Diary of a Hospitalist

Giorgia Virgili (illustration)/Getty Images (photography)

Kate Knepper, ’93, is a hospitalist—a physician who specializes in hospital-based care—and one of many alumni around the world who are treating patients during the COVID-19 crisis. She lives in Fort Collins, Colo., with her husband, Gavin Polhemus, ’95, and their young adult son, Eric. We’ll be checking in with Knepper by email each time she gets a break from her hospital duties.

May 8

STANFORD: Did you get to take the full two weeks of vacation time? And what was the best thing you cooked?

Knepper: Yes, two weeks off. Now I’m back to it. The hospital is becoming busier again—I think people are a little less afraid to come to the hospital.

Best thing cooked: curried coconut halibut from Good Fish, by Becky Selengut. I highly recommend this cookbook, which focuses on sustainable West Coast seafood.

I see that Colorado is transitioning from a stay-at-home policy to a safer-at-home policy, and I also see that your county is ramping up outpatient testing for symptomatic individuals. Do you have a sense of what these developments may mean for you and your colleagues?

Colorado is indeed lifting some restrictions. Some people are going even further—gathering in groups, not wearing masks, etc. My health-care community is at a minimum frustrated, and even angry. We feel that the public doesn’t see what we do—the busy ICUs, people still dying. One of my partners had three patients die within 24 hours—he joked bitterly about feeling like the angel of death, when in reality he was doing everything he could to save them. We worry that with lifting restrictions we will surge.

Testing is supposed to be more widely available, but in reality it’s not. When testing centers open up, they’re rapidly swamped and run out of test supplies.

Since this is a novel disease, public health officials and scientific researchers are trying to learn about it at the same time physicians like you are on the front lines treating it. How does that affect your workload and patient care?

An exciting development is convalescent plasma [a treatment that includes infusing patients with antibodies from people who have recovered from COVID-19 in the hopes that they will boost patients ability to fight the virus]. Hydroxychloroquine is mostly discredited now, and we don’t have access to remdesivir, so this is something we can do that seems to help patients. Initially, we had to apply to the FDA for each patient requiring convalescent plasma—it was an expedited process, but still took over an hour of the physician’s time, per patient. Now we’re part of a study, and obtaining a patient plasma takes 30 to 45 minutes of the physician’s time (with the application process, obtaining informed consent, etc.). We have seen patients improve with this treatment, although it’s still anecdotal at this point; research studies are needed.

You’ve talked about the palpable support in the hospital—everything from appreciative families’ words to cartons of Girl Scout Cookies. What are the best ways we can support the health-care workers in our lives? What is not so helpful?

Girl Scout Cookies are lovely, but what we really want is for people to stay home. Follow the restrictions.

April 24

Knepper has been on staycation, so this week we bring you a guest post. 

Morgan McCarroll, ’93, is a pediatric anesthesiologist in Reno, Nev., where he lives with his wife, Nikki (Perrott, ’93), and their three kids, ages 20, 17 and 15. For more than a week, he has been working at a hospital in Newark, N.J., primarily intubating COVID-19 patients. 

STANFORD: How did you end up going to New Jersey?

McCarroll: We’ve had this combination of events in Reno: Elective surgeries have been indefinitely postponed; we’ve had minimal emergent procedures; and because we haven’t had a surge of cases yet, there’s no need for the anesthesiologists to step into intensive care unit roles or intubation teams. So my group unfortunately has had to institute unpaid leave and involuntary furloughs. And the people at one of our sister practices in New Jersey were just getting beaten up. They were having so many cases that they were having to work a much larger number of hours than usual, and after a few weeks of just getting hammered with work, the whole group became exhausted. This is really ground zero in New York and New Jersey.

I saw the effects of being furloughed on my three college funds, and thought, this is a total win-win opportunity. I can go out and help provide my colleagues with some relief when they really, really need it and help myself at the same time.

I can tell you it’s really rewarding being here.

Explain how anesthesiologists are helping during the pandemic.

What we do every day is a form of intensive care medicine. It’s a natural extension to step into a backup role in the intensive care units. Another thing we did was form intubation teams. To get a patient on the ventilator, you need somebody to put a breathing tube in their windpipe. And of course, that’s something we do 10 times a day. But with COVID-19, the concerns are about aerosolization [suspension of the virus in tiny airborne droplets] and the dangers of contracting the virus. So very specific safety procedures have been put in place, and the easiest way to implement them is to have a team: One person who’s actually doing the intubation. One person who’s an experienced anesthesiologist or nurse anesthetist who can assist with bringing extra equipment and, if necessary, extra drugs. And an anesthesia tech who assists with putting on the protective equipment and taking it off, making sure we get everything put on in the right order and that it’s taken off in such a way that we’re not self-contaminating or contaminating people around us.

Being on the intubation teams is very interesting work. Even though it’s what we do all the time, doing it in protective equipment is kind of like spelunking.

What have you learned about treating COVID-19 patients?

Because these COVID-19 patients are so sick, I’ve had to make some alterations in how I manage drugs for intubation. And what I’ve found from a technical standpoint is that the secretions from the disease tend to be very dry and sticky, and there are a whole lot of them. Part of the reason why COVID-19 patients get into respiratory distress is that they’re not able to handle their own secretions, and trying to get a breathing tube in around what sometimes feel like concrete blocks is a real challenge.

We use a video laryngoscope for all of our intubations here. It’s a fairly modern device that we normally save for patients whose airway anatomy makes them difficult to get a breathing tube into, but we’re just using it for everybody to maximize our first chance of success.

In one case, I put the laryngoscope in and I didn’t see anything resembling normal human anatomy. It was all just thick, dark, nasty secretions. And the only way I could actually find this person’s trachea was by wiggling and stirring around the secretions. I could see the shape of this patient’s larynx buried in there, and I just put the tube in the middle of this junk and hoped for the best. Thankfully, I got lucky on that one, but it’s just one example of how it can be such a challenge to intubate these people.

One of the main physical findings is hypoxia. And hypoxia is a very interesting entity in that when you get it, you don’t know you’ve got it. It’s the opposite. The greater the degree of hypoxia, the less likely you are to realize that you’ve got low oxygen levels in your blood. This is something that’s been a problem for pilots for a long time. What we’re seeing with some COVID-19 patients is they’re coming in already severely distressed from hypoxia because they’ve been dealing with this for maybe a week or two. And they don’t know it.

The way our bodies initially compensate for hypoxia is to try to breathe more deeply and more rapidly. We’re already designed to take a big sigh breath every minute or two, maybe three. That’s healthy for our lungs. But when you do that constantly, you can cause stretch injury to the alveoli in the lungs. These vital-capacity breaths are actually causing the kind of lung injury that we saw in patients who were managed on ventilators 20 years ago, before we realized what protective ventilation strategy was.

How would you say the health-care teams are faring at the hospital where you are working?

People are tired. And there are a lot of people who are really afraid of getting the disease. People are tough. And we’re in New Jersey—people are really tough. And they’re tired.

Under the best circumstances, where everything is ideal, by the time a COVID-19 patient reaches intubation and mechanical ventilation, they’re at the 80 percent mortality rate. And where I’m working, at an inner-city hospital in Newark, the mortality rate is close to 100 percent.

It’s different from what I’m used to doing. In my practice, I take care of a disproportionate number of very sick, complicated patients compared with my colleagues who work primarily in outpatient surgery centers, but when I intubate a patient, their expected 30-day mortality rate is probably around 0.1 percent or less. But here, I’m looking at somebody who’s got a 1 percent chance of survival.

What keeps us all going is the hope that this person is going to be in that group.

Do you have enough personal protective equipment?

The place where I do most of my work is doing well from an equipment standpoint. I never have concerns with PPE. Which was my biggest fear coming out here.

Now, I did work at another hospital one day and they were a little bit tighter with the PPE. So instead of double-gowning, I wore only one gown along with the powered air purifier hood. But I still had a powered air purifier, a gown and gloves. So I had the minimum I felt I needed to stay sane. Otherwise, I might have just said, you know what, with the likelihood of success here being so low, it’s not worth it.

Do you have a sense of how much longer you’ll be in New Jersey?

Probably another couple of weeks. The number of cases seems to be tapering off a little bit. I think it’s too early to say for certain that New Jersey’s on the backside of the curve, but anecdotally, we’re seeing fewer intubations, fewer admissions and more discharges. When I first started, we were getting paged to intubate a patient fairly regularly. I just got off an overnight shift where we intubated two people.

In Washoe County, Nev., where I live, we haven’t hit a surge of cases. Overall the curve is still pointing upward, but it doesn’t seem like we’re getting the explosive growth that we were a few weeks ago. And we’re starting to work on clearing some of the backlog of elective cases, so it looks like they’re going to start to need to put us all back to work.

I’ve got a two-week mandatory quarantine period after I return to Nevada. We discussed, kind of tongue-in-cheek, popping up our little camper in front of the house, which our neighbors said under the circumstances would be totally fine. But we’ll probably just shift around living arrangements, and I’ll stay in a separate room from the rest of the family.

What has your time in New Jersey taught you about this virus?

It’s easy for me to come up with some flip statement, like, “Wow, this is like nothing I’ve ever seen before.” But really, everyone I’ve talked to says this is unlike anything they’ve ever seen.

It’s not influenza. It’s not Ebola. It’s not HIV. It’s not SARS-CoV-1, even. This is truly something new and very severe, which is why I get kind of irritated when people make light of it. Because, yeah, OK, we have not seen the same mortality rate that we do with influenza overall. But the way people die from this disease is so horrific, and even the people who survive . . .

Yes, many people survive completely intact and it was like a bad cold. It’s the ones who end up hospitalized and in the intensive care unit. It’s almost like they’re two different conditions. A lot of it has to do with how our immune systems respond to it. But unlike the big influenza epidemics where it was the young people who had this hyperimmune response that ultimately killed them and the elderly who just didn’t have the strength to deal with it who died, this disease is hitting everybody. It does not seem to discriminate. The only thing that seems to be fairly consistent among severe patients is that they have some sort of chronic comorbid condition.

I would summarize the disease as being a horrible way to go. It affects so many organ systems and creates so much work of breathing and air hunger and gasping that this is not the condition I would wish on anybody. I think that at this point, all we have are public health measures—social distancing, wearing masks, limiting gatherings—to control the spread of it.

Even though there’s talk of certain drug therapies as being miracles, it’s just simply not true. We do not have drugs that are effective to prevent infection or to treat it or to cure it. We do have drugs that will treat secondary bacterial infections. We have drugs that can reduce the degree of cytokine storm [a potentially fatal overreaction of the immune system] that these patients often experience. And we do have experimental antiviral treatments, which are showing just a glimmer of promise, but let’s keep the public health measures in place until we do figure it out.

April 7

STANFORD: Most important, how was your week?

Knepper: The ICU has been very busy with COVID-19 patients. We’re doubling up patients in some rooms, and we created a new ICU in a recovery suite.

While the ICU has been packed, the other floors are eerily quiet. People are afraid of coming to the hospital, so they’re choosing telehealth with their outpatient physicians or just staying at home. We wonder—is the patient with chest pain chewing Tums at home, hoping that it will help the symptoms of what’s really a heart attack?

The community has poured out support. Chalk messages are written on the ground outside the employee entrance—“Not all heroes wear capes, some wear scrubs!” “Nurses rock!” “Thank you, environmental techs” [who provide sanitation]. A local microbrewery, Odell, gave out a six-pack of their beer to anyone showing an employee badge. Cartons of Girl Scout Cookies are everywhere.

I know there are nationwide shortages of personal protective equipment and ventilators, and I’ve read that Fort Collins has a particularly low level of ICU beds per capita. Are you experiencing shortages of anything, and, if so, how are you coping with them?

I think we can find physical room for more ICUs. The challenges I see are with staffing—will we have enough ICU nurses? Enough respiratory therapists? And the ventilator issue is very worrisome.

We have enough surgical masks, but N95s could be a problem. My group bought some construction N95s and has provided us with construction goggles as eye shields. What I wear in a COVID-19 patient’s room: gloves, gown, gloves again over that, N95, surgical mask over the N95, eye shield over my regular glasses. Our elderly patients who are hard of hearing are having a rough time understanding us through the masks. It’s also hard to show emotion through all that—with just a surgical mask on, I can “smile” with crinkling around my eyes, but an N95 is too tight for that.

We are nervous about the need for rationing. Medicine already rations—not everyone who wants a kidney transplant qualifies for one, depending on their other health issues and their age. The rules for that are established and clear, however. Each state is devising its own system for this crisis; for example, Pennsylvania’s system takes into account symptoms of current illness (such as multisystem organ failure), future years expected to live (which is not as simple as chronological age but takes into account prior health issues) and other factors. The individual doctor is not expected to make the decision on whether a patient receives a ventilator; rather, an ethics board will. I worry that the federal government will ignore our pleas for help finding ventilators, then command us not to ration. You can’t have it both ways. 

Do you feel like this is why you went into medicine, or is this more than you ever bargained for? 

I do feel that this is why I went into medicine. I wanted to help people in need, and surely the need is very great now. I’m not very afraid for myself—perhaps this is an extreme level of denial; no doubt it will change when I see my colleagues begin to fall ill. My greatest worry is bringing infection home with me. My son didn’t sign up for a life in medicine.

I have seen patients die of this. I have also seen recovery—a man in his 70s who was intubated for several days is now making the slow steps to strengthen to return home. He said this was worse than his cancer surgery; he was so weak before he was intubated that he couldn’t lift his hand. Yet so many remain intubated or have died.

How long is this stretch of time off, and what do you plan to do with it?

I now have two weeks off! I had planned a trip to New York City to see Broadway shows and to San Diego for our yearly hospitalist conference. Obviously, both are canceled. If one of my partners falls ill, or if the surge happens and is too much for our scheduled physicians to manage, I will be called in. Meanwhile, I will paint watercolors. Garden in my rock garden—despite recent snow, the alpine plants are already blooming. Cook my way through a new cookbook, Dinner in French, by Melissa Clark. Study up on critical care, including ventilator management. And spend time with family, of course.

March 29

STANFORD: Where would you say your community is in the outbreak?

Knepper: We’re seeing a lot of cases, but it’s not overwhelming yet. There have been a few deaths in the county. I think the state’s been good about social distancing—we have a shelter-in-place order—which I think will slow, but not stop, the surge. Of the five of us in my hospitalist group who are on duty at one hospital, two are the COVID team. (It used to be one person; now volumes have gotten to where there are two.) We’re trying to minimize diffuse exposure so we don’t all come down with it at one time.

The hospital is filling with patients for whom COVID needs to be ruled out, but we’re not swamped yet. It feels like the ascent on a roller coaster—terrifying anticipation awaiting the crash. We are planning for the surge: How we will fill in if a doctor becomes sick. How specialists can help us if we become overwhelmed. I am wondering if I should brush up on pulmonary medicine and learn ventilator settings.

While we’re seeing a lot of COVID rule-outs, overall numbers of patients are down—we think people are terrified of coming into the hospital. More families are pulling together to provide 24/7 coverage for elderly parents at home rather than send them to a skilled nursing facility for rehab, feeling patients are safer at home than in a SNF.

Everything is happening very fast—what I write now may not be true in two days.

How has your job changed?

I have given up a business-casual wardrobe for scrubs. Makes me feel like a resident again.

Due to the hospital’s no-visitor policies, families are so grateful for phone calls. They often encourage us at the end of a call: “Thank you for what you’re doing.” “Stay safe.” “You guys are true heroes.” Normally, I wouldn’t get so much positive feedback like that during the day.

What are you doing to keep yourself sane on your days off?

My group is being very good about encouraging us to practice self-care during our days off, because it may get very crazy in the days to come. There may not be many days off. I work 14 shifts a month (a bit less than average; I’m considered part time). I’ll work four to seven days on, then have a few or several days off. This chunk of time off, I gardened. I painted. I cooked a French meal of roast duck breasts with buttered endive, apples and grapes. Gavin and I went for a walk in a natural area. (Colorado has closed many public areas but not parks, as long as you practice social distancing.)

What kinds of precautions are you taking to keep your family members safe?

Good question. Gavin and I have wrestled with this. So far, we share the same bedroom. No kissing, but hugs OK. Lots of handwashing. I tried to punch Eric on the shoulder after a particularly bad pun and he shrank back, saying, “Don’t touch me!” From reading the blogs of the national hospitalist society, I know that many doctors have taken much more stringent measures: Separate bedrooms. Dividing the house into clean and dirty zones. Moving out.

What else can you tell us to help us understand what the pandemic is like?

I saw a critically ill patient last time I was on—an older woman who had been perfectly healthy until 10 days ago, when she developed a cough. “I wasn’t prepared for this,” she said as she struggled to breathe. When she said “this,” she was referring to dying, because that’s what she was on the brink of.

Kathy Zonana, ’93, JD ’96, is the editor of Stanford. She and Kate met as sophomores in Potter House. Email Kathy at kathyz@stanford.edu.