Care during COVID-19: Three OB/GYNs share their stories

Transcription:

Prakash Chandran: Throughout the COVID-19 pandemic, medical professionals have faced lots of challenges in the way they provide care. In this series, we'll hear from three OB-GYNs as they share their stories of what it's been like to practice as an OB hospitalist during COVID-19. These discussions occurred at different times during the pandemic. So it's interesting to listen to these stories now, as knowledge and experiences with COVID-19 have changed.

This is the Obstetrics Podcast from the OB Hospitalist Group. My name is Prakash Chandran. We first spoke with OB hospitalist, Dr. Melissa Larsen in July 2020. So Dr. Larsen, as a California-based OB-GYN, I understand that you cared for some COVID-19 positive patients really early in the pandemic. What was it like to care for some of those patients so early on?

Dr. Melissa Larsen: It was challenging for all of us, because we were going off of protocols for treating people who had other types of airborne and respiratory illnesses. But we didn't really know how it would affect pregnant women, how it would affect the babies and we were learning as we went in terms of what were best treatments. We have used personal protective gear in the past, but having to use it as much as we were using it was a challenge to know when to use the N95, when it was okay not to be using the N95 or the PAPRs, which are the more like spacesuit-type protective gear that are a closed breathing system where when women are undergoing anesthesia or something like that, it's thought to reduce the risk of COVID transmission.

Prakash Chandran: So now that we're a couple of months into the pandemic and California is seeing an increase in patients, what have you learned that has helped you as a hospital-based OB provider?

Dr. Melissa Larsen: In terms of COVID, I would say the majority of women have mild illnesses. It doesn't seem to affect them worse just because they're pregnant. The data hasn't really shown that. So when we're making a new diagnosis of this, there's a lot of anxiety for the women. So we try to be reassuring. For the women who do have the more severe cases that require hospitalization, we know so much more about maybe giving them steroids, dexamethazone, supporting their airways, trying to delay intubation for as long as possible and how to protect ourselves.

I work at different hospitals. And I think that the goal for everyone is to get to the point where all people who are coming into the hospital for any reason get COVID screening. Not all hospitals have that bandwith. So when you don't have that, even the hospitals where you do have it, you have to treat everyone as if they could be potentially positive.

Prakash Chandran: Yeah. And I was just going to ask you about screening. You know, you mentioned that some hospitals are screening all of their patients. Do you think that universal screening is the way to go?

Dr. Melissa Larsen: Yes, I do. Absolutely. Until we get the vaccine, we need to be able to screen. And for academic reasons, sometimes getting the antibody test is helpful, but we don't really know what it means if people show immunity to it. We don't know how long that lasts for and whether or not they are truly protected from reinfection. So right now, we have to go with the antigen screening and do it as often and as frequent as we can. Especially for frontline workers, I think that it's important that we have access to that type of screening.

Prakash Chandran: Absolutely. One of the other things that I wanted to ask you was, with all of the various visitor restrictions that are in place for OB patients at hospitals, have you noticed that some patients are kind of reluctant to disclose whether they've been exposed to COVID-19?

Dr. Melissa Larsen: Yes. We have experienced that in different places. And now, most labor and deliveries, there's like a preliminary thing when they come in, they're kind of like, "Have you been sick? Have you had a fever? Have you had a cough?" and stuff. But then there's a more detailed list of questions that people get asked even like asking if you've been to any social gatherings; about other people in the home, do they have COVID or have they had COVID and stuff. Because we've had a couple of situations where women have come in and their support person has been COVID positive, but they so much wanted to have the support person there that they weren't readily forthcoming about it. And then early on, sometimes the support person would maybe not have a mask on and stuff. And so you end up unintentionally having more exposure.

Prakash Chandran: Yeah. You know, it feels a little unfair that those support people may not necessarily always disclose the truth because I know they want to be in there with them, but they have to be mindful of the frontline workers like yourself that are taking care of people every day. And for them to be exposed is very dangerous for multiple parties. So do you have any advice around how a support person might still be able to be there for their loved ones?

Dr. Melissa Larsen: Yeah, I would say that there are ways, even if you're not in the room, to be there with the person who's laboring. We have some doulas who are, you know, labor support folks who actually Zoom with the woman the entire time that she's in labor and they have headsets and listen to her and it actually has gone okay.

Prakash Chandran: Wow, that's amazing!

Dr. Melissa Larsen: Yeah. I mean, Zoom is like the new thing, right? But you have to be respectful of the environment that you're going into. And if you are COVID positive or you think that you may be having any symptoms, you really should disclose it.

Prakash Chandran: I want to shift the focus to you personally. And I want to hear a little bit about what it's been like to practice medicine during this pandemic.

Dr. Melissa Larsen: It has been isolating. My children are older. One's in their late twenties. The other ones is in their early thirties. They both live in San Francisco and I live down here in Monterey County. I have not been in the same room with my younger son since mid-March. And usually, we would see each other more frequently than that. And my other son, I have not seen since the end of April. My older son is an ER nurse at Marin General and he's been on the front line, so we kind of consider ourselves both contaminated.

And so, yeah, I miss them. I really do. It's hard. I haven't been able to be with friends or even think about visiting my family on the East coast because they don't want me coming. And so, yeah, it's tough. I mean, I talk on the phone and we Zoom sometimes. It is isolating and you do the best you can.

Prakash Chandran: I really appreciate you sharing that. I think so many of us don't realize that frontline workers like yourself have families as well, and that unfortunately, to keep themselves safe, they choose to distance themselves from you. And so what that means is all you are exposed to is going to help others and then you come back to isolation and that must be really difficult. And if there's another provider out there like you listening to this, do you have any advice or tips for how to cope during this situation?

Dr. Melissa Larsen: I've tried to do some meditation. I planted a really big vegetable garden this year, so in another month, I'll probably have more tomatoes than I know what to do with. And I've worked on trying to make my home environment a little oasis, a little area where I'm safe and that's how I recharge myself.

I try to exercise. Just before this, my personal trainer and I, we Zoom. We Zoom workouts. So I saw her once since it started, but then everything started going up again. So that's kind of what I've been doing. And actually my person al trainer is like one of my links to the outside world. Unfortunately, you know, because you're in so much, for me, I start thinking about food a lot, you know.

Prakash Chandran: Yeah. I heard that all of us are gaining the COVID-19. That's the joke that's going around.

Dr. Melissa Larsen: Yeah. I'm not quite up there, but I think I've got about five. I've got at least five. Fortunately, the summer here in California has been nice weather. And when I come home, my garden has really kind of sustained me a lot.

One thing I want to commend you on is you are staying active. You're doing these Zoom workouts with your trainer. You're also creating this oasis for yourself, this vegetable garden. There's a lot that you're doing. And I think that's part of it, just really staying busy and staying active and just trying to make the best out of this situation. So I definitely commend you for that.

Prakash Chandran: As we close here, is there anything else that you'd like to share with people listening around what it's like to practice during this time? Or any advice that you might give to someone that might be coming into the hospital soon as an OB patient?

Dr. Melissa Larsen: Well, I think for the patients, they should know that we are fortunate that we do know more about this virus than we did, and we have some better treatment options to help support them. I think that we have protocols and procedures in place for protective gear and, at least at all the places where I've been working, we've had enough of the protective gear.

In terms of being a worker in this era of COVID, I would try to look at it as half full, not empty, to take pleasure in the moments of peer interactions of the community that you have of workers within the hospital. And how do you eat an elephant? You eat it one bite at a time, right? So you do what you can and take care of yourself. And that way, we can take care of her patients.

And I think that sometimes it gets too much for you or something like that. We're all human. I think that it's okay to say, "I need a break" or "I can't do something" and that's okay. And we all have different medical, personal issues too. So you have to take that into account as well.

I think it's sad that the rates are going up again. I think the data for masking is really strong, the scientific evidence. And I’m a doctor, so I do believe in science and I believe in Dr. Fauci and the CDC and all the fine work that they've done. And I think you can't mask enough and you can't wash your hands enough and you need to socially distance until we get a vaccine.

Prakash Chandran: Well, I think that's the perfect place to end. Thank you so much for that advice and your time today, Dr. Larsen. I really appreciate it. That's Dr. Melissa Larsen, obstetrician gynecologist at OB Hospitalist Group.

Next, we spoke with Dr. Sussanah Walsh, an OB hospitalist based in New Jersey in August 2020. So Dr. Walsh, it's great to have you here today. The first question I wanted to ask you is I understand that you work at a hospital in New Jersey, and I'd love to understand a little bit more about what it's been like for you to practice medicine during COVID-19.

Dr. Sussanah Walsh: It's been confusing, scary, and stressful, because this is a particular disease process that we know nothing about. We know more now, but we didn't know about how it would affect pregnant women. And I think that given how we nationally approached the pandemic, it was also scary for healthcare workers because people will still keep having babies and will need people to take care of them. So it was definitely a new experience. And I learned a lot about orchestrating basically public health efforts as well as about a new disease process.

Prakash Chandran: Wow. I can only imagine because especially when someone is giving birth that is closed quarters, there's a lot of blood and sweat, and there's just so much that you have to be exposed to, I mean, even throughout the process. So I'm curious as to just more details around how OB-GYN hospital care has changed as a result of this pandemic.

So one of the biggest, I guess almost fights I had in the beginning was trying to delineate the second stage of labor as an aerosolizing procedure. There was a lot of back and forth on it. And my goal was to protect my coworkers because here they are doing good work and it just didn't seem fair to them to not have the best protection that they could possibly have. So a lot of it has to do with just viewing the process as an aerosolizing procedure, implementing the protections that both the family and the healthcare workers need, and also trying to make sure that the mom, because labor and delivery is a very vulnerable time in a woman's life, still felt as though we were invested in her care.

And I did start at the one end of the spectrum, where I was really concerned about my coworkers, but slowly moved toward the middle where the delivery process itself is a place where the mom herself was very vulnerable and consider that we were offering these parents just things that we would never say to delivering mother in any other situation, such as "Would you elect to be separated from your baby initially?" "No, you can't have a support person in the room," things like that.

Yeah. It's such a delicate balance to strike and also to try to facilitate that personal connection that you normally can have with these mothers, as you mentioned at such a vulnerable time. I also understand, and I think you alluded to this, that you've been a strong advocate for just taking care of the staff and yourself. And one of the things that I've heard about is that you personally made special arrangements to keep your family safe from getting infected. I'd love for you to tell the audience a little bit more about the decisions and sacrifices that you've made to keep your family safe.

Dr. Sussanah Walsh: Well, you know, I wasn't completely on board with this, but my husband felt really strongly that we didn't know anything about this disease process. And here I was going into the hospital, breathing whatever air was being put out there, touching surfaces, everything. Initially, what I was doing was changing in the garage, throwing my stuff in the washing machine and heading for the showers. And I'd shower at work before I came home. And still, he was very, very worried.

And we didn't know how long this was going to go on. And here we are in August and we're still well deep into the pandemic. So initially, we had to talk, I said, "There's no way I'm doing that." And then I started to read more and think about it more. One night, I said, "Okay, you know what? We can talk about this." And then it kind of just sort of snowballed from there. And, ultimately, I moved out the next morning, went to a hotel and then found an Airbnb from there. So it wasn't something I was super happy to do. You know, I don't feel like wonderful for having done it. It's evolved from there. Eventually, we had a conversation and he said, "You know, this could go on for a year. You can't exactly live away from the kids for a year or two years or whatever." So as we're talking, I'm actually slowly packing up the Airbnb and getting ready to go back in.

Prakash Chandran: Yeah. I can't imagine what it's like to negotiate a situation like this, and it's something that the public doesn't really hear about, all the sacrifices that frontline workers need to make. Tell us a little bit about how this transition is going for you and how you go about getting support for yourself.

Dr. Sussanah Walsh: When we talked through it, it's not great for my kids for me to be away. Initially, I didn't see them at all except for FaceTime. And then I would talk to them through the fence. And then I said, "You know, I can't do this, Rob." Rob is my husband.

So now, we're at the point where I hang out with them in the backyard. I wear a mask in the house and I'm going to have to wear a mask in the house for God knows how long and sort of isolate myself to one area of the house, at least that's what he asked. And I said, "Okay, we’ll keep the pieces of what we'll do, because I surely don't want to get anybody sick."

As far as the support goes, you know, I ask colleagues, but I got to tell you, it was really, really, really, really hard.

Prakash Chandran: Yeah. Thank you for sharing that story. I appreciate it. And I can't imagine how difficult it is, but I just want to thank you for everything you and your staff are doing to help us and just the sacrifices that you're making.

So obviously, a lot has changed for you at work and providing maternal care. Do you think any of these changes will persist past COVID-19 in obstetrical care?

Dr. Sussanah Walsh: Once you go through this, I think there's always some little element of, I guess I'd call it PTSD. Now, you kind of have to think, "Well, gosh, am I going to catch something from this patient to bring home to my family?" it Really affected, I think, the provider-patient relationship. But I am old enough to remember the tail end of the HIV and AIDS epidemic. What I really wanted to try to avoid was I remember what a stigma that was for people at that time. And I really didn't want that to happen and affect the relationships that we had with patients go round.

Prakash Chandran: Yeah. That balance is tough. Just as we close here, there will be OB-GYN physicians who are listening to this who have not encountered COVID-19 positive patients. What advice might you have for them?

Dr. Sussanah Walsh: Try to know who the vulnerable populations are in your area. Try to know what the prevalence of the disease is in your area and keep an eye on your own hospitals for disease prevalence, because then you know what to start looking for. Take the public health precautions seriously. Wear a mask. Observe social distancing.

One of the things I really kind of get perturbed about is this is not the year to go on vacation. You know, I know we're all itching to get out of our houses, but I think one or even two seasons without a plane ride or a vacation to somewhere isn't going to hurt anyone. I think austerity now allows for a shorter time to permissiveness in our way of life later on. The more we focus on what we need to do, what we want to do right now, it will affect how soon we can get back to normal life.

Prakash Chandran: I certainly think that is very good advice. You know, everyone out there, do take this seriously. Hold off on those vacations and, yeah, just be safe out there. Dr. Walsh, is there anything else that you wanted to share today before we close?

Dr. Sussanah Walsh: Good luck to everyone. And the flu pandemic in 1918 ended. And that's what I just keep thinking. You know, that pandemic ended, this one will too, eventually.

Prakash Chandran: Yes, I believe so, too. So thank you so much for your time, Dr. Walsh. I truly appreciated. That's Dr. Sussanah Walsh, OB hospitalist at OB Hospitalist Group in New Jersey.

Our last guest was Dr. Edward D. Allen Clark, an OB hospitalist practicing in Tyler, Texas. So Dr. Clark, it's great to have you here today. Tell me what exactly has it been like for you to practice hospital-based obstetrics during the pandemic?

Dr. Edward Clark: Well, definitely things have changed prior to the pandemic. I think it presents a new set of challenges for us, some good and some bad. As far as the hospitalists at this point, we have to go into every patient encounter as if patients could potentially be an asymptomatic carrier of COVID. And so with that, again, the challenges there is certainly taking the recommended precautions that we've, for the most part, have been doing even pre-pandemic with exception of the mask wearing, but certainly the hand sanitizing and then definitely the distancing from the patient. And I think that for me has been the biggest thing that I've seen in terms of the changes prior to the pandemic. But as far as any additional challenges or anything like that, for the most part, for us, it's been the same, because again, we still practice the same way.

Prakash Chandran: Absolutely. And you know, one of the things that I saw is that you delivered a COVID-19 patient early on in the pandemic. What was that like?

Dr. Edward Clark: Well, I'm pretty certain that the distinction of being the first obstetrician to deliver a COVID-positive mom in the state of Texas. And with that, I think the biggest thing for us, this happened back in March before or right around the time of the shutdown in the country. And so we didn't know a lot about COVID-19 and so, again, it was the unknown that we were dealing with and I think it was very fearful. And at the time, you get COVID and you equate that with not a good outcome. And it put everyone on edge and put myself on edge, the nurses, staff on edge. And certainly, I'm sure the patient as well.

Fortunately for us, this was a known COVID-positive patient. So we knew that this patient existed. I just happened to be on-call when she came into labor and her water bag ruptured. And I think the key to all of that and why it ended up being a successful outcome is the preparation that the hospital had.

Again, I think the knowledge of knowing the patient was positive allowed us to put a plan in place should she, and then subsequently any other patients that came in that were COVID positive to be in effect. And so the preparation was key. We reviewed things beforehand. And fortunately, unfortunately for me, the patient came in, the water ruptured. But we had a plan in place and it worked well.

Prakash Chandran: Yeah, that's incredible. And I think one thing that people don't realize is during delivery, there's just so much blood and sweat and all of these different factors that can scare people on the frontline, like yourself around getting exposed to COVID-19. But it sounds like with all of the measures in place and with the preparations, like you said, you're able to avoid that and deliver safely, isn't that right?

Dr. Edward Clark: Absolutely.

Prakash Chandran: Fantastic. So just speaking about those measures in your experience specifically, what exactly has changed in the hospital since the beginning of the pandemic to now?

Dr. Edward Clark: Well, again, going back to what I said before about not knowing a lot about that the disease process and how it affected pregnancy or just us in general, things, as we know more about it, some of the things that we've done in the past, we've now changed to reflect the knowledge that we have now.

For example, with this patient, obviously we were taking all the normal COVID precautions and so forth, including wearing all of our-- in my case, I wore PAPR and so forth and all the equipment that we use. But this patient, because of her situation and because we didn't know much about COVID at the time, she was pretty much isolated.

And so there was no family members there. For the most part, she was able to see her baby once it was delivered for a few minutes, and then she was separated. And the baby was not allowed to go home with her, it had to go home with another family member that was COVID-negative. So now, when we come across the same situation, the patient can still have a family member in the room with her. The baby stays with her and can go home with her now. So that's a big change from six months, eight months ago.

Prakash Chandran: Absolutely. You know, still through all of this, people have this apprehension about going to the hospital for any sort of care at all. So I'm curious for you, do you think your patients have heightened fears about delivering a baby or coming to the hospital for obstetrics care during the pandemic?

Dr. Edward Clark: Absolutely. For the most part, I think everyone's idea of frivolously going to the hospital has changed. I think if you look at just pure numbers in the hospital, I'm sure that most hospitals can say there's been a decrease in patients arriving into the emergency departments and no longer did you just get the normal colds and flus. The most patients now that are presenting to the emergency departments are usually sick or sicker patients. So I think we are all using some precaution when it comes to going to the hospital. Certainly, no different for a pregnant mom, but she's first going to look out for her baby.

And so you definitely have different patients on different spectrums. You do have patients that are overly cautious and want to avoid the hospital at most costs, and I shouldn't say at all costs, but most costs, but understand and trust the healthcare professionals. You also are going to have patients that want to limit their exposure and feel like that hospitals can be an unsafe environment for their pregnancies. In fact, I had a patient today that came in and she actually had transferred her care from an obstetrician to a midwife because she didn't want to go to the hospital because of COVID fears. So you're going to definitely have some different perspectives. Then you're going to have patients that -- Well, this kind of reflects the divide in the country right now -- but you're going to have patients that don't believe that this is as serious as it is. And for the most part, their views don't change and it's business as usual for them.

Prakash Chandran: Yeah, absolutely. And I also think there is the whole nature of connection and establishing this very human connection with the patient behind all the PPE. Have you found that to be challenging at all?

Dr. Edward Clark: So from a hospitalist standpoint, again, we have to go into every room and assume that the patient could potentially be positive. And so again, yes, we are going to take the normal precautions, including wearing our PPEs and most hospital systems do require patients during that interaction to protect themselves as well. I think it's becoming the new norm. I think initially we were all a little bit uncomfortable, both healthcare professionals and the patients. But I think as time goes on, I think it's becoming the newer norm and patients are more accepting and less fearful. And I think everyone's aware as to why we have these things in place and it's not only to protect ourselves, but it's to also protect them as well. And I think most people are appreciative of that.

Prakash Chandran: So for you, has it been a good time to be practicing as an OB hospitalist rather than a private practice physician during this pandemic?

Dr. Edward Clark: I think that they both have their advantages in terms of an office-based practice versus a hospitalist. Though certainly from a hospitalist standpoint, I think the risks are the same. I think that for the most part though, coming from both sides of it, I think that with my office-based practice, I know my patients and I probably feel somewhat more comfortable in that setting and it works both ways. Whereas when you're dealing again with unknown, unknown patients unknown carrier status and so forth, it can be a little bit more challenging. But is it a detriment? I don't think so. I mean, I think that as a healthcare professional, we're kind of wired to take care of what's in front of us. And to provide the best care possible. So from a hospital standpoint, I do think that it definitely has advantages because, again, you're helping someone. In our case, from an emergency standpoint, you're helping that person in that situation. So I think definitely, it has an advantage as well.

Prakash Chandran: Yeah, that makes a lot of sense. So just as we close here, is there anything else that you want to share with our audience about operating as an OB hospitalist during this time?

Dr. Edward Clark: Again, I just can't reemphasize that planning is key and to have a plan in place. Each hospital system, I'm sure at this point, especially in labor and delivery settings now have a set plan in place. Having delivered that patient early in the pandemic, the system I was in is a very large hospital system in North Texas. And so we were able to take that experience and develop some protocols throughout the system. So I think planning is key, you know, and having a plan in place and knowing what to do, and even for the most part, having some sort of drills within the department, so everyone's on the same page when something like this comes up and I think that's key.

I think the second thing again is educating your patients and the healthcare staff, as well as to what to expect and how to handle certain situations. For me, I've probably now encountered at least five other COVID-positive pregnant patients. And only that first one was known. So again, going into the situation with taking the recommended precautions, I think is very helpful because you never know. And again, I think most patients and certainly the healthcare providers appreciate that, you know, that we're all trying to protect each other. But at the same time, trying to provide the best care possible.

Prakash Chandran: Well, I think that is the perfect place to end. I really appreciate your time today. This has been super informative. That's Dr. Edward D. Allen Clark, an OB hospitalist practicing in Tyler, Texas.

For more information about OBHG or to join the OBHG team, please visit OBHG.com. If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. This has been the OB Hospitalist Group podcast series. Thanks and we'll talk next time.