In March, Dr. Nick Johnson (above left), a physician in the Emergency Department, Medical Intensive Care Unit and Neurocritical Care Service at Harborview Medical Center, contributed an article to Prevention describing What Life Is Like Inside a Seattle Emergency Department During COVID-19.
We caught up with Dr. Johnson to learn what he and colleagues have learned over the past weeks, what he wishes more people would understand about COVID-19, and why practicing emergency medicine at a place like Harborview is so special.
In your piece for Prevention, you said, “this is an unprecedented time, and we’re figuring it out as we go along.” What have you learned—about COVID-19, about your colleagues, or about yourself—over the last weeks that you didn’t know at the time of writing?
So much. We have, in some ways, entirely changed the way we practice medicine and protect our colleagues and ourselves.
In other ways, we’ve learned that a lot of the fundamental tools we’ve used to care for patients with similar diseases still apply. Most importantly, I’ve learned that we have a tremendous capacity to come together as a team and accomplish amazing things under intense pressure.
How have conditions changed for you and your colleagues over the past month?
We have been fortunate in that the volume of people who became ill in Seattle were not as high as other places in the country, like New York. Because our surge was relatively early, we had an intense period of preparation where we, before anyone else, had to figure out how to test and care for patients with COVID.
We’ve seen good effects from the physical distancing efforts in our region, and are now figuring out how to return to some version of normal operations while still maintaining infrastructure to care for patients with COVID, which we know will be around for quite some time.
Back in March you shared a photo of the second round of COVID-19 airway simulations. Can you share more about the component of “practice” that goes into your work and what “real experiences” have taught you and your team?
Practice and simulation were an important part of our preparation. Some of the things we learned to do, such as placing a breathing tube while using high-level personal protective equipment, happened relatively infrequently before COVID-19.
We have a simulation expert in our department, Dr. Liza Rosenman, and an amazing simulation facility in UW WISH, where we were able to practice some of these skills as we were also learning to do them in real-time. Additionally, Dr. Rosenman led simulations in the hospital so we could test and refine our processes and equipment.
What’s the most challenging part of critical care and emergency medicine? During COVID-19?
The crux of emergency medicine is picking out who truly is sick enough to need hospitalization. Because COVID was entirely new to us, we didn’t have a complete understanding of which types of patients needed to be in the hospital, and rapidly had to develop approaches to this.
In critical care, a consistent challenge is making sure we’re aligning the care we’re providing with the goals of the patient. Because the patients are critically ill, we’re not often able to speak with them, so we rely on family and friends to help us learn about them. COVID-19 has required us to restrict visitors in the hospital, so we’ve had to move to other forms of communication, making these conversations more difficult.
We also strongly believe that family presence is an important part of ICU care, and not having family at the bedside has been a difficult part of this pandemic.
How does a COVID ICU differ from a “regular” ICU?
The biggest difference is the level of precautions we must take to ensure staff stays safe. We use special masks, eye protection, gowns, and have trained observers, that we call “dofficers” who ensure that nurses and physicians appropriately don (put on) and doff (remove) this protective equipment without contaminating themselves or the environment. We’ve also changed many of our routine practices by limiting the numbers of people who go into patients’ room and maintaining physical distancing on rounds and in our team rooms.
What’s something you’ve taken away from the past months’ work that you wish more people could know or understand?
I think there’s a lot of rumor out there about what this disease is or how severe it is. It’s important for people to know that this is a new disease, and it can be particularly severe, even in young and healthy people.
It’s also important for people to understand that we have tools to support patients with this disease, as long as our hospitals can operate under normal conditions. Many of the scary stories of high death rates are a product of overwhelmed systems in certain parts of the country and world. This is why physical distancing, masks, hand washing and other public health sanctioned interventions are so important: so that we have capacity to care for the people who become critically ill.
What’s a misperception about your work at this time?
In some ways, things seem less busy because many of the routine things hospitals do are cancelled. Overall numbers at most hospitals are down. But the doctors and nurses, especially those in fields most involved with COVID care, are extraordinarily busy.
Even small numbers of COVID patients, because of the intensity of care that’s required and the amount of time spent protecting ourselves with each interaction, are extremely time and resource-consuming.
What made you want to study medicine?
I’ve wanted to be a physician since I was a kid. I think it was originally a combination of wanting to truly make a difference, help people, and figure out challenging problems. 10+ years into my career, the reasons are about the same.
How did you come to specialize in critical care and emergency medicine?
I really like the fast-paced environment of the emergency department, and the central role it plays in the healthcare system. We see everything and everyone, 24/7/365. I found myself also attracted to deeply understanding physiology and enjoy being with patients and families during critical moments, so critical care was a natural extension. The combination allows me to use two different, but overlapping, skill sets and parts of my brain, at slightly different speeds.
What about the Harborview Medical Center made you want to work here? Are there specific aspects or factors that stand out or set it apart?
Harborview is a special place. It’s a county hospital and level 1 trauma center with mission that includes serving vulnerable populations, all with the amazing resources and staff that the UW provides.
You ended your Prevention article saying, “This will all end up in the history books in 10 years.” How would you like UW’s role to be remembered?
I hope that UW is recognized for its regional and national leadership at the beginning of the pandemic.
Because the Seattle area saw some of the first cases, my colleagues developed some of the first and most robust testing and clinical care protocols, many of which were shared widely throughout the country.