Dr. William Chiang is a native New Yorker who moved to California last year for a fellowship in wilderness medicine at UCSF Fresno. On April 12, he flew home to serve as a daily volunteer in the emergency departments of several New York City hospitals until May 7. On April 17, after four consecutive nights of 12-hour shifts, he shared his impressions of a healthcare system beginning to emerge from crisis.
Star-Revue: How did you decide to volunteer in New York?
Chiang: I grew up in Queens. I went to school in Manhattan. I went to med school in Brooklyn, and I went to residency in the Bronx. Every person in every aspect of my life has been affected by coronavirus, either through work or personally. So my social media was just inundated with that kind of information. There were nurses that I had worked with who were protesting, and I found out that one of my residents had ended up in the ICU, and we had a neurosurgeon at one of our hospitals that passed away. It was seeing people from my own hometown being afflicted by this illness and feeling helpless in Fresno that compelled me to come back.
Star-Revue: What have you been doing so far?
Chiang: I arrived on Sunday. I went to one of the hospitals on Monday and got credentialed, and that day they told me, “Hey, put on your scrubs. You’re going to start working now.” So that was kind of a running start. The first couple days was more shadowing, but mainly I was seeing my own patients, and then if there was any question as to how to do the process of admitting, discharging, or transferring patients, I would just ask anyone else who had slightly more experience with that system.
I’ve been involved with every aspect of care. I don’t know if you’re familiar with this, but most hospitals right now, in their emergency departments, are divided between “cold zone,” which means people who are not under investigation for COVID, and then “hot zone,” which is people who likely have COVID but have not had the test results. And then there’s a “critical zone,” where people are imminently dying, and if you don’t attend to them within minutes, they would pass away. I’ve worked in every section so far and dealt with the spectrum of non-sick patients, people who don’t have COVID, people who have COVID, and people who are actively dying.
Star-Revue: When a patient comes in with coronavirus, what do you do for them? What’s the standard procedure?
Chiang: When you say “a patient comes in with coronavirus,” that is a presumption. We don’t have test results that come in that quickly. The fastest I’ve ever seen was hours. Maybe if we’re doing the point-of-care testing, we’ll have something on the scale of seconds. But basically what people come in for is two things: either exposures to coronavirus, or they have a flu-like illness that resembles either coronavirus or any other viral syndrome. If you came in with the same coronavirus symptoms last year, I would’ve told you you had the flu. So a patient like that, with any viral syndrome, is treated exactly the same way: they’re treated supportively. If they have a fever or they’re dehydrated or they’re in renal failure, we try to support that system in order to keep body functions so they can fight the infection themselves.
The thing about coronavirus that everyone’s terrified about is that there’s a certain subset of patients that start accumulating fluid in their lungs. And we call that ARDS. And when they accumulate fluid in their lungs, they’re unable to oxygenate, and the only supportive measure that we can do for these patients is to provide oxygen. If your lung is full of fluid, you can’t get oxygen into the blood because the fluid is a barrier, so you’re going to work extra hard. Any muscle will fatigue after a long period of stress. You breathe with a diaphragm, and the diaphragm will fatigue, so that requires a ventilator to support the diaphragm to help the lungs expand. So that’s the limitation: when a patient comes in critically ill with their lungs full of fluid, they need a ventilator, and that is only way to keep them supported until they can fight their way through the illness.
When it comes to actual therapies, everything for this particular virus is investigational. I know the FDA is talking about hydroxychloroquine, plaquenil, azithromycin – those have not been proven yet. I know certain hospitals are administering those medications, empirically, but there is a lack of evidence basis for that, so it’s always recommended with caution.
Star-Revue: Do the hospitals have the necessary equipment to offer adequate treatment to everyone?
Chiang: I have arrived at the intersection of when cases are starting to come down and shipments of ventilators have gone up, so I haven’t had any issues obtaining a ventilator. From what I understand, during the peak last week, there was a lot fewer ventilators, and there was some triaging in terms of rationing those ventilators.
But also I’ve noticed that there’s been a more frank approach to goals-of-care discussions with patients, so that’s another interesting point: if a patient is not likely to benefit from a ventilator – I’m sure you’ve seen on soap operas people saying they don’t want to be put on life support. This pandemic actually offered us this opportunity to have this discussion with patients who most likely won’t benefit from being on life support, and they sometimes just say straight out, “I’d rather not be on a ventilator. I’d rather go.”
Star-Revue: Are the hospitals providing the protective materials and procedures that are needed to keep doctors and nurses as safe as possible?
Chiang: That’s another thing where I think I’m experiencing something that’s very different from what it was a week ago. I think there’s been a huge outpouring of support in terms of the local communities providing PPE and then shipments coming from the government or just local friends. I think people have been judicious about their use of PPE, so the rationing has leveled out.
That doesn’t mean that PPE is not in short supply. Typically, PPE would be disposable after every patient encounter. The hospitals have adapted by saying, “If you never take off the PPE, that’ll be OK.” So instead of wearing 20 different gowns for 20 different patients that I’m working with, 20 patients will be in one room and I’ll wear one gown for the entire day to deal with those patients. So it’s just being more judicious, but that’s fraught. A month ago, if we had done that, the Occupational Safety and Health Administration would cite us and fine us because it’s a danger to patient health. But this is what we do in order to ration our supplies.
Star-Revue: What’s the emotional toll of this work like for you?
Chiang: It’s kind of sustainable in that I’m relatively fresh. The volume and intensity isn’t as bad as it was. I like to say that I’m here doing a sprint – I’m doing a bunch of shifts all together, but the New York City healthcare providers have been taking care of these patients for a month and half, two months, with this incredible acuity. So they’re at the end of their marathon, and I’m just here to push them along.
