campaign. I would encourage people to continue to avoid large gatherings and to maintain social distancing precautions. In general, I feel that our community has really risen to this unprecedented challenge. I would love to see people continue to look out for one another, to support their essential workers, and to not allow fear to overcome kindness and compassion.
 
Dr. Shephard: Thank you, Dr. Rao. Stay well.
 
Dr. Rao: Thanks so much, Dr. Shephard.

Dr. Jayant Rao, an ER doctor at St. Joseph's Hospital in Tampa and other BayCare Health System hospitals in Hillsborough County, is president of the Hillsborough County Medical Association. Dr. Bruce Shephard is a retired Tampa Obstetrician-Gynecologist and Affiliate Associate Professor, Department of Obstetrics and Gynecology, USF Health Morsani College of Medicine. 

83 Degrees Media's series on local physicians working in the time of COVID-19:



 
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