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Monday Apr 06, 2020

Pandemic Highlights the Need for Full-scope FPs

When the COVID-19 crisis arrived in Boston, family physicians were among the first to mobilize. Family medicine attendings were pulled from clinic and dispersed to work on inpatient medicine floors and to cover additional obstetrics backup. As someone relatively young and healthy, and with school-aged children who are relatively independent, I was assigned to lead a COVID-19 team at my 300-bed safety-net hospital.

[headshot of MaryAnn Dakkak, M.D., M.S.P.H.]

The learning curve has been steep and complicated, with changing algorithms and recommendations. When I started that week, I preferentially placed our first pregnant patient who tested positive for COVID-19 onto my service. My reasoning was this: one exam, one exposure and done.

I am a board-certified family medicine physician with a fellowship in surgical and high-risk obstetrics. With my inpatient and obstetrical training, I am well trained to provide this level of care in concert with maternal-fetal medicine and infectious disease by phone.

By my patient's third day of hospitalization, she required intubation. She held my hand tightly as they pushed the propofol to sedate her for intubation. In just a few seconds, she was asleep, her hand let go and the tube was in. Her O2 saturation jumped to 99% and, while I didn't say anything, I felt a weight come off my chest. My previous patient who had to be intubated hadn't made that jump and did not recover.

"I'm from the OB team," I had explained to the ICU and anesthesia teams when I came in. "She was my patient on my medicine team yesterday."

They nodded. They knew me from both places; it made sense. It just was the first time we were intubating a pregnant woman with COVID-19 multifocal pneumonia in our ICU. I had operated with the same anesthesia team just weeks before during a cesarean section. With the intubation finished, I helped the nurse get the patient in restraints and positioned while I also slipped the nonstress test monitors to trace the fetal heart rate and contraction pattern. Doing an NST takes at least 20 minutes. All in all, I spent 40 minutes in her room that night. The previous day, with the rounding and then the rapid response when she needed to have additional oxygen and was sent back to the ICU, I had spent upward of an hour and a half with her.

Per our COVID-19 guidelines, we are to wear an N95 mask if we are spending extended periods of time on a confirmed patient's care, and this certainly qualified. I imagined what the patient's treatment would have been like under normal conditions: During morning rounding exams she would have had a separate fetal nonstress test from a nurse, a separate obstetric exam, a separate medicine exam and then repeated the whole sequence with the rapid response. With her COVID-19-positive status, that would have meant tripling exposures. Family medicine has long been able to provide comprehensive care with lower costs and streamlined care,(www.annfammed.org) so the solution was simple. I went in, did the full obstetrical and medical history and exam, and did the NST.

When I left her ICU room with the patient intubated, I chatted with the ICU attending about typical lab results in pregnancy and how they can differ from those in nonpregnant patients, blood pressure control in pregnancy, and the fact that under no circumstances would we hesitate to provide her any life-saving medication and intervention. As I finished there, I went back to labor and delivery to continue my shift. I delivered a baby. And later that night, a man who had needed intubation on my COVID service three days earlier died.

I send many more people home with COVID-19 than I have kept inpatient, but it's the ones that I've kept that stick with me. And after a post-call sleep day, I started back on the COVID-19 medicine inpatient team. It is also precisely why I trained the way I did, to be able to take care of the whole person at any point in their life, in the hospital or outside of it. As a family physician, I am trained in inpatient medicine, the ICU and step-down units. To be honest, I have never done as many arterial blood gases as I have done recently, and it is fortunate that I am so well trained for it. I have done more ABGs in the past week than I'd previously done since I started residency in 2011.

Additionally, my training in obstetrics makes care of the prenatal, postpartum and antenatal patient second nature to me now. With my additional training in ultrasound and high-risk obstetrics, in a regular month, I manage patients with gestational hypertension, gestational diabetes and twin pregnancies. I also perform cesarean sections, tubal ligations, vaginal deliveries and complex repairs.

I do inpatient medicine as a hospitalist about eight weeks a year, caring for adult medicine patients. I understand the nuances of medications and physiology of pregnancy, without hesitation or fear of treating them. I am working to create a COVID-19 team staffed by family medicine and OB/Gyn residents that will encompass prenatal, antenatal and postpartum women to streamline their care. My goal is to staff this team with family medicine residents, as well as their OB/Gyn resident colleagues, to build partnership and common training and to break silos between the practices. As we take care of these vulnerable populations with our unique training, we can give them higher-quality care and advocate for them in the health care system. In a safety-net hospital with patients who are experiencing homelessness or living in shelters or multifamily dwellings, it is more important during this pandemic to provide comprehensive training on how to care for them.(www.researchgate.net)  

Although my face hurts and shows the mark of PPE, which I am so grateful to have, I know that my expertise will also inevitably increase the duration of my exposures. I have chosen to send my family away to live with my parents while I work. Although many friends have fewer work hours or are working from home, my hours are only increasing, and I am working hard to maintain a balance so that I still get days off to relax, to garden, to write and to exercise.

I do cry, just a little every day, to let the pressure out of everything I am seeing, learning and holding. Otherwise, I am doing exactly what I always wanted to: practicing full-spectrum family medicine at a time when, more than ever, our country needs it.

MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is an assistant professor in an academic hospital center in Boston. She is also women's health director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.

Posted at 04:27PM Apr 06, 2020 by MaryAnn Dakkak, M.D., M.S.P.H.

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