By Jeong-Ho Hong, MD, PhD, Department of Neurology, Keimyung University School of Medicine, Daegu, Korea
Recently, I was working as a neurointensivist at one of the hub-hospitals treating COVID-19 patients, Daegu Dongsan Hospital (branch hospital) and one of tertiary hospitals, Keimyung Univerisity Dongsan Hospital (main hospital), in Daegu, South Korea. Daegu is the center of South Korea’s expanding COVID-19 outbreak.
Government-designated Hub-hospital for Only COVID-19 Patients vs. General Tertiary Hospital: A Neurointensivist’s Point of View
Currently, the main hospital is treating some COVID-19 patients in a limited number of negative-pressure rooms, while patients who are not infected with COVID-19 are also being treated simultaneously. Due to this situation, sudden closure can often occur in general wards, ICUs, emergency rooms or examination rooms.
Presently, all patients admitted via the emergency room are required to conduct COVID-19 tests. Nevertheless, two neurologists self-isolated for two weeks after treating an acute stroke patient who had no fever or COVID-19-related symptoms but later tested positive to COVID-19.
After the admission of infected patients, other struggles for medical workers begin with having to change in and out of protective suits every time physicians examine each patient. In addition, patients who are not infected with COVID-19 are admitted and examined with so many restrictions, like practicing tests such as brain MRI, which are not available for public use due to secondary infection problems.
On the other hand, the branch hospital is a government-designated regional hub-hospital to treat patients with only COVID-19 infections. So, working conditions at this hospital are a little better, and it also has safer environment. For instance, from the entrance door of the hospital, medical staff should wear personal protective equipment, including anti-contamination clothing (level-D protective suit) and powered air-purifying respirator (PAPR) to protect against invisible viruses.
As there is no need to wear and take off protective gear repeatedly, there is a reduced risk of infection, and various tests can be conducted without any restrictions whenever physicians want, since they are only used by COVID-19 patients.
Yet, the main drawback is that wearing a PAPR or a level-D protective suit makes it difficult to work long hours, as doctors and nurses get exhausted easily. It requires lots of strength to work in this kind of suit for such a long period of time.
The Role of the Neurointensivist for COVID-19 Patients
The hospital initially received patients with mild symptoms but is now using its ICU, too, with the recent rise of gravely ill patients. Consequently, The Daegu Medical Association recruited medical staffs, and the Korean Society of Critical Care Medicine dispatched intensivists and experienced nurses to the hub-hospital, regardless of their affiliation or region. Now they have implemented a collaborative approach for ICU patients with COVID-19 infection. Several weeks later, ICU team asked some neurointensivists to work together because ICU patients treated with ECMO, CRRT and mechanical ventilator had various neurologic complications. When I first went to the integrated ICU, one patient had epilepticus, and two other patients who didn't come to consciousness after CPR were already brain dead. More patients than expected needed detailed neurological examination and brain structure and functional monitoring, such as EEG and brain image.
Many ICU patients infected with COVID-19 have also neurodegenerative disorders, such as Parkinson disease, Alzheimer’s disease, or some motor neuron disease and cerebrovascular diseases. Delirium was another big concern in the early and recovery stage of ICU management. Dr. Mao from China reported that about one-third of patients infected COVID-19 have neurologic symptoms, and this is more common in patients with severe infection.
Severe neurologic complications, such as acute cerebrovascular disease and conscious disturbance, especially occurred in the later stage. Acute cardiac injury or sepsis occur relatively often in ICU patients with COVID-19 compared to other medical or surgical ICU patients. Therefore, neurointensivists need to step into the frontline of coronavirus battle field.
The Role of the Control Tower for COVID-19 Crisis
In the early days of setting up ICU, the biggest problem was the explosion of COVID-19 patients and their unexpected rapid deterioration, and the most important thing was the support of human and physical resources as soon as possible.
In this kind of situation, it is important for the academic societies and government to play the role of control tower in recruiting experts who can treat critically ill patients infected by COVID-19 from other regions, distributing them efficiently and identifying all critical patients in real-time.
In addition, cross-regional support of essential medical resources, such as ECMO, mechanical ventilators and PAPR were the driving forces behind the rapid treatment of COVID-19 patients.
Now, we also have to prepare to long-term battle against COVID-19 crisis. Exhausted COVID-19 fighters emerge as a foremost issue in drawn-out struggle. On the day I drafted this article, Daegu reported zero new cases. However, more than 1,400 patients are still being treated in isolation, many of whom are being treated in the ICU. Daegu citizens will soon return to their daily lives, but we have to stay to the end and treat them.